Medicines Management for Elderly During Disaster Research Paper

Abstract

Objective

The elderly population is one of the most vulnerable when natural or manmade disasters strike. The bulk of life lost in disasters is mainly that of the elderly, which is either directly or indirectly from the effects of the disaster. Accordingly, the objective of this systematic review was

• To summarise the best available evidence that described medicines management for elderly patients during disasters
• Make recommendations towards the promotion of disaster preparedness with the elderly in mind

Inclusion Criteria

The review considered qualitative research that focused on previous disasters, management of the elderly in those disasters, and the recommendations that resulted. The main articles selected were those that considered disaster victims in their old age. The age selected was 60 years. Those articles with this age and above were considered for the review. The preferred language of article publication was English. Any other language was not considered in the final review. The articles selected also had to be recent. Therefore, those between the years 2000 and 2012 fit the selection criteria. This is in light of the progressive and continuous change in medical practice.

Search Strategy

The search strategy sought to find both published and unpublished research papers (limited to the English language). An extensive search was performed using the following databases: CINAHL, EMBASE, PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Premiere, PsycINFO, and Healthsource. Nursing/Academic edition, Science.gov, scricus.com, and Robert Wood Johnson Institute, Dissertations Abstract International were used also. Furthermore, the reference lists of the identified papers, as well as relevant worldwide websites were searched to capture all pertinent materials for the review.

Methodological Quality

Two reviewers for methodological quality assessed each paper before inclusion in the review using the critical appraisal instrument (Qualitative Assessment and Review Instrument (QARI) from software developed by the Joanna Briggs Institute (JBI).

Results

Eighteen articles were selected from the initial literature search. These were mostly journal articles with forty-four initially identified and most excluded because they did not meet the inclusion criteria. The results are summarised below and relevant findings are included for this review.

Conclusion

In all the materials reviewed, the elderly are described as one of the most vulnerable cohorts when disasters strike. This, according to the findings, is due to their reduced mobility, their poor health, and inadequate social support systems. The elderly are also the biggest group with chronic conditions. They are therefore always taking medicines for control. In times of disaster, the articles reviewed suggest special attention to the elderly. Their medication should be included in the list of items for appropriate disaster preparedness.

Introduction

The management of medicines in the elderly population in times of disasters is very important considering their large numbers and the frequency of disasters. It has been suggested that the elderly population is at a greater risk of reduction in the standards of living after disasters compared to the younger generation of victims (Bolin, & Klenow 1988, p.29–43). In the previous disasters, power failure has led to the challenge of medication provided to the elderly and the population in general. For those with chronic conditions requiring power to administer medication such as home nebulizers, this has provided a risk of missing their medication, getting the associated complications, and even death (Geehr, & Salluzzo 1989, p.604). The reduction of the incidences of this happening in disasters is therefore important in the reduction of disaster-associated mortality.

Background

The preparedness, response, and recovery of disaster victims are dependent on factors beyond their control. Some of these factors include the type of event, the duration of the event, and the warning systems that are in place. Some individual factors include the victims’ state of health and the resources available to them. Individuals who are isolated and restricted to houses with impaired mobility and poor social support have the worst response to disasters and recovery from the resultant complications. This also includes those relying on regular medications, nursing care, or even on treatment services. Some other vulnerable people include those reliant on volunteer services for their food and essential care.

The elderly population in Florida and California, both of which are disaster-prone geographical areas, is on the rise with the population forecasted by the United States Census Bureau doubling its 1993 number (Hobbs, & Damon 1996, p.23). The increased elderly population poses a challenge in disaster preparedness and the response that follows. Knowledge of the best medical management practices for the elderly population is therefore important to adequately prepare for the future disasters besides preventing unnecessary loss of life. This review is also important to geriatric physicians and nurses, as it will equip them with the best available medical skills for disaster management.

Method

The search strategy aimed at finding both published and unpublished studies. In this search, a three-step approach was utilized for this review. The initial step involved a limited search of the keywords in the title of the article, the abstract in MEDLINE, and CINAHL. The second step involved the search of the same keywords in the included databases. In the last step, the reference lists of all the identified reports and articles were searched for additional relevant studies. Only studies done and published in the English language were included in the analysis. The search period was from the inception of the databases to the current date, and the selected articles ranged from the year 2000 publications to the year 2012.

The databases searched include CINAHL, EMBASE, PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Premiere, PsycINFO, and Healthsource: Nursing/Academic edition. The search for unpublished studies included those in the databases such as Science.gov, scricus.com, Robert Wood Johnson Institute, and Dissertations Abstract International. The appraisal of the selected studies utilized the JBI form.

Results

From the literature search, eighteen were selected for the review since they had relevance to the subject. In the research review, most of the articles elected were done in the wake of disasters that have taken place in the United States in recent times. In most of them, an interview was conducted with the general population in the disaster areas. Later, these were grouped into age cohorts. The elderly population was the focus of this review. Therefore, this cohort was selected.

Paper 1: (Anetzberger 2002, p.611-625),

Finding 1: Need for a reassessment of existing programs

In the first article by Anetzberger (2002, p.620), the use of community resources by the elderly population is focused on the conclusion that there is need for their reassessment. It is noted that the programs providing services are not fully utilized with the results of only 20% of the elderly reporting to have used any community services in the previous year. Worth noting is that most the elderly people prefer help from friends and family to other sources.

Finding 2: Utilisation of services

The only services reported to be sufficiently utilized include the educational programs, the World Wide Web, and case management. An estimated 15% of the elderly population adequately cope with depression, and about 10% of them had dementia (Anetzberger 2002, p.615). Few were utilizing the medical services especially those associated with mental health due to the stigma associated with them. In the findings, fewer elderly people were utilizing any form of medical services. The adult day health care centers, senior housing centers, and community centers should be prepared to handle the number of elderly patients with the desire to use these services especially in disasters.

Paper 2: (Chou et al. 2003, p.792-798)

Finding 3: Emotional response to disasters

In this paper, the researchers did a study on the emotional response of the elderly, the middle-aged, and young people after two technological disasters that were traumatic to them (Chou et al. 2003, p.796). These people had been involved in an airplane crash in the year 1994 and later a train collision in the year 1996. Half of those involved in each event were used for the study. They numbered one hundred and forty-eight. Interviews on how they coped with the traumatic event began with conclusions being derived from them.

Finding 4: Age affects response

It was found that the response to the disaster depended not on age, but on the disaster type and the intensity that the people were subjected to. All the specified age groups reacted and adapted in the same manner with the catastrophes and the resulting complications. Other factors affecting the response included how close the respondents were to the disaster when it occurred, the symptoms that they displayed after the event and the level of care given including medical care. This research however did not support the theory that age was significant in the response and that previous disasters would ease the response to subsequent traumatic conditions.

Paper 3: (Fernandez et al 2002, p.70)

Finding 5: Vulnerability of the elderly

In this paper, the authors did a literature search for medical materials and a review of Websites, news reports, and government training materials (Fernandez et al 2002, p.67). The aim of this was to key out and implement schemes of handling the risk of exposure of the aged members of the society in the event of a tragedy. They identified factors leading to the vulnerability of the elderly during disasters. They stated them to be pre-existing medical impairment, diminished sensory awareness, and impaired physical mobility, as well as social and economic constraints (Fernandez et al 2002, p.64).

Finding 6: Strategies

According to the authors, three categories result in their intervention strategies, and these include personal strategy, agency, and community strategies. Personal strategies include educating the elderly on disaster preparedness, as well as how to manage their medication in a bid to make sure they can last for a few days. They also include the education of elderly on how to respond in times of emergencies and disasters. Community and agency strategies aim at making use of the existing basic resources. Healthcare access is a component of community strategy, and this involves stocking important drugs for use in emergencies.

Finding 7: Transport of medicines

The article emphasizes transportation as one of the major demands of the aged in times of disasters besides being one of the constraining elements. The authors conclude that medical help for the elderly should be transported to them if they cannot be transported to the medical centers themselves (Fernandez et al 2002, p.74).

Paper 4: (Ford et al 2006)

Finding 8: Chronic illnesses

In this paper, the researchers analyzed data from people above the age of 18 years participating in the Behavioural Risk Factor Surveillance System (BRFSS) in 2004 (Ford et al 2006). They aimed at estimating the number of people suffering from chronic illnesses such as hypertension, diabetes, and stroke living in New Orleans at the time Hurricane Katrina struck. In the month of August 2005, 9% of the adult population there had diabetes, and most of them (79.4%) were on oral hypoglycemic agents for diabetes control. This is against a background of higher diabetes incidence in the elderly. 29% of the respondents reported being hypertensive with 81.1% of them taking antihypertensive drugs.

Finding 9: Medication dependence

Approximately, “4.6% of the adult population interviewed reported coronary heart disease or angina pectoris, 3% reported having a myocardial infection and 2% were stroke victims” (Ford et al 2006). After the hurricane, widespread destruction of roads and other transport infrastructures was apparent. This meant that the patients could not access their medication. From this study, it is clear that disaster teams should put into focus the treatment of chronic conditions in their programs when there is a disaster. Public health officials also need to take this consideration when putting appropriate disaster preparedness measures in their planning.

Paper 5: (Hastings, & Mitchell 2005, p.978-986)

Finding 10: Medication and recovery

In this research paper, the authors set to determine the research done relating to the commonly held theory that patients recover better and quicker when they receive adequate care in the emergency departments. Their homes are used as transition points. They surveyed publications in CINAHL and MEDLINE that link with the aged patients and casualty maintenance. Several interventions targeting the elderly population were found to include “discharge of patients to their primary physician with a referral note, geriatric assessment using specially trained nurses, and continuous home-based care and follow-up” (Hastings, & Mitchell 2005, p.980). A substantial discovery from the research is that aiming at the Most at Risk Populations (MaRPs) such as the aged in the intercessions proposed, brought appealing outcomes in relation to an open intercession. Further research was suggested to determine which of the strategies is more effective in the management of the elderly in disasters and emergencies.

Paper 6: (HelpAge International, London 2006)

Finding 11: Guideline available

The guide by HelpAge International, which is an umbrella of nonprofit organizations working with disadvantaged old people, has the information necessary for elderly patient care in disasters. In the guide, a stress is made on the importance of managing the medications of the elderly with chronic illnesses during a disaster. Other resources that are recognized as being of equal significance include shelter and nutrition for the elderly during this crucial period. Other issues handled in the book are defending the elderly from ill-treatment and management of their composite psychosocial demands. This guide is well suited for planning disasters management for the elderly.

Paper 7: (Jeste, Blazer, & First 2005, p.265-271)

Finding 12: Medical psychiatric illnesses after a disaster

This is among the few studies done investigating the incidence and prevalence of medical psychiatric illnesses other than dementia in a population of elderly patients. This study recommended that further studies focus on differentiating the illnesses in the elderly from those of psychiatric origin. In their findings, a confusion of physical and psychiatric illnesses was found to be common in the management of the elderly especially in the emergency centers (Jeste, Blazer, & First 2005, p.270). A common reason was the under-reporting of symptoms that the elderly were prone to.

Finding 13: Medications provided for non-organic conditions

In the past, the medications supplied to the elderly in disaster areas have mainly been to treat organic conditions and physical injuries with fewer, if any, medicines for any mental health issues that may arise. The study therefore suggests the inclusion of psychiatric drugs in the list of emergency drugs for the elderly in times of disasters.

Paper 8: (Knight, Gatz, Heller, & Bengston 2000, p.627-634)

Finding 14: Age, depression and medication after a disaster

This report is from data obtained from a longitudinal study involving generations of families. “Multiple generation families numbering 250 were initially sampled in the year 1970 and surveyed after every three years” (Knight, Gatz, Heller, & Bengston 2000, p.627-634). The Northridge earthquake in California preceded a survey that was to be done in 1994. The information garnered from the survey was noteworthy in substantiating the feedback to the earth’s tremor calamities in relation to various ages. The levels of depression after the earthquake were higher in the people with some degree of depression before the earthquake compared to those with lower levels or no depression. The patients in the “ages between 55 and 75 years had the lowest levels of depression both after and before the earthquake” (Knight, Gatz, Heller, & Bengston 2000, p.634). They, therefore, proved that exposure to disasters reduces the posttraumatic symptoms in subsequent disasters though this was weakly supported by their findings.

Paper 9: (Kohn, Levav, Garcia, Machuca ME, & Tamashiro 2005, p.835-841)

Finding 15: Psychopathological reactions

In this study, “800 Hondurans were studied after Hurricane Mitch in 1998 for their psychopathological responses” (Kohn, Levav, Garcia, Machuca, & Tamashiro 2005, p.841). The aged people used in this research had an age of 60 and beyond with the consideration of the state of life expectancy evident in the area of study. The tools that were used included a self-reported interview and a questionnaire. They found that posttraumatic reactions in people over 60 years were the same as those in the younger population. This is despite the reduced ability to cope with the trauma and the posttraumatic events that the elderly have.

Finding 16: Psychiatric epidemiology

In the research, it was noted, “little is known of the psychiatric epidemiology in the developing countries like the Honduras” (Kohn, Levav, Garcia, Machuca, & Tamashiro 2005, p.841). The study therefore suggested room for further research on this issue. This was in light of the existing differences between the elderly population in the developed and developing countries. There exists a solid support and disaster preparedness in the developed countries with well-laid down guidelines on disaster management compared to the developing countries.

Paper 10: (Kuo et al. 2003, p.249-251)

Finding 17: Post-traumatic stress disorder and treatment

In this research, 120 people who lost their relatives in the 1999 earthquake in Taiwan were surveyed. Of the few reviewed, 53% displayed some form of Post-traumatic Stress Disorder. Most also experienced some form of remorse besides portraying increased signs of sorrow compared to other younger population cohorts. Despite the observed high prevalence of PTSD in this population, only about 25% of these patients sought medical treatment for the condition (Kuo et al. 2003, p.251). This means that, in the management of the elderly in times of disasters, mental health issues should adequately be planned for with appropriate medication being put in place. The research also emphasized the need for schemes for carrying on with the sorrowing individuals in Asia, which should vary from those in western countries due to ethnic deviations.

Paper 11: (McKain et al 2004, p.704-710)

Finding 18: Treatment at a specialized center

This study was done in Australia by a physiotherapist, a social worker and three nurses, and nine patients admitted or transferred to a rehabilitation unit undertook a semi-structured interview in the rehabilitation center. The research sought to find out whether the sick had enough entropy before admittance to the reclamation section regarding their status and anticipations. The patients did not mind this problem because they thought that their referral to this unit of the medical center was because they were almost being discharged. The authors concluded that, in times of emergencies and disasters and the periods following that, elderly patients should be well informed of the medications they receive, any transfers or admissions, and the necessity of the same in their management (McKain et al 2004, p. 710).

Paper 12: (Miller & Campbell 2004)

Finding 19: Eldercare supportive interventions

The investigators in this discipline probed the effectualness “of the of the Elder.

Care Supportive Interventions Protocol (ECSIP), family-based interventions, and nursing care in reducing any discomfort in those patients with delirium and dementia” (Miller & Campbell 2004). The study took place in a geriatric medical unit with a 34-bed capacity belonging to an academic hospital. However, they developed a bias that reportedly arose from the sampling limitations and a small nursing staff. The findings indicated that there was no noteworthy deviation between the initial status and the treatment situation for the length of stay of the sick, physical role, and penetrative discombobulation in the patients involved in the analysis. A finding that was of importance is that the “undergraduate nursing students in the hospital serving the elderly as assistants had positive effect on the family, lowered hospital costs and improved on staff satisfaction” (Miller & Campbell 2004).

Paper 13: (Mudur, 2005, p.422)

Finding 20: Disaster response and medication

In December of 2004, a tsunami hit the Asian coast killing 300,000 people and displacing another 92,000 elderly people (adults over 60 years). In this paper, the response and attention are given to the elderly in relation to their special needs during a disaster take the centre stage. The special needs included the medications for the many elderly people with chronic conditions. In this article, it is noted that the elderly had a hard time getting relief and medication that was to be distributed by the aid agencies and special government agencies (Mudur, 2005, p.422). They also received little attention relating to their nutritional needs besides even getting money and allowance that was distributed. It concludes that more emphasis should go to the special medical and other requirements of the aged whenever artificial or natural calamities strike.

Paper 14: (Nates 2004, p.686-690)

Finding 21: Essential factors when disaster strikes

In June 2001, the tropical storm Allison resulted in severe damage to Houston Medical Centre after it produced about three feet of rainfall. In this report, the response of Memorial Hermann Hospital to this disaster after its emergency system failed is put into perspective. It is among the two grade-I trauma sections in Houston. The study presents the reaction to the situation by its faculty with or without electricity, as well as the critical hospital routines during the predicament. The author states nine essential factors in addressing internal problems when disaster strikes. These include “electricity, water and other important supplies, patient ventilation, communication, human response coordination, essential services protection, patient-logging system, media communication, and a plan on evacuation” (Nates 2004, p.690). These are important in the medical management of patients in the times of disaster.

Paper 15: (Rockwood et al. 2005, p.489-495)

Finding 22: Effectiveness of clinical frailty scale

In this research, 2,305 aged patients taking part in the second round of the “Canadian Study of Health and Aging (CSHA) had their frailty levels” (Rockwood et al. 2005, p.495) measured. The ultimate objective was to track the efficiency of the clinical infirmity scale after a subsequent analysis of this group of people for half a decade after they partook of the CSHA. They proved that this scale is important and effective in the assessment of clinical frailty of the elderly population, and it is easy to use and train others in its use. They also concluded that this tool would be important to measure the frailty in elderly patients who were victims of a disaster (Rockwood et al. 2005, p.489). This is important in the medical management of patients during a disaster.

Paper 16: (Romano 2005, p.6)

Finding 23: Surge hospitals

This paper focuses on the measures set up to accelerate health responses and emergency care in times of disasters and emergencies (Romano 2005, p.6). Since September 11, 2001 and the recent disasters that have taken place in the US, the officials in government and those specifically concerned with disaster preparedness have developed various suggestions for taking control of the resulting humanitarian crisis after disasters. Surge hospitals are one of the models that have been suggested as effective ways to deliver healthcare during a disaster.

Finding 23: Extending existing facilities

In this proposal, hospitals have to extend their services to the facilities that exist or are at close sites to cope with the great number of patients after a disaster. An example is in “Washington DC where a section of the Washington Hospital Centre is being changed to surge unit with a bed capacity of 350 patients” (Romano 2005, p.6). A better idea involves the transformation of non-medical areas such as a stadium into a medical facility. An example is the successful use of Astrodome that took place in September 2005.

Paper 17: (Saltvedt et al 2002, p.792-798)

Finding 24: Management at a geriatric clinic

In this paper, the researchers performed a randomized control trial determining whether treatment in geriatric evaluation and management care units (GEMU) contributed to cutting down mortality rates for patients. This research was conducted in the University Hospital of Trondheim, Norway. The staff consisted of a “geriatrician about two resident nurses, a physiotherapist and an occupational therapist” (Saltvedt et al 2002, p.790). The mean patient age for the study was roughly 82 years in the case of GEMU and a mean of the same for the case of cosmopolitan examination wards. The conclusion was that treatment at the GEMU considerably reduced the mortality rate for these elderly patients. Following the set period of the research, the death rates of these patients in the GEMU and the cosmopolitan examination wards leveled off. The study’s implication in the medical management of the elderly patients in disasters is that management in a specialized unit specifically for geriatrics has better results. Thus, the elderly should be targeted in disasters for specialized medical support.

Paper 18: (Watanabe, Okumura, Chiu, & Wakai 2004, p.63-67)

Finding 25: Levels of depression and medication

This is a report of the research conducted in Taiwan after the 1999 earthquake six months and a year later. The longitudinal study sought to determine the level of depression in the elderly patients displaced by the earthquake. The level of depression remained unchanged in the periods of six months and one year after the earthquake, but the study had a small sample size. Displaced elderly had higher levels of depression compared to those who were not displaced according to the study. The level was also higher in those elderly patients who had little or no social support systems. The elderly with immediate family supporting them did better compared to those without. The depressive symptoms were also lower in those elderly patients with support from neighbors (Watanabe, Okumura, Chiu, & Wakai 2004, p.67).

This study concludes that a social support system for the elderly is crucial in times of disasters in addition to medical management. During disasters and the period thereafter, the elderly need people close to them to assist in their management since most of them are not aware of the medication outlets available during this time. The reduced mobility, poor health, and increased vulnerability to injuries mean that the elderly disaster victims have reduced chances of getting their medications and thus the need for the social support.

Categorization and synthesis of findings

Categorization of common themes from the findings enables the grouping into categories and production of single synthesis findings. The 25 findings were grouped into three synthesized and directive findings for use as a basis for the best evidence-based practice.

Synthesis 1

In this synthesis, categorization of the findings with results of how the elderly are affected by disasters is the criteria. It includes ten of the findings from the review. In most of them, the elderly are described as frail and immobile with little access to help in disasters.

Synthesis 2

In the second synthesis, four studies looking at the medical management of the elderly are the main content. The authors look at the medicines and their management in disasters, as well as their relevance to the elderly.

Synthesis 3

In this synthesis, eleven studies focusing on the psychiatric effects of disasters on the elderly are the focus of the studies. Most of them measured the depression levels of the elderly after a major disaster with some comparing with the results before the disaster with those after.

Discussion

The literature above addresses the impact that disasters such as floods, earthquakes, and tornados had on the elderly population involved, as well as the emergency medical measures put to cope with their injuries. The majority of the findings give attention to the psychological impacts that these disasters had on the elderly patients. However, they also mention the management of medications in geriatric emergencies. Most of them propose a system of delivering the medication to the patients or taking the patients to the medication center. The initial step considered is adequate preparation strategies before the disaster happens. In this plan, all the necessary medications should be stocked with dissemination of information through the media and educational programs on where to get the medication being put in place. The programs available should also be married to ensure the elderly have few intermediaries between them and their drugs during disasters.

Pre-existing physical impairment in the elderly population limits their response to disasters (Imperiale 1991, p.8–10), and this may slow them down in getting to the medication outlets in disasters. A proposal to have a special transport system to deliver medication to the elderly disaster victims is also featured in the literature, and this may be useful in addressing the problem of medication supply. Another proposal to have temporary institutions set up in times of disasters features in the literature review. This would go a long way in easing the access to medication for the elderly victims of disasters. Another limitation to access of medication for the elderly in disasters is the loss of power in multi-story buildings. This means they cannot use the elevators and pump water to their residences (Krause 1987, p.69). The above-suggested strategy may also be used to cope with this issue.

The elderly have few if any sources of income. Most are dependent on their family members, the society, and the government. In the event of disasters, the elderly have reduced chances of getting their desired medication especially if the price is unfavorable (Bolin, & Klenow 1982, p.297). Thus, their medical conditions are likely to worsen. In the literature review, the role of social support for the elderly by their friends, neighbors, and family are emphasized. The role played by aid agencies is also taken into account, and a suggestion for creation of special agencies dealing with the elderly during disasters is given.

In the above review, the importance of the inclusion of mental health drugs in the emergency drug list for the elderly is suggested. In most of the studies that have mainly focused on the psychiatric implications of disasters on the elderly, appropriate mental health conditions management was not considered. This contributed to negative outcomes for the disasters. Therefore, future consideration of mental health in disasters is necessary. In the literature review, the suggestion of temporary medical services for patients with chronic conditions in disaster areas is evident. In this plan, a transport system would be set up to distribute and administer the medication to the elderly.

In the medical management of the elderly in disasters, nutrition is described as part of the medical management of these patients (Meals on Wheels of Central Maryland 2012). A suggestion is made to deliver meals free to the disaster victims especially the weak and those unable to access help centers. In the review, aid organizations are reported to deliver relief to the victims of disasters around the world. The aid agencies should also deliver medication to the elderly population along with food rations.

In the development of policies related to emergency response, more attention should be given to the needs of the elderly disasters. In most of the research done and reviewed above, a common sentiment is that medication management for the elderly is a key pillar of disaster preparedness. It is therefore important to consider the stocking, information distribution and delivery of medical supplies to the elderly in disasters.

Conclusion

In conclusion, the management of medicines for the elderly in the occurrence of disasters is a very important topic of review. In the findings, the elderly are a vulnerable population in the absence of disasters, and the risk is higher when they do occur. In disaster preparedness, therefore, special attention to the needs of the elderly should be a key priority. A consideration that the elderly population constitutes the bulk of patients with chronic illnesses and in dire need of medication is also necessary. When a disaster or emergency takes place, the response has been general with no special program for the elderly. In the above studies, a suggestion is given for special disaster response units dedicated to the elderly population in the society. Aid agencies have been suggested as a major arm of disaster management and that they should be involved in the distribution of drugs to the elderly sick along with nutritional support. In the literature, the development of a system to transport medication to the elderly is noted to be important with previous disasters leading to large losses of the elderly since they cannot access the medical services available at the time. Mobile units for the delivery of drugs are therefore suggested.

Implications for Practice

This review has several implications for the management of medicines for the elderly in times of disaster. As a common principle, the elderly are considered weak and vulnerable with most of them suffering from chronic medical conditions. An implication is that all states need to put in place a sound disaster-preparedness strategy with frequent drills. A proper method of disseminating information to the elderly in the population as to what to do in times of disasters also needs to be taken into account. Past failures in the transport and power distribution systems in disaster times mean that authorities should have special places for storage of emergency medicines in populations with a large number of elderly people especially those with chronic medical conditions and in need of the medicines.

Implications for research

The majority of research included in the review was conducted in the United States with only a few taking place in the developing countries. This is a probable cause of cultural bias in the response to the studies. Disaster response in different countries and cultures varies with the developing nations setting different strategies from those in the developed ones. There is therefore a need for further qualitative research from other countries to account for the cultural bias in the establishment of the best practices for medicines management for the elderly in disasters. In most of the research reviewed, a focus was made on the mental health issues that developed for the patients. The findings were that, despite the high prevalence of depression, PTSD, and other psychiatric conditions after a disaster, there was a limited medication included for these conditions in the list of emergency medicines. In future disasters, preparedness will involve the stocking of antipsychotic medication and other mental health drugs.

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