Closing the Gaps: Advancing Disaster Preparedness, Response and Recovery for Older Adults - 25 Evidence-Informed Expert Recommendations to Improve ...
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Closing the Gaps: Advancing Disaster Preparedness, Response and Recovery for Older Adults 25 Evidence-Informed Expert Recommendations to Improve Disaster Preparedness, Response and Recovery for Older Adults Across the United States JANUARY 2020
Table of Contents
Report Development Contributors................................................................................................1
Organizational Endorsements....................................................................................................... 3
Abbreviations.....................................................................................................................................4
Executive Summary.......................................................................................................................... 5
Background and Context............................................................................................................... 10
Domain 1: Individuals and Unpaid Caregivers....................................................................... 18
Domain 2: Community-Based Services and Programs........................................................ 25
Domain 3: Healthcare Professionals and Emergency Response Personnel................... 29
Domain 4: Care Institutions and Organizations....................................................................32
Domain 5: Legislation and Policy............................................................................................... 35
Domain 6: Research........................................................................................................................ 41
Glossary..............................................................................................................................................43
References.........................................................................................................................................44
Appendices........................................................................................................................................50
Appendix A: Index of Recommendations and Enabling Bodies..................................................................... A-1
Appendix B: Training Materials and Resources for Healthcare Providers and Emergency
Medicine Personnel....................................................................................................................................................................B-1
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS iii
Report Development Contributors
In June 2018, the American Red Cross Scientific Expert Contributors:
Advisory Council, in partnership with the Allison Gibson, PhD, MSW, LISW-CP
American Academy of Nursing, initiated a review Co-Convener, Disasters and Older Adults, Special Interest
of the latest evidence on disaster preparedness Group, Gerontological Society of America
Assistant Professor, College of Social Work,
for older adults. Following the review a group
University of Kentucky
of experts were invited to participate in a Policy Lexington, Kentucky
Expert Round Table on Emergency/Disaster
Bill Earley, JD, BBA
Preparedness for Older Adults to inform the
Chief Operating Officer & General Counsel, West Health
development of recommendations to improve San Diego, California
disaster preparedness, response and recovery for
Christopher Taylor, PhD
older adults. Enlisted experts that contributed to
Epidemiologist, Alzheimer’s Disease and Healthy Aging
the development of this report are listed below. Program (AD+HAP)
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Co-Chairs, American Red Cross/ Prevention (CDC)
American Academy of Nursing (ARC/ Atlanta, Georgia
AAN) Emergency/Disaster Preparedness The findings and conclusions in this report are those of the authors
for Older Adults Project and do not necessarily represent the official position of the Centers
Samir K. Sinha, MD, DPhil, FRCPC, AGSF for Disease Control and Prevention.
Member, American Red Cross Scientific Advisory Council
Erin Prendergast, MPH, BA
and Preparedness and Disaster Health Sub-Council;
Senior Manager, Quality Improvement at American Health
Director of Geriatrics, Sinai Health System and University
Care Association (AHCA)
Health Network, Toronto, Ontario
Washington, District of Columbia
Assistant Professor, Department of Medicine, Johns
Hopkins University School of Medicine Jacqueline T Snelling
Associate Professor, Departments of Medicine, Family and Preparedness and Health Services Sub-Council
Community Medicine, and the Institute of Health Policy, American Red Cross Scientific Advisory Council
Management and Evaluation, University of Toronto, Ontario Washington, District of Columbia
Wanda Raby Spurlock, DNS, RN-BC, CNE, Jane Carmody, DNP, MBA, RN
FNGNA, ANEF, FAAN Program Officer, The John A. Hartford Foundation
American Academy of Nursing, Aging Expert Panel
New York City, New York
(Emergency/Disaster Preparedness Sub-Committee)
Professor, College of Nursing and Allied Health, Southern Joanne Lynn, MD, MA, MS
University and A&M College, Baton Rouge, Louisiana Director, Program to Improve Eldercare, Altarum
Washington, District of Columbia
Kandra Strauss-Riggs, MPH
Education Director, National Center for Disaster Medicine
and Public Health (NCDMPH)
Rockville, Maryland
1 REPORT DEVELOPMENT CONTRIBUTORSKaren Moomaw Rose, PhD, RN, FGSA, FAAN Samuel R. Seitz, MEd, RN, NRP
American Academy of Nursing, Aging Expert Panel Senior Year Curriculum Coordinator
(Emergency/Disaster Preparedness Sub-Committee) Assistant Professor, School of Health & Rehabilitation
Assistant Professor of Nursing, College of Nursing, Science, University of Pittsburgh
McMahan-McKinley Professor of Gerontology, The Pittsburgh, Pennsylvania
University of Tennessee
Knoxville, Tennessee Tener Goodwin Veenema, RN, PhD, MPH,
FNAP, FAAN
Kathryn Hyer, PhD, MPP Associate Professor, Johns Hopkins School of Nursing,
Professor and Director, Florida Policy Exchange Center Center for Refugee and Disaster Response, Johns
on Aging, School of Aging Studies, University of South Hopkins Bloomberg School of Public Health
Florida, Tampa, Florida President and CEO, Tener Consulting Group, LLC
Baltimore, Maryland
Kevin Munjal, MD, MPH
National Association of EMS Physicians (NAEMSP) – Tom Heneghan, BA
Community Paramedicine/Mobile Integrated Health Care Senior Manager, Community Preparedness
Committee Chair Education Program
Emergency Medicine Physician, Mount Sinai Hospital Disaster Cycle Service, American Red Cross
New York City, New York Fairfax, Virginia
Lynn Slepski-Nash, PhD, RN, PHCNS-BC, FAAN
United States Public Health Service (Retired) Project Staff
Gaithesburg, Maryland Nicoda Foster MPH, PhD(c)
Project Manager
Michael L. Malone, MD ARC/AAN Emergency/Disaster Preparedness for Older
Medical Director, Senior Services Program, Aurora at Adults Project
Home, Aurora Health Care, Milwaukee, Wisconsin Office of the Director of Geriatrics, Sinai Health System
Clinical Adjunct Professor of Medicine, Department of and the University Health Network
Medicine, University of Wisconsin School of Medicine Toronto, Ontario
and Public Health,
Milwaukee, Wisconsin Shionne Hitchman, BScH
Research Assistant
Mary Casey-Lockyer, MHS, BSN, RN ARC/AAN Emergency/Disaster Preparedness for Older
Senior Associate, Disaster Health Services, Adults Project
American Red Cross Office of the Director of Geriatrics, Sinai Health System
Washington, District of Columbia and the University Health Network
Toronto, Ontario
Mattia J. Gilmartin, PhD, RN
Executive Director, NICHE I Nurses Improving Care for
Healthsystem Elders Acknowledgments
New York University, Rory Meyers College of Nursing The authors would like to thank Elliot Nguyen,
New York City, New York
Catherine Stratton, Peg Christensen, Daphne
Paul Reed, MD, CAPT, U.S. Public Health Service Horn, Shruthi Janardhanan and Allan McKee
(USPHS) for their important contributions towards the
Deputy Director, National Center for Disaster Medicine and
development of this report.
Public Health (NCDMPH)
Rockville, Maryland
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 2Organizational Endorsements
The American Red Cross Scientific Advisory Council in partnership with the American Academy of Nursing
Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults that led the development of
this report and its recommendations wishes to thank the American Red Cross and the American Academy of
Nursing for their official endorsements of it.
We would also like to thank the following organizations who have also given their support and official
endorsement of this work.
3 REPORT DEVELOPMENT CONTRIBUTORSAbbreviations
AAN...................................................................................................................................................... American Academy of Nursing
ADA ....................................................................................................................................................Americans with Disabilities Act
ADLs................................................................................................................................................................. Activities of Daily Living
ADRD........................................................................................................................ Alzheimer’s Disease and Related Dementias
ARC ...........................................................................................................................................................................American Red Cross
AARP............................................................................................................................... American Association of Retired Persons
CDC ............................................................................................................................ Centers for Disease Control and Prevention
CILs ..................................................................................................................................................... Centers for Independent Living
CMS ......................................................................................................................... Centers for Medicare and Medicaid Services
DHS .............................................................................................................................................. Department of Homeland Security
DOE ...................................................................................................................................................................... Department of Energy
ED .......................................................................................................................................................................Emergency Department
EMS ......................................................................................................................................................... Emergency Medical Services
FEMA ............................................................................................................................. Federal Emergency Management Agency
HHS ..................................................................................................................The Department of Health and Human Services
HRSA ................................................................................................................ Health Resources and Services Administration
ICS ............................................................................................................................................................... Incident Command System
JCAHO ........................................................................................................................................ Joint Commission on Accreditation
of Health care Organizations
LTC .....................................................................................................................................................................................Long-Term Care
PTSD .................................................................................................................................................. Post-Traumatic Stress Disorder
NABP ....................................................................................................................... National Association of Boards of Pharmacy
PDA ................................................................................................................................................................Personal Digital Assistant
PPE ...................................................................................................................................................... Personal Protective Equipment
SAC ...............................................................................................................................................................Scientific Advisory Council
SDM ..............................................................................................................................................................Substitute Decision Maker
SMART ..................................................................................................................................... SiMple triage And Rapid Treatment
SWiFT ............................................................................................................................................... Seniors Without Families Team
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 4Executive Summary
Background and Context rule, Emergency Preparedness Requirements for
Medicare and Medicaid Participating Providers
Older adults consistently experience the greatest
and Suppliers. Implemented on November 15,
proportion of casualties during and after natural
2016, this rule outlines emergency preparedness
disasters compared to younger age groups
requirements for 17 types of participating
(Fernandez, Byard, Lin, Benson, & Barbera, 2002;
Medicare and Medicaid providers and suppliers,
Mokdad, 2005). In 2005, approximately half of
including hospitals, long-term care facilities,
all deaths resulting from Hurricane Katrina were
psychiatric residential treatment facilities, and
among persons age 75 years or older (Brunkard,
home health agencies around four aspects of
2008). Similarly, following Hurricane Sandy
emergency preparedness: risk assessment and
in 2012, The New York Times reported that
planning, policies and procedures, communication
approximately half of those who died in the storm
plan, and training and testing. To standardize
were age 65 or older, many of whom drowned
the adoption of collaborative emergency response
at home or died from storm-related injuries
plans nation-wide, relevant providers and
(Keller, 2012).
suppliers are required to establish emergency
Several research studies have demonstrated that plans that incorporate services from federal, state,
these poor outcomes are linked to physiological tribal, regional, and local emergency preparedness
age-related changes such as impairments to systems (Smith & Mcdonald, 2006). Despite these
sensory, cognitive and mobility disabilities or efforts, deficiencies in emergency preparedness for
access and functional needs; social isolation and a older populations continue to threaten the safety
lack of access to familial and other social supports; of older adults in these settings along with those
having limited financial resources; and insufficient living in assisted living facilities and those living
policies and procedures (Al-Rousan, Rubenstein, in their own homes.
& Wallace, 2014; Fernandez et al., 2002; Killian,
During the 2017 hurricane season, tragedy
Moon, McNeill, Garrison, & Moxley, 2017).
occurred in a Florida nursing home after
Furthermore, interruption to the timely provision
Hurricane Irma disabled the facility’s air-
of routine medical care is recognized as a likely
conditioning system, leaving 14 residents dead and
contributor to mortality and morbidity associated
many sustaining heat-related injuries (Nedelman,
with exacerbation of medical conditions during
2017). The existing gaps in disaster management
natural disasters, especially in the immediate
around the United States were further reinforced
months following major natural disasters.
by images of older adults sitting waist-high in
Recent events have prompted a variety of floodwater when an assisted living facility in
legislative actions to better prepare the nation Texas was reportedly initially denied evacuation
for disasters, such as the adoption of the Centers assistance from first responders during Hurricane
for Medicare and Medicaid Services’ (CMS) final Irma (Bell, 2017). This provoked a resident’s
5 EXECUTIVE SUMMARYdaughter to publicize the devastating state of the management nation-wide, the recommendations
assisted living facility to initiate an emergency are categorized across six relevant emergency
response (Said, 2017). In order to improve the management domains: 1) individuals and unpaid
response to disasters, the nation needs greater caregivers; 2) community services and programs;
adoption of evidence-informed, uniform 3) healthcare professionals and emergency
and collaborative emergency management response personnel; 4) care institutions and
interventions. These efforts will further require organizations; 5) legislation/policy; and 6)
the necessary resources and capacity to meet research. The intention of these recommendations
the emergency/disaster needs of all older adults is to encourage interventions that can bridge the
regardless of the variety of circumstances and existing gaps in disaster preparedness, response
settings in which they may be living. and recovery, and facilitate better outcomes
for older adults across the United States.
To address these gaps in emergency and disaster
preparedness and management, members of An index of the recommendations with their
the American Red Cross Scientific Advisory associated domains can be found in Appendix
Council and the American Academy of Nursing A: Index of Recommendations and Responsible
Policy Expert Round Table on Emergency/ Emergency Management Domains.
Disaster Preparedness for Older Adults agreed
to collaborate in conducting a scientific review
Summary of Recommendations
of the latest evidence and current available
legislation policies, in order to develop a set of After a systematic review of the literature and
recommendations that could be further reviewed an evaluation by an expert panel on disaster
and strengthened by a broader panel of experts preparedness, response and recovery for older
with specific expertise in the fields of social work, adults, 25 final evidence-informed expert
education, public health, research, health policy, recommendations for intervention are proposed
emergency management, geriatrics, and nursing. to reduce adverse outcomes for older adults during
Through a rigorous consensus decision-making and after disasters. The final recommendations
process, a comprehensive final set of 25 evidence- have been organized based on the six identified
informed recommendations were ultimately emergency management domains:
developed and endorsed by this group.
1. Individuals and Unpaid
This report presents these 25 evidence-informed
Caregivers Domain
recommendations, and the rationale behind them,
for improving disaster preparedness, response Recommendation 1.1: Older adults and their
unpaid caregiver(s) should be provided with
and recovery interventions for older adults
tailored, easy-to-access information related to
across the United States. In order to achieve a
emergency/disaster preparedness and guidance
collaborative approach to improving disaster
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 6on how to develop customized emergency plans. Recommendation 1.7: Older adults, and their
Volunteers representative of older persons should unpaid caregivers, who are reliant on medical
be recruited and involved in training material devices that require electricity, should ensure they
development and implementation, to ensure have back-up power supplies in place, especially if
their voices and perspectives are reflected. required while sheltering-in-place.
Recommendation 1.2: Older adults who • Older adults and their unpaid caregivers should
are reliant on mobility aids should remove or contact their electricity company in advance to discuss
minimize barriers affecting their ability to their needs and ensure options for alternative power
evacuate, and should take steps to ensure their sources are available, especially addressing the need
safety within their surroundings. for access to power to charge cell phones and other
mobile devices.
Recommendation 1.3: If registries for people
with functional and other needs, including • Older adults and their unpaid caregivers should
persons with disabilities, have been established by seek assistance with obtaining and maintaining an
alternative power source at home, if required, such as
local emergency response agencies, older adults
when being required to move heavy equipment and fuel
and/or their unpaid caregiver(s) should register so
or in accessing these resources in rural locations, and
they can be assisted/supported efficiently during
operating equipment.
emergencies/disasters.
Recommendation 1.8: Older adults should be
Recommendation 1.4: Older adults who have
encouraged to continually maintain an adequate
a sensory impairment, such as a visual or hearing
local support network that can be called upon
disability, should take additional precautions to
during impending disasters and unexpected
prepare themselves for emergencies/disasters.
emergencies, especially if they live alone or lack
Recommendation 1.5: Older adults who easy access to relatives.
live with chronic health conditions should
Recommendation 1.9: Unpaid caregivers of
maintain a readily accessible list of their current
persons with Alzheimer’s disease and related
medical conditions, treatments (medications,
dementias should know how to identify signs of
durable medical equipment, supplies and other
distress, anxiety, or confusion, and how to redirect
healthcare needs), healthcare professionals, and
their attention, or calm them down during these
emergency contacts including substitute decision
times. In addition, unpaid caregivers should be
makers (SDMs).
prepared to prevent wandering, and have plans in
Recommendation 1.6: Older adults who take place and resources to locate their care recipients
medications should work with their healthcare if they do wander away during a disaster.
professionals to ensure they have access to at
least a 30-day supply of medications during
an emergency.
7 EXECUTIVE SUMMARY2. Community Services and by making an effort to assess the psychological
Programs Domain well-being of older adults and provide appropriate
treatments as needed.
Recommendation 2.1: Access to tailored
community-based programs that educate older
adults and their unpaid caregivers about disasters/ 4. Care Institutions and
emergencies that affect their region and how Organizations Domain
best to prepare for and respond to them should
Recommendation 4.1: Care institutions and
be increased.
organizations should include emergency/disaster
Recommendation 2.2: Programs that provide preparedness and response education in their
essential community services, such as Meals routine training courses.
on Wheels, and assistance with daily living
• Multi-modality educational tools and practices should
activities for older people (financial, medical,
be used to better facilitate knowledge acquisition and
personal care, food and transportation) should
behavioral change.
develop plans and protocols related to responding
adequately to the needs of their clients during • Volunteers representative of older persons should be
emergencies/disasters. recruited and involved in training material development
and implementation, to ensure their voices and
Recommendation 2.3: Local governments perspectives are reflected.
should leverage data sources such as registries
that identify at-risk individuals to enable Recommendation 4.2: Additional strategies to
emergency responders to more easily prioritize improve the collection and transfer of identifying
their search and rescue efforts following a disaster information and medical histories should be
or emergency. adopted into current standardized patient handoff
procedures to better facilitate effective tracking,
relocation and care of patients during a disaster.
3. Healthcare Professionals
and Emergency Response
Personnel Domain 5. Legislation/Policy Domain
Recommendation 3.1: Healthcare professionals Recommendation 5.1: The US Congress 2017
and emergency response personnel should receive Bill S. 1834 “Protecting Seniors During Disasters
training on providing geriatric care relevant to Act” that recommends the establishment of
their discipline and how best to assist older adults a national advisory committee on activities
and their unpaid caregivers during disasters. related to disaster preparedness for older adults
should include at least two older adults, those
Recommendation 3.2: Health care with geriatric care expertise and improved
professionals and emergency response personnel representation from the private sector.
should strive to mitigate psychological distress
among older persons during and after disasters
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 8Recommendation 5.2: Agencies with the 6. Research Domain
Department of Health and Human Services
Recommendation 6.1: There is a need to
(HHS) should provide change-funding guidance to
prioritize the creation and funding of research
allow Centers for Independent Living to use their
efforts to better support the development of a
contingency funds to provide food and water to
common framework for measuring the quality
their clients during disasters.
and levels of disaster preparedness among care
Recommendation 5.3: All states and/or local institutions, organizations, paid professionals,
governments should support the implementation community organizations, and other groups that
of tax-free emergency preparedness weekends work primarily with older adults and their unpaid
during specific times of the year or in anticipation caregivers during and after disasters.
of a disaster. Items covered should include
Recommendation 6.2: There needs to be
disaster/emergency supplies, such as batteries,
a more concerted effort in utilizing outcomes
portable generators, additional mobility aids
from existing evidence to support the planning,
(canes, walkers), hurricane shutters, rescue
design, and refinement of more evidence-informed
ladders, radios, and ice packs.
emergency/disaster preparedness interventions,
Recommendation 5.4: The Licensure Compact policies, and regulations in support of older adults
that provides multi-state licenses for nurses, and unpaid caregivers, as well as organizations
physicians, and emergency medical service and care professionals that will be responsible for
personnel should be adopted by all states. meeting their needs during and after a disaster.
Recommendation 5.5: All persons should • Published studies related to disaster preparedness and
be able to obtain at least a 30-day supply of recovery should be made open access to strengthen
knowledge translation and exchange that support
emergency prescription medications prior to
improvements in disaster/emergency responses and
and during a disaster.
recovery efforts across communities.
Recommendation 5.6: In alignment with
Recommendation 6.3: A network of
the State of Florida’s “Environmental Control
disaster preparedness researchers to encourage
for Nursing Homes Rule”, all US nursing homes
partnerships in the ongoing evaluation of
and assisted living facilities should be mandated
emergency/disaster preparedness interventions
to include additional contingencies in their
targeting older adults needs to be created.
emergency/disaster plans to ensure that, in the
Network members should advocate for an
event of a power outage, temperatures are kept
increased focus on emergency/disaster
at reasonable levels to avoid the exacerbation of
preparedness research among the various
existing health issues among nursing home and
societies or journals that they are members of.
assisted living facility residents.
9 EXECUTIVE SUMMARYBackground and Context
The Current State of Disaster Outcomes in health, while continuing to report lower rates
for Older Adults in the United States of disaster preparedness (Al-Rousan et al., 2014;
Brunkard, 2008; Cherniack, Sandals, Brooks,
Natural and man-made disasters pose a great
& Mintzer, 2008; Gibson & Hayunga, 2006;
risk to public health and safety because of their
Kosa, Cates, Karns, Godwin, & Coppings, 2012;
ability to disrupt the functions of a population.
Mokdad, 2005).
Traditionally, disaster/emergency preparedness
and response efforts have predominantly As the baby boomers continue to age, it is expected
focused on the large-scale evacuation of persons that the population of older adults will double
to prevent harm; ways to provide basic shelter from 46 million in 2016 to over 98 million by
and nutrition; and how to control the spread of 2060, making older adults the fastest-growing age
infectious diseases in densely populated settings group in the United States (Mather, 2016; United
(Mokdad, 2005). However, in 2005, the response States Census Bureau, 2011). This exponential
to Hurricane Katrina highlighted the important growth in the population of older Americans
existing gaps in disaster management for older will increase the demand for disaster/emergency
adults (The White House Administration, 2006). services to meet the disaster preparedness,
Approximately half of all deaths resulting from response and recovery needs of these individuals
Hurricane Katrina were among persons age 75 at greater risk for negative outcomes. The need
or older (Brunkard, 2008). Similarly, following for more age-friendly disaster/emergency services
Hurricane Sandy in 2012, CDC reported that is further supported by the expected increase
close to half of those who died in the storm in the frequency and severity of weather events
were ages 65 or older. Many of these older (Field, Barros, Dokken, Mach, & Mastrandrea,
victims drowned at home or died from storm- 2014). In 2017, weather and climate-related
related injuries (Center for Disease Control and disasters reached historic levels in the United
Prevention, 2013). States. Communities nation-wide were affected
by a variety of weather and climate disasters,
The effects that disasters have on older adults
including wildfires, three category-4 hurricanes,
rarely end once a disaster has ended. Interruptions
eight severe storms, two inland floods, crop freeze,
to one’s medical care, especially for those living
and drought (Smith, 2018). As the frequency and
with chronic conditions can cause increased
severity of disasters continue to increase, ensuring
morbidity and mortality in the months following
the safety of older adults will require greater
a severe disaster. Despite the insufficiencies in
efforts in the overall area of disaster management
disaster preparedness and response efforts that
for this growing population.
were highlighted by the events of Hurricanes
Katrina and Sandy, older adults continue to Disaster-related literature further highlights
experience a greater proportion of disaster- the socioeconomic factors that make older
related mortality rates, disaster-related declines adults more vulnerable to experiencing adverse
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 10outcomes during and after a natural disaster, scientific review of the latest evidence, current
and the insufficiencies present among various available legislation and policies, in order to
levels of emergency management. Particularly, develop a set of recommendations to improve
older adults have been found to experience more disaster-related outcomes for older adults. This
adverse outcomes during a disaster compared to review aimed to determine the factors that make
their younger counterparts due to their complex older adults and their unpaid caregivers more
and individualized capabilities and challenges. As vulnerable to adverse outcomes during disasters,
one gets older, age-related changes begin to take identify existing gaps in disaster management
place, such as an increased chance of having a within the public and private sectors, and present
chronic health condition or multi-morbidity, living successful interventions that could be used to
in social isolation, and experiencing declines develop evidence-informed recommendations.
in sensory, cognitive and physical functioning
During the development of this white paper and its
(Aldrich & Benson, 2008). While these changes
evidence-informed recommendations, members of
are often sufficiently managed in an older adult’s
the American Red Cross (ARC) Scientific Advisory
day-to-day life, disasters can impose additional
Council (SAC) and the American Academy of
barriers to accessing resources and supports,
Nursing (AAN) hosted a Policy Expert Round
putting older adults with complex needs at an
Table on Emergency/Disaster Preparedness for
increased risk of harm.
Older Adults (Policy Expert Round Table) in
Disaster management for older adults can be June, 2018, in Washington, DC. The Round Table
further weakened by healthcare professionals’ brought together 15 experts from a variety of
low levels of disaster and geriatric education and fields, including social work, education, research,
training (Pesiridis, Sourtzi, Galanis, Kalokairinou, health policy, emergency management, geriatrics,
2014; Scott, 2010; Wyte-Lake, 2014); limited and nursing. The Policy Expert Round Table used
provision of community-based disaster training a consensus decision-making process to critique
programs for older adults and their unpaid the existing scientific evidence that was retrieved
caregivers; and statutes and regulations that during the scientific review, and, with the
impose barriers to individual preparedness application of its members’ collective expertise,
and lack a standardized approach to disaster provided an evaluation of and unanimous support
preparedness nation-wide. for the development of evidence-informed
expert recommendations.
To address this gap in disaster preparedness,
members of the American Red Cross Scientific This report’s reference panel and its related
Advisory Council and the American Academy organizations have endorsed 25 final
of Nursing Policy Expert Round Table on recommendations that aim to implement
Emergency/Disaster Preparedness for Older disaster preparedness-related changes among
Adults agreed to collaborate in conducting a the following relevant emergency management
11 BACKGROUND AND CONTEXTdomains: 1) individuals and unpaid caregivers; 2) and organizations, policy/legislation and research
community services and programs; 3) healthcare as the relevant domains that contribute to
professionals and emergency response personnel; disaster/emergency management for older adults.
4) care institutions and organizations; 5)
Adequate disaster preparedness was found to
legislation/policy; and 6) research.
depend on synergy among relevant disaster
management domains in order to mitigate the
Report Recommendations factors creating increased vulnerability among
Development Approach older adults to disasters. Surrounding five of the
Initial Scoping Review and Development six emergency management domains, and the
of an Ecological Analytical Framework seven factors of vulnerability, is the domain of
The American Red Cross Scientific Advisory research because it can identify and help to fill
Council and the American Academy of Nursing the existing gaps in knowledge and behavior.
Policy Expert Round Table on Emergency/Disaster Bronfenbrenner’s Ecological Framework was
Preparedness for Older Adults began an initial adapted to illustrate the interacting relationship
scoping review of the age-related factors that make of the seven factors of vulnerability and the
older adults more vulnerable to adverse outcomes six disaster management domains identified
during and after a disaster. For the purpose of this (Figure 1).
research, a disaster was defined as a natural or
man-made phenomenon that causes interruptions
Systematic Review Process
to loss of life. Disasters based on this definition
included the following: floods, hurricanes, A subsequent systematic review was conducted
tornadoes, nuclear explosions, and complex to examine existing gaps in disaster preparedness
among the six previously identified disaster
disasters. Disasters arising from biological and
management domains for older adults
chemical agents, and terrorism were excluded.
(see Figure 1) and to determine successful
Older adults were found to be more vulnerable interventions. The findings were used to
to adverse outcomes during and after disasters develop evidence-informed recommendations
due to an increased prevalence of chronic health to better address outstanding issues identified
within each domain. The search was guided
conditions, physical, cognitive and sensory
by the six research questions listed below.
disabilities, weak social networks, accessibility
and equity issues, and limited financial resources.
This literature review also identified older adults
and unpaid caregivers, community services
and programs, healthcare professionals and
emergency response personnel, care institutions
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 12Figure 1. Adapted from: Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American
Psychologist, 32, 513–531
1. Individuals and Unpaid • Is there a difference in the incidence of
Caregivers Domain psychological distress among older adults
What are the factors that make older adults across different socio-demographic factors
more vulnerable to adverse outcomes (education, income, race, and geography)
during a disaster compared following a disaster?
to younger adults?
• I s there a difference in the incidence of
1.1 Are
there age and/or function-related factors psychological distress among older adults
that make older adults more vulnerable to with dementia, dementia-related disorders
adverse outcomes compared to younger adults? or other cognitive impairments?
1.2 What is the incidence of psychological distress 1.3 A re there specific actions unpaid caregivers
among older adults following a disaster of older adults should undertake to minimize
compared to younger adults? adverse outcomes of the older adults they care
for during or after a disaster?
13 BACKGROUND AND CONTEXT2. Community Services and 3. Healthcare Professionals and
Programs Domain Emergency Response Personnel Domain
What are the strategies and resources What are the strategies and resources
that can be leveraged at the individual that can be leveraged to improve disaster
(older adults and family caregivers) and response among healthcare professionals
community levels to improve disaster and emergency response personnel?
preparedness for older adults?
3.1 Is there a need for increased use of geriatric-
2.1 Is there a need for more geriatric-focused focused triage care strategies when
supportive care strategies to better prepare assessing the needs of older adults before or
older adults and/or family caregivers during disasters?
for disasters?
3.2 What are the age- and function-specific
2.2 A re conventional disaster preparedness training methods that healthcare
resources effective at facilitating knowledge professionals and emergency response
acquisition and behavioral change among personnel should follow when caring for
older adults and/or family caregivers with low and assisting older adults with varying
literacy skills, or among those who are not capabilities and limitations during a disaster?
fluent in English or Spanish?
• What are the most effective methods to
2.3 What are the most effective formats that teach age- and function-specific education
can be used to communicate guidance to facilitate knowledge acquisition and
on preparedness, warning messages, and behavioral change?
messages on how to access recovery resources
3.3 What are the recovery resources required
in times of pending disaster among older
to mitigate adverse outcomes for older adults
adults and/or family caregivers?
following a disaster?
• W
hat types of community/not-for-profit-
4. Care Institutions and
led interventions can be implemented
Organizations Domain
to facilitate positive recovery outcomes
What are the strategies and resources that
for older adults and/or family caregivers
can be leveraged at the organizational or
following a disaster?
institutional levels to improve disaster
2.4 What are the recovery resources required to preparedness and recovery efforts for
mitigate adverse outcomes for older adults older adults?
and/or family caregivers following a disaster?
4.1 Is there a need for more geriatric-focused
supportive care strategies or design elements
to better prepare organizations or institutions
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 14(disaster relief agencies and shelters) that may The titles and abstracts of the populated articles
be required to provide care for older adults were screened to identify peer-reviewed articles
during or after disasters? that were eligible for a full text review. Articles
were selected based on the following inclusion
5. Legislation/Policy Domain criteria: titles and abstracts that contained search
Are there pieces of legislation or policies terms or content relevant to disaster management
that have been developed or adopted outcomes for one of the six identified domains.
at the municipal, state or federal levels Relevant populations of older adults included
to improve disaster preparedness and those that live in assisting life facilities, nursing
recovery efforts for older adults? homes, independently at home, and those that
5.1 Is there evidence that shows the effectiveness/ are homebound or homeless. There were no
positive impact of any particular piece of geographic restrictions for the study population.
legislation or policy? All articles that met the inclusion criteria were
saved in the reference manager Mendeley for
5.2 Is there any evidence to suggest any existing future review and referencing. Legislative and
legislation or policy may contravene what policy documents were retrieved using Google.
existing evidence would support?
This research strategy yielded a total of 826 peer-
6. Research Domain reviewed journal articles, 56 of which met the
What research or evidence gaps have inclusion criteria for data extraction, in addition
been noted in the literature that could to five legislative documents (see Appendix A).
better inform efforts to improve disaster Review of the findings led to the generation of
preparedness and recovery efforts for an initial set of draft recommendations that
older adults? were then reviewed and discussed as a part of
a consensus decision-making process.
Search Strategy and Study Selection
The search for academic literature was restricted
to databases with literature relevant to the fields of Consensus Decision-Making Process
medicine, public health, nursing, and healthcare,
In June 2018 the American Red Cross (ARC)
which included PubMed, MEDLINE, Google
Scientific Advisory Council (SAC) and the
Scholar, AgeLine, Global Health, HealthStar,
American Academy of Nursing (AAN) Policy
UpToDate, Clinical Key, EBSCOhost, and Scopus.
Expert Round Table on Emergency/Disaster
The databases were accessed from June, 2017, to
Preparedness for Older Adults hosted a Policy
June, 2018. The reference lists of relevant articles
Expert Round Table on Emergency/Disaster
were also manually searched. The search was
Preparedness for Older Adults (Policy Expert
restricted to articles that were published between
Round Table) to evaluate the findings of our
2008 and 2018 in English.
scientific review and the feasibility of the
proposed recommendations.
15 BACKGROUND AND CONTEXTTo facilitate an evaluation of the recommendations To begin the decision-making process, the existing
and potential remaining gaps in disaster issues related to disaster preparedness, and the
preparedness, a consensus decision-making proposed recommendations for intervention, were
process was adapted for the Policy Expert introduced and explained to all the participants
Round Table because it is an effective method of in one large group. This gave the participants an
facilitating a collective contribution to a solution opportunity to briefly review the methodology,
or intervention by encouraging dialogue, with the a summary of evidence tables (see Appendix C)
aim of considering and addressing the opinions and the recommendations for intervention. The
and concerns of each of the participating experts recommendations were divided into six sections
(Seeds for Change, 2010). Consensus decision- based on the emergency management domains
making is a problem-solving process that aims that were determined to be responsible for
to develop solutions that are supported by all adopting or enforcing a given recommendation.
the contributors. This is in contrast to voting
After reviewing the supporting documents,
processes, which generate solutions that reflect
two rounds of breakout sessions divided the
and satisfy the opinions of the majority of the
participants into three groups consisting of five
contributors, but not the entire group (Seeds for
experts per group. Breakout session one was
Change, 2010).
used to review the list of recommendations for
Nineteen experts were invited to participate in individuals and unpaid caregivers, community
the Policy Expert Round Table; however, only 15 services and programs, and healthcare
participants were able to attend. The final group professionals and emergency response personnel.
consisted of experts from a variety of backgrounds Breakout session two was used to review the list
related to disaster preparedness for older adults, of recommendations for care institutions and
including social work, education, public health, or organizations, legislation/policy and research.
public health research, health policy, emergency Participants were able to select which breakout
management, geriatrics, and nursing. To better session groups they wanted to be placed in by
facilitate engagement in the topic during group indicating their preferences during the week prior
discussions, all the participants were emailed to the Policy Expert Round Table. Since there were
a copy of the summary of evidence tables from 15 participants and six sets of recommendations,
the systematic literature review. This gave the each panellist participated in one recommendation
participants an opportunity to become familiar discussion per breakout session. In their
with the findings that were used to formulate discussion groups, each participant was asked to
the initial recommendations, and guide any consider the following discussion questions when
external research of their own which could reviewing the recommendations:
later be used in discussion and amendments
• What issues/topics related to this area are missing from
to the recommendations.
the evidence available?
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 16• Are the current recommendations adequate to address After the participants reviewed all the
the issues related to this area? recommendations in their breakout groups,
the Policy Expert Round Table concluded
• What further additions/edits do you suggest to the
with a final face-to-face meeting with all 15
current recommendations and why?
participants. This meeting gave each breakout
The goal of the research questions was to group an opportunity to present the final copy
facilitate discussion regarding the feasibility of of their proposed recommendations drafted
the recommendations and whether or not the from the outcomes of their discussions, and also
proposed recommendations were thought to be provided the participants who were not present
able to sufficiently address the current gaps in in the remaining two groups an opportunity to
disaster preparedness, response and recovery discuss the feasibility of these recommendations
for older adults. Breakout sessions one and two as well. Review of the recommendations by
were conducted for a duration of one hour which the panel led to the generation of 25 evidence-
gave the experts an opportunity to provide informed recommendations that aim to reduce
their comments and critiques on the initial the occurrence of adverse disaster-related
recommendations, make amendments to the outcomes for older adults by increasing disaster
initial recommendations, or propose additional preparedness among individuals and unpaid
recommendations that were not included in the caregivers, and leverage appropriate disaster-
initial draft. The time allocated to the breakout related resources and strategies among the
sessions were also used to discuss and reach remaining disaster management domains.
consensus on issues related to comprehension
In August 2018, a draft of this report was sent to
and syntax of each of the recommendations that
all attendees of the Policy Expert Round Table,
were delegated to a specific group. A consensus
and additional experts and organizations who
was required before new recommendations were
were not able to attend the Policy Expert Round
added to the list, or omissions or amendments
Table. This gave all attendees another opportunity
were made to the initial recommendations. If
to provide final critiques of the recommendations,
participants reached a point of disagreement
and all non-attendees an opportunity to
within their group, facilitators probed participants
contribute feedback to the recommendations.
for additional comments, clarification, justification
The combined contribution of the two rounds
or new approaches to problem-solving in order to
of review ultimately generated the 25 final
reach a consensus within the group.
recommendations presented in this white paper.
17 BACKGROUND AND CONTEXTDomain 1: Individuals and Caregivers
Older adults, particular those who are living with and involved in training material development
chronic health conditions, are low-income and/or and implementation, to ensure their voices and
have low literacy skills, tend to disproportionately perspectives are reflected.
experience greater adverse outcomes during
disasters and emergencies. There is a clear
Recommendation 1.2
opportunity to develop, implement and evaluate Older adults who are reliant on mobility aids
disaster/emergency preparedness and response should remove or minimize barriers affecting their
activities at the individual level that can better ability to evacuate, and should take steps to ensure
improve knowledge and recovery outcomes for their safety within their surroundings.
older adults and their caregiver(s).
Recommendation 1.3
An investigation of the vulnerabilities of older If registries for people with functional and
adults during disasters was guided by Research other needs, including persons with disabilities,
Question 1: What are the factors that make have been established by local emergency
older adults more vulnerable to adverse response agencies, older adults and/or their
outcomes during a disaster compared to unpaid caregiver(s) should register so they
younger adults? (see Development Approach). can be assisted/supported efficiently during
The search strategy that was used yielded 56 emergencies/disasters.
articles that met the inclusion criteria, 14 of
which were used for data extraction related
Recommendation 1.4:
to this specific question. The review of these Older adults who have a sensory impairment,
14 articles revealed that older adults who are such as a visual or hearing impairment, should
reliant on medications, and life-sustaining take additional precautions to prepare themselves
or assistive devices to support their health for emergencies/disasters.
and well-being, have an increased risk for
Understanding the Unique Personal
experiencing an adverse outcome during a
and Functional Needs of Older Adults
disaster. Consequently, in response to this gap, During Disasters
nine evidence-informed expert recommendations During a disaster, or while sheltering-in-place,
were developed with the aim of increasing the an older adult’s access to the support services
levels of disaster preparedness among older adults that they require to maintain their overall
with health- and/or function-related declines, quality of life and independence, such as home
and their caregiver(s). care and community services, can be disrupted.
Recommendation 1.1 These circumstances can be further challenged
by a lack of age-friendly services, a lack of
Older adults and their unpaid caregiver(s)
accommodations for older adults at relief shelters,
should be provided with tailored, easy-to-
and concerns around pet safety and evacuation.
access information related to emergency/
Indeed, households who own pets are less likely
disaster preparedness and guidance on how to
to evacuate than those without pets. This is likely
develop customized emergency plans. Volunteers
because people are concerned that they will not be
representative of older persons should be recruited
CLOSING THE GAPS: ADVANCING DISASTER PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 18evacuated with their pets, which is often cited as to address solutions to overcome the unique
one of the main contributors to why people do not challenges that many older adults face when
evacuate during disasters or emergencies (Benson, preparing for, responding to, and recovering
2017; Whitehead, et al., 2000). from a disaster.
A survey conducted in a Medical Special To address this current gap in disaster
Needs Shelter that housed 199 evacuees during preparedness guides for older adults,
Hurricane Gustav in 2008 reported that some of Recommendation 1.1 aims to encourage
the services and aids provided at the relief shelter older adults and their unpaid caregivers to be
did not meet the functional and/or health-related particularly mindful of their functional and
needs of the evacuees, such as a lack of provision health-related needs when developing a disaster/
of “diabetic” friendly foods, having to wait for 15 emergency plan. By encouraging older adults and
to 30 minutes to check in, and having to sleep their unpaid caregivers to take an initiative in
on cots that were reported to cause back pain or evaluating their needs and developing appropriate
were difficult for older evacuees to use because plans to accommodate their expected challenges,
they were too low to the ground (Missildine et al., this can help older adults to be more self-reliant
2009). Many evacuees also required and received when responding to an emergency/disaster or
assistance with walking, medications, and provide the additional resources needed to help
respiratory machines (Missildine et al., 2009). The emergency response personnel better assist older
conditions in the Medical Special Needs Shelter in adults with functional limitations. For example,
Tyler, TX, illustrate the importance of providing older age is often associated with a decline in
older adults with the tools and services they need motor functioning which can put older adults at
to be better prepared for the health and quality of risk of harm if they are unable to access their daily
life challenges associated with disasters. assistive devices, such as walkers and wheelchairs,
or their unpaid caregivers during an evacuation
One of the many strategies that can be leveraged to (Bhalla, Burgess, Frey, & Hardy, 2015). However,
improve disaster preparedness among older adults as outlined in Recommendation 1.2, by
is to encourage self-preparedness through the preparing to overcome this barrier to evacuation
provision of easy access to disaster preparedness by installing wheelchair ramps, evacuation
educational materials and planning guides. chairs and/or arranging for home evacuation
Many health and safety organizations currently and transportation assistance from a family
provide access to online emergency preparedness member, friend, or caregiver, older adults can
resources, such as the Ready Campaign, developed independently ensure that they have developed a
by the Department of Homeland Security (DHS) more effective emergency evacuation plan.
(Department of Homeland Security, 2018), which
provides printer-friendly preparedness booklets The Potential Role of Registries for People
specific to a variety of disaster types and links with Functional and Other Needs, Including
to additional community resources. While many Persons with Disabilities
of these resources aim to encourage older adults Registries for people with functional and
to prepare for a variety of disasters, they fail other needs, including persons with
19 DOMAIN 1: INDIVIDUALS AND CAREGIVERSYou can also read
