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AAGP Position Statement: Geriatric Disaster Response

Published Saturday, November 1, 2008 7:00 am

This statement was prepared by the AAGP Disaster Preparedness Task Force authorized by the AAGP Board of Directors, and approved by the AAGP Board in November 2008.

Kenneth M. Sakauye, MD, Task Force Co-Chair
University of Tennessee Health Science Center, School of Medicine

Joel E. Streim, MD, Task Force Co-Chair
Geriatric Psychiatry Section
University of Pennsylvania
VISN 4 Mental Illness Research Education and Clinical Center
Philadelphia VA Medical Center

Gary J. Kennedy, MD
Division of Geriatric Psychiatry
Montefiore Medical Center

Paul D. Kirwin, MD
Department of Psychiatry
Yale University School of Medicine
VA Connecticut Health Care System

Maria D. Llorente, MD
Miller School of Medicine at the University Of Miami
Miami VA Healthcare System

Susan K. Schultz, MD
Department of Psychiatry
University of Iowa Carver College of Medicine

Shilpa Srinivasan, MD
Department of Neuropsychiatry and Behavioral Science
University of South Carolina School of Medicine

Case example: Mr. X was a 68-year-old African American man who had been successful in real estate in New Orleans. He had many rental properties and involved many of his children and extended family in the business. In addition, he had put all these family members through college and many through graduate school. He stayed in New Orleans during Hurricane Katrina to protect his property. All of his property was flooded or damaged during the hurricane, but he repaired most of it out of his own savings because there was minimal financial help from insurance or the Federal Emergency Management Agency (FEMA).

Mr. X had experienced an untreated depressive episode in his 20s, but did not show psychiatric symptoms again until the property repairs were completed and he had turned over his assets to family to get rid of his pressures. He was promptly excluded from business decisions, even though he wanted to remain involved. The family’s decision was partly to relieve him of stress, but partly because they did not like his domineering and controlling personality style. He began to complain of severe anxiety and insomnia.

One year after Hurricane Katrina, Mr. X was hospitalized for depression outside of New Orleans, as the wait was too long to be treated locally. He was started on an antidepressant and psychotherapy. Upon discharge, he was referred to a therapist in New Orleans because his family insisted he return there. He never followed up with care. Three months later he was discovered drowned in the Mississippi River after jumping off a bridge.

In a study, this death would not ordinarily be counted as a direct consequence of the disaster, but in actuality it was. His sense of abandonment by the government and his family, his role change and sense of uselessness, his overall sense of loss (New Orleans did not seem the same to him and was not recovering as he thought it should), and an absence of psychiatric services all directly led to his death.

The Disaster Preparedness Task Force of the American Association for Geriatric Psychiatry (AAGP) was formed after Hurricane Katrina devastated New Orleans in August 2005. Persistently high rates of adverse physical and mental health were reported for all ages from very early after the disaster, with most survivors being undertreated or untreated (1, 2). One year after the hurricane, suicidal ideation in the population as a whole was present in 6.4% of individuals surveyed, and serious mental illness was increased by 89.2%, PTSD by 31.9%, and suicidality by 61.6% from baseline levels (3). The elderly had the highest mortality rates, health decline, and suicide rates of any subgroup; while these events most certainly devastated the families of those affected, there has been minimal attention by the academic or public health communities to the vulnerability of the elderly. Most of the differences in statistics were captured by the Associated Press and various local news media and were not highlighted in clinical studies.

Minimal new information and research on elderly mental health outcomes was generated in the years immediately following the Katrina disaster. However, a bill was introduced in the U.S. Senate in mid-2007 by Senator Herbert Kohl (D-Wisconsin), the Chairman of the Senate Special Committee on Aging, directing the Secretary of Homeland Security to tailor emergency preparedness to the unique needs of the elderly and make grants to assist emergency management agencies of local governments in establishing a special needs registry.

Natural disasters such as earthquakes, extreme heat, floods, hurricanes, landslides and mudslides, tornadoes, tsunamis, volcanoes, wildfires, and winter weather are common around the world (4, 5). Man-made disasters from terrorist attacks, accidents, or war are also threats. Although a lifetime of experience may lead many elderly to be more resilient in times of disaster, frail elderly or those with psychiatric or medical limitations appear especially vulnerable to stress caused by disasters. Furthermore, physical disabilities and mobility limitations leave the elderly in a precarious position when evacuations are needed emergently. Consequently, the elderly may be more frequently exposed to dangerous conditions due to failure to move rapidly to safer surroundings.

In post-Katrina New Orleans, mental health problems were profound in the elderly. Many felt they had lost their life’s work and savings, and became hopeless. Family members were often separated from each other. Medical and psychiatric care was often interrupted. Practitioners saw problems of generalized anxiety disorder, depressive disorders, somatoform disorders, primary insomnia, high rates of suicide attempts, and memory complaints; although PTSD, substance abuse, and aggression were not as prevalent as in younger patients. High rates of psychosomatic problems were seen, with worsening health problems and increased mortality and disability. The number of obituaries for elderly in the newspapers rose despite a markedly reduced population.

Variable Nature of Stress and Those at Highest Risk for Stress Effects

As defined in the Diagnostic Statistical Manual, Fourth Edition, Text Revision (DSM-IVTR), a catastrophic stress is defined by direct exposure to an event that is a threat to one’s physical integrity or to someone close to them, and is associated with intense fear, helplessness, or horror. In children and older adults, the response can manifest as disorganized or agitated behavior rather than a conscious sense of fear or horror. Chronic or recurring stress can be overwhelming. PTSD is the most extreme reaction, but severe stress can trigger a number of other psychiatric problems.

The many forms of disaster differ in the degree of destruction and loss, community fragmentation, and separation from social supports. The trajectory of recovery is often underestimated in its scope and duration. The elderly patient in particular may have difficulty in adjusting to new surroundings and accommodating new routines. The acute stress during a disaster can be as wide-ranging as the severe isolation and quarantine-like situation in post-9/11 New York, to forced relocation and loss of possessions for post -Katrina New Orleans. The common theme is that a rapid return to a relatively normal and predictable life is clearly an important factor in recovery. Chronic stress has a major influence on persisting mental health problems. On the other hand, many factors can be considered buffers that might mitigate even extreme hardship. The most important buffers are a strong support network, hope, a sense of control, and resources.

Unique problems for the elderly exist for those with pre-existing cognitive impairment. Those with dementia may interpret even minor stressors or changes in routine as a potential catastrophe. Severe medical illnesses, such as insulin dependent diabetes mellitus or congestive heart failure, also create problems if evacuation is needed. Many such patients cannot be moved long distances without “relocation trauma,” where forced relocation is a severe stress in itself that can hasten decline or death. The physiologic response to stress with release of corticosteroids and catecholamines may induce acute cardiac instabilities as well as exacerbate many underlying conditions such as glucose control, creating a very vulnerable state for an elderly patient who may simultaneously be lacking access to his/her routine medications and health care providers.

SAMHSA (Substance Abuse and Mental Health Services Administration) outlined six broad groups in decreasing order of risk for psychiatric sequelae after a disaster. This list applies equally to elderly (6).

  1. Seriously injured victims; bereaved family members (most acute and most at risk)
  2. Victims with high exposure to trauma; evacuees (second highest risk group)
  3. Bereaved extended family members and friends; rescue/recovery workers; service providers involved with death notifications and bereaved families (third highest risk group)
  4. People who lost homes, jobs, pets, valued possessions; mental health providers, clergy, chaplains, emergency health-care providers, school personnel involved with survivors, families of victims, media personnel covering the disaster (fourth highest risk group)
  5. Government officials; groups that identify with target victim group; businesses with financial impacts (next highest risk group)
  6. Community at large (least at risk for mental health sequela)

This hierarchy roughly corresponds to the Severity of Psychosocial Stressors Scale (Axis IV) in the DSM-IVTR, which rates severity of stress from no stress to catastrophic stress. Catastrophic stress is experienced by groups 1 and 2. Extreme or severe stress is experienced by groups 3 and 4. Moderate to mild stress is experienced by groups 5 and 6. One limitation in using this scale is the variability brought about by each individual’s appraisal of his or her situation, i.e., one person’s mild stress is another’s catastrophe. While groups 5 and 6 may be considered at lower risk, those individuals may perceive their stress as extreme because of uncertainty about the future; insecurity; loss of a supportive community, infrastructure, or essential services; having no doctors, churches, stores, phone or internet service, transportation, or mail; interruption of treatment; and seeing little or no progress toward recovery.

Risk factors for negative psychiatric outcomes that may help identify persons who need special planning for response are:

  • Advanced age or frailty
  • Cognitive impairment (e.g., elderly with dementia)
  • Severe mental illness or chronic disability due to mental illness (e.g., schizophrenia, affective disorder, depression)
  • Poor physical health, complex medical illness or mobility impairment
  • Lack of close family caregivers or local social supports
Psychiatric Effects of Disaster in Elderly

Because of variability in the extent and type of disaster, no consistent rates of psychiatric illnesses can be predicted for every situation. Post-traumatic Stress Disorder (PTSD) remains a major concern due to its disabling and persistent nature, but it is not the most common psychiatric problem to occur after a disaster in any age group. Only a small number of elderly appeared to develop PTSD after Katrina. More common problems were memory disturbance (“Katrina Brain” as many locals joked about the post-Katrina effect), anxiety disorders, insomnia, pathological grief, major depression, dysthymia (mild persistent depressive symptoms lasting more than two years), psychosomatic illness (medical problems worsened by stress), somatization disorders (e.g., hypochondriasis), and relapse of pre-existing psychiatric illness.

The highest risk group of elderly who suffered the most after Hurricane Katrina were frail elderly who could not be relocated without extreme strain or who required care that was no longer accessible, and elderly with a dementia who could not understand or cope with the changes around them.

The long-term impact of an extensive disaster on the elderly (in terms of psychiatric disorders that persist for a year or more after the trauma) remains unclear, leaving the following questions unanswered: Do elderly ever recover from such a disaster? If so, what intervention might be most effective?

PTSD, anxiety symptoms, and memory impairment may be explained by biological changes in the hypothalamic-pituitary system (7), and a search for medications that may blunt the biological changes caused by stress and prevent the persistent negative changes that lead to PTSD, anxiety disorders, depression, or other psychiatric disorders may be possible. Previous research has examined whether beta-adrenergic blockers given after a traumatic event may reduce the likelihood of PTSD. However, one might argue that in the case of the elderly individual there is a great challenge in addressing basic safety needs during an acute event such that simple survival and minimizing imminent health threats still remain the most pressing need. Along these lines, the interventions described below focus on adequate preparation and rapid responses to mitigate the extent of the trauma for the elderly adult.

Interventions

Three phases of disaster response require attention. In all phases, care providers must be alert to the high risk of negative psychiatric outcomes after a disaster and know the signs of emotional distress (8).

  1. Preparation
    • Modify state disaster plans to include special plans for frail elderly and dementia patients that address communication needs to ensure that the elderly are warned of impending disasters when possible.
    • Train first responders to deal with frail elderly.
    • Establish services for frail elderly or dementia patients and contingency plans in the event the primary plan falls short.
    • Develop plans to prevent separation from family and pets.
    • Identify programs that deal with the elderly; make prior arrangements with the state or federal agencies in charge to involve these programs in recovery efforts.
  2. Early response
    • Administer psychological first aid: provide information, offer reassurance, restore psychosocial supports, connect with services.
    • Withdraw those with severe symptoms to a safer area until they are able to cope. Do not force reliving the traumatic events just experienced. Return as soon as possible.
    • Make treatment services and medications available.
  3. Late response
    • Provide special care to deal with the long-term negative impact of disaster on elderly.
    • Address new transitions in housing and adjustment to new care providers that may result in enduring stressors, particularly for the elderly who require supervised settings such as nursing homes.
    • Restore routine services and continuity of care.

Regarding longer term and late response care for the elderly following a disaster, the lack of parity for mental health coverage creates an additional barrier to care such that the private sector is not likely to deliver it even n the event of a post-disaster situation. In July 2008, the U.S. Congress acted to end the statutory discrimination against Medicare beneficiaries seeking treatment of mental disorders by passing legislation to eliminate the 50 percent copayment requirement and ensure that Medicare psychiatric outpatients incur the same 20 percent cost as patients seeking treatment for all physical illnesses. Arbitrary limits on coverage of mental health coverage should be eliminated wherever they exist. It is time that all health benefit programs end discrimination between health insurance coverage for mental disorders and all other medical illnesses.

Considerable information already exists on early response, called psychological first aid. The most detailed sources include publications from SAMHSA, the Veterans Administration (National Center for PTSD), and APA (American Psychiatric Association). Downloadable references are available online and listed in the references.

After Katrina, existing knowledge about screening for mental illness in elderly was not applied. The elderly were not identified as a high-risk population, and basic services were frequently unavailable. Excessively slow recovery led to chronic and persistent stress for elderly residents of the disaster area. Prevention of mental illness and reduction of suicide would have been possible if preparation and coordination of care were present. Many investigations and reports on the failure of initiative around Hurricane Katrina in all phases are listed in the references and can be downloaded online. The most useful summaries were a White House Report, a Senate Committee Report, and Brookings Institution reports listed in the references.

The late response phase generally involves restoration of services and outreach. Key interventions include establishing security, stability, and safety; reunifying families; and providing psychiatric services to the most severely affected.

It is evident from prior disaster experience that addressing the needs of elderly will not be made without a stronger mandate to do so from the major governmental agencies dealing with disaster response and health (FEMA and SAMHSA).

Recommendations

  • Frail elderly and dementia patients must be designated a high-risk population requiring specific disaster protocols that address their safety needs.
  • A geriatric psychiatrist must be appointed to all disaster planning committees.
  • Special provisions on geriatric mental health must be present in state and local disaster plans for training, continuation of care, and accessibility to specialists.
  • Plans to keep families/caregivers and pets together must be in place.
  • Plans to ensure that all-important documents (i.e., birth certificates, marriage certificates, property deeds, etc.) are kept in easily accessible waterproof locations must be in place.
  • Plans to ensure that elderly have enough medication for at least two weeks as well as a list of all medications, doses and frequency must be in place.
  • Individuals should have flashlights and an adequate supply of cash-on-hand, in the event that electricity is out for an extended period of time.
  • Homes should be stocked with dry foodstuffs and bottled water to last for a minimum of three days.
  • Frail elderly, especially those with cognitive impairment, should have identification bracelets that include their name, age and next of kin.
  • Procedures must be developed and tested to enhance communication regarding disasters to the elderly, address deficits in mobility during evacuations, and minimize interruptions in care and support.
  • Special funding must be set aside to train first responders and care providers to deal with the elderly and to develop and widely disseminate training materials specific to the needs of the elderly.
  • The knowledge base must be broadened on how to respond most effectively for this population during and after disasters.
Lessons Learned to Reduce Psychological Trauma for Disaster Victims
  • Logistical Considerations
    • Federal, state, and local coordination is essential before, during, and after an event.
    • A horizontal organizational structure of care must be planned; that is state and federal employees must work hand-in-hand with local health care agencies.
    • Funds must be available to nongovernmental service organizations or private practitioners to make the horizontal organizational structure work after a disaster. There is often no source of revenue unless the government provides it.
    • A local command structure must be in place and rehearsed for health care.
    • A system for mental health care deployment is needed for the state.
    • Medications and supplies should be stockpiled or readily available for injured or displaced locals.
    • Volunteers and donations that meet actual, rather than perceived, needs must be solicited.
    • Tertiary health care services (hospitals) must be restored quickly.
    • Registries of frail elderly and dementia patients are probably needed so that those who require special care or who cannot be relocated receive special attention after a disaster. Safety and lodgings for these patients as well as the workers and family members who must stay with them must be arranged in advance.
    • Portable medical records must be available; electronic medical records (EMR) appear to be the most logical thing to develop.
    • Local shelters (safe houses) must be available locally for the elderly who cannot be moved. Safe houses are designed to withstand the anticipated catastrophe (e.g., high ground in flood areas, reinforced in earthquake areas, independent power and water sources).
    • First responders and health care professionals must be trained on mental health disaster guidelines.
    • Funding should address the full range of needs, from screening services to treatment.
    • Local practitioners who return must be part of the disaster plan. They must be paid because they have no means of support themselves.
    • A backup communication system must be in place. There may be no cell phone towers, mail delivery will stop, and supplies will be scarce.
    • Families must be kept together and have a rendezvous point in case of separation.
    • Pets must be allowed.
    • Public service disaster planning programs should be established. At a minimum, measures must be taken to secure the home, protect mementos and special papers, and throw away perishables in the refrigerator before evacuating. Know what to bring if evacuating or what to store if trapped in the home, and carry a list and a supply of current medications in wallets or purses.
  • Prepare for behavioral health
    • Familiarize workers on existing mental health disaster manuals.
    • Train workers on psychological first aid in the initial phases of disaster aftermath.
    • Train workers to screen for severe psychological reactions in later phases.
    • Train mental health workers in disaster psychiatry.
    • Have a complete spectrum of treatment services available.

References

(1) Weisler RH, Barbee JG, Townsend MH: Mental Health and Recovery in the Gulf Coast After Hurricanes Katrina and Rita. Journal of the American Medical Association 2006;296:585-588

(2) Wang PS, Gruber MJ, Powers RE, Schoenbaum M, Speier AH, Wells KB, Kessler RC: Mental Health Service Use Among Hurricane Katrina Survivors in the Eight Months After the Disaster. Psychiatric Services 2007;58(11):1403-1411

(3) Kessler RC, Galea S, Gruber MJ, Sampson NA, Ursano RJ, Wessly S: Trends in Mental Illness and Suicidality After Hurricane Katrina. Molecular Psychiatry 2008 Apr;13(4):374-84. Epub 2008 Jan 8.

(4) CDC. Centers for Disease Control and Prevention: Natural Disasters & Severe Weather. Available at: http://www.bt.cdc.gov/disasters/. Accessed January 31, 2008

(5) NASA. National Aviation Natural Disaster Reference Database. Available at: http://ndrd.gsfc.nasa.gov/. Accessed January 31, 2008

(6) U.S. Department of Health and Human Services. Mental Health All-Hazards Disaster Planning Guidance. DHHS Pub. No. SMA 3829. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003. Available at: http://download.ncadi.samhsa.gov/ken
/pdf/SMA03-3829/All-HazGuide.pdf

(7) Yehuda R, LeDoux J: Response Variation following Trauma: A Translational Neuroscience Approach to Understanding PTSD. Neuron 2007;56:19-32

(8) Substance Abuse & Mental Health Services Administration: The Spirit of Recovery meeting (New Orleans, LA). May 22-24, 2006.

Appendix for Additional Sources

Coping with Disaster:

American Psychiatric Association: Acute Stress Disorder and Posttraumatic Stress Disorder. November 2004. Available at: http://www.psychiatryonline.com/pracGuide/pracGuide
Topic_11.aspx

American Psychiatric Association Committee on Psychiatric Dimensions of Disaster: Disaster Psychiatry Handbook. November 2004. Availabel at: http://www.psych.org/Resources
/DisasterPsychiatry/APADisasterPsychiatryResources/Disaster
PsychiatryHandbook.aspx
. Accessed July 23, 2008.

Brown SH, Fischetti LF, Graham G et al: Use of Electronic Health Records in Disaster Response: The Experience of Department of Veterans Affairs After Katrina. Am J Public Health 2007; 97: Suppl 1:S136-41

DeWolfe DJ: Training Manual for Mental Health and Human Service Workers in Major Disasters. Rockville, MD, U.S. Department of Health and Human Services, DHHS Publication No. ADM 90-538, 2000. Available at: http://mentalhealth.samh
sa.gov/publications/allpubs/ADM90-537/fmintro.asp

The National Center for PTSD: Clinician’s Trauma Update (CTU-Online). Available at: http://www.ncptsd.va.gov/ncmain/
publications/publications/ctu_online.jsp

The National Center for PTSD: Psychological First Aid: Field Operations Guide, 2nd Ed. July 2006. (www.ncptsd.va.gov)

The National Center for PTSD: Fact Sheets. Available at: http://www.ncptsd.va.gov/ncmain/information/

The National Center for PTSD: Self-Care and Self-Help Following Disasters. Reviewed/updated May 22, 2007. Available at: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_se lf
_care_disaster.html?opm=1&rr=rr58&srt=d&echorr=true

The National Center for PTSD: Disaster Mental Health Manual. 1998. Available at: http://www.ncptsd.va.gov/ncmain/ncdocs
/manuals/nc_manual_dmhm.html

Oriol W: Psychosocial Issues for Older Adults in Disasters. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services; 1999. Available at: http://downl
oad.ncadi.samhsa.gov/ken/pdf/SMA99-3323/99-821.pdf

Substance Abuse & Mental Health Services Administration: Mental Health All-Hazards Disaster Planning Guidance (for States). 2003. Available at: http://www.samhsa.gov/Matrix/ma
trix_disaster.aspx

Substance Abuse & Mental Health Services Administration: Care Tips for Survivors of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life. Available at: http://mentalhealth.samhsa.gov/publications/allpubs/KEN-0
1-0097/default.asp

U.S. Department of Homeland Security: Preparing Makes Sense. Get Ready Now. Available at: http://www.ready.gov/america/
_downloads/Ready_Brochure_Screen_EN_20040129.pdf

Failures in Response:

Brookings Institution reports. Available at: http://www.brookin
gs.edu/search.aspx?doQuery=1&q=Hurricane%20Katrina

A Failure of Initiative: Final Report of the Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina. Available at: http://katrina.house.gov/

Government Accountability Office (GAO) reports: Katrina Related Reports and Testimony. Available at: http://www.pogo.org/p/
contracts/katrina/GAO.html

Office of the Investigator General (OIG) Reports on Katrina. Available at: http://www.bespacific.com/mt/mtsearch.cgi?In
cludeBlogs=1&search=katrina

Office of Inspector General, Department of Health and Human Services: Nursing Home Emergency Preparedness and Response During Recent Hurricanes. August 2006. Available at: http://www.oig.hhs.gov/oei/reports/oei-06-06-00020.pdf

Townsend FF: The Federal Response to Hurricane Katrina: Lessons Learned. White House Report. February 2006. Available at: http://media.govtech.net/Sprint_RC/katrinalessons-
learned.pdf

 


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