The radio announcer said nursing home residents were being evacuated to the Pasadena Convention Center, so Dr. Laura Mosqueda headed over.
Older adults were arriving at the evacuation shelter with hair and hospital gowns covered in ash. People urgently needed to be on oxygen — in a large convention hall with few electrical outlets — or their catheters were getting full but responders didn’t have gloves. Some had had time to wrap medications in bubble wrap and bring them, or they had their medical charts, but some didn’t.
“It was quite a scene,” Dr. Mosqueda recalled.
Dr. Mosqueda, a University of Southern California professor of family medicine and geriatrics, doesn’t confine herself to campus life. As an expert on geriatric care and anti-abuse advocate, she’s been a long-term care ombudsman for more than a dozen years and serves as director of the National Center on Elder Abuse. She’s also not afraid to jump in when she’s needed.
Like so many first responders, she was needed that Wednesday night. Nursing-home residents, reliant on staff and one another, had to be grouped together. Patients had to be helped onto cots, with no lifts available. Privacy screens had to be hunted out so caregivers could change adult diapers.
Dr. Mosqueda remembered one man whose wife had Alzheimer’s and couldn’t be left alone. The couple needed food, but he was afraid if they left their cot it would be taken: “It was first come, first serve.”
A woman who needed oxygen was placed far away from the rest of her group, near an outlet, but Dr. Mosqueda was concerned no one would be able to watch out for her. She found an engineer, who set up a power box near the woman’s fellow nursing home residents.
“I saw several people…who were just baffled about cell phones, or their neighbor dropped them off and they don’t know what medicines they’re on,” she recalled.
While Dr. Mosqueda was impressed by the dedication of the caregivers she saw, they had their own concerns. One paid caregiver’s shift was ending; she had to pick up her kids and couldn’t stay. (She came back the next day, Dr. Mosqueda recalled.)
“It was the worst life has to offer,” said Dr. Esiquio Casillas, a geriatric physician who was also at the convention center that night. “The flip side is it was the best of humanity in many respects.”
“You could just see how scared she was”
Dr. Casillas, a senior vice president and chief medical officer at AltaMed, oversees his health center’s Program for All Inclusive Care for the Elderly (PACE) and its senior services. He said his background in the PACE program, which works to keep older adults living independently by providing a range of health and support services, helped him provide effective care.
Patients didn’t want to go the medical area and risk losing cots and personal items, so his team went to them. “There’s a focus on meeting people where they’re at…rather than having the medical clinic be the hub of everything” in geriatric care, he said.
Some patients were in hospice and end-of-life care, and getting them placed more comfortably was an urgent priority. Others, relying on paid caregivers, needed extra attention, so Dr. Casillas said staff members made sure to spend additional time with them. One patient wanted a specific variety of dental adhesive that Dr. Casillas’s team didn’t have. “By the time I got there on Friday, she’d already been transferred, so I hope she got her Fixodent,” he said.
Los Angeles County is home to about 2 million older adults — a number that’s expected to grow in coming years. The wildfires that ripped across Southern California communities this month will hurt the health of millions — causing everything from short-term respiratory symptoms to long-term adverse outcomes from chronic disease — but older adults will likely be among the most vulnerable.
Dr. Mosqueda said immediate health impacts are a concern for many older adults, whether physical or mental.
Particles in the air during and after wildfires can trigger serious respiratory symptoms and worsen the health of people with chronic diseases. Patients will have gone without their medications — Dr. Mosqueda described an older patient who’d received an artificial heart valve but been forced to evacuate without anticoagulant medication.
An older adult may have trauma from military service or dementia. “They may have a lot of difficulty coping with all of this,” she said. “It could be very triggering.”
She’d been especially concerned about a woman with dementia who was at the shelter with no caregiver. Dr. Mosqueda asked the public health nurses to look after the woman, and checked on her frequently. “She did remarkably well,” she recalled. “But her face, you could just see how scared she was.”
One nursing home had moved patients back into their rooms as quickly as they could, even though the facility’s water was still contaminated, Dr. Mosqueda recalled. The contamination was from chemicals, not bacteria, so the water couldn’t be boiled for safety. And she was concerned older adults in urgent need of housing or care would be more vulnerable to scams, and skilled care facilities would lose vital staff members amid the displacement.
“Calm and circumspect”
But as with any disaster, the longer-term impacts, while more complex and harder to isolate, may be much more severe.
Fewer new physicians are choosing to specialize in geriatrics — the number has declined more than 25% since 2000 — in part because the specialty is lower paid. Older adults often rely on Medicare, and their appointments are lengthier and more complex.
Dr. Casillas explained that medical care for older adults is often centered on shared decision-making. A surgery or medication that might be an obvious choice for a younger patient isn’t always a good fit for an older one. His focus as a physician is on “the things that make their lives meaningful.”
An added challenge is the complexity of older-adult care. Keeping an older patient healthy and active often requires a constellation of services: regular check-ins at their home or residential facility, a combination of paid and informal caregiving, transportation, social opportunities. The Los Angeles wildfires will cause widespread financial instability and displacement, increasing the likelihood that paid caregivers may move or leave; family members and neighbors will be less likely to provide informal support; and housing, medication, and other needs will become more expensive and harder to access.
While Dr. Casillas only knew of two nursing homes destroyed by the fires, he said placing older adults in long-term care, especially for people reliant on Medicare, an ongoing problem statewide. “Placement is very hard to find,” he said. “There hasn’t been a nursing home built in Los Angeles in many years.”
The shortage may mean that more people choose to live at home for longer, even if that’s not the best fit for their medical needs. Dr. Casillas explained that the vast majority of his older patients do prefer to live independently for as long as possible, and supporting that goal is one of PACE’s aims. But he saw families pull older adults out of skilled nursing facilities during the Covid-19 pandemic, terrified of the deadly new disease, and knows catastrophes often force people to find another way forward.
“We’ve already started to do wellness calls,” he said. “I want to make sure we account for all of our patients and participants.”
Dr. Mosqueda cautioned that while older adults may be more likely to be medically fragile, many aren’t. Many have perspectives that help them navigate frightening, uncertain situations like the wildfires.
“Older adults…were among the most calm and circumspect people I spoke with,” she recalled. “They just had a lot of wisdom and life experience, and they weren’t getting freaked out. They had so many internal resources.”
Direct Relief supported first responders at the Pasadena Convention Center with requested emergency medications and supplies, and is providing $1 million in grants to frontline organizations responding to the Los Angeles area wildfires.
