By Cindy Holle

Implications for Public Health

Awareness of the “three Ds”—dementia, depression, and delirium—in older adults can help those staffing shelters recognize distress and respond appropriately before symptoms worsen.

For older adults, time spent in a disaster shelter can be just as distressing as the disaster itself. Age-related conditions—such as dementia, depression, or delirium—can make unfamiliar surroundings and disruption in routines especially disconcerting and cause individuals to become excessively irritable, forgetful, or agitated. To complicate this, these behaviors might be seen as normal and associated with old age instead of worrisome, leaving these individuals at risk of not receiving the care and treatment they need.

Disaster responders and shelter staff are not expected to be experts in detecting or differentiating between dementia, depression, and delirium in older adults. But by knowing the signals to watch for in older adults, mass care workers can more easily recognize when something isn’t right and respond quickly—improving safety, reducing the burden on shelter resources, and decreasing the chance of more severe consequences for these vulnerable adults. This piece offers mass care workers a starting point for understanding how to respond to troubling behaviors.

The Three Ds: Dementia, Depression, Delirium

It is important to recognize and respond to signs of dementia, depression, or delirium—the three Ds—in older adults in mass care situations. The three conditions may look the same but are very different and require distinct approaches to care. It is often difficult even for experienced clinicians to differentiate between the three Ds. Most disaster shelter workers are not health care professionals, which can make it difficult to triage older adults based on observed behaviors and provide them with the most appropriate level of care and safety.

Mass care workers are, however, often trained to identify and treat issues based on clear policies of care. For instance, head lice and scabies are not uncommon in mass care settings, and when these easily identified conditions are present, there are routine steps to address them. Since dementia, depression, and delirium in older adults are more difficult to recognize, this is not often the case. But understanding the basic symptoms can be a first step to creating consistent guidelines.

Dementia, such as Alzheimer’s disease, is a slow and chronic decline in memory, thinking, reasoning, and language skills. People with dementia might remember things from long ago, but lack short-term memory, forget how items are used, or ask the same questions repeatedly. They can be at risk for falling, become lost, or be unable to care for themselves.


Members of the U.S. Coast Guard carry an elderly survivor of Hurricane Katrina to safety. ©U.S Coast Guard, 2005.

Delirium, on the other hand, is an acute brain emergency marked by impairments in attention, arousal, and awareness. People with delirium can appear hyperactive or hallucinatory, or they may appear extremely drowsy. They can cycle back and forth between the two states. Hyperactive delirium can be mistaken for intoxication, mental illness, or over-medication. If untreated, delirium can lead to deterioration that results in institutionalization or death.

Depression is a mood disorder that affects how people behave and think and can include sadness, apathy, changes in sleep or appetite, and lack of concentration. People with depression may be stable and need minimal support or they could be at risk for self-harm and require intervention.

It’s important to note that older adults may have more than one of these conditions and that the presence of one condition can increase the likelihood of another. Having even one of the three Ds, however, can increase an individual’s vulnerability to and risk of long-lasting consequences that potentially include the inability to return to their previous living arrangements.

Awareness for Efficient Shelter Operations

Unaddressed dementia, depression, or delirium not only puts the safety of older adults at risk, it can also increase demands on mass care staff, making it even more important to identify needs early. Those in decline will require extra supervision and assistance with basic activities such as toileting, eating, bathing, and dressing, as well as protection from exploitation. These added care tasks can deeply impact a system that might already be laboring under constraints.

You don’t have to be a clinician to ensure clients do well and shelter workers aren’t overwhelmed—it’s enough to realize that something isn’t right. Asking clients open-ended questions such as, “How are you doing today?” and watching for other signals of distress listed in this checklist can help determine when assistance is needed. Rather than trying to “diagnose” the cause of the behavior, awareness and observations of client behaviors can guide the shelter worker’s actions and keep older adults safe.

Suggested Tools


Identifying Vulnerable Older Adults and Legal Options for Increasing Their Protection During All-Hazards Emergencies
Centers for Disease Control and Prevention

This guide is intended to help close many of the gaps in emergency planning and preparedness for vulnerable older adults. It aims to give essential partners from a range of sectors and at all jurisdictional levels critical information, strategies, and resources they need to improve the planning for and protection of vulnerable community-dwelling older adults.

Something is Wrong! Safety for Older Adults in Mass Care Settings: Responding to the Signals of Dementia, Depression, and Delirium
Cindy Holle

A guide for mass care workers to identify signals of dementia, depression, and delirium so that they can respond to keep shelter clients safe.

For a list of all the tools included in this special collection, visit the Mass Sheltering Tool Index. A list of further readings are also available.