Impacts of Extreme Weather Conditions and Disasters on Older Adult Health

Welcome and Introductory Remarks

Emerald Nguyen, PhD, NIA

The National Institutes of Health (NIH) Climate and Human Health Initiative launched in early 2022 with the goal of reducing health threats from climate change across the lifespan and building health resilience in individuals, communities, and nations around the world. The core elements of this initiative include supporting health effects research, achieving health equity, supporting intervention science, and enabling training and capacity building. This transdisciplinary approach includes multiple scientific areas, such as behavioral and social science, research data integration, epidemiology, and predictive modeling. In addition to understanding climate events and their health impacts, research-based interventions are desperately needed to help communities understand, prepare for, and recover from climate-related challenges. Importantly, social, behavioral, and environmental determinants of health are key domains that must be integrated into studies of how climate affects human health. This initiative also intends to foster global, cross-sector, interagency, and community partnerships, given the enormity and urgency of the impacts of climate change on human health.

The Director of the National Institute on Aging (NIA) , Dr. Richard Hodes, is one of 11 NIH institute and center directors who serve on the Executive Committee of the NIH Climate Change and Health Initiative , indicating NIA’s commitment to understanding the effects of climate change across the life course. NIA’s core mission is to understand the nature of aging and the aging process, and diseases and conditions associated with growing older, to extend healthy, active years of life. This mission acknowledges that aging begins the moment an individual is born and that exposures during early- and mid-life can impact aging trajectories later in life. NIA supports this research across the fields of genetic, biological, clinical, behavioral, social, and economics research. As one of four NIA divisions, the Division of Behavioral and Social Research (BSR) supports social, psychological, economic, and behavioral research on the processes of aging at the individual and population level. Cross-cutting themes include understanding and addressing health disparities, the life course perspective on aging processes, and biobehavioral and biosocial integration. Along with the other three NIA divisions, BSR also focuses on understanding the impacts of Alzheimer’s disease and Alzheimer's disease-related dementias (AD/ADRD) on individuals, their caregivers, and their communities.

NIA funding priorities are informed by strategic directions, goals, and milestones, some of which are relevant to climate change and others name understanding the impacts of climate on aging as a main priority. Goal B of NIA’s Strategic Directions names understanding the effects of personal, interpersonal, and societal factors on aging, and Goal F prioritizes understanding health disparities to improve health of older adults in diverse populations. In addition, NIA’s AD/ADRD milestones and BSR’s National Advisory Council Review both explicitly call for climate change as a priority research area. Recent NIA activities further demonstrate its commitment to climate and health research. In 2022, NIA and the National Academies of Sciences, Engineering, and Medicine (NASEM) hosted the Consequences of Climate Change for Health at Older Ages seminar , and during the NIA Division of Neuroscience 2023 workshop, Future of Population-Based Studies in AD/ADRD, one theme for future research was centered on specifically addressing climate change adaptation strategies to slow age-related cognitive decline. NIA is also a member of the National Advisory Committee on Seniors and Disasters under the auspices of the Administration for Strategic Preparedness and Response (ASPR) within the U.S Department of Health and Human Services (HHS).

NIA also supports the development and maintenance of publicly available, harmonized datasets. The Health and Retirement Study (HRS) includes a nationally representative cohort within the United States and has companion studies in over 40 other countries, known as the HRS International Family of Studies . HRS collects venous blood samples as well as information on study participant demographics, cognition, family structure, housing, job status and history, and health care use and costs. NIA is also expanding data infrastructure to include environmental measures, like the Gateway to Global Aging Environmental Exposome , to facilitate U.S.-based and cross-national studies. Current NIH funding opportunities include a Notice of Special Interest for research on climate change and health ( NOT-ES-22-006 ) and a Notice of Funding Opportunity titled “Long-Term Effects of Disasters on Healthcare Systems in Populations with Health Disparities” ( PAR-24-109 ).

Questions that guided subsequent workshop discussions are outlined below:

• What are the current scientific advances in understanding older adult health impacted by climate events, and what are the drivers of health inequities?
• What individual, community, and systems-level resources and strategies are needed to protect older adults before and after extreme weather events and disasters?
• Social and behavioral data availability – what resources and training do the research community need to conduct aging and climate research?
• What does successful multidisciplinary and transdisciplinary research look like, and what are challenges to achieving highly integrated research collaborations?

Deborah Carr, PhD, Boston University

Interdisciplinary collaboration in the study of climate change and aging can help advance and foster expansion of the field to include subject matter experts with distinctive perspectives and approaches. Including a variety of academic disciplines and subspecialties can improve data collection, analysis, and translation. Dr. Carr is a social scientist who has primarily studied aging but was introduced to the study of climate health through a project focused on population aging and heat exposure launched in 2023. Collaboration with climate researchers introduced Dr. Carr to climate change projection models and allowed her to contribute her expertise on aging. Recent efforts by social gerontologists such as the newly formed Gerontological Society of America’s (GSA) Climate Change and Aging interest group, the 2024 special issue of The Gerontologist on climate change and aging, as well as the influential 2022 United Nations and Pan American Health Organization (PAHO) Decade of Healthy Aging report have highlighted the importance of research on the confluence of climate change and aging.

Scholars of aging can provide deep knowledge of older adult’s health vulnerabilities, social networks, family structures, housing arrangements, economic (in)security, and migration and retirement patterns to highlight the ways in which climate change affects older populations. Family demographers, social workers, and gerontologists can leverage their expertise in family structures, housing arrangements, social integration or isolation, cognitive processes, and stress adaptation. In addition to disciplinary variety, diverse global research and perspectives can highlight data gaps in the Global South and the impact of climate change on older adults in the world’s most vulnerable regions.

Deborah Balk, PhD, CUNY

Since the start of the 21st century, both the percentage of the population and number of adults over the age of 65 have increased worldwide. Especially in parts of the Global South where infrastructure and government support for public health is poor, there is an increased burden on family and support networks. Older populations are also more likely to live in concentrated urban areas (which are disproportionately exposed to climate-related hazards) as global urbanization continues to increase, which will impact disaster responses, including the available workforce for recovery efforts. This urbanization will likely continue as people migrate to cities for many reasons, among them to avoid declining rural livelihoods impacted by climate change. The climate of the 21st century has also experienced significant change, with rises in global temperature and increases in the frequency and intensity of climate events such as storms, droughts, floods, sea level rise, and wildfires.

Major gaps still exist in the knowledge base of climate and aging research. While climate researchers have a strong understanding of the factors that make some populations more vulnerable to climate change, much of the current work insufficiently addresses aging and older adults. Existing datasets lack sufficient representation of historically understudied populations in climate health and aging research, such as older adults with cognitive impairments, immigrants, and the LBGTQ+ community. There is also a dearth of information on the causes of climate exposures and the unique impacts of exposures on older adult’s health. For example, how extreme heat affects older adults and what factors contribute to vulnerability to high heat remain unsettled. Most knowledge of exposure in the discipline focuses on extreme heat, but other climate events, such as air pollution from wildfires, require further study. Available climate data have both temporal and spatial scales that are largely incompatible with many health or demographic datasets, making data integration challenging when examining more than a single location or time period (as is often the case in socio-behavioral health research). In addition, researchers typically do not connect biophysical mechanisms of exposure with social mechanisms. Climate researchers have developed several frameworks that address the interactions between climate and health, aging and health, as well as environment, health, and aging. However, no frameworks currently examine the confluence of climate change, health, and aging. Lastly, much of the climate, health, and aging knowledge base is related to the direct impacts of climate events and disasters, with little study of long-term effects. Older adults have not typically been a focus of long-term studies of heat and sea-level rise and the role of migration and family demographics in the long-term impacts of climate change are not well understood.

Dr. Balk echoed Dr. Carr’s emphasis on interdisciplinarity and building bridges between different disciplines. A multidisciplinary or multi-perspective approach to studying climate vulnerabilities can also benefit climate health research. Climate vulnerabilities in older adults often have a wide variety of biophysical, social, economic, cultural, and equity factors that require a diverse set of data measures to examine. In addition, there is a need for more data on the impacts of climate vulnerabilities of older adults before the age of 65 to inform an understanding of climate-related health effects across the life course. Interdisciplinary approaches, while only necessary in some cases, can be useful for many climate health studies, especially as more datasets become available. Collaboration between producers of data and researchers analyzing it can inform which measures are included in a study as well as ways to improve future research.

The disciplines included in an interdisciplinary study are often dependent on the specifics of the case at hand. Social and behavioral scientists may collaborate with climate scientists, engineers, land use specialists, oceanographers, hydrologists, and ecologists, depending on the context of their study and its needs. Further echoing Dr. Carr, Dr. Balk noted that social and behavioral scientists who study climate change will also likely need to enlist experts in demography, sociology, economics, public health, gerontology, and geography. She further illustrated that interdisciplinary studies will likely take longer to complete and encouraged collaboration in small groups that carefully and deliberately unpack research questions, data traditions, and research assumptions. Attending conferences and workshops outside of one’s discipline can also expose researchers to input and perspectives from interdisciplinary sources.

Session 1: Behavioral and Social Mechanisms

Session 1: Behavioral and Social Mechanisms Linking Climate Exposures to Short- and Long-Term Health Outcomes

Global Population Aging and Heat Exposure in the 21st Century: Implications for Late-Life Well-Being and Policy

Deborah Carr, PhD, Boston University

High temperatures, especially for long periods, can have pronounced effects on older adults, who are particularly vulnerable to heat due to underlying health conditions, medication side effects, and age-related biological changes. Dr. Carr’s research seeks to identify regions, or “hotspots,” where population aging and rising temperatures intersect and place high numbers of older adults at risk of heat exposure, and to tailor interventions to specific areas based on the relative contributions of rising temperatures vs. rising populations of older adults to aggregate-level exposures. Dr. Carr presented maps depicting current and projected daily average and maximum temperature, the proportion of the population over age 69 years, and the aggregate exposure of older adults to extreme heat (represented by the proportion of the population over age 69 years overlayed with measures of average temperature and exposure to heat). Based on these maps, regions that are currently old and getting hotter in the Global North, as well as regions that are currently hot and getting older in the Global South, are likely to experience pronounced health impacts of aging and rising heat. Dr. Carr noted that different interventions may be needed in these different areas. Communities with large populations of older individuals may be equipped to address aging issues but need to develop interventions, such as improved cooling systems, to address the impact of rising heat on older adults. Regions with already high temperatures but increasing population age will need to address the impacts of advanced aging, including expanding their health care workforces and messaging tailored to older populations.

Impact of Population Aging on the Health Impacts of Climate Change

Kai Chen, PhD, Yale University

Population aging can amplify health impacts of climate change, and as the global population ages and temperatures worldwide increase, the field of climate epidemiology seeks to understand the relationship between aging and the health impacts of climate change. Dr. Chen illustrated that population age, baseline rates of health outcomes, expected change in exposure to climate change, and epidemiological exposure-responses (i.e., the link between the exposure and the climate-sensitive health outcomes) all influence the overall health impact of climate change. Older adults are more vulnerable to climate-related health risks and experience a higher rate of poor health outcomes due to climate change, thus future calculations of the health impacts of climate change should incorporate age-specific exposure-response functions. Although extreme cold and heat result in higher mortality rates, moderate cold and heat contribute to a higher overall mortality burden because moderate temperatures are more common. Climate change and rising temperatures also cause higher levels of ambient ozone concentrations, which are associated with high levels of mortality among older adults.

The Confluence of the Exposome, Extreme Weather, and Demographics in the Aging Population

Chirag Patel, PhD, Harvard University

Studying the confluence of the exposome, extreme weather, and demographics in the aging population requires advanced informatics resources. To assess the impacts of extreme heat and cold weather events on the aging process and AD/ADRD trajectories, in particular, researchers need (1) methods of phenotyping older adults who are at risk of or currently undergoing cognitive decline based on their medical records as well as (2) detailed longitudinal geospatial mapping of temperatures across the United States to characterize weather- and climate-related exposures. As part of an interdisciplinary team, Dr. Chirag Patel has addressed the first challenge by developing and testing multiple analytic scenarios for using Medicare and electronic health record (EHR) data to detect cases of AD/ADRD. Because Medicare claims are a specific but not sensitive dataset on AD/ADRD, the team has worked to improve sensitivity by developing a method that uses multiple Medicare claim and EHR data points over time to detect cases. To address the second challenge, Dr. Patel’s group has developed GridEX, which contains high-resolution maps of extreme heat and cold temperature events from 2008 to 2022, based on time-series data of daily temperature values from the NOAA Integrated Surface Dataset and Exposome Data Warehouse. Dr. Patel’s team mapped the spatial boundaries of extreme heat events using two methods—a nearest temperature station model and a spatial interpolation model. Spatial interpolation was significantly more accurate, and the resulting data, along with analogous data for extreme cold events, are available from the Confluence Project website. Another useful tool is GraphCast, which is an artificial intelligence-based model for faster and more accurate global weather forecasting compared to traditional methods.

Because phenotypes are ultimately a function of genotypes and relevant exposures, Dr. Patel’s group has examined twin and sibling dyads to characterize a complex exposomic architecture of individuals with the same disease of interest; these individuals had a large proportion of non-shared exposomic factors. Further integration of exposomic data across domains will enable more detailed exposome-wide association studies (ExWASs) to identify clusters of modifiable and non-modifiable exposures associated with specific diseases. Dr. Patel will conduct ExWAS analyses at pre- and post-climate-related event timepoints to assess how these exposures are associated with certain AD/ADRD trajectories.

Migration as a Driver of New Orleans Population Change, 2004-2017

Elizabeth Fussell, PhD, Brown University

Migration after a disaster caused by extreme weather events can exacerbate or mitigate health outcomes, yet little research exists on demographic differentials in post-disaster population mobility over multiple years. Dr. Fussell’s research focused on the repopulation of New Orleans after Hurricane Katrina, which was mainly due to residential mobility. Fussell examined the American Community Survey (ACS) data for New Orleans between 2004 and 2017 to measure differences in the probability of in- and out-migration by race and age group. Dr. Fussell found that, while residential mobility was elevated for everyone in the post-disaster period, older adults were comparatively less mobile than young and middle-aged adults, as they are in general. However, non-Hispanic Black older adults were twice as mobile as older adults of other races and ethnicities. While measures of health outcomes are not available in the ACS, elevated levels of residential mobility among older adults are likely to be associated with poorer mental and physical health and disruptions in health care.

Discussion

Ideal Retrospective Data

When studying the effects of extreme weather and climate change on older individuals, building a sufficient counterfactual for understanding the current effects of climate change requires retrospective data. Panelists agreed that combining retrospective residential, exposure, and health outcome data would enable researchers to examine the effects of exposures, including exposures to extreme weather, on health outcomes over the life course. In addition, longitudinal residential data would allow researchers to assess whether residential histories and associated exposures—including duration of heat exposure or migration to a region where one is unaccustomed to the local climate—can influence an individual’s resilience to the effects of extreme weather. Social networking, voting patterns, and green consumption behaviors among older adults can provide important information about behavioral adaptations to climate change. While combining historical residential, exposure, and health outcome data can enable rich data analysis approaches to understand the impacts of climate change, one panelist noted these activities should be undertaken with caution, as this combination of data is highly sensitive and can threaten data privacy.

Measuring Resilience to Extreme Weather

Resilience among older adults can be measured with a variety of methods, and the research field needs to define specific measures of resilience among older adults exposed to extreme weather. Potential measures include cognitive assessments and specific fluid biomarkers.

In addition, various factors can affect an older individual’s resilience to extreme weather. For example, higher socioeconomic status (SES) may be a key factor that reduces a person’s risk to the negative impacts of extreme heat. The panelists emphasized that incorporating SES data into studies of health impacts of climate change could help inform strategies to reduce future risks of negative health impacts of climate change on older adults. However, panelists also noted that individual characteristics alone may only capture a limited scope of factors that contribute to resilience, as housing, neighborhood, geographic and ethnic population-level resilience factors can also impact resilience.

Session 2: Climate-Related Vulnerabilities

Session 2: Climate-Related Vulnerabilities Associated with Inequities in Mid- and Later-Life Health and Wellbeing

Aging in Precarious Place: Older Adult Climate Beliefs and Social Infrastructure Needs

Alexis Merdjanoff, PhD, New York University

A rising number of older adults live in areas with high risk of disasters and extreme weather and are vulnerable to the effects of climate events on their health, mobility, and social structures. Older adults are also the least prepared age group for natural disasters and are considered the most at-risk age population during all phases of a disaster. To identify necessary social resources and community supports for reducing the vulnerability of older adults during extreme weather events, Dr. Merdjanoff collected data from older Americans on their exposure and resilience to disasters, perceptions of climate change, and willingness to make climate-related adaptations in their lives. She used Social Science Research Solutions to assist with study recruitment. A large percentage of older adults believe that climate change caused by human activity will harm future generations, and many are willing to make climate-related changes in their lives and support government investment in renewable resources. This data conveys that older adults are underrepresented in climate change movements, despite a willingness to engage in climate activism and support for climate-related resources in their communities. To understand the role of climate risks in an older person’s choice to age in a place, Dr. Merdjanoff is currently conducting a study of older Floridians who experienced Hurricane Ian in 2022. Study recruitment efforts were comprised of phone calls, emails, and letters to known older adults in the area. The study will follow up with respondents over the next five years to examine recovery among older adults, effects of disaster risk on their decisions to age in place, and climate policies and social infrastructure supports in vulnerable communities. Interviews with older adults in Southwest Florida conveyed that accessible and affordable homeowner’s and flood insurance and proximity to family support systems have key impacts on older adults’ decisions to age in a place, and most wish to live independently in at-risk places because of existing community support services and preferable weather. Social infrastructure, such as non-profit groups and public social spaces, can serve to mitigate the effects of extreme weather and promote the building of social connections and networks to assist vulnerable older adults. Social infrastructure does not receive as much funding or awareness as physical infrastructure like levies and bridges, but these resources are also important for the safety of older adults in vulnerable areas.

Impact of Climate Change on Mortality: The Multiethnic Cohort Study

Iona Cheng, PhD, University of California – San Francisco

Although a significant amount of literature has examined the short-term impacts of climate change, far fewer research studies have investigated the long-term health effects of extreme temperature and weather. To better understand the long-term effects of extreme temperature in Los Angeles County, Dr. Cheng’s study aimed to (1) identify the effects of long-term extreme heat and air pollutants on mortality in older adults from predominately Los Angeles County and (2) identify potential biological pathways such as DNA methylation and epigenetic age by which extreme heat and wildfire smoke may operate. The study uses data from the Multiethnic Cohort (MEC), a population-based study of a racially and ethnically diverse set of residents predominately from Los Angeles County alongside extensive residential history information to map environmental exposures and assess their differential health effects across racial and ethnic population groups.

Dr. Cheng and team found statistically significant associations of increased daily average maximum temperature with all-cause and cardiovascular-specific mortality. These patterns of associations were seen for African American/Black, Japanese American, and Latino adults as well as adults residing in low SES neighborhoods. In contrast, no associations were observed among White adults and those residing in high SES neighborhoods. Dr. Cheng noted that this study was limited by a lack of information on work locations or residential history prior to enrollment in the MEC. Future research will examine the association of additional climate exposures with mortality and life expectancy as well the impact of climate exposures on DNA methylation and epigenetic age. Finally, identifying vulnerable subgroups within the MEC and building partnerships with policymakers and communities can help develop and promote solutions to the long-term impact of extreme heat and climate exposures.

Have Extreme Flooding Events Affected Older Population Health in Coastal Indian Cities? Is There a Protective Role for Multigenerational Family Households?

Michael S. Rendall, PhD, University of Maryland

Global climate change has contributed to a large rise in extreme flooding events in India over recent decades. Across India, the annual number of severe flooding events has more than doubled since 1985. Two Indian cities, Mumbai and Kolkata, are projected to be the world’s two largest in their population exposure to coastal flooding by 2070. Dr. Rendall’s research used the Indian Human Development Survey (IHDS) to assess the effects of extreme flooding on older adults in India’s four largest coastal cities and the role of multi-generational households and family support networks in the health of older Indian adults in those cities. Several previous studies using data from the IHDS found that living in multigenerational family homes was associated with higher overall wellbeing and health among older adults. Dr. Rendall reviewed studies of the health impacts of coastal flooding on older adults during events such as the Indonesian Tsunami of 2004 and Hurricane Katrina to identify structures and resources that could be investigated to better understand and potentially mitigate older-population vulnerability in Indian cities and other urban areas. Older adults in the aftermath of the 2004 Tsunami were vulnerable to the high rates of forced mobility, which is directly associated with a high risk of disability among older adults. Older individuals affected by the 2004 Tsunami in different study sites across South and Southeast Asia saw reduced mortality if they lived in multigenerational households compared to those who did not, and those who lived in permanent housing structures experienced half the mortality rate of those in non-permanent housing. However, remaining with the family unit immediately following an extreme coastal flooding event has been shown to be difficult in some contexts, such as Hurricane Katrina, when people experienced high rates of separation from families.

Finally, Dr. Rendall presented results from his own recent study using IHDS data in which he examined disability acquisition over a seven-year period among older Indian adults exposed to extreme flooding events in India’s four largest coastal cities in 2005-2007. He used similar IHDS data from the five largest inland Indian cities as a control. Living in a flood-impacted coastal city resulted in an increased likelihood of disability acquisition, and individuals in a single-generation household also experienced high rates of disability. The study also found that marital status impacted rates of disability acquisition, as unmarried or recently unmarried people experienced higher rates of disability than those married continuously. Older adults with a chronic illness were another subgroup that was far more likely to develop a disability. Future research on the health impacts of coastal flooding should examine the likelihood of forced mobility and household breakup during urban coastal flooding events as well as the potential health impacts of household moves.

Conceptualizing and Measuring Climate Vulnerability

Brian Thiede, PhD, Pennsylvania State University

Climate vulnerability is often used to examine the relative risk of a population to negative health outcomes of climate change, but defining disparities in climate vulnerability and identifying indicators of vulnerability is highly complex. Vulnerability has had an inconsistent definition in climate research but in the context of extreme weather events can be informed by three aspects: risk of exposure, risk of inadequate capability to cope, and the risk of suffering consequences or experiencing slow recovery. While these three aspects imply a longitudinal perspective to vulnerability to extreme weather events, those at high risk for one aspect may not be at high risk for the other two aspects. In addition, much social science research around vulnerability to climate change usually focuses on just one or two of these three aspects of vulnerability.

A wide range of social and geographic factors are hypothesized to shape vulnerability to climate change, but the evidence about these disparities in complicated. In lower- and middle-income country (LMIC) contexts, rural populations are often believed to be most vulnerable to the effects of climate change due to various factors including poor infrastructure, low income, and dependence on agriculture, which can be impacted greatly by climate shocks. However, empirical evidence, such as Dr. Thiede’s examination of data from more than 50 health surveys worldwide, suggests that the differences in indicators of rural and urban climate change vulnerability are often less significant and much less consistent than commonly believed. This discrepancy may be due to differing mechanisms by which climate change impacts urban and rural communities, migration patterns or social linkages between urban and rural populations, and varied definitions of rural versus urban communities.

Current challenges for future research on climate change vulnerability include a lack of vulnerability measures in many large-scale datasets, complexity in interpretations of patterns of vulnerability, and inherent population heterogeneity. Importantly, determinants of vulnerability may not be universal across contexts, and sometimes, the most vulnerable populations are excluded from some existing datasets. Future research on climate vulnerability should use existing longitudinal datasets, data reduction techniques, and mixed methods research to improve interpretations of census and survey data. Overall, climate researchers should consider how vulnerabilities change over time and how populations accumulate multiple vulnerabilities.

Discussion

Similarities and Differences in Climate Vulnerability in Older and Younger Adults

While both younger and older adults experience forced relocation due to climate change, relocation can have more negative impacts on the health of older adults due to their lower mobility. Middle-aged adults also experience climate vulnerability differently; people with elderly parents, college-aged children, or who are near retirement age tend to feel the brunt of climate change impacts but are often underrepresented in studies of these effects.

Vulnerability Factors Among Diverse Population Subgroups

Climate vulnerability researchers should more closely consider intersectional factors when examining the health impacts of climate change on racial and ethnic subgroups. Incorporating education, location, occupation, neighborhood context, and socioeconomic status alongside race and ethnicity could allow for more precise identification of vulnerable subgroups. However, researchers need more advanced analytical methods to sufficiently analyze these smaller subgroups, whose sample sizes are often too small for traditional analytic methods.

Potential Assets for Adaptation Among Vulnerable Populations

Improvements to physical housing structures and the development of migratory networks are some of the strategies vulnerable populations employ to adapt to climate change. Examining strategies such as these in studies of climate vulnerability can allow for further understanding of how vulnerability can change and develop. In addition, the panelists highlighted the need to characterize potential assets for mitigating the effects of climate change in a manner that appeals to the social and political character of the population. Some panelists suggested that researchers and policymakers also need to better understand how to frame assets that can help more conservative communities who may have a negative view of public climate change efforts or government support services.

Session 3: Behavioral and Social Measures

Session 3: Behavioral and Social Measures and Data to Facilitate Aging and Climate Research

Behavioral and Social Measures and Data to Facilitate Aging and Climate Research

Deborah Balk, PhD, City University of New York

Demographic and climate data are typically collected and structured in distinct ways, posing challenges for data integration and studies of the impacts of climate change on health outcomes. Demographic data (such as surveys and health administrative data) have coarse geographic resolution; use table, polygon, or point format; and follow an annual to decadal temporal cadence; climate data range more widely in geographic resolution from fine to coarse; use raster or point format; and follow a sub-hourly to annual cadence. Moreover, both climate and demographic data may have important gaps: climate data may indicate the presence of stressors without measuring actual exposure to them, and important dimensions of biophysical, social, economic, and cultural vulnerability to climate events are often missing in demographic data (e.g., data on thermoregulation) or not available across the life course.

To overcome these challenges, Dr. Bak has conducted several studies that integrate multiple data types to assess population growth in low-elevation coastal zones (LECZ) likely to experience extreme weather. One study used three decades of U.S. Census data to determine that older adults disproportionately inhabit LECZ and at increasing levels: 15% of the LECZ population is over 65, compared to 12.5% outside LECZ, with an even wider gap for urban LECZ (15%) versus non-urban LECZ (12%); the number of older adults in LECZ increased from 3.7 million in 1990 to 4.7 million in 2010. Another study of heat-related mortality combined historic temperature data, mortality data with heat coding from the ICD-9 and ICD-10, population data, and vulnerability and adaptation measures to determine that the threshold at which heat is associated with increased mortality varies by location and that poverty is a more important driver of mortality than population age. Future research should expand on these efforts by continuing to think spatially (e.g., adopting meaningful geocoding principles and considering data resolution); being age-inclusive (e.g., oversampling older adults and considering specific challenges relevant to older populations); responding rapidly to climate events (e.g., forging partnerships between data collectors and relief workers); and using alternative data collection methods (e.g., designing longitudinal studies of causation and integrating new technologies).

The Impacts of Wildland Fires on Adult Health in the US

Yang Liu, PhD, Emory University

Climate change and an expanding interface between urban areas and wildlands have led to longer wildfire seasons, larger wildfires, and more population exposure to wildfires. The health impacts of wildfire exposure are likely to differ from the health impacts of ambient air pollution and require focused research to define exposures, associated health risks, and vulnerable populations. To begin to address these questions, Dr. Liu presented three case studies of the health impacts of various levels of acute and chronic wildfire exposure.

The first study examined acute wildfire exposures. Using a case control study of 1.9 million emergency (ED) visits in 5 Western states, Dr. Liu found that 48-hour average exposure to wildfire smoke with particulate matter of 2.5μg (PM2.5) and to major fire events were associated with an increased risk of ED visits for anxiety disorders, with a larger impact of smoke exposure on females and older adults. The study identified two pathways for these health impacts: direct smoke inhalation or the psychological impact of smoke plumes. The second study examined sub-chronic wildfire exposures. This cohort study found that patients with wildfire exposure between 0 and 3 months after lung cancer surgery had a 46% increase in risk of mortality, declining to a 17% increased risk for exposure 7 to 12 months post-surgery. The size of the effects of wildfire exposure compared to effects reported in studies of air pollution suggest that wildfire exposure is supplemented by a compound exposure, such as polluted air, water, and soil, or negative mental health. The third study examined chronic smoke exposure. This open cohort study of Medicare recipients from 2007 to 2018 found that long term exposure to smoke PM2.5 increased dementia risk; that the association was stronger for people without comorbidities; and that risk accumulated over time. By contrast, the health impacts of ambient air pollution were stronger in those with comorbidities and did not accumulate over time. Collectively, these findings show that wildfires are linked to a variety of adverse health outcomes and that their multifaceted impacts vary based on disease endpoints and populations. Further research is needed to explore this variability.

The Potential of Large-Scale Population Data for Aging & Climate Research

Sarah Flood, PhD, University of Minnesota

Incorporating large-scale population data from sources such as censuses and surveys with climate data could improve the study of climate and aging. In particular, although most climate and aging research focuses on downstream health outcomes such as hospitalization and death, large-scale population data can capture the heterogeneous ways in which older adults adapt their behavior in response to extreme weather and enable study of these behavior changes as pathways through which multilevel social determinants of health can create unequal health outcomes. Dr. Flood presented her integration of (1) time use data from the American Time Use Survey (ATUS) and (2) temperature data from GridMet as a lens onto the opportunities and challenges of this approach. The ATUS collects 24-hour diaries of individuals’ daily activities and behavior with a high level of detail on timing, location, and contact with others. When matched to GridMet data on maximum and minimum temperature, humidity, precipitation, and other weather characteristics, the ATUS can be analyzed for climate-influenced behavior, such as time spent indoors vs outdoors and selection of activities at different times of day.

This data matching approach offers several advantages. The availability in the U.S. of a wealth of large-scale population data and of temporally and geographically precise weather data enables researchers to overcome sampling challenges and to identify weather-related behavioral patterns that might require decades to identify through longitudinal studies. Using this approach successfully, however, also requires overcoming several key challenges. First, researchers must determine what time scales matter for weather-related behaviors (e.g., a specific day, time during the day, day during a heat wave, etc.). They must also resolve differences between the geographic resolutions of time use data on the one hand, which is available at the county level, and climate data on the other hand, which has higher geographic resolution; these differences can make it challenging to estimate the effects of exposures in coarse geographies with a great deal of heterogeneity. Several ways to overcome this “coarse geography” challenge include promoting access to smaller geographic units (e.g., through a federal statistical data center) and fostering multidisciplinary collaborations between health and environmental researchers.

Introduction to the Climate Change and Health Research Coordinating Center (CAFÉ)

Kevin J. Lane, PhD, Boston University

The Climate Change and Health Research Coordinating Center (CAFÉ), a part of the NIH Climate Change and Health Initiative, aims to accelerate climate change and health research and translation by supporting and growing a network of researchers and community partners in a Community of Practice (COP). The COP encompasses more than 2,000 members who are professionally interested in climate and health, including academic researchers, health care practitioners, government agencies, non-governmental organizations (NGOs), funding agencies, community organizations, and industry partners, among others. CAFÉ’s activities focus on convening COP members, accelerating their research through access to tools and resources, fostering communication and collaboration, and expanding participation in the multidisciplinary community. One of CAFÉ’s key goals is the development of data management resources to foster data sharing and reuse and facilitate implementation of the NIH Data Management and Sharing Policy released in January 2023. These resources include common data elements as well as data science and software tools for processing, linking, and analyzing climate change and health data. CAFÉ hosts a searchable repository of synthetic and publicly available datasets that follows FAIR principles, as well as a community GitHub that provides R and Python code, accompanying tutorials, and an NIH Data Management and Sharing Policy template. Beyond data management resources, CAFÉ also posts on its website free or low-cost training materials and resources related to climate and health research; supports a pilot award program to fund research projects; and organizes annual conferences, a virtual collaboration channel, networking events, a mentorship program, and webinars and workshops.

Session 4: Reflections on Day 1 Sessions and Discussions

Key Data Measures and Linkages

While there are many useful data sources, measures, and pathways shared among climate and health researchers that can be used to evaluate the health impacts of climate change, panelists agreed that these types of measures should be categorized to discern between direct and indirect effects of extreme weather events as well as different pathways that reveal how different types of extreme weather events affect human health. Further study of the indirect pathways through which extreme weather events and climate change affect human health outcomes can provide researchers with more comprehensive data on the full spectrum of climate impacts on health. Researchers should also consider the interactions between multiple extreme weather events and their compound effects on human health. Some panelists added that climate events such as high heat and wildfires can have enhanced health effects when they occur simultaneously, and sequential events like floods following a drought can have stronger effects than they would have exhibited on their own.

Gaps and Barriers to International Research and Collaboration

While health surveys of LMICs are important data sources (e.g., the Demographic and Health Surveys [DHS] supports the collection of data from LMICs funded by the U.S. Agency for International Development), data from these surveys lacks information on the health statuses of older adults, especially from countries in the Global South. The global companion studies to the HRS that comprise the Gateway to Global Aging platform (e.g., SHARE, ELSA), for example, lack data from large parts of Africa and South Asia. Expansion of surveys such as HRS and DHS to include additional countries and questions relevant to caregiving and health of older populations could facilitate a stronger understanding of the health impacts of climate change worldwide, particularly in LMICs. However, because of the sheer length of these surveys, adding more questions will require a strong rationale as not to increase respondent burden.

U.S.-based researchers and institutions can provide computational support and data infrastructure, such as access to cloud-based computing, for LMICs that lack such infrastructure. U.S.-based researchers should also build and maintain relationships with researchers, policymakers, and organizations from LMICs to increase diversity of study teams and facilitate the use of research findings to inform interventions. Additional funding specifically for research in LMICs could encourage collaboration with researchers from LMICs and the formation of international partnerships and networks. Although relatively few international research efforts receive NIH funding, NIA has discussed the need for collaborative global infrastructure, support, and funding. At the same time, local researchers must take the lead in driving international research collaborations so that the process is not directed by contributors from wealthy nations.

Political Variables in Climate Change Analysis

Political affiliations and ideologies can shape climate change awareness and responses, especially in states such as Florida where recognition of climate change has not been a major factor in state policy. Therefore, climate researchers need to emphasize community-level solutions and programs that transcend political boundaries. A potential approach to climate change awareness in areas that do not recognize climate change politically or have well-developed climate action plans is to emphasize the consequences of climate change, such as such as housing, hunger, and health. This approach avoids politicizing social service programs and focuses on the tangible impacts of climate change on individuals in their daily life, such as health status and food security. Researchers should also be attentive to the policy space related to climate change and relief and resources provided by non-federal entities (e.g. non-profits, local and state governments) to understand existing resources, how adaptations and mitigation strategies are implemented at different levels, and how they affect a population. Examining the role of non-climate specific policies, such as social protections and poverty assistance, can also help researchers assess the impact of such policies on climate shocks.

Meeting participants acknowledged that climate change research may have limited impact on policy decisions if that research directly or indirectly contradicts the political views of a party in power at a given time.

Implementation of Mixed Methods Research

The panelists agreed that supplementing longitudinal surveys with qualitative data, such as interviews or surveys of members of a population, can provide additional context to survey results and foster greater understanding of how the impacts of climate change affect individuals and their decision making. Interviews and focus groups can also help explain, interpret, or contextualize data points from conventional surveys that seem to be outliers. For example, NIH funded the Resilience in Survivors of Katrina Project, which employed these mixed methods approaches to understand the effects of Hurricane Katrina. More in-depth interviews of carefully chosen subpopulations of a study cohort can provide additional explanations and qualitative data that explain patterns in other data types. In addition, stratifying respondents by age or other salient factors such as income level can provide key contextual information. Panelists added that including measures that incorporate temporal effects of climate exposure can also add to the long-term understanding of how climate change impacts health over time. Qualitative methods such as focus groups can also gather feedback on the study and identify gaps in methodology.

The Impact of Pre-Existing Health Conditions on Climate Health Effects

Stratifying climate exposure data by preexisting health conditions or medication needs can provide additional information on the health impacts of climate change on specific groups of individuals. For example, differentiating by medication intake can identify certain medicines that can exacerbate risks to climate events such as high heat. Medications like beta blockers can impair certain bodily functions, regulation, and affect body temperature.

Different Approaches to Assessing Temperature

Exposure to extreme temperature and its health effects is often measured using absolute temperature, but phenomena such as climate acclimatization can impact how individuals respond to extreme weather. In multi-location studies, the same absolute temperature can have different impacts on populations depending on their level of adaptation to the climate. The panelists recommended using relative or scaled temperature and temperature percentile data to better assess the impacts of temperature on certain populations. This is especially important given high levels of migration among retirees, often from historically cooler northern regions to historically hotter southern regions. Several panelists identified the need to increase available funding for multi-location studies and suggested that international consortia conducting large-scale global research could also supplement the ways researchers assess and measure temperature.

Differences in Mortality from Cold and Heat

Cardiovascular disease and respiratory illness play a large role in the mortality rate of extreme heat and cold, however other health impacts such as mental disorders and suicide mortality are often associated with only extreme heat. Certain diseases and disorders may only exacerbate mortality due to one temperature extreme but not the other.

Day 2 Welcome

Day 2 Welcome and Introductory Remarks

Emerald Nguyen, PhD, NIA

Dr. Nguyen welcomed meeting participants to the second day of the workshop. She re-summarized NIH and NIA’s research priorities for understanding the impacts of climate change and extreme weather on human health, particularly for older adults, who are especially vulnerable to these effects. She also summarized Day 1 presentation and discussion themes, outlined below:

• Bringing together various research disciplines and methods can help overcome data challenges and foster multidisciplinary research.
• Maximizing retrospective data and being purposeful about prospective data collection is critical for future research.
• Making data widely accessible and in usable formats, as well as training researchers on analysis methods can benefit the field overall.
• Increased cross-national and global research on the impacts of climate change requires additional capacity building.
• Research on health impacts of climate change and extreme weather events should focus on other health outcomes in addition to mortality.

Elizabeth Frankenberg, PhD, University of North Carolina – Chapel Hill

Climate drivers (e.g., fires, drought, flooding, precipitation, sea level rise, intensifying storms, etc.) result in exposures that influence both immediate and long-term behavioral responses and health outcomes. These responses are eventually incorporated into preparation and adaptation behaviors for future exposures to these climate drivers with the aim of reducing future negative outcomes. Understanding these responses, adaptations, and health outcomes requires a multidisciplinary approach, which can inform development of interventions that can reduce risks of poor health outcomes.

Dr. Elizabeth Frankenberg outlined key research questions related to climate drivers and future approaches to mitigate negative outcomes:

• How can we measure climate drivers?
• How can we model changes in these climate drivers over time?
• How do exposures to these climate drivers affect ecological, biological, and physiological systems in the short- and long-term?
• What engineering, architectural, biomedical, and policy approaches for mitigating negative effects of climate drivers can be tailored for older adults?

Dr. Frankenberg discussed the research infrastructure that supports social science approaches to understanding climate change and health, including the importance of population representation (though not necessarily at the national level), measuring exposure to climate change, assessing exogeneity relative to other drivers of population health, and attention to creative interventions and rigorous evaluations of them.

Sue Anne Bell, PhD, FNP-BC, FAAN, University of Michigan

The effects of climate change continue to worsen; 2023 was the hottest year on record with 28 billion-dollar disasters. During climate- and weather-related extreme events, those who already have limited access to health care are especially vulnerable to negative health effects. To protect the most vulnerable, society urgently requires a deeper understanding of behavioral, organizational, social, and political factors that affect equitable access to effective delivery of high-quality health care during extreme weather events. Both the NIH Climate Change and Health Initiative Strategic Framework and Horizon Europe are working to tackle climate change issues and how they impact health.

Dr. Sue Anne Bell outlined some important extreme weather event resources and activities. The National Advisory Committee on Seniors and Disasters (NACSD) provides advice and recommendations to the Secretary of Health and Human Services. NACSD includes representatives from the Federal Emergency Management Agency (FEMA), Centers for Medicare and Medicaid Services (CMS), NIA, Veterans Health Administration, and Administration for Community Living. Recent recommendations include delivery of leadership and management training for long-term care disaster readiness, provision of support and
technical guidance to implement climate resilience strategies in long-term care settings, and design of a Center of Excellence for disasters and older adults. The Technical Resources, Assistance Center, and Information Exchange (TRACIE) is a resource repository with critical information for health system preparedness for extreme weather events. The HHS emPOWER program identifies people especially vulnerable to the negative effects of extreme weather events, such as those who have medical equipment requiring electricity. By combining this information with weather and hazard maps, agencies and organizations can plan and address needs during disaster situations. Lastly, the Office of Climate Change and Health Equity continues to support research on the effects of climate change combined with social determinants of health on the health and resilience of Americans.

Session 5: Individual- and Community-Level Protection

Session 5: Individual- and Community-Level Protection, Adaptation, and Mitigation Factors to Reduce the Impacts of Climate Exposure on Older Adult Health and Wellbeing

Individual- and Community-Level Protection, Adaptation, and Mitigation Factors to Reduce the Impacts of Climate Exposure on Older Adult Health and Wellbeing

Elizabeth Frankenberg, PhD, University of North Carolina – Chapel Hill

Individual characteristics, neighborhood attributes, connection to place, and access to assistance programs all can shape the ways that health outcomes are affected by exposure to extreme weather events and climate change. In addition, rigorous evaluations of the effects of assistance policies in the aftermath of extreme weather are rare. Implementation of adaptation strategies and uptake of assistance following an extreme weather event are not random, which must be addressed in evaluation studies. The diversity of extreme weather effect modifiers and complexity of potential study confounders necessitates formation of multidisciplinary research teams to fully understand the effects of climate change on human health and assess whether interventions are effective. Dr. Frankenberg’s work has focused on how exposure to extreme events affects families and individuals. She discussed the differences between extreme events and the more gradual changes in baseline conditions of temperature, precipitation, humidity, and sea level. Changing baseline conditions potentially affect health outcomes but individuals’ perceptions of these changes are more difficult to capture. Her presentation focused on two extreme events—the Indian Ocean tsunami of 2004 and Hurricane Dorian in 2019, both of which created massive flooding as a result of a pulse of saltwater over land.

The Study of Tsunami Aftermath and Recovery is a longitudinal study of individuals, families, and communities in Indonesia before and after the tsunami of 2004. Data collected through household surveys include detailed measures of biomarkers and cognition, economic resources, demographic behaviors, and physical and psychosocial health. Satellite imagery and machine learning techniques were used to characterize the extent of tsunami damage and subsequent recovery across the nearly 500 study communities. Individuals surveyed in the baseline were tracked in subsequent waves and 96% of survivors were interviewed in at least one post-disaster follow up.

Focusing on the impacts of receipt of assistance, researchers found that receipt of housing assistance after the tsunami was less likely for those who had more resources prior to the disaster. Among recipients of housing assistance, post-traumatic stress reactivity levels declined significantly after receipt of the assistance. For older adults, the recovery process was shaped in important ways by family context and by various dimensions of social and economic status. Overall, recovery trajectories were not significantly different for older adults compared to younger age groups.

The Dynamics of Extreme Events People and Places (DEEPP) is a study of the impacts of Hurricanes Florence and Dorian on 35 North Carolina communities with high SES inequality and high proportions of older adults. DEEPP leverages a multidisciplinary team to measure exposure to flooding associated with two storms and assess the impact of exposure intensity on well-being. Preliminary results suggest that in comparison to younger age groups, older adults were less likely to evaluate. Among individuals whose homes were damaged by Hurricane Dorian, older adults were less likely to have insurance. In one community evacuation was more common among females living alone. This group was less likely to have lived in elevated homes, and interior flooding was more likely than for those in households of different compositions. As expected, the modelled depth of interior flooding was a strong predictor of whether households reported that their house was flooded and was strongly associated with a higher index of exposure to trauma and index of post-traumatic stress. Evacuation resulted in lower exposure to traumatic experiences than remaining in place.

In conclusion, developing ways to protect individuals from the impacts of exposure to extreme events is more complex for older adults. Providing effective assistance for older adults requires an understanding of kinship networks and of the links between economic status and exposure. For older adults change becomes more difficult, and their connections to where they live are often stronger than for younger age groups. In addition, declines in physical and cognitive ability may impact overall physical mobility. Moreover, potential lack of digital connectedness further limits access to information and ease of accessing assistance programs. Moving forward, the field should consider both how climate change likely exacerbates the complexities of caregiving for older adults as well as how to combine studies of exposure to extreme events and the effects of changes to baseline temperatures and precipitation.

Disaster Preparedness with a Multilevel Layered/Intersectional Vulnerability and Resilience Perspective

Zhen Cong, PhD, University of Alabama – Birmingham

Dr. Zhen Cong used FEMA National Household Survey data and primary data collected on residents impacted by tornadoes to study disaster preparedness and formulate a disaster research perspective that integrates multiple theories into a multilevel and intersectional perspective that highlights how accumulated vulnerabilities and resiliencies across the life course are reflected at multiple levels in preparation and response to disasters. Disaster preparedness is an important climate change adaptation behavior, and existing studies have varied findings of whether older adults are more prepared or less prepared for disasters than younger age groups. Notably, studies of older adults should be further stratified based on other co-existing vulnerabilities to determine whether inequities exist. Among White people with insurance, older adults are more financially prepared than other age groups. However, in communities with other co-existing vulnerabilities (e.g., low SES), older adults are less financially prepared compared to other age groups in these communities.

Prior exposure to extreme weather events makes an individual more likely to be better prepared with higher levels of social engagement. Factors that strengthen this association include a higher proportion of older adults living in the community and a higher proportion of people living in mobile homes. Factors that attenuate this association include living in a community with a high proportion of minorities, a high proportion of single-parent households, and a high proportion of households without a vehicle.

Additionally, in a survey about emergency plans for tornadoes, Dr. Cong found that more detailed, easier-to-follow plans were more beneficial and effective during real tornadoes for older adults compared to younger age groups.

Decision making related to getting prepared for an emergency depends on perceptions of stakeholders as well as perceptions of the overall threat risk and capability of dealing with the threat. Older adults and their caregivers are more likely than younger age groups to experience barriers to their capabilities of dealing with a threat. Overall, barriers to capabilities of handling a threat likely contribute more to disparities in disaster preparedness than barriers to accurately assess threat risks. In addition, perception of response efficacy is important for older adults to take actions to prepare for extreme weather events, especially for those with shorter lead times (e.g., tornadoes, earthquakes, wildfires).

Weathering the Storm(s) During the Pandemic: The Double Vulnerabilities of Vietnamese American Older Adults

Mai Do, MD, DrPH, Tulane University

Older immigrants are especially vulnerable to extreme weather events due to social, language, and sometimes geographic isolation. They also rely on younger family members and friends for support. Dr. Mai Do studies the effects of hurricanes on Vietnamese American older adults and their caregivers. During the COVID-19 pandemic, Dr. Do’s team conducted phone interviews in Fall 2020 and 2021, both of which occurred after major hurricanes—Zeta and Ida, respectively. They hypothesized that both hurricanes could have effects on the health status of older Vietnamese Americans and these effects could be mediated by social connections. The COVID-19 pandemic likely exacerbated negative health effects. After each hurricane, Dr. Do’s group collected data on damages caused by each hurricane, health status, levels of distress, social connectedness, community cohesion, and COVID-19-related effects. Damage from both hurricanes had a significant negative effect on bonding ties for older Vietnamese Americans, and those who perceived themselves as less likely to recover from COVID-19 had lower self-assessed health statuses and higher levels of distress.

This research required study team readiness and preparedness for study interruptions due to disasters. The study team remained within the community they studied, which helped maintain their connections with the community. It is worth noting that the study had a relatively small sample size and a very simplified community cohesion measure, limiting overall interpretations of results. However, results from this study suggest that interventions that provide social support for older adults could be effective in mitigating adverse impacts of both natural disasters and pandemics. These social interventions should include those that do not require gathering in person, including group text messaging. In addition, social interventions should be bundled with post-disaster aid and vaccinations. More proactive and systematic data collection are needed to provide additional insights into disaster preparedness in older immigrant populations.

Climate Impacts on Older Adults: Institutional Dependence, Trusted Brokers, and Failed Systems

David Abramson, PhD, New York University

Members of the civil sector can serve as a critical protection mechanism for those affected by extreme weather events, especially older adults who are particularly vulnerable. In the Gulf Coast Child and Family Health (G-CAFH) Study, Dr. David Abramson examined the effects of hurricane Katrina in longitudinal cohort representative of displaced and greatly impacted populations in Louisiana and Mississippi. Five waves of interviews have been conducted across 13 years post-Katrina to examine the short- and long-term effects of the hurricane.

Of those surveyed, two-thirds were not able to achieve stable housing within 18 months of the hurricane. Using Kaplan-Meier Survival Curves, Dr. Abramson found that the time to achieve stable housing was not significantly different between African Americans and non-African Americans, and the amount of damage sustained to the home was not associated with any significant difference in time to achieving stable housing. However, those 66 years of age and older took far less time, about 800 days, to achieve stable housing compared to their younger counterparts who took approximately 1,500 days. However, due to the significant risk of mortality for those aged 70 and older, these results may be due to a selection bias toward older adults who are heartier, more resilient, and have access to more resources. Notably, older adults are at especially high risk of mortality due to heat waves, cold snaps, and hurricanes, compared to younger individuals, but this trend does not hold true for tornadoes, which have overall similar risks of mortality across the lifespan.

Some reported observations from qualitative data provided further insights into factors that affect vulnerabilities of older adults to extreme weather events. Populations can be vulnerable to specific sensitivities, like a weakened immune system, or a lack of capacity to adapt to stressors, often caused by lack of mobility, sensory limitations, cognitive deficits, and scarce resources. In the context of G-CAFH, many older adults were living alone in trailer parks with family nearby who were equally compromised and displaced due to the hurricane. A lot of these older adults appeared far older than their actual chronological age, and some were living with evident and significant comorbidities, but were uninterested in accessing needed care, medications, or equipment. Overall, these older adults experienced failure of bonding ties with kin and friends, resulting in social isolation. Therefore, civil sector agencies are needed to fill the void of social isolation for these individuals to aid in their recovery after extreme weather events.

Civil service agencies, including NGOs, community-based organizations (CBOs), faith-based organizations (FBOs), and volunteer groups can provide resources to protect older adults and advocate for them in times of extreme weather events. Unfortunately, these organizations are often unprepared for an extreme event, taking 10 to 12 months to ramp up a program; widened eligibility and deeper service provisions, an overly burdened organization workforce, and insufficient funding also combine to undermine longer term activities. To more thoroughly characterize ways that these organizations can help older adults, Dr. Abramson combined Hobfoll’s Conservation of Resources and Bourdieu’s Forms of Capital to create the Resilience Activation Framework. In this framework, when a person cannot maintain economic, social, human, or political capital, they experience distress. Community- and individual-level interventions from organizations can help link older adults with these forms of capital. These organizations can replenish older adults’ human capital by serving as substitutes for fractured social networks and providing case management and assistance with activities of daily living. To provide economic capital, organizations can serve as trusted information brokers to help people navigate recovery processes and access financial assistance. Organizations can also anchor older adults within the community, connecting those most severely impacted with more stable peers, ultimately providing social capital. Lastly, organizations can improve older adults’ political capital by serving as advocates on their behalf.

Session 6: Health system adaptation and mitigation strategies to reduce the impacts of climate exposure on older adult health and wellbeing

Examining the Impact of Disasters on Older Adults in Health Care Systems

Sue Anne Bell, PhD, FNP-BC, FAAN, University of Michigan

Climate disasters pose specific risks to aging populations and often exacerbate age-related conditions. To address long-term impacts of disasters on older adults, Dr. Bell assessed hospitalization rates of older adults in Medicare and Medicaid service hospitals following the 2011 Super Outbreak of tornadoes in the southeastern United States. Hospitals geocoded in zip codes with confirmed tornado touchdowns saw a 4 percent increase in hospitalizations post-disaster, even upon exclusion of the first three days after the storm, demonstrating the long-term effects on health care needs by older adults after climate disasters. Furthermore, people living with AD/ADRD, who already have diminished situational awareness and increased dependence on others, had particular vulnerability to climate disasters in the longer term; after Hurricanes Irma and Harvey, mortality in adults with dementia increased, peaking three to six months after the storms. Even weeks and months after disaster events, prolonged community disruption interferes with healthy aging in place. In interviews and focus groups conducted after Hurricane Harvey, home-health nurses described how loss of homes and personal possessions negatively impacted the identities of older adults. They also reported feeling unprepared to address these impacts on their patients and themselves.

Proper preparation for disaster situations is imperative to addressing vulnerabilities of older adults. However, the gap between knowledge of disaster response best practices and actual execution of response during and after a disaster continues to widen. According to a National Poll on Healthy Aging, while most older adults surveyed said they were prepared for a disaster, less than 30 percent had a stocked emergency kit; only 40 percent had talked to family, friends, and other loved ones about evacuation plans; and only 25 percent of those who used life-sustaining equipment requiring electricity had a backup battery supply.

Continued work should focus on anticipating and responding to the needs of older adults during disasters. For example, implementation science approaches are being used in ongoing work to build health care resilience in long-term settings. Improving health care workforce education to better prepare caretakers to meet the demands of climate change on health care systems may complement these approaches. Additionally, HHS recently declared strengthening emergency preparedness and response as a top priority. Such work requires sustained investments from these and other similar organizations, including communities, funders, and policymakers. Connecting the knowledge of current procedures effectiveness with broader policy goals will allow for development and implementation of systems that center the needs of older adults during climate disasters.

Interventions to Identify At-Risk Populations

Arnab Ghosh, MD, MSc, MA, FACP, Cornell University

Climate-amplified threats pose several challenges to health care, specifically in managing health care delivery in the short- and long-term post-disaster. Dr. Arnab Ghosh’s work and other previous studies have demonstrated the specific impacts of climate change on older patient populations, especially those with chronic medical conditions. Members of the disaster medical assistance team (DMAT) providing care in Manatí, Puerto Rico after Hurricane Maria treated young children and adults aged 50 and older at a greater frequency than other ages, the latter of which required proportionally higher chronic condition care. Firsthand experience with these patients amid exacerbating conditions such as water insecurity, limited power, and a general collapse of the health care system provided researchers with a better understanding of the issues faced by communities in the wake of climate disasters.

Such problems necessitate systematic approaches using existing resources. The HHS emPOWER Program, for example, is a data analytics tool that uses receipt of home services and durable medical equipment (DME) claims to identify populations most vulnerable to climate-sensitive weather events. Using this program, public health officials in New York City, Los Angeles County, and other urban metropolitan centers are assessing potential changes to current planning and adaptation procedures. However, emPOWER may benefit from improvements like consideration of hazard-specific prevalent outcomes; incorporation of clinical, demographic, socioeconomic, and environmental factors; and observations across longer time periods to better identify at-risk populations across various medical conditions. Ongoing efforts that recharacterize the emPOWER risk threshold to better identify at-risk populations outside of claim receipts for home health or DME make use of previous data, including research on cardiovascular disease (CVD) risk in the five-year period following Hurricane Sandy.

Health care systems also already employ several mitigation procedures that should be adjusted to focus more on adapting to current and future climate change effects. These systems serve as primary sites of access to and coordination of a patient’s health and thus house large amounts of patient-level data, which uniquely positions them to determine and support at-risk populations. Effective interventions during and after climate-amplified threats can occur at patient, physician, and even population levels, and additional research into best practices will help active health professionals manage risks to their patients. Future development of risk identification, mitigation, and adaptation requires forward thinking, better integration with social networks that exist (e.g. communities), and consideration of challenges such as responsibility of care, ethical determinants of risk, and data sharing.

Assessing Nursing Home Exposure to and Preparedness for Potential Wildfire Episodes

Natalia Festa, MD, MHS, Yale University

Emergency preparedness (EP) in nursing homes is an important focus of study since residents exposed to environmental hazards either directly or indirectly have an increased risk of non-fatal clinical outcomes and death. In 2016, CMS defined EP standards and began requiring nursing homes to undergo regular Life Safety Code (LSC) inspections in order to identify potential EP deficiencies. Together with federal guidance, CMS encourages nursing homes to adopt an “all hazards” approach in which local facilities are responsible for assessing and preparing for potential risks and environmental hazards. However, this appraisal requires skills that are distinct from the direct resident care responsibilities of nursing home staff. Additionally, uncertainty remains about EP compliance alignment with specific categories of local environmental hazards as well as incorporation of local risk factors into federal oversight practices.

To address these knowledge gaps, Dr. Natalia Festa’s group performed a study on the preparedness of nursing homes and responsiveness of regulators to potential wildfire episodes. For the purposes of this study, researchers defined “exposed” or “at risk” nursing homes as being within 2.5 kilometers of areas that are at or above the 85th or 95th percentiles of nationalized wildfire hazard potential for the United States. They considered EP deficiencies as a proxy for overall nursing home EP, focusing on critical deficiencies that broadly encompass four domains: maintaining an active EP program, conducting appropriate training for staff regarding roles and responsibilities during emergency response, establishing policies and procedures during evacuation, and establishing procedures to support sheltering-in-place. They group hypothesized that facilities with greater exposure risk would exhibit greater EP compliance, and that surveyors would return to exposed homes with EP deficiencies sooner than unexposed nursing homes.

Cross-sectional analyses revealed that exposed nursing homes in the Mountain West and Pacific Northwest were more likely to have a critical EP deficiency than their unexposed counterparts. No regions showed stronger EP in exposed nursing homes than their unexposed counterparts, contrary to the hypothesis of the researchers. The authors also conducted time-to-event analyses of exposed and unexposed nursing homes with an identified critical EP deficiency over a follow-up period of 15 months, which is the maximum recommended duration between LSC inspections. Results of the analysis showed the Mountain West as having the lowest absolute time to reinspection for both exposed and unexposed facilities, although exposed facilities in this region were reinspected an adjusted average of three months after their unexposed counterparts. The analysis showed no regions in which exposed facilities were reinspected more than their unexposed counterparts, demonstrating the absence of significant relationships between risk of wildfire exposure and time-to-reinspection for non-compliant nursing homes.

This study uncovered potential areas of improvement in the responsiveness of nursing homes and regulators to surrounding environmental risk, which are also supported by complementary research findings regarding nursing home preparedness for storm surge inundation for the Atlantic and Gulf coasts. However, a couple of factors limit this analysis. Administrative EP compliance may not reliably translate to effective emergency planning or response. Furthermore, cross-sectional analyses require additional longitudinal research to supplement data deficiencies. Future work will address these limitations, focus on additional disaster categories, and be used to establish practical recommendations for nursing home staff and regulators to improve EP and resident outcomes.

Discussion

Data Source Access

One panelist indicated that publicly accessible data sources on individuals and from specific subregions can help complement nationally represented data. For patient-level data, sources include Veterans Affairs, EHR from local hospital systems, and Patient-Centered Outcomes Research Institute (PCORI) databases that contain aggregated individual-level data from multiple health care systems. Researchers can obtain regional data from sources like CMS, community health centers, and local health care coalitions. Public health departments may provide regional and individual-level data, as well.
Challenges remain for data access and use. For example, not all health care coalitions provide or even collect data. Additionally, obtaining data from these and other databases may require significant amounts of time. Finally, interpreting these datasets in tandem may prove difficult, especially spatiotemporally.

Disaster Assistance Kits for Older Adults

Providing disaster assistance kits to older adults, particularly those with AD/ADRD and other chronic health conditions, may support their recovery after climate emergencies. Although this initiative awaits further development, other entities have made similar progress to assist vulnerable populations: DMAT teams deploy with supply caches; the Center for Climate, Health, and the Global Environment at the Harvard T.H. Chan School of Public Health prepares and distributes pre-disaster kits to primary health care facilities; and the National Academy of Medicine recently published a report detailing the essential health care services for people experiencing intimate partner violence. Understanding best practices of these and other humanitarian aid organizations can inform the creation of preparedness needs for older adults and those living with AD/ADRD.

Health Care Workforce Emergency Preparedness Needs

Health care workers require sufficient preparation to ensure that health care delivery is maintained during and after a disaster. Incorporating pandemic and emergency preparedness as a staple in pre-service education may improve their ability to address climate crisis impacts to health care. Beyond modifying professional training, reinforcing the resilience of health care systems after climate events by providing necessary resources, allowing for flexibility in challenging circumstances, and maintaining awareness of moral harm and burnout may also help support health care workers in these situations. Any changes to health care workforce preparation will rely on granular data collection to compel evidence-based action.

Session 7: Reflections on Day 2

Session 7: Reflections on Day 2 Sessions and Discussion

Collaboration with Stakeholders in Aging Care on Emergency Preparedness

Stakeholders in older adult health, such as nursing home staff, can provide critical input on the day-to-day challenges and needs of older adults and those who care for them. Nursing home staff in particular balance numerous administrative and patient care responsibilities, and shifting responsibilities such as risk assessment to local, state, and federal authorities could alleviate research burden and assist in identifying local hazards. Research is also needed to identify the most protective standards for nursing home residents exposed to disaster, which can be shared with stakeholders such as CMS and trade organizations, like LeadingAge.

Strategies for Collecting Perishable Data Following an Extreme Weather Event

Climate researchers often face difficulties collecting perishable or ephemeral data such as survey data about people’s decision-making process during extreme weather events. While emergency room and hospital discharge data during an extreme weather event are not perishable, researchers often experience significant delays in obtaining these data. Major obstacles for researchers collecting this data include varying levels of willingness of affected individuals to work with researchers so soon following a disaster as well as the extent to which populations and communities are displaced by disasters, which makes tracking location and movement of individuals difficult. The Natural Hazards Center at the University of Colorado – Boulder has developed ethical guidance for field researchers working with affected populations which can help study teams design a careful approach that balances sensitivity to people’s recovery after an extreme weather event with ensuring data are collected before loss of recall. Embedding researchers with assistance and aid organizations to provide participant information on immediate relief efforts and impacts of the disaster could be a less-intrusive alternative to interviewing survivors after an event.

Researchers may also experience delays in Institutional Review Board (IRB) approval and funding, limiting how quickly research can begin in the aftermath of a disaster. NIH has some initiatives for accelerating IRB approval for studies in the aftermath of extreme weather events, but the pathways for achieving accelerated approval are often unclear. Researchers can consider predefining data types and collection methods in preparation for the next extreme weather event so they can rapidly submit study plans for approval after an extreme weather event.

Programs from federal agencies such as the National Institute on Environmental Health’s Disaster Research Response Program provide resources to assist climate researchers in collecting perishable disaster data. The National Science Foundation’s (NSF) Rapid Response Research program provides funding for proposals specifically aimed at collecting ephemeral data, and NSF also supports development of digital tools for measuring structural damage. One panelist highlighted the need to identify crucial or priority perishable data prior to entering the field to reduce the time it takes to collect data. Existing tools such as indirect estimation (measures derived from broad population-level indicators), aided by qualitative information measured early in a disaster period can inform researchers how best to move forward with their data collection and research.

Developing Interventions to Prepare for and Mitigate Effects of Extreme Weather

Research and development of interventions for extreme weather events mainly focus on improving responses to these disasters, rather than interventions to help people prepare for and mitigate the effects of these events. Successful development of interventions centered on preparation and mitigation require an understanding of the unique vulnerabilities of older adults to the health impacts of climate change. For example, compared to younger age groups, older individuals exhibit more resilience to financial losses, but are more vulnerable to social isolation and declining mental health. Connections to family, friends, and community are critical for mitigating the effects of social isolation during relationships. These relationships are especially important for older immigrants in their decision-making before, during, and after extreme weather events. The role of fictive kin (relationships not determined by blood relation or affinity by marriage) and peer relationships should also be examined to identify how these relationships impact older adults’ responses to disasters and the ways in which non-familial social connections can supplement mitigation efforts.

Engagement and collaboration with health care providers can provide social scientists with important context around the implementation of climate health policies and mitigation efforts. External health risks unrelated to a disaster can impact the decision making of affected populations and their willingness to engage with resources that could mitigate potential health effects. For example, older Vietnamese American adults in New Orleans during Hurricane Zeta who had the ability to evacuate to shelters expressed concerns over the risks of contracting COVID-19 from a crowded shelter.

Older adults are uniquely positioned to educate younger generations within their communities on climate change and extreme weather event preparations. This can improve how future generations react to climate change and extreme weather events, while also providing older adults with social connections to their communities. Effective public education efforts paired with interventions designed based on results from rigorous studies can help prepare the next generation to mitigate the effects of extreme weather events and climate change.

Tailored Interventions for Vulnerable Groups

In many cases, individuals experience similar problems to their peers, family, and friends, which can result in heightened vulnerability within a social network. However, engaging some groups in studies can be difficult due to an unwillingness or inability to answer questions or lack of time. Researchers can conduct surveys of vulnerable populations and their caregivers to identify the best approaches to ensure their participation in studies.

Closing Recommendations and Key Takeaways

One of the major points emphasized by this workshop was the importance of comprehensive interdisciplinary efforts to assess all aspects of the health impacts of climate change on older adults. By studying built environments, for example, researchers can better understand how built environments can modify the effects of extreme weather events at multiple levels. Fostering connections between data scientists and climate researchers can also facilitate collaboration and assist non-social scientists in adding to the field of climate health research.

Researchers should carefully design their studies to ensure inclusion of vulnerable populations typically excluded from large studies or general data collection efforts, such as older immigrant groups, older adults in institutionalized care, and the older unhoused population. The panelists agreed that the funding, creation, and dissemination of large-scale longitudinal cohorts that cover shifts throughout the life course, such as changes in dependence, institutional status, and migration, are crucial to improving the quality, depth, and diversity of climate health data. These robust datasets, combined with the continued development of theoretical frameworks in climate health research, can help identify key characteristics of climate change and disaster impacts for future research. Ultimately, the work of climate health researchers requires translation into actionable policies and interventions.

Agenda

Agenda

Invited Speakers

David Abramson, PhD, MPH, New York University
Deborah Balk, PhD, Baruch College
Sue Anne Bell, PhD, FNP-BC, University of Michigan
Deborah Carr, PhD, Boston University
Kai Chen, PhD, Yale University
Iona Cheng, PhD, MPH, University of California-San Francisco
Zhen Cong, PhD, University Alabama-Birmingham
Mai Do, MD, DrPH, Tulane University
Natalia Festa, MD, MBA, Yale University
Sarah Flood, PhD, University of Minnesota
Elizabeth Fussell, PhD, Brown University
Elizabeth Frankenberg, PhD, University of North Carolina-Chapel Hill
Arnab Ghosh, MD, MSc, MA, Cornell University
Kevin James Lane, PhD, MA, Boston University
Yang Liu, PhD, Emory University
Alexis Merdjanoff, PhD, New York University
Emerald Nguyen, PhD, NIA
Chirag Patel, PhD, Harvard University
Michael Rendall, PhD, University of Maryland
Brian Thiede, PhD, Pennsylvania State University