Supporting Oregon’s rural older adults during emergencies

How can older adults with mobility or vision impairments safely evacuate during an emergency? What medications or assistive devices would they need to bring with them to a shelter? How can emergency workers communicate the urgency of a situation to older adults with cognitive impairments?

A new training program has been helping first responders in some of Oregon’s rural communities answer those questions. The training was conducted by the Oregon Geriatrics Workforce Enhancement Program, which aims to increase access to age-friendly care in underserved areas.

Union County Emergency Manager Nick Vora participated in the training. He joins us, along with Laura Byerly, program director for the Oregon Geriatrics Workforce Enhancement Program.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. How can older adults with disabilities safely evacuate during an emergency? How can first responders communicate the urgency of a situation to older adults who have cognitive impairments? A new training program has been helping first responders in some of Oregon’s rural communities answer these questions and many more. The training was conducted by the Oregon Geriatrics Workforce Enhancement Program to increase access to age-friendly care in underserved areas. Laura Byerly directs the program. She is a geriatrician at the Oregon Health and Science University. Nick Vora is the Union County Emergency Manager. He participated in the training. They both join us now. It’s great to have both of you on Think Out Loud.

Laura Byerly: Thanks so much for having us.

Nick Vora: Yeah, thank you, Dave.

Miller: Nick, first. Union County has an older population than the state as a whole. How much has that been on your mind as an emergency manager, the demographics of your county?

Vora: So the demographics of Union County are similar to a lot of rural counties in Oregon where we have older populations that are not just in urban areas but dispersed throughout the counties and sometimes our most rural residents are also some of our most elderly residents, and that can lead to a lot of challenges in regards to emergency planning, evacuation. And the types of resources and assistance that those residents may need in getting out of the way of something such as a wildfire or a flood or some other emergency.

Miller: What are some of those challenges? I mean, how has this cropped up for you in recent years?

Vora: So some things that are somewhat common recurrences in this topic would be people that maybe don’t have a working vehicle or maybe they, due to dementia or something like that are having trouble grasping the gravity of the situation or even understanding potentially where they are relative to where the emergency is. Other things could be reliance on durable medical equipment. Maybe they’re on a home oxygen concentrator and they don’t have bottles that they can take with them, or they’re reliant on walkers and wheelchairs or things like that, or maybe also just our ability to communicate with them as far as not having cell phones or things like that. So it’s a pretty wide variety of factors that all have to be addressed in different ways but definitely increase the complexity of our planning.

Miller: Doctor Byerly, as I was listening to Nick there and one of the challenges he mentioned was talking with people who have dementia and how to talk with them about, say, evacuation. An example I mentioned in my intro, it reminded me of what I’ve come to learn from geriatricians as the 4Ms, a kind of a simple way to focus on four things that really can help guide care. As I understand them, they are what matters to the patient: medications, mentation, and mobility. It seems like what Nick was talking about there in terms of dementia, it gets to maybe three of those all in one. It gets to what matters to the patient, mentation and mobility. So it’s, which is, I mean, a very complicated combination. So where do you start in your case as a physician?

Byerly: Yeah. So, the wonderful thing about this 4Ms age-friendly framework is that, sort of with intention, when we teach about it, we explain that the Ms don’t exist in silos, right? So what is important to somebody, what matters most to them, is likely going to be directly tied into their mobility, their mentation, and their medications, and what we are giving them, basically, as part of their routine. So when we start to tease apart kind of the construct for age-friendly disaster planning, well, my team teaches each of the Ms a bit separately.

We do some training on mentation and what it means to provide patient-centered, person-centered, strengths-based communication strategies during an emergency. We then tie it into then, how do those communication strategies for a person who has dementia really then impact maybe how you decide what matters most to them, and who else needs to be a part of the decision to stay or go if you are a rural, older adult and maybe are trying to decide if you want to stay behind or if you want to evacuate.

So, while we often teach the Ms separately, we then spend some synthesis time trying to pull it all together to show how no M exists as a single entity, and that they all really have to be factored in when you are working with an older population, particularly during an acute crisis or emergency situation. So that it’s not just a matter of saying, we’re just going to take your walker because I know we need to take your walker with you, but really stepping back and saying, we do need to think about your mobility, but we also need to think about who this person is in front of us and what matters most to them in terms of their goals, their ability to make decisions, and how we’re going to be communicating effectively.

Miller: Nick, how might that play out differently now in Union County? I’m imagining a kind of emergency door to door, checking in on older residents that sheriff’s deputies, say, or people in the community know to be that they need to check in on – there’s a fire coming and folks are going door to door. After you’ve done the training with Laura and her team, would you approach those conversations differently?

Vora: Yes, so the training that I did with Laura and her team really opened my eyes to a lot of the different things to consider, and one of the things that I really appreciated about it is it was very operational training rather than theoretical about, these are just some things to think about. These are some things to think about, and this is how it can help you communicate with someone who has that condition or is experiencing that disability. So, some of the things that we did this spring is also we had some new curriculum that came from the Oregon State Sheriff’s Association for evacuation training, and I delivered the training that I incorporated elements from Laura’s curriculum.

As far as some of the big takeaways into the training that we delivered to our search and rescue volunteers and our sheriff’s deputies that allowed us to address not only the mechanics of door to door mapping addresses, things like that, but also some considerations with elderly populations and then going beyond that to not just elderly but dealing with what if there’s an unattended minor or something like that at a residence that is in a critical area that’s being threatened by an emergency.

So it was very helpful as far as just informing and helping further our overall program and community preparedness, and I would really love to have an opportunity, down the road if we could have Laura’s program back, to help provide more training for the first responders that are actually doing that door to door, down the road.

Miller: Well, Laura, I’m curious, and I can’t emphasize enough that obviously the two of you have very different professional roles. You’re a physician, with a focus on geriatrics, and Nick manages a whole wide variety of emergency situations at the county level. So it’s not like it’s your job, Laura, to go to people’s homes in the middle of a fire and get them to safety. But what kinds of questions would you want someone to ask quickly, if the person who’s knocking on the door, if their main job is, there’s a fire coming and I want to get you to leave. How would you want them to approach that?

Byerly: Yeah, it can be a lot about how do you form a really quick, trusting relationship, and how can you really use the words that we all use when we’re in an interaction with an older adult to really optimize the chances of a successful, trust-filled relationship. So we, what Nick was alluding to about communication strategies – and Nick, we will come back anytime you want me to. We will bring our team back over to Union County. But what we really wanted to get across to people is that you’ve got about 30 seconds to try to make an impact on this person that you are trying to explain a disaster to.

And as geriatricians, we see this in clinic, and we see this in the nursing homework that I do, where that initial kind of feeling that the older adult, regardless of their cognitive status, gets from this person who is coming up to them, who maybe they don’t know, you’ve got a window of time really to try to develop that rapport so that that person will, one, listen to you, and two, may agree with what you are suggesting for their safety. And so, what I would love for first responders to take away from the training we have is just this idea of how to use the words in a way that is really person-centered, really empathy-focused, really kind of humanistic and strength space in our approach instead.

So rather than coming in and just starting to talk really fast and using a bunch of technical terms about what’s happening outside, trying to kind of take a step back, gauge who this person is. Is this somebody who seems like they are alone, and that they are potentially maybe not doing so well. We can size a lot up from a doorway about the state of someone’s environment and maybe how they are doing cognitively and functionally. And being able to take a moment to say, I’m gonna change my wording, I’m gonna change the questions I’m asking, I’m gonna change the terms that I’m using to try to match where this person is, rather than using a complex technical jargon, to really step back and try to build that relationship first and make sure we’re using closed loop, or kind of simpler questions for the people who may benefit from a bit of a more straightforward approach.

One of the other big things we teach in the training is how to not alienate the person that you are trying to help assist by using something called elderspeak, using the terminology and the words that so often slip into our society when we are talking with older adults: the baby talk, the terms of endearment that have been shown multiple times, especially in a crisis, to not be helpful and to actually be a hindrance. And so, what I would love for people to take away is really that, how do you start that initial connection and conversation with the older adult you are trying to help in a disaster so that they will continue the dialogue with you and be able to follow along with what you are saying and hopefully agree with the safety plan you are pitching to them.

Miller: You know, it’s striking that that last bit you mentioned really was very clearly specific to avoiding maybe a common pitfall when it comes to talking with older adults. But so much of what you were saying there and even that example, which could be sort of tweaked in different ways, it seems like this is broadly applicable advice to healthcare providers or emergency responders who are dealing with anybody: be kind, be clear, be empathetic, figure out ways to meaningfully establish trust.

I mean, this is something that I think all of us would want everybody in some position of authority to think about when they’re dealing with all of us, from toddlers to people who are over the age of 100. I don’t mean to diminish the specificity of helping older adults. Obviously, that’s the focus of today’s conversation and your program. But it just seems like there’s a lot of universals here. Does that ring true to you, Nick?

Vora: Yes, 100%. So also, in addition to being county emergency manager, I also am a captain with the Rural Fire Protection District here and work in law enforcement as well. And a lot of the takeaways from this course are, as mentioned, incredibly relevant to everything we do. And there are things that I probably haven’t really fully grasped how much I’ve been using some of the takeaways from the class, but just one example is the different glasses that we had an opportunity to wear and go through a little obstacle course simulating different types of vision impairments or eye conditions. And just being able to fully appreciate how difficult it is to walk, or when you’re talking to someone, how not being able to see their facial expressions and things like that. Well, I could have told you academically before I hadn’t experienced, and so that was something that has definitely helped me reframe the way I approach talking to people in all contexts.

Miller: Laura, I want to go back to those 4Ms, because we really focused a little bit more on the mentation part and what matters to the patient, but I want to zero in for a little bit on mobility. What’s included in that, specifically when you’re talking about older adults?

Byerly: Yeah, so Nick just hit on a little bit of it that sometimes we forget how different it might be to stay mobile as your body is normally aging, and that’s part of why we did what I keep calling the empathy building exercise obstacle course, which is what Nick was alluding to of having these sensory impairment devices added to a first responder sort of state of being, and then having them do some basic mobility tasks to simulate really what does it feel like on a day-to-day basis to be a person who has arthritis or peripheral neuropathy, or vision impairment or hearing impairment, how does that change how they move about? So, for mobility, it’s not just about falls. It’s not just about reducing the risk of falling. It’s also about maintaining mobility, utilizing the person’s own strength and balance, but also trying to optimize it with durable medical equipment, things like canes and walkers and lifts that that person might need.

In an emergency situation, this is hugely important because we’re frequently rushed for time, and you’re asking somebody to move quickly, and you’re asking them to potentially do multiple steps of an evacuation at the same time: pick up that bag, come with me, get in the van, we’re gonna go. And this might be really challenging, not just cognitively for some folks, but also mobility-wise. If they are living life with arthritis, or living life with peripheral neuropathy or pain, trying to teach first responders what are some of the main challenges related to mobility, so that it’s not just about telling someone to go faster.

It’s about stopping and saying, what is potentially the mobility challenge here that’s making it more difficult for this person to follow along with me or move as fast as I need them to? And how can I potentially help with that? What kinds of equipment can I use? What kinds of strategies could I potentially do? So we teach a little bit about normal physiology of aging for the musculoskeletal system, and then we launch into a little bit more of, here’s how this feels for an older adult who’s trying to stay mobile.

Miller: I mentioned that you’re a geriatrician, an internal medicine doctor who focuses specifically on the needs of older adults. How many geriatricians are there in Oregon, to serve how many older adults?

Byerly: Yeah, so our current counts, based off of data that we have nationally, is there are about 93 geriatric board-certified physicians, both from family medicine and internal medicine combined across the entire state of Oregon. And we are looking at a rapidly rising group of older adults. We’re actually at the point in Oregon where there are as many, if not more, persons over the age of 80 as kiddos. And this is a new era, really, where we are seeing things really change and how the population is set up. So, we are looking at 900,000 to a million older adults across the state.

And if you do the math, you would see how many patients I would need to see in order to basically adequately provide each person who would say over the age of 65 with a geriatrician. It’s not going to happen. There aren’t enough of us. There are never going to be enough of us to basically be the primary care provider or the nursing home doctor for every person who is aging in Oregon. And that’s why the grant that I run, the Geriatrics Workforce Enhancement Program, is so focused on teaching amazing teams like Nick’s how to do the work without us, how to basically be the change in their community without having to have a geriatric care specialist who is rooted in that community.

Miller: Nick, another of those Ms is medications. We’ve heard in the past about the challenges of managing medications for older patients in non-emergency situations and being aware of, especially if prescriptions just keep getting added and added and added and interact with each other in various ways. In a non-emergency situation, it’s already challenging enough, but how do you think about medications as a first responder?

Vora: So that is a huge challenge from a planning as well as response standpoint for us. So we approach it a couple of different ways. On the preparedness side of it, so with emergency management, you could talk about different phases being prevention, mitigation, preparedness, and then response and recovery. On the front side of that cycle, we’re focused on our messaging to the public about trying to have at least a two-week supply of your medication so that if you did need to evacuate, that it wouldn’t be an emergency the next day that you had your last dose or now needed to be at a pharmacy when there wasn’t one accessible. But then also that presents a significant financial barrier to some people on maybe, do they have the financial ability to maintain two weeks of a medication? But that’s something that on the preparedness side that we really try to encourage people to think about.

And then, on the response side, so we have an evacuation, someone needs to leave their home, come to a shelter. That’s when we work with our partners in public health and the amazing volunteers with American Red Cross and try to leverage relationships and partnerships to identify who arrived that needs medications. Do they have the medications with them? If they don’t, where’s their prescription? Can we try and track that down? And then, what do we need to do to try and get a fill of that prescription for them, but that obviously is a pretty significant logistical workload, depending on the amount of people that need that done for them. So that’s where we really try and focus on the preparedness side for that two- week supply.

Miller: Laura, the point of these trainings are for you and your colleagues to share your experience and knowledge with people like Nick. But have you been learning things yourself as the trainer?

Byerly: Yes. I remember I was over in the Yellowhawk community, it’s the Yellowhawk Tribal Health and Wellness Center, which is part of the Umatilla reservation, the Confederated Tribes of the Umatilla Indian Reservation. And they are already doing some amazing work in preparedness for their tribal elders. And before I even made this talk, or made this workshop for first responders, they were showing me what they are setting up in their community in terms of go boxes and things to put on your door, things to put on your outside window to let a first responder know that you are somebody who has done some of the prep work and that you have materials already put together and have things bundled together.

And you realize that a lot of communities are already really getting into this on the community side of things. They are working together as groups of older adults and volunteers to start game planning for the next potential disaster that might hit them. They are already thinking about what kinds of community events can we put together to get backpacks prepped. And so we certainly value and very much appreciate, I think all of us, that older adults are really taking this upon themselves to try to get ready for what might be coming next for them. And they are really interested in learning more about how they can be independent and autonomous and prepare on their own for their own health and well-being and for that of their loved ones who are in the same community. Really, where we come in is just to kind of fill in that last piece, which is making sure that emergency preparedness teams like Nick’s team in Union County also feel like they have the same training and the ability to respond, knowing that a lot of older adults are already doing a lot of great work across the state.

Miller: Laura Byerly and Nick Vora, thanks very much.

Byerly: Thank you, Dave.

Vora: Thank you.

Miller: Laura Byerly is a geriatrician at Oregon Health and Science University. Nick Vora is a Union County emergency manager.

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