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 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 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 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: Older people going to bed at 7pm to save on fuel bills. SOURCE: The Irish Times – Sept Fuel Allowance cut to hurt the poorest of older people. hurt the poorest of older people. SOURCE: Age Action, Jan 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

Households receiving fuel allowance: Source: Dept of Social Protection, Sligo and Dept. of Environment, Community and Local Government. N=264,400N=274,000 N=286,200N=290,000N=300,000 N=376,000N=400,000

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 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 To describe the causes of death and reasons for hospital in-patient admissions among the elderly in winter vs. summer months. 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 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 Patients aged ≥65 years who were admitted to acute hospitals as emergency admissions during winter months vs. summer months extracted from HIPE database. Patients aged ≥65 years who were admitted to acute hospitals as emergency admissions during winter months vs. summer months extracted from HIPE database. Statistical analyses were carried out in JMP, Stata and StatsDirect. Statistical analyses were carried out in JMP, Stata and StatsDirect.

Mortality coming down in all age-groups-particularly in elderly:

Mortality coming down in all age- groups:

No. of deaths in elderly (aged 65+ yrs) by season of death (winter vs. summer )(All deaths) 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 period, average 650 excess deaths per year in elderly during winter compared to summer.

Deaths from respiratory illness in those aged 65+ years 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 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: 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. 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 HIPE data over 65s emergency only over 65s emergency only comparing winter admissions with summer admissions comparing winter admissions with summer admissions

No. of emergency hospital in-patient admissions in elderly (aged 65+ yrs) by season (winter vs. summer): 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: Excess hospital admissions due primarily to: –Respiratory diseases: 7,129/8,040 (88.6%)

Summer Adms Winter Adms Diff. % Diff I00-I99 Diseases of the circulatory system % J00-J99 Diseases of the respiratory system % R00-R99 Symptoms, signs and abnormal clinical findings % K00-K03 Diseases of the digestive system % S00-T98 Injury and poisoning % C00-D48 Neoplasms % N00-N99 Diseases of the genitourinary system % G00-G99 Diseases of the nervous system % M00-M99 Diseases of the musculoskeletal system % E00-E89 Endocrine, nutritional and metabolic diseases % L00-L99 Diseases of the skin and subcutaneous tissue % D50-D89 Diseases of the blood and blood-forming organs % A00-B99 Certain Infectious and Parasitic Diseases % F00-F99 Mental and Behavioural Disorders % H00-H59 Diseases of the eye and adnexa % Z00-Z99 Factors influencing health status % H60-H95 Diseases of the mastoid process % Q00-Q99 Congenital malformations % TOTAL %

Winter vs. Summer Admissions: Length of Stay: Winter season = 1,842,691 bed days Winter season = 1,842,691 bed days Median LOS Winter = 7 days (range days) Median LOS Winter = 7 days (range days) Summer season = 1,689,663 total bed days Summer season = 1,689,663 total bed days Median LOS = 6 days (range days) Median LOS = 6 days (range days) Excess bed days used in winter season vs. summer season = 153,028 bed 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) 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. Winter excess mortality and morbidity still present in elderly although it has reduced over time. Respiratory diseases and circulatory diseases over-represented. Respiratory diseases and circulatory diseases over-represented.

Discussion: This study has found that more households than ever are in receipt of the fuel allowance. 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. 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. 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 multi- factorial. The causes of the excess mortality still need further research as it is likely to be multi- factorial. Many of these deaths are likely to be avoidable and an hypotheses is that they are linked to poor housing, and temperature 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. 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. 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. 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 6 th Feb 2012 Dr Elizabeth Cullen Department Community Health HSE Department Community Health HSE

Outline of presentation 1. Excess winter mortality 1. Excess winter mortality 2. How do cold temperatures affect health? 2. How do cold temperatures affect health? 3. Who is most vulnerable in Ireland? 3. Who is most vulnerable in Ireland? 4. A look at other countries 4. A look at other countries 5. Conclusions 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 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 Majority due to respiratory and circulatory diseases. Majority due to respiratory and circulatory diseases. However, countries with warmest winters (over 5 o C) tend to have highest rates However, countries with warmest winters (over 5 o C) tend to have highest rates ‘Paradox of excess winter mortality’ Shah and Peacock 1999 ‘Paradox of excess winter mortality’ Shah and Peacock 1999

2: How do cold temperatures affect health? Through the cardiovascular and respiratory systems Through the cardiovascular and respiratory systems Cardiovascular disease is declining as a cause of mortality, but still causes a third of deaths in Ireland 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 Respiratory mortality has shown no fall, causing approximately 14% of deaths in Ireland Almost a half of mortality in Ireland is temperature sensitive Almost a half of mortality in Ireland is temperature sensitive

Cardiovascular Exposure to cold results in significant and prolonged changes in the general population 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) (Donaldson Keatinge and Allaway 1997)

After six hours of mild cooling Packed cell volume by 7% Packed cell volume by 7% count increased to produce a 15% increase in the fraction of plasma volume occupied by platelets. Platelet count increased to produce a 15% increase in the fraction of plasma volume occupied by platelets. Whole blood viscosity increased by 21%; Whole blood viscosity increased by 21%; Arterial pressure rose on average from 126/69 to 138/87 mm Hg. 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. Plasma cholesterol concentration increased, in both high and low density lipoprotein fractions, but values of total lipoprotein and lipoprotein fractions were unchanged. increased 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) 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 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). (Eurowinter, 1977; Donaldson et al 1998).

3: Who is most vulnerable in Ireland? People suffering from cardiovascular People suffering from cardiovascular and respiratory disease and respiratory disease The older population The older population

Mortality from Ischaemic heart disease per 100,000 Irish population

Mortality from respiratory disease per 100,000 Irish population

Relationship between lagged minimum temperatures and mortality from respiratory disease per 100,000 R square p<0.000

Mortality from cancer per 100,000 population

Increase in mortality below threshold temperature in Ireland %65-742% % Over % Total2% 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 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 and 65-74, mortality from cardiovascular disease and all causes was unchanged as temperature fell to °C In Yakutsk, in the age groups studied: people aged and 65-74, mortality from cardiovascular disease and all causes was unchanged as temperature fell to °C Mortality from respiratory disease only increased as temperatures fell below −20°C (Donaldson et al 1998) 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 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 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) An average of 4.2 layers of clothing were worn (Donaldson et al 1998)

A comparison: Norway and Ireland IrelandNorway Smoking prevalence 32%33% Obesity10%9% CholesterolHighHigh Both countries are demographically similar ( Clinch and Healy 2000)

A comparison: Norway and Ireland IrelandNorway Roof insulation 100mm200mm Wall insulation 40mm125mm Floor insulation 25mm150mm January temperature 5oC5oC5oC5oC -1.1 o C Average internal temperatures 15 o C 21 o C

A comparison: Norway and Ireland IrelandNorway Crude mortality rate from cardiovascular disease/1000 population Crude mortality rate from respiratory disease/1000 population Excess winter deaths per day from cardiovascular disease Excess winter deaths per day from Respiratory disease Clinch and Healy 2000

(Walsh 2008 Statistical and Social Enquiry Society of Ireland) Excess winter mortality is clearly modifiable

Recent reduction Mortality Respiratory82%58% Ischaemic heart disease 27%23% Crude27%18% Walsh 2008 Statistical and Social Enquiry Society of Ireland Reduction in the peak to trough variation in winter mortality

Maximizing Ireland’s Energy Efficiency Measure Number of homes deficient Measures made to 2008 Wall insulation 60,8363,807 Draught proofing 74,52413,401 Roof insulation 54,75217,982 Homes18,465 (Dept. Communications, Energy and Natural Resources ) Figures related to lowest income quintile

Factors associated with excess winter mortality  Warmer housing  Increased spending on health care  Reduced air pollution  Impacts of better socioeconomic conditions “Remains a puzzle” “Remains a puzzle” Merits further research 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)). (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