Excess winter deaths in Ireland among persons with Alzheimer’s disease or related dementia: lessons to be learnt Dr. Anne O’Farrell* ,Mr. Charles Roarty^ and Greg Straton~ *Strategic Planning and Transformation, HSE. ^ Energy Action Ireland, Dublin ~Department of Health

What are excess winter deaths (EWDs): These are deaths which are directly related to cold weather. These occur among people who generally have underlying health problems who die in winter but would have not have been expected to die during this period. This is why we call them “excess winter deaths”.

Background: EWD has been observed in Ireland and in other European countries.1 Previous studies found EWDs are greatest in older persons with respiratory and cardiovascular conditions. McAvoy H. (2007) All-Ireland Policy paper on Fuel Poverty and Health. Dublin: Institute of Public Health of Ireland.

Background: A recent UK study* found that those with Alzheimer’s Disease or Related Dementia (ADR D) are also at greatest risk of dying during winter. For e.g. in the UK 40% more persons aged >75 yrs or over with ADRD die in winter than at any other time of the year. *Liddell, C. (2013) http://news.ulster.ac.uk/releases/2013/6869.html.

Possible pathways contributing to excess winter deaths related to ADRD: Of the many pathways …. A few Source: Gray et al (2015) Excess winter deaths among people living with Alzheimer’s Disease or related dementias.

Aim: Determine whether this excess winter deaths in Alzheimers disease and related dementia (ADRD) is present in Ireland. Our study used updated data from 2010-2015. Our study based on those aged ≥ 65 yrs.

Method: All deaths (all causes) and also deaths with principal cause of death recorded as Alzheimer’s Diease and Related Dementia (ADRD) by month of death was obtained from the Central Statistics Office (CSO): ≥65 years Alzheimer’s Disease and Related Dementia (ADRD) deaths were identified using: ICD-10 Codes: *F00 - Dementia in Alzheimer’s Disease *F01 - Vascular dementia *F02 - Dementia in other diseases classified elsewhere. *F03 - Unspecified dementia *G30 - Alzheimer’s Disease

Analysis: Statistical analyses were carried out in: SPSS JMP StatsDirect.

Excess winter deaths WHO calculation: Winter deaths = deaths occurring in the 4 months of winter (Dec-Mar) Non-Winter deaths = deaths occurring the 4 months preceding (Aug-Nov) the Winter period and the 4 months following on from the Winter (Apr-July)

Excess Winter Death Index: EWDI = the excess winter deaths expressed as a percentage of the average number of deaths in non-winter months. 95% CI = EWM index ± 1.96 x (EWM Index / √ # EWM)

Excess winter mortality, all causes in those ≥ 65yrs 2010-2015: N=6,664 excess deaths for those aged 65yrs and over in 5 year study period.

Excess winter mortality index for those aged ≥65 years, all cause mortality by year: While no direct evidence, this reduction could be due warmer homes policy.. * 24.1% excess winter mortality for all ages in 2014/15 vs. 15.6% in 2010/11

Excess winter deaths from ADRD by year of death in ≥ 65years: N=672 excess winter deaths from ADRD in Ireland over 5 year study period.

Excess winter mortality index for ADRD deaths, by year of death, ≥ 65yrs

Results: Excess winter mortality from all causes among those aged 65 + years still exists in Ireland today: Increased from 1097 in 2010/11 in 2009 to 1,803 in 2014/15 15.6 % excess mortality in 2010/11 vs. 32.8% in 2014/15

Results: Excess winter mortality from ADRD among those aged 65 + years Ireland today: Increased from 91 in 2010/11 in 2009 to 172 in 2014/15 33.7% excess mortality in 2010/11 vs. 24.1% in 2014/15

Results – New Findings: Excess ADRD-related winter deaths evident in Ireland. Higher % than for excess winter deaths for all cause mortality but..... The % of excess ADRD-related winter deaths lower in Ireland than UK.

Limitations: This traditional method of measuring excess winter mortality in Europe has been questioned. If majority of cold days occur between December and March (few or none in autumn or spring), then the classic EWDi method is likely to be fit for purpose. If majority of cold days occur in non-winter months the classic EWDi method is likely to under-estimate the number of cold-related deaths.

Summary of new findings: These findings suggest that people living with ADRD have an excess risk of dying in the winter.

Discussion: The causes of the excess winter mortality among those with dementia still need further research as it is likely to be multi-factorial. Many of these deaths are likely to be avoidable. Norway vs. Ireland. Relative excess winter mortality from cardiovascular disease in Ireland is 2.1 times that in Norway. Housing stock in Norway much better.

What can be done and what is being done here in Ireland? Energy Action Ireland: In latter years, Energy Action Ireland has provided a free home insulation service to qualifying households*. Low-income households Elderly households Vulnerable households* Improve the energy efficiency and comfort conditions of homes. *Those receiving either winter fuel allowance, job seekers allowance for over 6 months (and with children <7yrs); those receiving family income support.

What can be done and what is being done here in Ireland? Warmth and Wellbeing Pilot Partnership Approach: Department of Communications, Climate Action and Environment; Sustainable Energy Authority of Ireland; Health Services Executive; and the Department of Health 900+ homes in Community Health Office 7 Focus on Chronic Obstructive Pulmonary Disease and Children with chronic Pulmonary conditions Rollout = Opportunity to increase scope to other causes of excess winter mortality

Recommendations: Ageing population will lead to increase in incidence of ADRD – likely to be major problem unless good policies in place. Public awareness of vulnerability of those with dementia to excess winter mortality: Discharge care plan for all persons with dementia

Recommendations: Energy audit of homes for those who are diagnosed with dementia. Those with dementia added to priority list for free home insulation service.

Further research: Identify reasons for big difference between Ireland and UK. Analysis of EWDs in those with dementia by: Place of residence Nursing home vs. own home Presence of co-morbidities Social inclusion

Acknowledgements: CSO for the data Communications