1. Lessons Learned from the 2004 Florida Hurricanes: Older Adult Mental Health RON ACIERNO, PHD ASSOCIATE DEAN FOR RESEARCH, COLLEGE OF NURSING, MUSC PTSD CLINICAL TEAM RALPH H. JOHNSON VAMC

2. Collaborators  Dean Kilpatrick, PhD, Kenneth Ruggiero, PhD, Heidi Resnick, PhD, Sandro Galea, MD, Karesten Koenen, PhD, Joel Gelertner, MD, John Boyle, PhD  Funded by NIH MH05220, DA 017642

3. Paths of the 2004 Florida Hurricanes

5. Study objectives  To make use of the fact that a population overrepresented with older adults was affected by a natural disaster  To identify the prevalence of Post-traumatic stress disorder (PTSD), Major Depressive Disorder (MD), & Generalized Anxiety Disorder (GAD) among adults affected by the Florida hurricanes  To compare prevalences of these disorders in terms of Age

6. Methodology: RDD Specifics  We used random digit dialing methodology to survey 1,130 older adults (60 + years) and 413 younger adults (tot: 1,543)  Participants resided in Florida counties directly affected by the 2004 hurricanes and spoke either Spanish or English  A multistage process was used to select the sampling frame. Telephone exchanges in FL counties that were declared disaster zones were identified.  Next, we systematically selected residential telephone exchanges within the primary sampling units. One telephone number for each Primary Sampling Unit was randomly selected from telephone directories for those counties affected by the Florida hurricanes and declared disaster areas.

7. General Areas of Assessment  PTSD, Depression, GAD since the hurricane  Social Support preceding the Hurricane  5 items measured 3 areas: emotional, instrumental, appraisal in the 6 months preceding hurricanes  Increased Cigarette use since the hurricane  Extreme Fear During Hurricane  Increased Alcohol use since the hurricane  Hurricane Exposure: defined as two or more of : being present for hurricane winds, significant property damage, displaced from home more than one week, loss of two basic utilities

8. Florida Hurricanes: Sample Characteristics  Of the 1,130 older adult participants, 727 (64.5%) were women and 401 (35.5%) were men; for younger participants 257 (63%) were women and 151 (37%) were men;  The mean age of each group was 71.0 years (SD = 7.9), and 42.9 years (SD = 10.5).  The racial/ethnic distribution for the older adult group was as follows: 1012 (92.0%) Caucasian, 56 (5.1%) African American, 12 (1.1%) Asian or Pacific Islander, and 20 (1.8%) Native American or Alaskan. For younger adults: 342 (84.6%) Caucasian, 45 (11.1%) African American, 11 (2.7%) Asian or Pacific Islander, and 6 Native American or Alaskan (1.6%).  Hispanic ethnicity was endorsed by 48 older adults (4.3%) and 32 (7.7%) younger adults.  Considering the entire sample, the overall cooperation was 81%.

9. Prevalence of disorders, first for full sample, then in terms of age groups

10. Post-Hurricane Psychopathology: Florida Population Estimates  6-month PTSD = 3.6% (Florida population = 267,000).  6-month PTSD - H= 1.4% (Florida population = 104,000).  6-month Depression = 6.1% (Florida population = 453,000).  6-month GAD = 5.5% (Florida population = 408,000). Overall, 10.9% met criteria for at least one of the three disorders (PTSD-General, GAD, or MD) since the hurricanes. (Florida population estimate = 806,600)

11. Prevalence of Full Disorder By Age

12. Average Number of DSM-IV Symptoms by Age

13. Increased Cigarette Use x Study Variables

14. Increased Alcohol Use x Study Variables

15. 2004 Hurricane Study Substance Use Findings 1. At 5 to 8 months post-hurricanes, 21.8% reported having smoked cigarettes and 57.4% reported having consumed alcohol (since the hurricanes). 2. Of those who had smoked since the hurricane, 21.3% reported an increase over pre-hurricane levels. 3. Of those who drank alcohol since the hurricane, 6% reported an increase over pre-hurricane levels.

16. 2004 Hurricane Substance Use Findings (continued) 4. Increased smoking was associated with: - Degree of hurricane exposure - Peritraumatic fear during hurricane - PTSD and MD since the hurricane 5. Increased alcohol use was associated with - Peritraumatic fear - PTSD and MD since the hurricane

17. So let’s look again at the summary of risk factors…which would be things we could target for preventive interventions

18. Risk factors (symptom counts): Older vs Younger Younger Adults (25% Dx variance) Low Social Support PTE Health Problems Female Older Adults (20% Dx variance) Low Social Support PTE Health Problems Lower Income Hispanic Ethnicity # Days Displaced Out of Pocket Expenses

19. Psychopathology risk factors: Older Adults For Older Adults, higher PTSD, MD, & GAD were associated with:  Lower social support  Hispanic ethnicity  Lower income  Prior traumatic events  Number of days displaced  Out of pocket storm damage expenses  Health problems  Hurricane exposure variables that produced economic loss were particularly relevant  Older adults were more greatly affected when economic loss was greater.

20. But look what happens when social support is available (PRIOR) to the hurricane

21. Prevalence of Disorder by Social Support Note: * p <.01; base rate for low social support = 35%

22. Conclusion  Older adults evince lower post-disaster mental health problems than younger adults…  nonetheless, about 10% evinced mental health problems following the disaster (note that this does not mean it resulted from, or did not precede the disaster, as this was a cohort study)  Social support, in this case existing prior to the disaster, appeared to be a protective factor against developing psychopathology after the disaster

23. So What Can We Do?  Anything and everything that will increase social support (perceived) in communities BEFORE the disaster strikes or stress event occurs.  TRANSPORTATION, or lack there of, is a key factor in isolation. Isolation predicts low social support.  WE NEED BETTER TRANSPORTATION INFRASTRUCTURE TO HELP AGING IN PLACE, POST DISASTER OR STRESS RECOVERY, OH, AND TO REDUCE ELDER ABUSE  Once a disaster strikes, or is about to strike, resources tailored to older adults are important, such as:  Specific shelter sites or sections of sites reserved for older adults.  Onsite pharmacy expertise and or med storage and dissemination assistance  Pet support  Expedited Post-disaster economic reimbursement