Using Preventive Gerontechnology Systems to Monitor Residents’ Behavior for Health Services During Emergencies

1. Using Preventive Gerontechnology Systems to Monitor Residents’ Behavior for Health Services During Emergencies Dr. Robert Roush, Baylor College of Medicine, Houston, TX Dr. Gloria Gutman, Simon Fraser University, Vancouver, BC 7th World Conference of the International Society for Gerontechnology, Vancouver, BC May 28, 2010 This educational resource was developed, in part, with grants from the U.S. Health Resources and Services Administration – All rights reserved, 2010

2. Our Wonderful World Is Also a Dangerous Place Anthrax 2001 SARS 2003 Tsunami 2004 Bombings 2005 Hurricanes 2005 Avian Flu 2006 Swine Flu 2009 Earthquake & floods 2010 What’s next? ‘11 September 11, 2001 Is health care prepared? Are you?

3. Global Aging • 1.2 billion older people worldwide in 2025 • 70% will be in developing countries • 1 million people turn 60 monthly worldwide now! • 12,000 persons in the U.S. turn age 62 daily! • 1st of 77 million U.S. boomers turn 65 in May 2011

4. Context and Perspective – GEPR • Older persons have altered levels of immune function • Higher risk of infectious illness and reduced response to antibiotics • Few health care workers have had adequate training in disaster planning • Even robust elders have a greater risk in natural disasters • We need all-hazards approach to geriatric emergency preparedness and response – GEPR • Technology can play an important role in mitigating effects of disasters

5. Topics for This Program • Need for disaster training • Preparedness issues • Diagnosing & treating older adults • Bioterrorism and emerging infections • Natural disasters, evacuation or shelter in place • Communications and technology • Reverse alerts to PERS subscribers

6. Heat waves – France Extreme cold – England Floods – Manitoba and Nashville, TN Wild fires – Australia and California Tsunamis – S. Asia Earthquakes – Haiti Hurricanes – Katrina, Rita, Wilma, and Ike! Avian Influenza (H5N1), then Swine Flu (H1N1) Weaponized biological agents Your hometown Your family Your residents/patients Need for Local Training inGEPR

7. Need for National Training inGEPR • <50% health care workers have had bioterrorism and emergency preparedness training, only 1 in 10 have had geriatrics-specific training • Health care workers, acute and LTC administrators, 1st responders & receivers, and ED staff need training in treatment and geroethics of triage, regardless of type of disaster – whether natural or human-caused

8. Need for International Training • GEPR – Geriatric Emergency Preparedness & Response issues are global …since 1995, heat waves, extreme cold, and floods in Europe plus earthquakes and weather-related disasters around the world have killed almost a million with over 2.5 billion people affected and costing $738 billion in US dollars . • Older people are always among those disproportionately affected. • The Public Health Agency of Canada’s Division of Aging and Seniors has started a global initiative on GEPR issues.

9. Canadian-led Initiatives in GEPR & PERS • 1st meeting of International Work Group on Emergency Preparedness held in Washington, D.C., in 2005 • Subsequent international conferences sponsored by the Public Health Agency of Canada/Division of Aging and Seniors held in Toronto, Winnipeg, Halifax, and Paris • Regular teleconferences of the IWG on EP • Research projects funded on GEPR tools used in LTC facilities and on use of PERS in disaster mitigation plans

10. Our Role in Emerging Threats • Think “pre-event” preparedness • Develop local relationships • Education and training • Communicateto our patients/public • What is their risk? • What is being done to protect them? • How can I protect myself? • How can I protect my colleagues? • What else do we need to know? • Which technology can help? RB McFee, 2004

11. The Disaster Cycle Today

12. What You Need to Know and Can Do Regarding All Hazards • What is the threat? • What are the vulnerabilities? • What special geriatric preparedness issues need to be addressed? • What needs to be done? • What can we do now? • conduct community risk assessments • train, train, train • empower seniors • take preventive actions • use communications and technology

13. Understanding, Diagnosing, and Treating Older Adults

14. Common Age-Related Changes Homeostatic ∆s • Baroreceptors – postural, hypo- tension, syncope • Thermoregulation – hypothermia cardiac reserve – fluid overload • Renal perfusion – nocturia, drug toxicity Barrier ∆s • Skin – thinner barrier with reduced blood flow • Lungs – less active cough reflex • Stomach – reduced gastric acid • CNS – absence of fever • Immune system – reduced cell-mediated immunity

15. Clinical Features by Age: 20-49 50-64 65+ Unclear History 12% 23% 44% Temp <100 9% 15% 29% Peak Temp 104 103 102 WBC<10,000 26% 40% 34% Mortality 14% 32% 44% Patients with pneumoccocal infection where the bacteria grew from their blood. >65 were more frequently without fevers, had lower peak temperature, and had higher mortality. Screening for infection in older people can’t have absolute temperature cutoff = many will be missed. Less response does not mean less severe infection. Older People Show Less Response to Severe Infections Gleckman, 1981, Chassagne, 1996

16. Human-caused Disasters: BNICE • Biological weapons • Nuclear/radionuclides • Incendiary devices • Chemical agents • Explosive materials Source: RB McFee, 2004

17. Basic needs: shelter, fuel, clothing, bedding, household items Mobility: incapacity, transport Health: access to services; appropriate food, water, sanitation; psychosocial needs Family and social: separation, dependents, changes in social structure, loss of status Economic and legal: income, information, documentation Natural Disasters Source: HelpAge International. 2001. “Older People in Disasters and Humanitarian Disasters: Guidelines for Best Practice.” Available online as a pdf file: http://www.reliefweb.int/library/documents/HelpAge_olderpeople.pdf .

18. Emerging Infections: SARS in Toronto • Outbreak of SARS, early March 2003: 1st case diagnosed March 13, peaked mid-March; resurgence early May with peak in mid-May; ended mid-June • March 28th Baycrest received a directive (Code Orange) to take SARS prevention measures • >15,000 persons underwent voluntary quarantine in greater Toronto area • 44 deaths,100 health care workers infected, 3 deaths M. Gordon, 2006

19. Preparedness Issues

20. The Four Pillars ofGEPR Today • Mitigation – identifying threats and resources, taking preventive actions • Preparedness – planning, training + exercises • Response – acting decisively with Incident Command structure • Recovery – getting back to normal, feeling safe again, analyzing response mode for next event Key: How many health professionals have been trained for disasters where you live?

21. Natural vs. Human-caused Disasters • Similar concerns for frail elders whose lives are disrupted by hurricanes, floods, wild fires, power outages • Could experience interruption of home care services if damage is widespread and large numbers of people are affected – i.e., their informal caregivers • Even robust elders are affected more than younger people in times of natural disasters • Same concerns for making people feel safe again • Evacuation vs. shelter-in-place decisions Source: Fernandez, LS, et al., Prehosp Disast Med 2002;17(2):67-74

22. Public Health Disease surveillance Respond to outbreaks Investigation Control and prevention Laboratory support Participate in planning activities Training Assess for communications technology Hospitals & Health Care Workers Disease reporting Immediately notify public health of unusual group expressions of illness or outbreaks State laboratory utilization Participate in planning activities Exercise plans Training Know where frail elders live and what their special needs are Roles and Responsibilities:Pre-eventPublic Health Emergency D. Lakey, 2004

23. Hospitals & Health Care Workers Implement notification protocols Activate staff Implement response plans/guidelines Coordinate efforts with public health Provide care Coordinate health-related information public health officials citizens media outlets check on communications with elders Roles and Responsibilities:Duringa Public Health Emergency D. Lakey, 2004

24. Public Health, Hospitals & Health Care Workers Evaluate response Review after-action reports Coordinate/implement changes to plans and procedures Implement recovery plans Determine if communications technology worked Roles and Responsibilities:Post-EventPublic Health Emergency D. Lakey, 2004

25. Overview of American Society on Aging Article in Healthcare and Aging • 1st step – knowing where our frail elders are before, during, and after disaster • 2nd step – training frontline health care providers on how older people present differently • 3rd step – teaching all-hazards approach on physical, mental, and psycho-social issues • 4th step – ensuring that providers know about culturally and linguistically appropriate communication strategies and services • 5th step – making sure health care providers and older persons are involved in planning for such practical considerations as evacuations, shelters, and receiving emergency alerts

26. Communications and Resources

27. Challenges to Aging in Place • Gerontechnology can be used to assess well-being • Expensive “smart homes” to inexpensive devices • Activities of Daily Living Reporting Systems • e-ADLRS gather data on elders’ routine home activities • Wireless motion and light sensors upload data • Establishes baseline, looks for marked changes • Clients sent reports via website, e-mail or phone • Possible problems checked out sooner • Receiving reverse alerts from PERS in emergencies

28. PERS Helps Elders…. • Live safer and more independently in their homes longer by: • Alerting caregivers to emerging problems, thereby reducing risks of hospitalization • Providing “circle of safety” via e-ADLRS integrating PERS & motion sensor monitoring + bi-directional communications 24/7 • Recognizing and better understanding resident/patient condition • Facilitating eldercare agencies to fill gaps in coverage and direct care where most needed • Reducing anxiety of and burden on family caregivers • Mitigating effects of disasters

29. Indications for Smart Home Technology • What are the leading medical indications – CVD, frequent faller, recent hospitalization? • What are the main social indications – living alone, no informal caregivers nearby, can’t afford in-home help? • What criteria should be used in writing an environmental Rx for e-ADLRS monitoring? • Is the SmartHT bundled with a reverse-alert PERS?

30. Local Intelligence Smart Home Technology for Telecare Sensors Only required information leaves home

31. Why PERS, e-ADLRS & GEPR? • Congregant care communities are where the density of elders at risk is far higher than among community dwelling elders • 24/7 emergency response and motion-by- locus monitoring systems help mitigate risks of elders harmed in disasters when systems have bi-directional communications capability • Mitigation requires interoperability between caregivers, both at a distance and those on site

32. Funded Study on PERS in GEPR • DAS contracted with Sandra P. Hirst, RN, PhD, GNC(C), Director, Brenda Strafford Centre for Excellence in Gerontological Nursing, University of Calgary, for a 3-phase environmental scan to determine the state of PERS services used to mitigate harm to elders in disasters • 1. Literature scan on general uses of technology in personal and large scale emergency settings to understand key technical and non- technical considerations and hence criteria for study’s assessment • 2. Detailed survey of North American PERS providers, to understand product capabilities and variations in technologies, target clients, and patterns of communication • 3. Contacted PERS providers to obtain company assessments of the actual and potential benefits of their systems in disaster settings

33. Assumptions of Study on PERS & GEPR • PERS system support in disasters settings would have these minimum capabilities: • Be able to reach all the targeted individuals • Allow broadcast of specific messages to a targeted set of individuals • Permit local authorities to provide messages for distribution Putative benefits of PERS systems for disaster situations were these: • PERS have databases of client information, including medical information and chains of contacts for both caregivers or family and the entire caregiver network • PERS technology designed to accommodate older adults with special needs, e.g., large buttons, lights or audio accessories for those with hearing impairment • PERS technology is accessible to and accepted by older adults and • communications/systems infrastructure is in place.

34. Results of Study on PERS & GEPR • SWOT analysis of 28 PERS companies revealed: • PERS communications systems are not generally designed for mass broadcast • PERS on-person alert devices are usually not designed for incoming notices • Geographic coverage is fragmented: a region may be covered by multiple PERS providers, resulting in even greater difficulty for local a authority to distribute messages • No existing channels for local authorities to communicate with PERS providers

35. Recommendations for PERS use in Disasters • Demographics • Assess percentage of seniors using PERS to solicit response in personal medical emergencies and coverage of providers • Plan for next generation of seniors or their caregivers who will be looking for PERS with such enhanced capabilities as wide-area coverage, global positioning Technical aspects • How can current technologies such as GPS, and cellular voice & data services be packaged into simple, effective devices easily usable by seniors with a variety of age-related limitations? • What data flows will be needed between PERS and other agencies so PERS can participate as fully as possible in an overall disaster management setting? Non-technical aspects • What information security, privacy, and regulation considerations are needed for private companies to play key roles in overall disaster management?

36. Center for Aging Services Technologies – CAST

37. CAST Members with Reverse Alert Capability • CAST director Majd Alwan, PhD, in a personal communication on May 14, 2010, stipulated that, to his knowledge, only two PERS companies have reverse alert capability <malwan@agingtech.org>. • Touchtown’s e-Notify system was recently used to warn residents of Holley Creek Retirement Community near Denver, CO, to take appropriate action as they were in the path of a tornado. http://www.touchtown.us/welcome/products/safety-devices.aspx • Wellcore’s bi-directional communication capability converts text messages to voice, forwarding them to residents regarding up-coming events. While not used yet for disaster messages, the “on the go” feature uses GPS with compatible mobile phones to locate residents should they leave the facility for any reason. http://www.wellcore.com

38. Touchtown’s e-Notify System

39. Touchtown Command Center Showing Location of Unit Acknowledging “OK”

40. Wellcore’s Bi-directional Communications Capability

41. Wellcore’s “On-the-Go” Feature Uses GPS and Residents’ Mobile Phones

42. Online Resources 1 • Center for Aging Services Technologies (CAST) http://www.aahsa.org/article_cast.aspx?id=10235 • International Community on Information Systems for Crisis Response and Management http://www.iscram.org/index.php?option=com_front page&Itemid=1 • WHO Report, A Safer Future: Global Public Health Security in the 21st Century http://who.int/whr/2007/en/index.html

43. Online Resources 2 • Decision-making Criteria for Evacuation of Nursing Homes • http://www.fhca.org/emerprep/evacsurvey.pdf • GAO Report on Evacuation of Hospitals and Nursing Homes Due to Hurricanes • http://www.gao.gov/new.items/d06790t.pdf • Older people in disasters and humanitarian crises: Guidelines for Best Practice • http://www.helpage.org/Resources/Manuals

44. Online Resources 3 • Public Health Agency of Canada Pandemic Flu Plan http://www.phac-aspc.gc.ca/ep-mu/index.html • U.S. Department of Health and Human Services: Disasters and Emergencies http://www.hhs.gov/emergency • U.S. Centers for Disease Control and Prevention - Pandemic and Avian Flu www.pandemicflu.gov/

45. U.S. Agency for Healthcare Research and Quality: Disaster Response Tools and Resources http://www.ahrq.gov/path/katrina.htm U.S. Federal Emergency Management Agency – Metropolitan Management Resource Centers http://www.mmrs.fema.gov/ Baylor College of Medicine & American Medical Association – “Best Practices for Managing Elderly Disaster Victims” http://www.bcm.edu/pdf/bestpractices.pdf Online Resources 4

46. Summary • Healthcare workers must have mitigation training for all disasters, natural & human-caused • HCWs need to have training for each vulnerable population – the young, the old, the disabled • HCWs need to remember that we’re always in the pre-event mode of the next disaster • GEPR planning & frequent exercises required • Need reverse alert capability via PERS

47. Smart Homes of the Future: Aging Trekkie Welcomes R2D2

48. Contact Information for GEPR/PERS Issues Dr. Robert E. Roush Huffington Center on Aging Baylor College of Medicine One Baylor Plaza, MS230 Houston, Texas 77030 (713) 798-4611; www.bcm.edu/hcoa rroush@bcm.edu;