We're very grateful for you to come over here for our session. So we'll be talking about climate change and mental health of older adults. There have been multiple sessions on climate change this year in this conference. We wanted to make sure the older adult population was also not missed in the midst of all the discussion because older adults have special challenges due to climate change. This session was supposed to be chaired by Dr. Jason Strauss. He's not with us here today due to other commitments. So three of our speakers will be running the show. I would like to introduce Dr. Eduardo Esparidion. He's the chair of the Department of Psychiatry at Reading Hospitals Tower Health at Philadelphia. He's also an associate professor of psychiatry at Drexel University College of Medicine at Tower Health. The second speaker is Dr. Rajdeep Burman. Dr. Burman and I trained in residency at Covillian Clinic at Virginia Tech. Dr. Burman went to do his geropsych at Harvard. I did my geropsych back at Virginia Tech. He's also kind of like my mentor also. He is right now the medical, he's an attending psychiatrist and medical director and chair of Inpatient Behavioral Health at Genesis Medical Center, Davenport, Iowa. He, both of us actually did our psychiatry residency back home in India. He did it at Calcutta Medical College. I did from Toronto Medical College too. After completing his training, he joined Berkeley Medical Center at Western Virginia University of Medicine as an assistant professor and was also the clerkship director for medical students. He has special interest in late onset PTSD and late onset trauma, cochlear decline trauma and stress-related disorders, and also patient suicide and inappropriate antibiotic use in older adults. Myself, I can introduce, I'm Dr. Bhadrath Nakran. I'm a geriatric psychiatrist. I run an outpatient geropsych and palliative care psychiatric clinic. I also do consult work with the APA. I'm part of the APA Geriatric Psychiatric Council. I'm also the president-elect of Psychiatric Society of Virginia. And all three of the speakers have no conflicts of interest to disclose. And our session, we are hoping to discuss about the impacts of climate change on health and mental health of older adults and what it means. How does climate change influence your assessment of older adults? What should you do to mitigate risk? And also recommend some potential solutions in teaching our future physicians about mental health of older adults in the context of climate change. And now I ask Dr. Espiridion to talk about the impact of climate change to older adults. Yeah, good morning, everyone. So let's begin with, by discussing the climate change indicators out there. Obviously, these are the realities of the world that we live in. Climate.gov have actually highlighted some of these things that are out there in the community. Number one is increased weather temperatures around the world. They started monitoring world temperatures around 1880. And it has actually increased by at least one degree Celsius or two degrees Fahrenheit since then. And the bulk of those rising temperatures have happened since 1975. With that increase in weather temperatures, there's also an increase rising sea levels. And it depends on the ocean basin where you're measuring it. It may have risen by as much as six to eight inches already. And with increased temperatures, there's some ice loss from the Earth's poles, as well as extreme weather events. So these are particularly important, primarily because extreme weather events like hurricanes, typhoons, flooding, and wildfires have significantly impacted the lives of older adults. So what are the demographics that we are dealing with as older adults? There are more than 75 million older adults who are age 60 and older in the United States. Since 2019. The projection is by 2060, the older adults will make up 23% of the U.S. population. And significantly, the 85 and older population is expected to triple to 19 million. We live longer lives nowadays. And as such, you will see the demographic shift. And there are a lot of older adults who will be out there in the community. And that's why we are really very happy to give this lecture. Because we will be able to express our concerns about this vulnerable population. Because older people tend to have actually more hospital-related, heat-related hospitalizations than any other older group. And so they are really vulnerable. So what's the vulnerability all about with older adults? Number one, the physiologic aging process. Older adults have limited mobility and physical functioning. Could you imagine them being exposed to those catastrophic events? And how would they be able to get out of those situations? It will be very difficult for them to get into safety zones or amid those extreme weather patterns. I mean, they are kind of stuck. Imagine if you are suffering, there was a hurricane or some sort of a catastrophic event where there's no electricity. Older adults will be trapped. There's no elevators for them to go to. They will not survive too much because they will not, without air conditioning or heater. It depends on the temperature of the outside world. That will be very hard for them to adjust to. In addition, a lot of older adults have medical conditions. And they require some electronically powered medical equipments. And without that, when those catastrophic events happens, they are extremely vulnerable to suffer. So other noted physiologic aging process is the multiple chronic conditions. That's the reality of things. As we age, we tend to have more medical comorbidities that we have to live with. And with that, you get to be more dependent on a lot of things. So if you are having some breathing problems from like an obstructive or restrictive lung disease, you would need those breathing machines. And the more likelihood those are sensitive to temperature changes. In addition, older adults tend to have diminished sensory awareness. And again, our sensory modalities tend to dull when we get older. And like your vision and your hearing, for instance, that may be very hard to adjust when there's something catastrophic happening in the world around you. Then other conditions that pose vulnerability to older adults include cognitive impairment. That's a known fact. When we get older, our neurons don't reproduce. So as you know, when we were born, we have millions of neurons. And since the neuron don't reproduce itself, we have lesser neurons now than we were when we were two years old. So there's a risk of developing Alzheimer's disease, which increases with age, unfortunately. And of course, with the cognitive impairment, there will be limitations in your ability to communicate, as well as how to actually take preventive measures. Because that comes now with some difficulties. Other vulnerabilities that we encounter are older people tend to have some social isolation. That's a challenging thing, because that does affect their mental health, as well. When you're isolated, it reduces your ability to cope with any climate-related stress. And it is estimated that one quarter of Americans age 65 and older are isolated in the community. Number four will be the socioeconomic status. As we age, unfortunately, poverty tends to be associated with older age. And that's associated because there's no money. They are accessing substandard housing, which makes them more vulnerable. Because problems with equipment tend to happen to those substandard housing, unfortunately. Other things that make them vulnerable would be the geographic location. So the coastal zones, which are with issues with storms and hurricanes, are really terrible places, too. But where do people retire? Unfortunately, they are there in those areas. Also, those who are living in the large metropolitan areas have heat-related illness. You know, one phenomenon that I was, like, fascinated with is the urban heat island effect. You know, the sunlight, when it's actually projected, there's no trees or anything like that. That sunlight will be absorbed by the pavements of the street. So they actually absorb that and then radiate the heat. So in the city, it's really very hot. And these are older adults who are isolated because they have very limited housing options. They're going to leave this kind of environment. And that's why these are really very important to note. Finally, the racial and ethnic disparities associated with older adults. Unfortunately, minority groups are associated with poorer health status. They have limited access to healthcare and poorer housing conditions. And these are all tied to the other factors that I kind of mentioned, including the socioeconomic status of the older adults in this country. So that being said, we wanted to make sure that you are aware that these are challenges that you're going to be dealing with with older adults in the community. So what are the impact of climate change on older adults? We talk about the heat waves. When there's a heat wave, you see this all the time in the news. The risk of hospitalization increase, primarily because the heat is not well managed by older bodies, and there's excesses in deaths and mortality rates when the age increases. For psychiatry, this is particularly important because if we prescribe psychotropic medications, there are some sort of side effects associated. It's a class effect. We call it poikilothermy. Our patients, if they are exposed to like antipsychotics, for instance, they can't tolerate heat. And if they get exposed to a heat wave, they will actually be vulnerable. And the worst case scenario, they end up in a state of delirium very quickly. And these are people who are isolated in a delirium state. So that will make them really vulnerable to some sort of catastrophic event. Another thing is air quality. That's why they are isolated, because if they go out, there's so much smog out there, that it causes negative and deleterious effects in their physical health. And it is somewhat related with the higher incidence in dementia patients. Also, extreme weather events has a higher risk of 90-day mortality during a hurricane. And particularly in the East Coast, this is a significant issue because it increases the emergency room visits among this older population after a hurricane event. Evacuations, obviously, they are limited with their limited mobility, plus they have chronic illnesses, including dementia. So it's really very hard for them to relocate. They're kind of really stuck where they are. And also, finally, the psychological impact of those things, because if you're an older adult who gets exposed to these catastrophic events, the likelihood of an adjustment disorder or a post-traumatic stress disorder is very high. They remember. And when they remember, the body reacts to it emotionally. And that's why when you actually sit down with an older patient, a lot of them bite back their tears. But they remember, and they will tell you the story of what they have experienced. So those psychological effects are very important to note because the effects of them are long-lasting. Okay. Then we welcome back, we will ask Dr. Barman to continue the discussion. Thank you, Dr. Esparidian. Good morning, everybody. I'm Raj Barman, and I'm going to cover the consequences of climate change on mental health of older adults. Although it is a topic on the older adults, but I think it would not be completed unless we discuss like how climate change affects the general population as well, to better understand that how they are different. So older adults, we all know that older adults and younger population, like children and adolescents, they are very vulnerable for different things. But how does, you know, heat, temperature, like the temperature changes, the humidity, air pollution, there are so many climate, so many pieces of climate change. And I will try to cover like how each of them separately, they affect the older adults and their mental health. So their heat, weather, that is one of the most important thing. And then, you know, like air pollution, flooding, earthquake, volcanoes. There are so many natural disasters. Now, in higher income countries, there's a few data I want to mention. In high income countries, heat is one of the largest weather-related cause of death. And we use this term heatwave, but what does it actually mean? Heatwave does not mean that, you know, just one temperature. So heatwave means it is defined as the temperature more than 95th percentile in the study location. And if it persists for more than three days, then it is called a heatwave. In 2003, I believe there was a heatwave in Europe and like 20,000 people, they died. Oh, yeah. Yeah, of course. I mean, I, it's like, you know, in India and the Southeast Asian countries, the heatwave is significantly affecting people. In the United States, for heatwave every year, near about like 500 people, they die. Now, in global burden of disease in 2017 study, they found that one in 10 people globally, they live with a mental health disorder. And I think that's a very significant number. So one in every 10. For each degree of centigrade change in the temperature, there is higher mortality of mental health disorder by 2.2% and the morbidity that increases by 0.9%. And that's like a general worldwide statistics, like for each degree centigrade, there is a mortality that increases 2.2%. And of course, if there is like pre-existing psychiatric illness, you know, there are higher risks, it actually triples the mortality risk when compared with people who do not have psychiatric conditions. Now, how does it impact our mental health? So there are a few acute events. And there are a few chronic changes. And acute events mean like, you know, wildfire, like flood and tornado. They can affect a lot of different things. Like suppose if there is a flood, you know, I am from Quad Cities, Iowa, and just two or three weeks ago, there was a huge flood in Mississippi. And the most important, the most common, you know, problem what we faced that patients, they were not able to have their transportation, or not able to have their electricity. And few people they use nebulizers, they have like CPAP machine, they're not able to, and especially the older adults who already has like, I'm not saying every older adult they have, but a majority of the older adult who has some cognitive impairments, who has lack of social support. And it's very difficult for them to use the technologies. And although there are like resources in the community, it's difficult to access. It's difficult to like, you know, operate the smartphone and order online, so that the medications can be delivered. So there are multiple, you know, consequences that occur immediately. And then there are some chronic changes like air pollution, like drought, that happen over time. And all of these, they can cause some socio-economical threats. Suppose if there is an acute event, like a flood, or suppose the government is planning for making a dam, like a water reservoir. A lot of people, they have to be, they are forced to migrate from that area. And that's the major trauma of what we commonly don't think about. We think like we are doing good for the people, but maybe they are psychologically traumatized. They are losing their home, they are losing their traditions, their attachments, their own house, own social system, own support system. So migration, and along with migration, there comes like food insecurity. How do I feed myself? How do I feed my family? And especially older adults in the United States, 50% of the older adults, more than 85, they live on their own. Because, you know, maybe that their spouse has already died. Their children are like all over the country. So these are, it becomes very challenging. So for multiple reasons, there can be increased risk of PTSD, increased risk of depression, increased risk of anxiety, substance abuse. We see a higher hospitalizations, more suicide, more aggression. And also think about, you know, older adults, this is a very unique population. They have grown up in an era, you know, they, and especially, you know, with aging, people have the feeling of their autonomy, you know, and when some kind of catastrophic event happens, they feel powerless. This air, air, suppose if we think of air pollution. Older adults, especially they want to, if you think of like addiction in stages, they're in a stage where they want to contribute to the society. And for the air pollution, particularly, there is something we call a survivor guilt. That means that, you know, what have I done for the community? You know, probably I am responsible for this air pollution. In between like 1990 and 2010, I think there was like 7% increase in the air pollution. So there can be this survivor guilt. So, and they deal with it. And it's not very easy for an older adult to deal with this survivor guilt. So sometimes, you know, if you involve the older adults in the community to take the leadership role, that, you know, you are the person who can help the new generation to have a better world. So, and there's a term for it, it's called environmental volunteerism. So if you can involve the older adults, they feel the worth. They feel I can, I am doing something for the community. And that helped with their self-esteem and the depression as well. Now, with the heat weather changes, there is elevated risk of suicide. But it is more in men compared with women. But there are mixed results as well in other countries. People aged more than 65, they are more vulnerable to temperature than younger people. And it has been seen that the productivity begins to decline at around 20 degrees centigrade and progressively decreases as temperature rises. So if temperature rises, your productivity begins to decline, but that doesn't mean that, you know, whenever there is temperature rise, everything is going bad. So I'll touch that later. All right. Now, try to understand the physiological mechanism, heat that affect us. So according, like the normal physiology is when there is like heat stress, we have vasodilatation and excessive heat that evaporates from the body, right? So if there is excessive heat, you're losing your water, you are getting dehydrated, and there will be more stress on your cardiac system, on your cardiovascular system. There will be more risk of kidney fibrosis, chronic kidney disease. And again, the medications, they can be very notorious. You know, the anticholinergic medications, antidepressants, opiates, people who go through these climate changes, they also do a lot of drugs, a lot of substance abuse, and among them, you know, cocaine is so common, and cocaine causes vasoconstriction, right? So it would not allow your body heat to dissipate in the air. So that also complicates your system, that makes you more prone to have more cardiovascular symptoms. There are also some changes you notice in the brain because of heat. There is direct inhibition of acetylcholine, and acetylcholine, we know that is one of the major neurotransmitters that controls our sweating, that is responsible for skin vasodilatation. And also, like antipsychotics, like some narcotics, they can also influence our thermoregulatory function in the brain. There is reduced behavioral capacity, so the people, they are confined to bed, they're living alone. What happens when there is heatwave? You try to be inside the home. So now the older adults, you know, if someone has like poor mobility or poor support system, so they cannot even go outside to have like fresh air. So that again increases their risk. The other thing is, you know, in many countries it happens, people use, especially in the tropical countries, they use mosquito net at night. But when there is like too much of heat, they don't use the mosquito net because to get like more air, and that increases the risk of other diseases like dengue and malaria. So it affects like in so many ways. We don't usually like think about it, but in different countries, in different population, because of their own practices and the increased temperature, they can affect them differently. So if the older adults, they're already isolated, and if they're not going outside because of the heat, there is social isolation, and that can increase the risk of depression. Also because of heat, it can initiate the neuroinflammation. There are like cytokine release in the brain, and that can cause more damage. And individuals like psychological and behavioral adaptation strategies, that can be challenged as well. So with like increasing temperature, you see a lot of alcohol substance abuse, aggression, violence, and there is higher risk of suicide as well. The other issue is sleep. So heat definitely, you know, it immensely affects your sleep, and you know that sleep is so important for our mental health. So if you cannot sleep well, there will be like more irritability, more frustration, more negative emotions. Again, like most of the psychiatric issues, they can get worse. How does it affect our cognition? It has been seen that a single episode of hyperthermia can lead to short-term or prolonged effects in attention, memory, or personality. It can reduce people's cognitive awareness of the environment. So especially people who have dementia, they may feel more confused. They can have short attention span, and there can be cognitive dissonance. So especially people with Alzheimer's disease, they are very vulnerable to heat changes. Also heat can affect your medications. It can affect your medication storage. The other important thing is we keep like, you know, there are transdermal patches, like, you know, nicotine patches. There are like rivastigmin patch or selenogelin patch. So what happens when there is increased temperature? Again, like you're getting vasodilatation. So there is a rush of blood in that area where the transdermal patch is, so there will be sudden absorption. And if there is sudden absorption, there will be higher risk of side effects, right? And there are few medications, particularly thorazine, chlorproprazine, and the other phenothiazines. They are very sensitive to heat, and they can very easily generate the free radicals. Even like oral antibiotics and diuretics, if you expose them to heat, they will be more dangerous for your body. Now, not only the temperature, humidity is also important, right? If it is a very humid condition, you will feel more uncomfortable. It has been seen that 20% of the population affected by an extreme weather event, they experience mental health problem, and that's a huge number. And 20 to 30% they develop depression or PTSD. It was found in the Hurricane Sandy in 2012. Similarly, you know, after other natural catastrophes, these PTSD, depression, anxiety, although the percentage that varies in different countries, different places, but usually 20 to 30%, that's what I have found in most of the studies, that is for depression, that's the 20 to 30% people, they develop depression or anxiety. Now, interestingly, the prevalence of PTSD is much lower in older adults, in comparison to younger adults. It may be because of their resilience, or because of their past experience. Someone has already survived a natural disaster in the past, so they are well prepared. So there can be multiple reasons. But these study results also vary. Like, I believe there was an European study, and after a hurricane, there was more PTSD of the older adults who were living near bigger cities than younger adults. But in most of the studies, it has been found that prevalence of PTSD is much lower in older adults than younger adults. And we all know that in older adults, the prevalence of anxiety is lower than younger adults in general. So, even in like, not only in like Western countries, but even like in Southeastern Asian countries, like tropical countries, like in Taiwan, they have, they did one study and they found that there was 7% increase in major depression per one degree centigrade increment in the region with an annual temperature above the median 23 degrees centigrade. In a study in North America, monthly temperatures above 30 degrees centigrade, that increased the probability of mental health difficulties by 0.5%, and ongoing one degree centigrade increment in every five years, that increased the risk like by 2%. Now the mortality. Like, there are several other studies like from UK, from Finland, from, of course, from United States and Mexico. There is higher risk of psychosis, especially in the population more than 65. A study from UK that found that primary care patients with psychosis, dementia, alcohol, and substance abuse, they experience significantly higher health-related mortality. In Finland, they found the temperature variability that increased, I mean, that explained actually more than 60% of the total suicide variance. In United States and Mexico, that also, suicide risk also increased by 0.7% and 3.1% for every one degree centigrade change in the temperature. Now, this is a very interesting study. They did, this is from, I believe, University of Michigan. It was done in 2021. It is the association between temperature exposure and cognition. The study was among near about 20,000 people, and they checked how they did when they are exposed to extreme cold temperature, especially in the areas where people are not used to cold temperature. So, they selected Arizona, and they selected in California, like oceanic region, and so they found that over two days when they are exposed to like cold temperature, the cognitive function is declining. But there was no significant associations for slightly higher temperature. Rather, it has been found that slightly higher temperature, that actually improved the cognition. In comparison to the lower temperature. So, that's a very interesting finding. And it is not only like in the United States. They also did a study, I think, somewhere in the Middle East. They also found the same results. The slight increase in temperature, that actually helped cognition. Yeah. So, that's about temperature effect. Now, air pollution. Carbon monoxide, ozone, and particulate matter. Especially particulate matter 2.5 and PM 10. I believe 2.5 and 10, they're like related to the diameter. I'm not 100% sure, but that's how it is. They're named. And so, how the air pollutants, they can affect our brain. The most important mechanism is neuroinflammatory reaction. They release a lot of cytokines, and there are free radicals. They can affect the hippocampus, and stratum, prefrontal cortex. And we know that prefrontal cortex, that is so important for depression. Especially in depression, there is hypoactivation of prefrontal cortex, and hyperactivation of amygdala. So, if your PFC is getting affected by cytokines, there is, of course, higher risk of depression. And it can affect the cognitive processing as well. Something about neuroplasticity is very interesting. So, they found in one study that people who are biking, who are bicycling in a heavily polluted road, they did not have any increase in BDNF in their brain. And BDNF is brain-derived neurotrophic factor. It helps with our cognition. It helps with improved blood circulation in the brain. But usually, when we do exercises or yoga, meditation, the BDNF level increases in the brain. But they have found that when people, they are bicycling, doing exercises in the heavily polluted area, there was no increase in BDNF. And even like oxygen deficiency, that is closely related to impaired serotonin synthesis. So, there are multiple ways they can affect our brain functioning, starting from the neurochemical, from different connections, from BDNF, neuroinflammatory reactions. And particularly, these two aeroallergens, PM10 and PM2.5, it has been found they're highly associated with completed and attempted suicide. Now, another interesting thing is pollen, what we don't usually think about. And, I mean, before I moved to, you know, Iowa, I was in Virginia, and we were in a valley, like it was in Roanoke. And over, like, after living there for two, three years, I developed, like, a lot of different pollen, like, allergies. So, after I moved to, like, a bigger city in Iowa, and I thought, okay, I got rid of it. So, for two years, I was fine. But for third year, I started having these allergies again. So, now, but it is very interesting to know that pollen allergies, actually, it has been, it may be related or not related, we don't know yet. But there is a peak in suicide rate in late spring, when pollen counts are higher. Okay. But again, this is, like, there is not enough evidence to correlate it with pollens. You know, for the seasonal affective disorder, people, they usually get depressed in this country in winter, and when the temperature, when the daylight improves. So, in late spring, there should be, like, less depression, right? But it has been seen, like, so there, the hypothesis is maybe because of the pollens, it increases the inflammatory, it causes neuroinflammation, there can be, like, a higher rate of suicide in late spring. Noise. Noise is another, like, major factor. It can interfere with your sleep. It can also affect your hypothalamic pituitary axis. And especially in older adults, and who has dementia, they are very sensitive to noise. When I was doing my geriatric fellowship, this is an interesting, like, it was an interesting event, actually. An 85-year-old male, and he was getting agitated every day, at, like, lunchtime. And we're kind of very surprised that this person is, like, fine all over the day, and very pleasant, very, like, cooperative. We really like talking to him, but why he gets agitated at, like, around 11.30. So, then we realized that, actually, they are bringing the food in cart, and the cart was causing some scratching noise. That is something was making him agitated, okay? So, you have to be, like, very aware of these sensory, you know, the system, how pollution is affecting. And even, like, the Wi-Fi, mobile phones, you know, power sockets, they can also affect your HP axis. They can affect your hypothalamic pituitary axis, okay? BPA, that's a part of the plastic, right? That can affect the steroid-induced synaptogenesis, so there will be less neuro, so it can affect the neuroplasticity. There can be loss of hippocampal and prefrontal synapses. Then pesticides, they can also decrease the degradation of acetylcholinesterase, and that can affect the neuronal growth. Heavy metals, like cadmium, lead, mercury, there is, it has been, they have been, I mean, they are strongly associated with higher risk of depression and suicide, irrespective of the countries. Now, there are other natural disasters, like drought. It has higher risk of suicide because of economic hardship. The grief, loss of identity, and that is linked to their occupational role or their gender. There is a terminology called solastalgia, and I'll talk about that a little later, a little more. So it's really painful for a person to move to a different area, and with so much, so much insecurities regarding their finances, regarding their social support, regarding food, regarding shelter, regarding employment. So drought is a chronic situation, and in, even like in, in, in countries like, you know, India and, like, Southeast Asian countries, when there is drought, there, like, higher risk of suicide. It increases even, like, four, five to ten times. Prolonged wildfire and flood, and even, like, the volcano eruption in Hawaii recently, that has immensely affected the mental health. Who are the vulnerable people, population? Of course, the younger and older adults, but especially the children aged six to eleven, and older adults more than sixty-five, indigenous people, low- and middle-income countries, and people who have pre-existing mental illness. Not only because of the factors we discussed, but also because of the biological changes, also because of impaired thermo-regulatory mechanisms by psychotropic medications. And when there is a natural disaster, there are inequalities in vulnerability. So it, it does not affect all the groups, groups equally. Some nations, some groups within the nations, they are more geographically and economically vulnerable. So suppose if you get a hurricane in the Midwest versus in Puerto Rico, that is going to affect them differently. That is going to cause, there can be the prevalence of the psychiatric disorders that might be different. So, and especially the groups, they lack socio-political power, they may face more extensive impacts, like the women, like younger children, like people with mental illness, who cannot even vouch for themselves, who don't have like much power in the community. And then again, forced relocation, that may have a detrimental effect. So these are a few terminologies are used, like climate anxiety, or ecological grief, or eco-anxiety. This is a grief about the loss of places, activities, their traditions, as well as fear about the potential scope of the impact. In the US samples, 17 to 25 percent people, they reported experiencing such effects. So almost like one-fourth of the population. There is a terminology called solastalgia, apparently newer concept. In 2002, Albrecht, he created this term to particularly describe the feelings of distress and anger that is experienced by this particular population. Like who, so the solastalgia, it came from the word solace, and solace, you know the meaning. So they are losing their peaceful environment, they are losing their connections, and their attachments. So now it result in like anger, more frustration, more discomfort, their mourning, they're hopeless and depressed. It is not like nostalgia, you know. Nostalgia is where you also like reminisce some good memories. There are like, you know, you have the pain, but you can say solastalgia is a profound nostalgia, when the good memories are not there. This is like all negative emotions. Although like we talked about the studies, but there are certain limitations in the studies that we should consider while interpreting the results. So most of the studies were quantitative, and they used a cross-sectional design. And mostly they are conducted in high-income countries like, you know, United States, Canada, Australia, UK, and who are more aware, more prepared for the mental illness. But the evidence indicates that the low- and middle-income countries, they are more at higher risk. And most vulnerable countries in the face of climate change globally in 2016, they were Central African Republic, Demographic Republic of Congo, Haiti, Liberia, and South Sudan. So if we want to deal with the climate change better, you have to involve all the population. You have to involve the world. You cannot do it only in a single country. Now, I think it was just in the newspaper that how the wildfire in Canada that is affecting the weather of United States in the Midwest. So they are linked with each other. If there is a volcano in Hawaii, don't think that you can escape. You know, you can also, you will also face the heat, directly or indirectly. And especially for older adults, for this particular population, they are so vulnerable. If they are well-prepared, if you have a well-planning, that's the only way you can handle this disaster. So I let Dr. Ratnakaran take care of the next piece. Thank you. west where we are now, which impacts. Absolutely, absolutely. Yeah, thank you for your input. Right. So thank you for mentioning that comment. I don't know how many of you remember a few years ago there was a volcano eruption in Iceland and it disturbed the whole of Europe and travel. So with that question, I want to pose a question to the audience. How many of you have been affected by climate change related events or have parents affected by climate change related events? There are a couple in this group. I can interrupt every minute, but I think it's because I think it's hard to have lived and not had a heat wave. But I think when you ask the question, people think, oh, have I been in a flood? Have I been in a, but I think we're all feeling it. Yeah. And I would like to tell you something about why this topic is so important for us from my experience. So the lady in red is my wife. She's a PGI tourist and she was also a psychiatrist. We have older adults back home. We come from a town called, city called Cochin in Kerala. It's a coastal town. I've been there. I was born in Dubai, my brother and I, and my brother's now in Abu Dhabi right now. Things have changed so much in six years. My brother's talking about floods in desert city like Dubai or Abu Dhabi and there's rain. They're worried about the city getting flooded, actual floods. We just unheard of when I was a kid when he was growing up. And we, I moved, we moved back to home in 1992. 1992 till I moved to this US in 2016 for residency, our city never had any floods or anything. And in 2018 there was a rain and the rain continued for a few days. It was not stopping. The dams were getting flooded. That opened this dam slowly and there was no preparation, no idea what that was going to happen. Everybody's home got flooded. The whole state got flooded. Her home got submerged in 2018. And there was no inkling. Everybody is slowly seeing the water rising. I was like, oh, it's just going to go away. It slowly, slowly started rising. My home started getting flooded in the last few days, a few, a couple of years, every year. Just like that. It's never heard of. And from then we as caregivers started becoming more vigilant every year, that every day before I go home, go to sleep, I check the weather. And I see, hey, now they started classifying weather alerts as orange alert, yellow alert, red alert, based on severity. Even that is not, is very unpredictable. You might have a forecast of a mild rain and it can all of a sudden turn into a big storm. And it happened. There was a day that when I went to sleep, there was no forecast for rain. And when I woke up, so there's a 12-hour time difference between here and there. So I sleep at 8 o'clock, 9 o'clock. That's around 6.30, 7 o'clock that time in the morning. And there was no forecast for rain or anything. They don't watch the news very much because the news is now very inflammatory. They hate seeing it. They read the politics paper of the news. They don't look at the weather forecast in the newspaper. So I had to look at it, look into it. There's no forecast. And when I woke up in the morning, my mom tells me the whole house is flooded. That's happened. And like you said, two weeks ago, so I hadn't been home in six years. And I was going back home. I was seeing my neighbors, the foundation of the houses have been raised to mitigate the flooding. And my mom was telling that she's going back home in July. After she leaves, they're planning to raise the foundation of their home to just prepare for the monsoon season. And that's where heat waves also come. Things are getting very hotter. And I see the heat wave alert in the news. And I had to tell my father, like, hey, if you're going out for work, come back by 10. There's a heat wave alert from 10 to 3 p.m. You see your workers, give the instructions, come back, and you're back in the night. Because they don't read that or see that. There's no mobile notifications in the phone or things like that. And you have to prepare. It brings us anxiety, and us as caregivers for children who are overseas, my brothers and Abudabi. We're always looking in the news and stuff, keeping track. They are scared if there's a rain in the night, would it flood all of a sudden in the night? It affects their sleep. And there was a new movie that came out recently based on the flooding in 2018. And my mom said this is what it is. People are scared right now when it rains in the night that they take turns to look out, see if the roads are getting flooded or rising up. And we see news about some storm. We tell our folks, get your papers and valuables ready. Leave everything else aside so that if there's a flooding, keep the gold and everything away. If there's flooding, get at least your identification documents and passports and all of the important papers ready with you. That's the only thing you need to carry. I was in Iceland, and people there, they live like that. They're told that they just have everything ready to go. They live in a volcanic area. So people have that experience. But that's what they'll say. They're ready to go as soon as they come. We just grab what is ready to go and leave. What can you do? Yeah, and that's where people who have this experience are prepared. And this is where we have this presentation for us. We should be prepared for changes in our climate and geography. We can't assume that it's not going to happen in our locality. Some way or some sort of events are happening. And it's a problem in the geographic population because there's not many geriatric trained people. When I was in fellowship training last year, there were only 45 fellows in the country. This year, this academic year, it's 48. There are more geriatricians retiring. The patient population I'm getting is getting more and more complex, more medications, more medical issues. And every system is asking for help from geriatricians. You don't get paid more. They're asking for valuable input experience because there are many systems that don't have geriatric trained folks. There are many residency programs that don't have geriatricians. And that's going to be a problem. And this is going to be an added layer of challenges of treating this population. The population is just going to increase. There are other reasons why people don't go into this workforce, ageism, monetary issues, or you don't want to deal with medically complex people. But you cannot shy away anywhere. It's going to cross paths with you. And climate change is going to add a bigger problem to us. And so each end of the developmental spectrum, children and elderly who are dependent and powerless are the people we don't invest in making sure that they're caregivers, health caregivers as well as others. So that's why we're talking. That's why we wanted this session. Because people in child having it invested. One of my close friends is Joshua Watsell. He's in the Committee for Climate Change in APA and ACAP. And he's also a child. But not many people are talking about the older adults in this picture. So we didn't want them to be excluded on this. We want to have a session. Dr. Berman and I wrote a paper recently which we will talk about. The question is, how are we teaching people or residents about climate change? How many residency programs do you think have included climate change? Few. People feel they're not an expert in this field. But we ourselves were self-educated due to our experiences that we should know. Like we have personal experience of how anxiety-provoking it is of climate change events. So programs understand slowly incorporating it. But how do you include the geriatric population? And this is where Dr. Berman and I wrote a paper recently. There was a special edition of the Academy Psychiatric Journal on Climate Change. We did a small piece. And we told that we recommend teaching at least four things on mental health issues faced by older adults related to climate change. One, how does this physical and psychological factors cause them to become vulnerable to climate change? Like a good example, Dr. Esperian said, the mobility is decreased. What if there's a flood? How are they going to escape from there? What is the impact of climate change on physical and mental health? There's a lot of implications. Cognition, muscle loss, electrolyte imbalance, infectious disease. Older adults' immunity is lost. They are very vulnerable to diseases. This is going to cause an increase in hospitalizations, access to care. Are we prepared for it? Have we anticipated it? It's a problem. And disaster preparedness. Disaster preparedness is not new, because all the disasters that happen, especially Hurricane Katrina and all, those cities have learned how to prepare, how to mitigate this risk. But this needs to be universally adapted. We know including a session in curriculum can be challenging, because everybody's fighting for a space in curriculum. So how do you, you can either include a curriculum or a session. Geriatric fellowship, we're saying this has to be included. But you can include this in different ways in other sessions. You can include it in psychopharmacological teaching. Like, hey, if you're prescribing antipsychotic to an older adult, be aware of hypothermia or hypothermia. If you're prescribing lithium to an older adult, if you have a heat wave, how are they going to manage their kidney problems, right? You can do that. Or if you're asking for a geriatric assessment, have you ever asked, have you been in a climate change related disaster? Based on your geography, how are you preparing for it? Or in heat waves, do you have enough air conditioning or dehydration? Those things. So in that way, you can incorporate teaching. But in your practice, not only for your own practice and also teaching residents, it's best to start incorporating assessment. Like understanding what does impact of climate change mean in evaluation of older adults. What are you going to ask? Is it access to healthcare? Is it how you're storing your medicines? Does a medication side effect? Start thinking about it. You include those. And you can ask, especially dementia patients, it's common practice for us to ask, hey, if it's a gloomy day outside, how does your, how does a dementia patient react? They're either agitated or cold. You ought to start thinking about heat waves and cold waves. This last past Christmas weekend, there was a cold wave in Virginia, where I'm from. And a lot of people were on vacations here and there. And then when they come back, everybody's house is in water because all the pipes burst. And they lost their roofing and housing. So they're coming back after seeing their children, like, I don't have a roof on my house. I don't have a place to stay. So what does, and since then, they're now scared to travel. What would happen during Thanksgiving weekend or Christmas weekend or a New Year weekend? Who would tell me? Because sometimes the neighbors are not there, or they might know there's a flooding happening in the basement So that has brought in an anxiety. Anticipatory anxiety that something might happen. How do you address it? You can do therapy techniques, but a lot of the problems are real life, real problems. And what about how do you prepare for future changes in climate? And climate change, like heat waves. Do you have enough water? Are you eating enough salt, or are you eating too much salt, or things like that? And how do you plan for issues related to body temperature, related side effects from psychotropics, or other life imbalances from like your antidepressants and things like that? So you educate your caregiver. Like in those events, if you see a change in your parent or your uncle or aunt, think of something going on. So look, you've got to educate your caregivers to look for patterns. I even ask patients right now, like, if your grandma or your parent is not behaving well on certain days, is it because there's an air pollution going on outside? Have you checked that? So if you look at the weather websites, they also talk about air pollution that day, too. And there's a website called airwave.in. You can look at the pollution of that day. So it's now good to look for patterns, how to prepare for it, and teach about how climate change can affect the caregivers and their loved ones, too. And this is based on region. If there's a climate change event, like heat waves or floods, what are the systems issues in that area? Some people live in segregated neighborhoods, there's not much access. There might not be buses or anything going on. So would there be a problem with access to care? Keeping that in mind is always good. And creating safety and backup plans, which we'll be talking a little bit. But a lot of times, institutional leaders have created plans when there's a climate change-related issue. Are you aware of it? How many of us know what would happen in a hospital if there's a flood? Like, there's a, I forgot the hospital name, there's a very interesting story about a hospital in New Orleans when the flood happened and there was kind of like a disaster. I think they made it into a series in Hulu or HBO or something. I forgot the name of that. Memorial Hospital. Memorial Hospital. And it was very fascinating. They didn't have any plans for triage or anything, and it ended up in a disaster that they had to cut off the life support system for a lot of patients. It was a difficult decision, but they had no triage plans or plans for those patients. Those lessons are valuable inputs for all hospital systems or healthcare systems to know you've got to be prepared for it. Teaching trainees in clinics. It's time to teach them, right? They should know how do they instruct, assist the patient in proactively identifying or acting with backup plans, right? They should be trained so that when they go into practice on their own, they're ready for it. And if needed, usually if I have a cold wave or a heat wave, usually in the winter season, if it's bad, I usually call the patient's caregivers and say, hey, how are they doing? Do you need help? If you need, come in. Things like that. So you should ensure the continuity of plans or something like that. Sometimes caregivers don't want to bother a physician or, hey, this is the hospital's holiday season. He might not be there. I don't want to bother him. It's also sometimes when you see events happening in the paper or something like that, if you know there's a vulnerable patient, I get particularly scared when I know I have an older patient who's living alone without any social support. But those are the patients who fall in the cracks. They're sometimes isolated living alone. They might be living in a heat wave desert where they're confused, dehydrated, and then a couple of days later I see them in the ER with an acute kidney injury or something going on. And that happens. It should be taught, and that's why you have to be teaching trainees about anticipated guidance to the families. And also when an event happened, like I said, the cold wave happened, people lost their house. Have you ever talked to the patient like what it means when that event happened? Are you worried about it? Some older adults are very proud, very resilient. They would say they're not worried about it. But if you have a good connection, they will say, yeah, next year this time I had to be prepared. There's some anxiety going on. And that's where patient education lies. You educate patients on heat waves to stay cool and hydrated. If it's a cold wave, get enough warm clothing. Be informed about air quality, especially with caregivers. Make sure if you're living in a tropical area that you don't get insect bites, like dengue has crept up in the southern part of the USA, and that's very surprising. And that's a lot about how the biodiversity, ecology has changed with climate change. And making a backup plan. We'll be showing a few resources. What do you make up as a backup plan? What kind of medicines do you have? Do they need storage? Is it good to have ice packs ready? Insulated carriers? Do you have emergency contact numbers in your phone? And who do you call to check up? If your loved one is in a long-term care facility, call them and check, hey, what's your backup plan if this is going to happen? Should I pick up my mom or dad for a few days if this is happening, just to be sure? And if somebody is on an oxygen tank or is on an electric mobilized vehicle, how do you get them up? How do they have battery backup? How do you mobilize them? And older adults have a lot of documents, Medicare documents, insurance documents, identification documents. How do you keep them safe? That's all important to be ready. If it's something like a flood, an emergency whistle is good, and medical ID is always good to have for them. And also places that have been very much affected by climate change-related events, like floods, they already have a system of like what we call in our place called camps, where people aggregate when there's a climate change-related event or they're forecasting a hurricane or tornado coming in their designated shelters. Where are they? How do you get them to there? So those are kind of the plans you can make. And what will be your support network? Who will you contact if you have a problem? And some guidance documents, which I'll be showing in the next few slides, talk about having a chain phone call system. One person calls one person, the other person calls one other person, and they all know where to meet if there's an event like that happening. And that's where you've got to be aware of the local community resources in your area for these patients. Some of the resources, APA has one on disaster mental health. Their page has resources on how to prepare for disasters. It's in the professional interest site. This one on AGP has one for a few years on older adults and disasters, and this also talks about forest fires too and things like that. And I found these resources very helpful. It's very simple in writing. It's from the American Psychological Association. They have documents for older adults for themselves how to prepare and also for caregivers how to prepare for disasters. But you've got to realize these are people who lived more than 60 years of their life. They've seen everything. They've seen how the economy has changed, society has changed. They've seen how the landscape has changed. Like when I came from Roanoke, Virginia, I used to walk from my apartment to the hospital. It's like a 20-minute walk. Even in the summer, it was always pleasant weather. The last year or two, I was telling my wife, like, it's very hot to walk outside. It's changed. So in six years, I noticed a change. And older adults can tell you what they have witnessed all these years. They have faced a lot of adversities, and they were resilient. They were able to survive it, and they can teach you a lot of valuable lessons. Those who have been displaced, they might grieve, but they still can teach you about what it means. That grief, what it means for them after losing things they have built up for decades. House, finances, security, relationships, friends, they're all gone. So they have more things to say about what they lost. And those who have not been displaced, they can have what Dr. Berman said, ecological grief. They're not able to find an emotional connection like deforestation or forest fires that change the landscape. You're not able to relate to that geography. It's like I lost the vegetation, I lost the flowers, I lost the animals that I used to see. So there'll be a loss that I'm detached from that environment. This is not the place I knew about. So they have things they can talk about. Ecological angst, grief, solastalgia has been shown more and ecological anxiety has been shown more in children, but there's a discount. Older adults don't suffer from it. And this is very important because when people are talking about climate change, they say, oh, the older generations are the villains in the story. No, your grandpa and grandma were coal mine workers and workers in oil field, they were driving gas guzzling machines and they are the ones who caused all this. They are the villains in the story. No, these are people who've seen, they may or may not have made mistakes knowingly or knowingly like in Virginia, when I contrast California and Virginia, California, I see a lot of EV vehicles because there are EV, electric vehicle charging stations. We don't have that much in Virginia, right? And then people blame it, oh, it's because of the elder politicians who don't want to change the whole stuff. But that doesn't mean the normal general adult population have concerns about climate change. They can teach you like, don't do this or that, or this is what happened during the, if you make a decision like this right now, this is how things will change. One stocking example is a place called Chesapeake Bay in Virginia where it's famous for its oysters. People are not finding good oysters right now because the temperature of the waters has increased, there's pollution, things like that, and now they're missing a business thing, and it happened over the span of two, three decades. So it's slow, so the older adults can teach you a lot of stuff. And the Chesapeake Action Climate Network. Network, yeah. Is very active with older adults leading that. Because they lost their livelihood. That's the worry about that. How many trainees do you know are doing projects on climate change? You can do a lot of things. You can look at the hospitalization rates, how people's medication are doing, heat waves or pollution. There's a lot of opportunities and low-hanging fruits for residents to pick. But what do we do as a society? This is a study by my friend, Dr. Watzel, again. He presented this last year at the New Orleans meeting. They published a paper looking at attendees from 2018 meeting in New York and 2019 meeting here in San Francisco. And checked how was the footprint of the attendees traveling. And they also reproduced it. What if the same number of attendees attended the previous 40 conferences, APA meeting locations? And they said the New York City, compared to New York City in 2018 and San Francisco in 2019, the carbon dioxide equivalent emissions were more in San Francisco compared to New York City. And they also found when they tried to reproduce it, the northeastern locations had lesser carbon footprint. And this was all based on the driving distances of the psychiatrists. And also, the other reason is most of the psychiatrists are located in the northeast. All right, there's another reason. International attendees travel from Europe through the Atlantic Ocean rather than from the Pacific Ocean. If you have a session in the Pacific Ocean, people have to travel through Europe, Atlantic Ocean, pass through East Coast and come to West Coast. That increases the footprint, right? So they made the case last year, probably it's good to have, if you are being more climate change conscious, it's good to have more session location, meeting locations in the East Coast. But you know how that discussion goes because you gotta give a balance between East Coast and West Coast too. But other societies have taken cue into this. The American Geographic Society decided that they will have meetings, alternate meetings as a virtual meeting. Yeah, so this year they're having in California, next year it will be virtual. In the year after, it'll be Chicago. And after that, it will be virtual. That's another option. A lot of societies are taking issues like that. Hybrid conferences are not easy. Doing hybrid sessions are not easy. I have burned my hand with those. It's difficult to coordinate stuff. But when you have a big meeting, with nearly 15,000 plus attendees, we've gotta be more conscious like, yeah, it's a business opportunity, it's a networking opportunity, it's a great place to meet friends. Meeting friends after the last two, three years is catching up everything. But we also gotta be conscious about how much are we contributing as physicians to climate change. Hospital systems are big carbon dioxide emission guzzlers. Their systems, their insulators, they have electricity going on 24 hours. We've gotta be more aware of how much we as a healthcare system contribute into climate change too. So I hope this has been food for thought for all of you guys. And we are open for questions. Thank you. If you can come to the mic, it's easier, because we are doing the recording. Hello, okay. So yeah, fantastic presentation. Thank you everyone for doing this. This is really helpful. So my question is, I live in Puerto Rico. So I have firsthand experience of just how much climate change affects the island. I guess my question is like, in terms of older adults, like in my experience, the older population in Puerto Rico can be a little stubborn. So, no, so when it comes to like, addressing and educating them on climate change, how do you approach like the learned helplessness that they have sometimes? Because not only are they an older population, but we also live on an island. So escaping climate events is not very easy, especially for older populations. So I just wanted to know your recommendations or perspectives on that. I had to argue with my father about the heat wave problem and explain to me, so it's fine, no, 10 o'clock, you come back home. So you got to take, you got to show them where to look for the news articles or weather articles, like, yeah, when you see things like that, you should be ready. Especially Puerto Rico has had instance, climate change related events. You tell them like, dad and mom or grandpa, grandma, this is the reality. It's dangerous as a physician, you educate them. It's also motivation from their side. But if they also notice community or society doing it, they go with the flow. That's what I've noticed. And that helps a lot. The other thing I want to mention, like for the older adults, they go through the phase of life when they want to contribute to the society. So probably we can take that opportunity to encourage them to be a part of it. So give them responsibilities. Make them, give them responsibilities as a leader. That led them to volunteering. Okay, so they can feel like respected, they can feel valued. And the stubbornness, you have to understand like where it is coming from. What are the barriers there? And then try to remove the barriers. And most of the times, like Dr. Ratnakaran said, their experience. We can use their experience to help the community. So this kind of little techniques, they can help to kind of encourage and motivate the older adults to be a part of it. Rather than just to receive the care, they can be the people who are involved in the team to provide care and help each other. I actually, I did volunteering with Red Cross for a while. And they have a very like well organized like disaster planning, management planning. Even like when there are like wildfires or like a house catches fire, they kind of go there and try to help each other. So not only like the firefighters, they have like a physician in the background. And like, so when I was like physician, my part was like being an on-call provider. And if so, sometimes they will call for like a refill, refill of the medications. So for older adults, also like they mostly, when they don't have access. And when like you are showing that I am here to help you, okay, and we have a team who are ready to help you. So that also encourage them to develop trust and develop like reassured that we are there like as a community. So I think that, you know, they need more education and like that chain call, like Dr. Vartanakaran mentioned, those kind of techniques and to be like more supportive, reassured them, you know, we are there. That's the way you can kind of engage them more. Okay. Thank you. Yeah. Hello, as a fourth year psychiatry resident and as a environmental sciences major, we studied environmental sciences in undergrad. This was an excellent presentation, very comprehensive. And you all, all three of you did an excellent job. I do have a question. I know you all talked about antipsychotics. Is there a difference between, and I have heard that before on how, you know, it could affect thermoregulation. Is there a difference between like first generation and second generation antipsychotics? And the other question I was gonna ask in relation to that, like, especially maybe in the summer when we were taking care of like older patients in places where there's heat waves, would you maybe consider like a switch to maybe an alternative medication? Like how would you like maybe practically manage this as heat waves become more common? So, Gary, do you have a question? Yeah, so I think the concern about the first generation is that photosensitivity that Dr. Barman kind of mentioned. But what I was actually alluding to was the class warning related to the atypical antipsychotics. So it's a class effect. And it has something to do with the structure of the person, the physiology of a person when you lose the body mass, or you don't have a lot of fat, and you have less muscles built into you. The person cannot really regulate the temperature around them, specifically the heat. That's why we don't allow, we always tell our patients jokingly that don't sunbathe when you're taking some of these medications. But the danger there really is their inability to actually adjust their body to the heat. And that's why, because of those unique physiologic determinants of the person, being an older adult, they are prone to develop delirium. And when they go to the delirium state, sometimes it's very hard to pinpoint what the cause is, because there could be hundreds of reasons why they would go into that stage. But I think as a physician, coming out from your residency program, try to make it a habit to educate the patient before you actually order a medication prescription for them. That way, it will come in handy to give them some sort of a warning, what are the things that could perceivably happen. It may not happen. However, if it does happen, at least they have that presence of mind it may be related to their medicine. And again, it's a class effect. Most people, we always associate antipsychotics with lowering of the seizure threshold, or some sort of problems with dystonic reactions, or metabolic problems, but poikilothermia is a very serious issue, and it has happened. And is it common with both first and second generation? No, it's more common in the second generation, at least my experience. Okay, okay, thank you all very much. I'm just gonna respond to that question, but I, this, I'm an older adult, but I have a second career. I'm still practicing at seeing patients, but my second career, hardly anyone has left here, is climate and mental health. I'm the co-founder and president of Climate Psychiatry Alliance, so I spend an incredible amount of my time thinking about this, and working on this, and I wanna just say, it is horrible that you are placed on Wednesday when half of the conference people have left already, because, and it's putting old people at the end, and what, I know this stuff. I'm an expert in this field, of climate and mental health, and I have learned so much from what your presentations have been today, and I'm blown away, and if you guys walk out of this room and don't join our coordinated work. Joshua's a good friend of mine, Joshua Watson. Josh just got off, and he's been staying at my house for the last week. Joshua, you're both APA leadership fellows. Joshua the chair, I was the vice chair. Yeah, so Josh told me that, but what you've brought to the table here is so important. Your question about what do we do with patients who we treat with antipsychotics, I think is really a knotty question now, and I'm so glad that more and more people know about the interaction, and the difficulty with thermoregulation, and medications for our seriously mentally ill, and our elderly. It seems to me extraordinarily risky to alter medications that are so essential for stabilizing psychotic patients for the brief periods of a heat wave, and that's one of the issues, is a heat wave is this temporary period. They're not extended, and people think, oh, I'll just wait it out, I'll get through it, and I know I feel that way. It'll go away, and I live in San Francisco here, so I know the fog will come in, but that's when elderly, and severely mentally ill, and isolated die. They die alone in their rooms. That's correct, yeah. It is so important, and your father was stubborn. My father. Or whoever is stubborn. My father was stubborn, which was my father. Your father was stubborn. I love your response, because you said it comes from somewhere. Getting old gives up autonomy. We don't want to give that up. Right. And so, how do you sustain the sense of dignity for those people who are losing functions? And your response, and your response is, how do we develop integrated networks across generations so that we take care of each other? Right. So, where's the young kid, or the middle-aged person in your father's neighborhood who you know, and say, hey, just, you know, check in on my dad. Yeah. Bring him something, in a way that doesn't humiliate him, but creating those networks of integration. And in terms of managing how to get through a heat wave, I think we have to develop the behavioral responses, because we can't, we don't have the time. They can't be taking off their medications that are so essential. Right. The slide that you have on how to manage a heat wave, that's really important. And I've written the one on the Climate Psychiatry Alliance website, that's a graphic, and it's not rocket science. Hydrate. If you're thirsty, you're already dehydrated. Don't wear polyester. And the polyester's cheap and available. Absolutely. Do you have cotton? Cotton. Keep out of the sun. Older, people don't know where those cooling places are, and they don't know how to get there, if they're poor and they're not right in their neighborhood. There's so many things that we can do. And I have to tell you, I am like, I am so glad I got up and came downtown today for the last session of this meeting. Yeah, thank you for your input. Even like these small things, like you said, that dress, like the type of the fabric you are using, that can make a big difference. And sometimes the older adults, they cannot process it, you know, that that is what I need. They need some ideas. And you said dementia, no, minimally cognitively impaired. I mean, it crosses the spectrum. Yeah. And after 90 degrees, you put on the fan, it just blows hot air on you. That's true, that's true. And regarding the like anti-psychotic question, it's again, like it's weighing the risk and benefits. You know, there are a few modifiable factors, few factors you cannot modify. So you have to look at different options. And also like how bad is the, how bad the medication is affecting the person. If someone gets like severely hypothermia, then and they are like in ICU, that's what actually happened in my practice, where I practice. We had a patient like who was on anti-psychotic and the second generation, and developed severe hypothermia. We had to send to ICU. So you cannot use that medication in that situation, right? But again, you have to like select the anti-psychotic. I'm not aware of like any studies that shows which anti-psychotic has less risk of temperature dysregulation. But second generation in general like has higher risk. But again, every individual is different. Every individual has a different temperature set point in the hypothalamus. So they respond differently. So you have to see that how much they are getting affected. Then you have to weigh the risk that if I stop the medications, their psychosis can then be controlled by something else. And so should I stop it versus reduce the dose or like change it to something else? You know, it's individualized. You still have four minutes for questions. So feel free to attack us. Yeah, thanks to everybody for making it so interactive and giving your comments and being a part of it. Thank you so much. Thank you. Thank you guys. Thank you for coming on the last day.

climate change

mental health

older adults

vulnerabilities

interventions

extreme weather

psychiatric conditions

residency programs

emergency preparedness

solastalgia

sustainability

healthcare