Excess winter mortality and
morbidity in the elderly
in Ireland: has a change in the
fuel allowance the potential to
affect it?
Dr. Anne O’Farrell and Dr. Davida De La
Harpe,
Health Intelligence Unit, HSE.
Background:
• Excess winter mortality has been observed in Ireland
and in other European countries.1
• The fuel allowance, which is means tested, can be
regarded both as a proxy measure for poverty and as a
real contributor to ameliorating the effects of poverty.
• The increase in fuel prices together with the reduction of
the fuel allowance from 32 weeks to 26 weeks could
impact on the numbers suffering fuel poverty
•
McAvoy H. (2007) All-Ireland Policy paper on Fuel Poverty and Health. Dublin:
Institute of Public Health of Ireland.
Recent Headlines:
Fuel Allowance cut to
hurt the poorest of older people.
SOURCE: Age Action, Jan. 2012
Older people going to bed at
7pm to save on fuel bills.
SOURCE: The Irish Times –
Sept. 2011.
Struggle of Irish people to pay
bills revealed in Credit Union
survey. “The increases in energy
and fuel costs have affected
85pc of people and 8pc said it is
impossible to pay their bills each
month”.
SOURCE: IRISH INDEPENDENT,
Monday 9th January, 2012
Gas price increases
to add €150 to
household bills.
SOURCE: The Irish
Times, Oct. 2011.
Households receiving fuel
allowance:
23.7%
25%
18.7%
20%
15.3%
14.9%
N=264,400
N=274,000
N=286,200
N=290,000
N=300,000
2005
2006
2007
2008
2009
14.9%
15%
10%
14.7%
15.0%
N=376,000
N=400,000
2010
2011
5%
0%
Source: Dept of Social Protection, Sligo and Dept. of Environment, Community and
Local Government.
AIM:
• The aim of this study was to determine whether
the excess in winter mortality and inpatient
hospital emergency admissions among the
elderly is continuing in recent years 2005-2010.
• To describe the causes of death and reasons for
hospital in-patient admissions among the elderly
in winter vs. summer months.
Method:
• Persons aged ≥65 years who died in
Ireland in Winter months (i.e.Nov-Jan)
versus Summer months (i.e. May-Jul)
extracted from the CSO for years 20052009.
• Patients aged ≥65 years who were
admitted to acute hospitals as emergency
admissions during winter months vs.
summer months extracted from HIPE
database.
Mortality coming down in all
age-groups-particularly in elderly:
y = -20.648x + 823.53
25000
20000
15000
y = -455.97x + 19526
10000
5000
Rate per 100,000
population
900
800
700
600
500
400
300
200
100
0
0
20
0
20 0
0
20 1
0
20 2
0
20 3
0
20 4
0
20 5
0
20 6
0
20 7
0
20 8
09
Rate per 100,000
population
Age standardised mortality rate for all cause
mortality for all ages and those aged 85+ years by
year.
Year of death
All Ages
85+
Linear (All Ages)
Linear (85+)
Mortality coming down in all agegroups:
Age standardised mortality rate for older age
groups by year.
Rate per 1000 population
250
200
60-64
65-69
150
70-74
75-79
100
80-84
85+
50
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year of death
No. of deaths
No. of deaths in elderly (aged 65+ yrs) by
season of death (winter vs. summer)(All deaths)
30000
28000
26000
24000
22000
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
29339
26106
5969
5895
5823 5379
5640 53156012
5136
5211
5065
2005
2006
2007
2008
2009
20052009
Year
Sum m er m onths
Winter m onths
N= 3,233 excess deaths in winter months vs. summer months over 5 year study
period, average 650 excess deaths per year in elderly during
winter compared to summer.
Deaths from respiratory illness in
those aged 65+ years
1079
No. of deaths
1200
1000
800
600
400
200
0
p
05
0
2
es
-R
ry
o
t
ira
06
0
2
784
996
943
867
671
661
740
Summer months
Winter months
e
D
R
1043
849
hs
t
a
p
es
to
a
ir
ry
07
0
2
D
R
hs
t
ea
p
es
to
a
ir
ry
08
0
2
D
R
hs
t
ea
p
es
to
a
ir
ry
09
0
2
D
R
hs
t
ea
p
es
to
a
ir
ry
D
hs
t
ea
1,223 excess deaths in elderly due to respiratory diseases in winter
vs. summer months over the 5 year study period.
Deaths from circulatory illness in
those aged 65+ years
2438
2015
2213
2021
ea
th
s
20
09
C
irc
ul
at
or
y
D
ea
th
s
D
y
at
or
20
08
C
irc
ul
at
or
20
07
C
irc
ul
C
irc
ul
at
or
y
D
ea
th
s
y
D
De
a
at
or
y
20
06
ea
th
s
Winter
ul
-C
irc
20
05
2463
2027
2365
1964
2324
2006
Summer
th
s
No. of Deaths
3000
2500
2000
1500
1000
500
0
1,770 excess deaths in elderly due to circulatory diseases in winter vs. summer months
Over the 5 year study period.
Results:
• Excess deaths due primarily to:
– Respiratory diseases: 1,770/3,233
(54.7%)
– Circulatory diseases: 1,223/3,233
(37.8%)
• Dr. Elizabeth Cullen will present data on other
countries’ experience and on the biological effect
of lower temperatures.
Moving on to hospital admissions:
• HIPE data
• over 65s emergency only
• comparing winter admissions with summer
admissions
No. of emergency hospital in-patient
admissions in elderly (aged 65+ yrs) by
season (winter vs. summer):
35000
30000
28943
27601
30316
28615
2965030342
32926
29633
3040131413
2006
2007
2008
2009
25000
20000
15000
10000
5000
0
2005
Summer Admissions
Winter Admissions
N= 8,040 excess emergency in-patient hospital admissions in winter
months vs. summer months over 5 year study period.
Results:
• Excess hospital admissions due primarily
to:
– Respiratory diseases: 7,129/8,040
(88.6%)
20052009
Summer
Adms
20052009
Winter
Adms
% Diff
Diff.
I00-I99 Diseases of the circulatory system
32424
33447
1023
3.2%
J00-J99 Diseases of the respiratory system
23312
30441
7129
30.6%
R00-R99 Symptoms, signs and abnormal clinical findings
19475
19796
321
1.6%
K00-K03 Diseases of the digestive system
15332
14682
-650
-4.2%
S00-T98 Injury and poisoning
14288
15436
1148
8.0%
C00-D48 Neoplasms
9642
9349
-293
-3.0%
N00-N99 Diseases of the genitourinary system
7752
7620
-132
-1.7%
G00-G99 Diseases of the nervous system
4370
4721
351
8.0%
M00-M99 Diseases of the musculoskeletal system
4130
3712
-418
-10.1%
E00-E89 Endocrine, nutritional and metabolic diseases
4123
4071
-52
-1.3%
L00-L99 Diseases of the skin and subcutaneous tissue
3274
2743
-531
-16.2%
D50-D89 Diseases of the blood and blood-forming organs
2592
2464
-128
-4.9%
A00-B99 Certain Infectious and Parasitic Diseases
2587
2648
61
2.4%
F00-F99 Mental and Behavioural Disorders
1216
1405
189
15.5%
H00-H59 Diseases of the eye and adnexa
668
628
-40
-6.0%
Z00-Z99 Factors influencing health status
350
367
17
4.9%
H60-H95 Diseases of the mastoid process
320
361
41
12.8%
45
49
4
8.9%
Q00-Q99 Congenital malformations
Winter vs. Summer Admissions:
Length of Stay:
• Winter season = 1,842,691 bed days
• Median LOS Winter = 7 days (range 1-850 days)
• Summer season = 1,689,663 total bed days
• Median LOS = 6 days (range 1-892 days)
• Excess bed days used in winter season vs. summer
season = 153,028 bed days.
Winter vs. Summer Admissions:
Estimated Acute Care Costs:
(emergency admissions only)
Hospital in-patient Costs
2005
2006
2007
2008
2009
2005-2009 inclusive
Summer
€
159,066,230.90
166,194,326.85
173,171,915.31
184,180,783.00
159,542,568.00
842,155,824.06
Winter
€
172,223,977.14
178,388,950.96
184,676,111.81
192,154,259.00
175,857,058.00
903,300,356.91
Excess costs winter admission vs. summer admission = €61 million
Discussion:
• Winter excess mortality and morbidity still
present in elderly although it has reduced
over time.
• Respiratory diseases and circulatory
diseases over-represented.
Discussion:
• This study has found that more households than
ever are in receipt of the fuel allowance.
• The numbers of those assessed as suffering fuel
poverty are increasing.
• Although the direct overall cost has increased
for the exchequer, the possible long-term cost
of reducing the allowance and the wider
consequences require further monitoring.
Discussion:
• The causes of the excess mortality still need
further research as it is likely to be multifactorial.
• Many of these deaths are likely to be avoidable
and an hypotheses is that they are linked to
poor housing, and temperature
• Socio-economic factors come into play.
Discussion:
• Further research into the link between
housing standards and in-adequate
heating and excess winter mortality needs
to be carried out.
• However, a cut in the fuel allowance has
the potential to exacerbate the problem
among the elderly.
Excess winter mortality
in Ireland
Energy Action Fuel Poverty Conference
Dublin Castle
February 6th Feb 2012
Dr Elizabeth Cullen
Department Community Health HSE
Outline of presentation
• 1. Excess winter mortality
• 2. How do cold temperatures affect health?
• 3. Who is most vulnerable in Ireland?
• 4. A look at other countries
• 5. Conclusions
1: Excess winter mortality
•We have seen from Anne’s slides, that we have excess
winter mortality and hospital admissions in those aged 65
years and over during the study period 2005-2009.
•Majority due to respiratory and circulatory diseases.
•However, countries with warmest winters (over 5oC) tend
to have highest rates
•‘Paradox of excess winter mortality’ Shah and Peacock 1999
2: How do cold temperatures affect
health?
• Through the cardiovascular and respiratory systems
• Cardiovascular disease is declining as a cause of
mortality, but still causes a third of deaths in Ireland
• Respiratory mortality has shown no fall, causing
approximately 14% of deaths in Ireland
• Almost a half of mortality in Ireland is
temperature sensitive
Cardiovascular
Exposure to cold results in significant and prolonged
changes in the general population

Constriction of blood vessels leading to higher blood
pressure

Immediate changes in levels of chemicals which
increase the tendency of blood to form clots.
(Donaldson Keatinge and Allaway 1997)
After six hours of mild cooling
• Packed cell volume by 7%
• Platelet count increased to produce a 15% increase in the fraction
•
•
•
of plasma volume occupied by platelets.
Whole blood viscosity increased by 21%;
Arterial pressure rose on average from 126/69 to 138/87 mm Hg.
Plasma cholesterol concentration increased, in both high and low
density lipoprotein fractions, but values of total lipoprotein and
lipoprotein fractions were unchanged.
Fibrinogen increased
•
• The increases in platelets, red cells, and viscosity associated
with normal adjustments to mild surface cooling provide a
probable explanation for rapid increases in coronary and
cerebral thrombosis in cold weather. (Keatinge et al 1984; Neild et al
1995)
Respiratory
• Cold temperatures
 Can induce constriction of the airways.
 Cause delayed changes in increase in clotting factors in
blood
 Also associated with indoor crowding, contributing to
both cross-infection and a lowering of the immune
systems resistance to respiratory infection.
(Eurowinter, 1977; Donaldson et al 1998).
3: Who is most vulnerable in
Ireland?
• People suffering from cardiovascular
and respiratory disease
• The older population
Mortality rate per 100,000
Observed
Quadratic
1.2
1.0
0.8
0.6
0.4
-10
-5
0
5
10
15
20
25
Mean temperature
Mortality from Ischaemic heart disease per 100,000 Irish population 1981-2004
Mortality rate per 100,000
Observed
Quadratic
0.8
0.7
0.6
0.5
0.4
0.3
0.2
-10
-5
0
5
10
15
20
25
Mean temperature
Mortality from respiratory disease per 100,000 Irish population 1981-2004
Mortality rate per 100,000
Observed
Linear
0.8
0.6
0.4
0.2
-15 -10 -5
0
5
10
15
20
Minimum temperature
Relationship between lagged minimum temperatures and
mortality from respiratory disease per 100,000 R square 0.892 p<0.000
Mortality rate per 100,000
1.0
0.8
0.5
-10
-5
0
5
10
15
Mean temperature
Mortality from cancer per 100,000 population 1981-2004
20
25
Increase in mortality below threshold
temperature in Ireland
15-64
0.7%
65-74
2%
75-84
2.4%
Over 85
3.9%
Total
2%
In accordance with national and international research (e.g. Aylin et al
2002, Eurowinter, 1997; Boulay et al,1999; Huynen et al, 2001; Moran et al, 2000; Goodman et al,
2004).
4 A look at other countries
• Yakutsk is the world's coldest city, with temperatures
averaging only −26.6°C during October to March
• In Yakutsk, in the age groups studied: people aged 5059 and 65-74, mortality from cardiovascular disease and
all causes was unchanged as temperature fell to -
48.2°C
• Mortality from respiratory disease only increased as
temperatures fell below −20°C
(Donaldson et al 1998)
Yakutsk
• High winter mortality in such regions is largely
preventable by warm housing and clothing
• Room temperatures were 19.1°C at outside
temperatures of -42°C
An average of 4.2 layers of clothing were worn
(Donaldson et al 1998)
A comparison: Norway and Ireland
1986-1995
Ireland
Norway
Smoking
prevalence
32%
33%
Obesity
10%
9%
Cholesterol
High
High
Both countries are demographically similar
(Clinch and Healy 2000)
A comparison: Norway and Ireland
Ireland
Norway
Roof insulation
100mm
200mm
Wall insulation
40mm
125mm
Floor insulation
25mm
150mm
January temperature
5oC
-1.1oC
Average internal
temperatures
15oC
21oC
A comparison: Norway and Ireland
Ireland
Norway
Crude mortality rate from cardiovascular
disease/1000 population
4.1
4.9
Crude mortality rate from respiratory
disease/1000 population
1.3
1.1
Excess winter deaths per day from cardiovascular
disease
39.6
6.3
Excess winter deaths per day from Respiratory
disease
4.3
Clinch and Healy 2000
24.3
(Walsh 2008 Statistical and Social Enquiry
Society of Ireland)
Excess winter mortality is clearly modifiable
Recent reduction
Mortality
1973-1999
2000-2006
Respiratory
82%
58%
Ischaemic heart
disease
27%
23%
Crude
27%
18%
Reduction in the peak to trough variation in winter mortality
Walsh 2008 Statistical and
Social Enquiry Society of Ireland
Maximizing Ireland’s Energy Efficiency
Measure
Number of
homes deficient
Measures made
to 2008
Wall insulation
60,836
3,807
Draught proofing
74,524
13,401
Roof insulation
54,752
17,982
Homes
18,465
Figures related to lowest income quintile
(Dept. Communications, Energy and Natural
Resources 2009-2020)
Factors associated with excess
winter mortality
Warmer housing
Increased spending on health care
Reduced air pollution
Impacts of better socioeconomic conditions
“Remains a puzzle”
Merits further research
(Walsh 2008 Statistical and Social Enquiry Society of Ireland)
Discussion:
We know the importance of:
good quality housing,
heating,
nutrition
and clothing in counteracting the impact of cold
in the Irish and international context
(Moran et al, 2000; Middleton et al, 2000; Donaldson et al, 2001(a)).
5. Conclusion:
A proportion of excess winter mortality is
avoidable
As you can see, we can monitor it
We have the opportunity now to track the
effects of socio-economic changes and
other variables on excess mortality
Further research needs to be done
 Avoidable mortality is a tragedy