The population of adults 65 and older is growing. So is the older population living with dementia or neurocognitive disorder. The prevalence of people living with Alzheimer’s dementia as of 2020 is estimated to be over 700,000. This makes up 12% of our 65+ Californians with Alzheimer’s.

This places these patients at higher risk of delirium than our younger community members. During disasters, our older patients are vulnerable to stress and high risk of morbidity, such as delirium and depression.
The most common disasters in our state are earthquakes, wildfires, or floods.

The proportion of older patients affected during disasters will be much higher than in other demographics in the coming years.

This creates the perfect storm of vulnerability superimposed on the baseline disaster vulnerability.
During a disaster, seniors could be displaced from their homes, RCFEs (residential care facility for the elderly), or even nursing homes to alternate sites or community shelters during the disaster.

Nurses or volunteers are trained to respond to more acute events such as heart attack or stroke symptoms. However, they may lack training and skill in triaging and caring for older adults with mental and psychological conditions such as dementia, delirium, and depression.

There is an acute need to train our workforce to care for the geriatric population during a disaster. This will reduce the stress on our strained emergency and hospital beds during a disaster. It is the right thing to do.
Also, we can help prevent delirium and other complications.

What is uniquely challenging about this population is:

1. They often have complex medical histories, illnesses, medications, and medical device needs.
2. They may have different and more complicated medical and psychosocial needs.
3. The unfamiliar/confusing environment of a shelter adds extra stress to persons with dementia or depression. It can precipitate delirium or an acute confusional state.
4. They may have been evacuated from their living environment without their meds or durable medical equipment.
5. Essential sensory aids such as hearing aids or glasses may been left behind, misplaced, or destroyed during the disaster.
6. They may be separated from their family, caregivers, or pets, which may add to disproportionate anxiety, stress, or loneliness.

Hence, the displaced older person with dementia, functionally impaired and without sensory or hearing aids, is at a higher risk for delirium when exposed to precipitating factors such as disaster, uncontrolled pain, missed medication, being administered inappropriate anticholinergic medications, not being able to access the restroom or limited to their cot and the chaotic nature of the shelter.

Then, the disaster and the shelters' chaotic nature add extra stress on these seniors.

They are more vulnerable and less resilient. The physiological term for reduced resilience and reserves associated with aging is homeostenosis as compared to homeostasis.

This requires our emergency preparedness teams to be aware and trained to be able to differentiate among delirium, depression, and dementia.

They can be trained to use the Confusion Assessment Method (CAM) to diagnose delirium or be readily available quickly.

1. Acute change in mental status or fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

Diagnosis of delirium requires 1 and 2 and either 3 or 4.

Emergency preparedness staff can be trained to implement non-pharmacological measures such as access to the bathroom, being aware of their sensory deficits such as hearing or vision, having their cot close to the nursing station, and away from children (to avoid sensory overload), use of orienting stimuli such as Clocks/calendars, and frequent mobilization with appropriate assistive devices and assistance.

In summary, as the geriatric population is growing at a rapid pace, so are those living with dementia. This could lead to many more cases of delirium in a disaster scenario. We should have a plan to address this emergency condition in older, cognitively impaired individuals. Having the proper education and skills, we can provide the right care at the right place to our elders.

References: Safeguarding older adults with dementia, depression, and delirium in a temporary disaster shelter. Cynthia L Holle, MBA, RN, Mary A. Turnquist LCSW, James L Rudolph MD.