Climate change poses significant health risks, particularly for older adults, through evolving environmental exposures including extreme weather events like flooding, rising temperatures and poor air quality from sources including burning fossil fuels and smoke exposure from wildfires. Utilizing the age friendly 4Ms clinical framework: What Matters Most, Mentation/Cognition, Mobility, and Medications, and the  5^th  M (  Multi-Morbidity due to the threat multiplier effects of climate on older adults), clinicians must understand climate’s impacts and how to act to protect the health and well-being of  older patients in the face of climate change.

What Matters Most

Understanding what matters most to older adults creates the foundation for providing patient-centered care. Climate change can exacerbate existing health conditions and create new challenges, making it essential to align care and counseling with patients’ values and preferences.

• Patient Preferences: Older adults often prioritize maintaining independence and quality of life. Extreme weather events, such as heatwaves, hurricanes, and fires can disrupt daily routines, access to care, home care devices and home utilities (eg, fans, heat, lights, security systems) that require power, impacting ability to safety live independently and/or to safely evacuate.
• Social Connections: Social isolation is a significant concern for older adults and creates vulnerability in extreme weather events. Developing plans to enhance social connectivity can prioritize what matters most and serve as a strategy to protect against adverse health outcomes and mortality in extreme events like heat waves. Discuss with patients their support networks and backup communication plans independent of power outages and transportation.
• Vector-Borne Diseases: Warmer temperatures expand the geographic range of where ticks, mosquitos and fleas can survive, breed, and transmit diseases in previously “safe” geographic region. Increased rainfall and droughts can affect breeding grounds by changing these vectors’ habitats. Active older adults’ risk of exposure through activities like gardening, hiking, and having petsincreases with climate change and must be discussed proactively and inform an expanded differential diagnosis.
• Alignment: Anchoring treatment goals in patient preferences simultaneously allows alignment with what matters most and reduces waste or unnecessary tests that can contribute to greenhouse gas emissions that help drive climate change.

Medications

With increasing frequency and intensity in the setting of climate change, extreme heat and weather events can create adverse conditions impacting adverse effects and efficacy of medications.

• Heat events – common medications can interact with heat, predisposing patients to dehydration, acute kidney injury, hyperhidrosis, or increased sensitivity to heat. Other medications may be inactivated and made ineffective when stored improperly and/or exposed to heat. Common medications that can interact with heat leading to adverse effects in heat include cardiac (eg, diuretics, calcium channel blockers, ACE-I, ARBs); beta blockers; anticholinergics; CNS stimulants; antipsychotics; antidepressants; Insulin and inhalers can be inactivated when stored at inappropriate temperature ranges.

• Extreme weather events – flooding and hurricane events compromise supply chains that affect critical supplies like IV fluids, clean water and medication production. High winds, severe storms, and other extreme events often result in power outages adversely effecting refrigerated medications including insulin, eye drops, hormonal/thyroid, certain antibiotic and biologics for rheumatoid arthritis. Advise patients to keep ice packs frozen to transfer with medications to a cooler and do not leave medications in high heat environments like parked vehicles.

Mentation

Extreme heat, worsening air quality and stressors from severe weather events pose risks for many older adults but especially those with anxiety, dementia, delirium and mental illness. These risks are particularly acute for those with existing social determinates of health.

• Delirium can be precipitated or worsened by exposure to high temperatures, and the trauma of displacement in extreme events like wildfires, tornadoes, flooding and hurricanes.
• High nighttime temperatures can increase sleep disruption, thereby predisposing to decline in cognitive functioning.
• Exposure to polluted air with increased PM 2.5 (particulate matter 2.5 micrometers) (from sources like wildfire smoke or air pollution from burning fossil fuels) has been linked to neuroinflammation, stroke and dementia.
• Depression and anxiety symptoms related to the mental health stressors with climate change related events, alongside concerns for sleep dysregulation and PTSD, may be more commonly seen in the chronic, outpatient setting leading to increased health care utilization and use of psychotropic medications.
• Above average heat indexes increase the risk of hospitalization for patients with Alzheimer disease and related dementias (ADRD). The effects of extreme heat may persist for several days also resulting in increased hospitalization risk.

Mobility

• • All older adults can experience mobility challenges during extreme weather events. Debris and damage can damage sidewalks, roads, and infrastructure making travel difficult. Those with existing impaired mobility are even at greater risks as they can experience increased challenges in leaving or getting to a safe location during extreme weather events, fires, ice/snow, and evacuation.
  • Poor air quality can worsen respiratory conditions, making it harder for individuals to move around and/or limit outdoor activity.
  • Extreme heat/cold impacts mobility for all of us but especially those are dependent on mobile devices as their battery range, duration and reliability decreases.