When it comes to public health, seniors really are different
Public health can be broadly defined, and many of its facets are of equal importance to the entire population. But when dealing with the health of seniors, it is risky to assume that one can always extrapolate from younger populations. Indeed, one can plausibly argue that many of the needs of older adults in the public health arena are unique. Consequently, there is a real disconnect between the special needs of seniors and existing public health guidelines, which often do not speak to those needs.
Geriatric issues differ from the challenges facing other population groups. Geriatric issues include frailty, incontinence, the peculiar needs of homebound and cognitively impaired older adults, polypharmacy and adherence to medication, and care plans for those with multiple comorbid conditions (with or without cognitive impairment). And even geriatric approaches to issues relevant to younger age groups (e.g., physical activity for those with health problems or disability, screening for chronic disease) must be modified when substantial subclinical disease or risk (such as in a disaster) exist. More about that later.
Several aspects of aging make seniors more susceptible to the same illnesses and hazards that threaten all of us. Aging is characterized by “a gradual deterioration in function and the capacity of the body's homeostatic systems to respond to environmental stresses” (Vander, Sherman, and Luciano, Human Physiology: The Mechanisms of Body Function, 1990). It is reflected in the diminution of an individual's physical, psychological, and/or social reserves.
This diminution of reserves poses special risks for seniors, regardless of where they call home. Certainly, long-term care is as uniquely cognizant of the different needs of seniors as is any cohort of healthcare professionals. But even we need to recognize that what traditionally seems to work for one subset of seniors (much less the population as a whole) might not work for all.
Any reputable public health system will establish screening and prevention programs to protect residents from contagious diseases. But even here, that system cannot—when it comes to seniors—simply mimic what works for other population cohorts. Rather, it needs to be oriented toward chronic conditions rather than acute care episodes. And it needs to be oriented as much toward quality of life as quality of care.
Even the relative importance of primary, secondary, and tertiary prevention differentiates seniors from younger population groups, with a considerably greater emphasis on the secondary and tertiary aspects than on the primary. Seniors are different. But seniors themselves present a heterogeneous group. A part of that heterogeneity lies in the fact that all seniors can be found somewhere on a frailty curve, one that ranges from extremely robust to extremely dependent. Movement along that curve will be manifested in differing levels of disability, frailty, and cognitive impairment. In other words, while seniors as a group present their own particular spectrum of public health needs, they also represent an incredible variety of need within the group.
So, why am I giving this primer to those who work with seniors, day in and day out, in a healthcare environment? Because so many of our communities are housed in urban environments where the needs of seniors have been all but ignored. And you can't ignore your environment. It will come back to haunt you. Yes, we know that seniors are different. In that regard, we are uniquely positioned to address their peculiar needs. But when it comes to the cities in which we operate and the public health systems they employ, the elderly are seen simply as 40-year-olds with wrinkles.
We do not have public health guidelines that speak to the particular needs of seniors. The majority of public health guidelines that do exist are primarily focused on increasing positive health behaviors, such as physical activity, in those who are still reasonably healthy.
Now, couple the unique needs of seniors and their increasing numbers (the so-called “silver tsunami”) and their convergence with an equally powerful social phenomenon—increasing urbanization. And bear in mind how little planning, of any type, has been devoted to their intersection. Clearly, we need a focus on geriatric public health issues and guidelines, particularly within the urban environment. We need a “blueprint” on relevant standards of practice for seniors. And we need a blueprint that lends itself to timely implementation.
Let's apply this concept to an issue of increasing interest, at least to me: seniors and crisis management. (And, following Hurricanes Katrina and Rita, that issue should be of equal interest to you, as well.) When environmental catastrophe strikes, the typical urban public health infrastructure is unprepared to deal with the general population—forget seniors. And for that reason, seniors suffer disproportionately from the effects of such disasters. One can look to countless examples other than Katrina, many from equally recent history. Look, for example, at the devastating heat waves that struck Chicago in 1995 and Paris in 2003.
A disproportionate number of Chicago's senior residents died or suffered significant health problems during the 1995 heat wave, primarily because they didn't have the respiratory or circulatory ability to fight off the heat (nor a public health system designed to help them through the crisis).
On the first day of the Chicago heat wave, Thursday, July 13, the temperature hit 106 degrees, and the heat index—a combination of heat and humidity that measures the temperature a typical person would feel—rose above 120. For a week the heat persisted, running between the 90s and low 100s. The night temperatures, in the 80s, were unusually high and didn't provide much relief. Chicago's houses and apartment buildings baked like ovens. Air-conditioning helped, of course, if you were fortunate enough to have it. But many people only had fans and open windows, which just recirculated hot air.
And who suffered? The U.S. Centers for Disease Control and Prevention did a thorough study of individual-level risk factors for heat wave victims, and it came up with a list of conditions of vulnerability: living alone, not leaving home daily, lacking access to transportation, being sick or bedridden, not having social contacts nearby and, of course, not having an air conditioner. In short, the elderly. In fact, hundreds of Chicago's seniors died alone, behind locked doors and sealed windows, out of contact with friends, family, and neighbors, unassisted by public agencies or community groups.
But the city did learn from its mistakes. In 1999, when Chicago experienced another severe heat wave, the city issued strongly worded warnings and press releases to the media, opened cooling centers and provided free bus transportation to elderly residents, phoned them, and sent police officers and city workers door-to-door to check up on seniors who lived alone. That aggressive response drastically reduced the death toll of the 1999 heat wave: 110 residents died, a fraction of the 1995 level.
And Chicago was not the only city to learn from the crisis of 1995. Baltimore's Commission on Aging and Retirement Education (CARE), for example, launched its Senior Citizens Emergency Response Network (SCERN) in an attempt to reduce isolation within the older adult population and identify and respond to the needs of isolated older adults. The city's stated concern was that the problems experienced in Chicago not be replicated in Baltimore. Baltimore's Commission on Aging partnered with the City Health Department in initiating a heat alert plan and a surveillance system, which now encompasses some 60,000 elderly residents. Clearly, cities can learn from disaster, if they take the time to do so.
Similar lessons have been learned in Europe. The death toll in France from the blistering heat wave in 2003 reached nearly 15,000 in August. That was 14,802 more deaths than expected for the month. The bulk of the victims—many of them elderly—died during the height of the heat wave, which brought suffocating temperatures of up to 104 degrees, incredibly high in a country where air-conditioning is rare. Others apparently were greatly weakened during the peak temperatures but did not die until days later. The deaths were accompanied by a harshly worded report from the French Parliament blaming the deaths on a complex health system, widespread failure among agencies and health services to coordinate efforts, and chronically insufficient care for the elderly. Again, recognition that the country's public health system was not up to the task of dealing with the particu-lar needs of seniors.
Yet, just three years later, in 2006—with new heat records set in many parts of Europe—the death tolls were significantly different, certainly when compared with the 35,000 people who died across all of Europe in 2003. One reason for the relatively low number of deaths last year was the warning system introduced by health authorities, especially in France. “After the drama of 2003, we prepared a vigilance plan which has been functioning since June 1st,” said Gilles Bruecker, director of the French Institute of Health Surveillance. “We wanted to anticipate the risks, and prevent any deaths.” In other words, civil authorities in France, just as in Chicago some 10 years earlier, learned from their own sad experience and revamped their public health systems to deal with the special needs of seniors.
And it's not just heat waves. And it's not just seniors living alone. A painfully visible lesson from the 2005 hurricane season was the absence of specific evacuation plans for older people in nursing homes. The issues of both where and how to safely evacuate individuals with significant health problems and/or limited resources is particularly complex, beginning with identifying individuals in advance on a community vulnerability map and extending through having the necessary medical and survival supplies available for uncertain evacuation journeys (Public Policy & Aging Report, 2006). Many older adults and other vulnerable populations experience daily problems with mobility because of inadequate and poorly integrated transportation. Disasters exacerbate these problems.
In fall 2005, New Orleans had the following guidance in its “Emergency Guide for Citizens with Disabilities,” posted on the city's Web site as part of its Comprehensive Emergency Management Plan: “If you need a ride, try to go with a neighbor, friend, or relative.” Great advice for a nursing home or assisted living resident! Tragic reports of abandoned nursing home residents who drowned during Hurricane Katrina or died in a bus fire after a prolonged trip on a highway jammed with Hurricane Rita evacuees prompted policy action at the state level to enact requirements such as those established by Florida requiring nursing homes to have disaster plans that ensure adequate amounts of food, water, and medical supplies, as well as access to generators and appropriate transportation resources or contracts with equipped vehicles.
The thrust of this argument is that we can learn from these experiences, not just replicate them. Paris and Chicago both analyzed and reacted positively to the experiences each suffered. Baltimore also learned from the misfortune of others.
There have been analyses of the disproportionate impact of such crises on the elderly, including “August 2003 Heat Wave in France: Risk Factors for Death of Elderly People Living at Home” by Vandentorren et al. in last December's European Journal of Public Health. The authors point out, for example, that lack of mobility was a major risk factor, along with preexisting medical conditions. Housing characteristics associated with death were the lack of thermal insulation and the risky practice of sleeping on the top floor. Temperatures around the building were also major risk factors. Behaviors (e.g., dressing lightly and the effective use of cooling techniques and devices) were protective factors. The authors' findings suggest that people with preexisting medical conditions are the most likely to be vulnerable during heat waves and, consequently, need pertinent information on how to adjust daily routines so as to better adapt. In the long run, they point out, building mechanics and urban planning must also be adapted to provide protection from possible heat waves. It is equally clear that improved communications systems can have a significant impact on survival rates.
But it's not just building codes and apparel. The public health systems and resources necessary for effectively forestalling or recovering from the ill effects of environmental catastrophe are even more critical. As Paris and Chicago have shown, infrastructure can be adapted to the prerequisites of effective crisis management, especially as it pertains to the elderly. Baltimore, for example, enhanced its communications systems following the disaster of Hurricane Agnes in 1972, transforming its “911” call system into a two-way communications medium for contact with the elderly.
It is not as though there are no models we might follow. In reality, the evidence for geriatrically relevant guidelines is reasonably well developed. It has simply not yet been translated into effective practice across most urban environments. We have clear evidence of effective responses to environmental catastrophe. As a society, we need to apply them.
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Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. Dr. Willging served for 16 years as president/CEO of the American Health Care Association, was President/CEO of the Assisted Living Federation of America, and later went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industry). He is currently Associate Director of both the Johns Hopkins Medical School's Division of Geriatric Medicine and Gerontology as well as the Johns Hopkins Center on Aging and Health. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.