The Vulnerable Geriatric Casualty: Medical Needs of Frail Older Adults during Disasters

Abstract

A daunting challenge. When Hurricane Katrina struck New Orleans in 2005, more than 70 percent of fatalities resulting from the storm were among people age 60 or older. The older population is particularly vulnerable to disasters, which obviously place a severe strain on the medical and social service networks that support them. The events of 2005 challenge us to better understand the needs of vulnerable elders in case of future events (Louisiana Department of Health and Hospitals, 2006). Acute injuries, dangerous evacuations, unfamiliar surroundings, and altered routines can all act as precipitants for a host of adverse medical outcomes among older casualties. And because large numbers of vulnerable older casualties will utilize healthcare resources at a high rate, older people pose a unique challenge for medical planners, first responders, triage and treatment facilities, and recovery efforts alike. For disaster planning purposes, the vulnerable older population at highest risk consists primarily of those with disabilities, those with dementia or other cognitive impairment, and nursing home residents. They are all at very high risk for a range of adverse outcomes such as worsening disability, immobility, delirium, dehydration, malnutrition, pressure sores, and side effects or withdrawal from medications. What follows is a summary of the particular medical needs of vulnerable older people during and after disasters, strategies for medical triage and treatment, and special considerations for older people during the recovery phase of catastrophic events. FUNCTIONAL STATUS Disability, or impaired functional status, is the primary window through which to view the effects of disasters on vulnerable older people. Disability in older people is defined as needing assistance with any activity of daily living (ADL). Basic ADLS include transferring in and out of bed, walking, using the toilet, and bathing (Katz et al., 1963). More complex ADLS, called instrumental activities of daily living (IADLS), include managing finances or medications, meal preparation, and light housework (Stuck et al., 1999). People with any disability are the ones most likely to suffer a decline in their functional status during or after a disaster. Such a decline can lead to further disability, which in turn can cause illness, hospitalization, or even death if not quickly recognized and addressed. For example, a frail older man who lives alone may have diabetes, vision loss, and an arthritic shoulder. A home attendant assists him with cooking (because of his poor vision and the shoulder), and a visiting nurse assists him with medication management (because of the vision). The man can do well under normal circumstances, dependent on others yet well supported and healthy. But if disaster strikes and he is alone for too long, he can quickly become dehydrated, weak, and dizzy. These symptoms together may cause a fell, and if he is unable to get up because of his arthritic shoulder, he may quickly become delirious or develop a pressure ulcer, which, in a person with diabetes, can easily become infected. By the time the man is found and moved to a safe place, he can no longer walk, is agitated and confused, and requires acute medical care (Henderson, 2005). This example highlights how the problems of vulnerable older people are like pebbles dropped into still water, creating ripple effects that cause new problems. Such a rapid decline, often seen in older people during and after disasters, mimics the effects of hospitalization and immobility. Research on the hazards of hospitalization for frail older people has shown that within two days the immobile hospitalized elder begins to have skin and muscle breakdown, sensory deprivation, altered sleep patterns, and is at high risk for delirium and confusion (Creditor, 1993). The situation is similar in disasters, where the support systems of vulnerable elders can disappear quickly, and the only direction to go is down. …