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TITLE Deadly Cold: Health Hazards Due to Cold Weather. AnInformation Paper by the Subcommittee on Health andLong-Term Care of the Select Committee on Aging.House of Representatives, Ninety-Eighth Congress,Second Session (February 1984).

INSTITUTION Congress of the U.S., Washington, D.C. House SelectCommittee on Aging.

REPORT NO House-Comm-Pub-98-414PUB DATE Feb 84NOTE 62p.; Data tables may be marginally legible due to

small print.PUB TYPE Guides - Non-Classroom Use (055) -- Information

Analyses (070) -- Legal/Legislative/RegulatoryMaterials (090)

EDRS PRICE MFO1 Plus Postage. PC Not Available from EDRS.DESCRIPTORS *Death; Federal Programs; Health Conditions;

*Heating; *Older Adults; *Physical Health; Poisoning;Special Health Problems; Temperature; *Weather

IDENTIFIERS Hypothermia

ABSTRACTThis paper, on the health hazards of cold weather for

elderly persons, presents information from various sources on thedeath rates in winter throughout the United States. After reviewingthe scope of the problem, specific health hazards associated withcold weather are discussed, i.e., hypothermia, fires, carbon monoxidepoisoning, and influenza and pneumonia. An analysis of federal andnonfederal efforts to reduce excess mortality associated with coldweather is given. Following a brief summary of the findings,suggestions for reform are offered (e.g., better monitoring by safetyand consumer agencies, a National Weather Service early warningsystem for cold weather, governmental energy response programs, andbetter immunization programs). The appendices include a cold weatherguide for the elderly; 12 tables of statistics on national mortalitydue to cold weather, fire, influenza and pneumonia between 1962 and1980, and home heating costs in 1983; city temperatures and deathschart by age; and service disconnection and reconnection policies bystate. (BL)

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[COMMITTEE PRINT]

DEADLY COLD: HEALTH HAZARDSDUE TO COLD WEATHER

AN INFORMATION PAPER

BY THE

SUBCOMMITTEE ON HEALTH AND LONG-TERM CARE

OF THE

SELECT COMMTTEE ON AGINGHOUSE OF REPRESENTATIVES

NINETY-EIGHTH CONGRESSSECOND SESSION

U.S. DEPARTMENT OF EDUCATIONNATIONAL INSTITUTE OF EOUCATION

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

'This document has been reproduced asreceived from the person or organization

originating it.Minor changes have been made to improve

reproduction quality.. .

Points of view or opinions stated in this docu-

ment do not necessarily represent official NIE

position or policy.

FEBRUARY 1984

Comm. Pub. No. 98-414

M.S. GOVERNMENT PRINTING OFFICE30-482 0 WASHINGTON : 1984

SELECT COMMITTEE ON AGINGEDWARD R. ROYBAL, California, Chairman

CLAUDE PEPPER, Florida^rr RIO BIAGGI, New York.K?; ANDREWS, North Carolina

',DON HONKER, WashingtonTHOMAS J. DOWNEY, New YorkIAMES J. FLORIO, New Jerseyii..11110LD E. FORD, Tennessee1LLIAM J. HUGHES, New JerseyIIARILYN LLOYD, TennesseeST'' V L.l. LUNDINE, New York

Ar.ft ROSE OAKAR, Ohio)VAS A. LUKEN, Ohio

!DINE A. FERRARO, New YorkB. 'h2Rr 1 B. BYRON, Maryland

Ind 11. T A.TCHFORD, Connecticuti AN MICA, FlorMaHENRI! A. WAXMAN. CaliforniaMIIKE SYNAR, OklahomaBUTLER DERRICK, El. nth Carolina

,11TCE F. VENTO, MinnesotaV .RNEY FRANK, Maysachusetts

,3 ?CANTOS, CaliforniaION WYDEN, OregonDONALD JOSEPH ALHOSTA, MichiganGPL1. W. CROCKETT, JA ., MichiganWILL:AM HILL BONER, TennesseeIKE SKELTON, MissouriDENNIS X. HERTEL, MichiganROBERT A. BORSKI, PennsylvaniaFREDERICX C. (RICK) BOUCHER, VirginiaBEN ERDREICH, AlabamaBUDDY MA2:1EAlf, Flori4nHARRY >fi Rem `eve'NORMAN Wall SI_ Y, VirginiaTOM VANDERGRIFF. TexasROBERT E. WISE, JR., West VirginiaBILL RICH ..IIDSON, New Mexico

JORGE YT. LAIIBRINOB, Staff DirectorPam Scuinazi., Minority Staff Director

MATTHEW J. RINALDO, New Jersey,Ranking Minority Member

JOHN PAUL HAMMERSCHMIDT, ArkansasRALPH REGULA, OhioNORMAN D. SHUMWAY, CaliforniaOLYMPIA J. SNOWE, MaineJAMES M. JEFFORDS, VermontTHOMAS I. TAUKE, IowaJUDD GREGG, New HampshireGEORGE C. WORTLEY, New YorkHAL DAUB, NebraskaLARRY E. CRAIG, IdahoCOOPER EVANS, IowaJIM COURTER, New JerseyLYLE WILLIAMS, OhioCLAUDINE SCHNEIDER, Rhode IslandTHOMAS I. RIDGE, PennsylvaniaJOHN McCAIN, ArizonaMICHAEL BILIRAKIS, FloridaGEORGE W. GEKAS, PennsylvaniaMARK D. SILJANDER, MichiganCHRISTOPHER H. SMITH, New JerseyMICHAEL DEWINE,, Ohio

SUBCOMMITTEE ON HEALTH AND LONG-TEEM CASE

CLAUDE PEPPER, Florida, Chairman

IKE ANDREWS, North Carolina RALPH REGULA, Ohio,Ranking Republican Member

THOMAS J. TAUKE, IowaGEORGE C. WORTLEY, New YorkHAL DAUB, NebraskaLARRY E. CRAIG, IdahoJIM COURTER, New JerseyTHOMAS I. RIDGE, PennsylvaniaJOHN McCAIN, ArizonaMICHAEL BILIRAKIS, FloridaMICHAEL DOME, OhioMATTHEW J. RINALDO, New Jersey

(Ez Officio)

JAMES J. FLORIO, New JerseyHAROLD E. FORD, TennesseeMARILYN LLOYD, TennesseeMARY ROSE OAKAR, OhioTHOMAS A. LUKEN, OhioWILLIAM R. RATCHFORD, ConnecticutBUTLER DERRICK, South CarolinaRON WYDEN, OregonGERALDINE A. FERRARO, New YorkHENRY A. WAXMAN, CaliforniaBRUCE F. VENTO, MinnesotaIKE SKELTON, MissouriDENNIS M. HERTEL, MichiganROBERT A. BORSKI, PennsylvaniaEDWARD R. ROYBAL, California

(Ex Officio)BILL HALAMANDARIR, Staff Director

KATHLEEN GARDNER CRAVEDI, Assistant Staff DirectorMARE BENEDICT, LL.B., Minority Staff Director

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PREFACE ,

INTRoDucu.1

CONTENTS

Page

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I. SCOPE OF THE PROBLEM 1

II. A PANOPLY OF COLD WEATHER HEALTHHAZARDS 7

Hypothermia 7Inadequate Heating andInsulation: Fires and Carbon

Monoxide Poisoning 8A. Fires 8B. Carbon Monoxide 9

Influenza and Pneumonia 10

III. AN ANALYSIS OF FEDERAL ANDNON-FEDERAL EFFORTS TO REDUCEEXCESS MORTALITY ASSOCIATED WITHCOLD WEATHER 11

IV. SUMMARY AND CONCLUSIONS 13

V. SUGGESTIONS FOR REFORM 15

APPEN DIXES 19

I. "Hypothermia: A Preventable Tragedy: A ColdWeather Guide for the Elderly"

II. Table 1: "Cold Wave of 1983-4 as Compared to1982-3"

Table 2: "Number of Deaths in the United States Dueto Cold vs. Heat"

Table 2A: "Deaths and Death Rates by Month: UnitedStates, 1977 and 1978"

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IV

Table 3: "Death Rates by Month: United States: 1964

to 1978"

Table 4: "Deaths by Month and State of Occurrence:United States and Each State: 1978"

Table 5: "Death Rates in 20 Cities in Relation toTemperature, 1962-1966"

Table 6: "Daily Total Mortality in Relation toTemperature for Selected States in the United Statesfor the period of January 25 - February 3"

Table 7: "Daily Total Mortality in Relation to

Temperature for Selected States in the UnitedStates, for the Period January 6 to 15"

Table 8: "Average Annual Home Heating Costs: 1983"

Table 9: "Average Annual Death Rates for BurnVictims, by Age, Sex, and Race Georgia,

1980-1981"

Table 10: "Distribution of burn-associated deaths anddeath rates, by cause category Georgia, 1979-

1981"

Table 11: "Trends of Crude Mortality Rates from

Influenza and Pneumonia, Summer and Winter by Sex-

Color, United States, 1968-78, Rate per 4-MonthPeriod"

Table 12: "Pneumonia and Influenza Deaths in theUnited States by Age, 1980"

HI. "Average Temperature on Day of Death for 32

Selected Cities: 1962-1966"

IV. "Service Disconnection and Reconnection Policies, by

State"

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PREFACE

Cold weather is the most important environmentalhealth hazard for the elderly outranking air pollution andhazardous exposures. Yet, there is little evidence of anorganized public health response even though it appears thatmany of the problems related to cold temperatures may beremedial.

This subject is important, the Subcommittee found,because there is an excess in deaths during the wintermonths. These health hazards are particularly lifethreatening for the elderly because they are "silent killers."

Take the case of Howard Spears. Spears, a 93-year-oldblind man from St. Louis, Missouri, whose gas was shut off fornon-payment of bills. He was found close to death last monthin his apartment in which the floors and walls were coveredwith ice. 1-1( died several hours after his arrival at a localhospital. He died of HYPOTHERMIA, subnormal bodytemperature due to exposure to the cold.

Those seniors with a little more money might invest ina space heater to protect themselves against the threats ofcold weather. Eighty-three-year-old Ida Blackwood, ofCleveland, Alabama, at the urging of concerned neighbors,had her antiquated space heater inspected by her local gascompany. It was discovered that the space heater wasleaking lethal levels of CARBON MONOXIDE a colorless,odorless fume a silent and invisible killer. Mrs. Blackwoodwas lucky. Her faulty space heater was discovered and herlife was saved. Most senior citizens are not that lucky.

Winter deaths due to FIRE are greatest among thoseover the age of 65. About one-third of all fire victims areelderly who are living in their own homes or in publicallyfinanced dwellings which are badly in need of repair. InDecember, six died in a fire in Detroit that raced through a40-unit apartment complex for the elderly and handicapped.

INFLUENZA, PNEUMONIA, and other infectiousdiseases claim numerous older lives during winter months. A

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George Washington University geriatrician, Dr. Greg Paulsen,told Subcommittee staff, "you'd be amazed by the number ofsenior citizens I see who due to inadequate and unreliabletransportation fail to find the food or medical assistance theyneed to remain healthy during the winter months. Imprisonedin their own homes, without nutritious meals or medicine,resistance is lowered and elderly are perfect candidates forpneumonia, flu, and other such infectious diseases."

The combination of these factors leads to excess andunnecessary. winter deaths. This fact has been noted forgenerations in the United States. Even so, there is noevidence of any improvement or reduction in the excess ofwinter deaths in the United States at least between 1964 and1980. If anything there is a widening of the differentialmortality between winter and summer deaths.

This paper concludes that: 1) there is a verysubstantial public health problem due to cold weather; 2) thatit is the greatest environmental health problem of theelderly; and 3) that a more vigorous and coordinated publichealth effort is needed to curb this increasing problem. Withevery day that we delay, more senior citizens will findthemselves victimized with little or no recourse.

Finally, we would like to commend the individuals whoassisted with this paper. Dr. Lewis Ku ller, a Robert WoodJohnson Fellow on assignment to the Subcommittee as aCongressional Fellow, was primarily responsible forpreparing, analyzing and summarizing the data contained inthis paper. He was assisted in this effort by W. MoultonAvery, Director, Center for Environmental Physiology,Washington, D.C. Also, without the direction and editingassistance of Kathleen Gardner Cravedi, Bill Halamandaris,and Melanie Mod lin of the majority Subcommittee staff; andMark Benedict and Susan Roland of the minoritySubcommittee staff, this report would not have beenpossible. Subcommittee interns Laurel Hixon and FrancesHill, and detailee Mary-Lou Stone, deserve special mentionfor the research assistance they provided the Subcommitteeduring their work on this important national topic.

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VII

We hope that this paper and our action will lead toneeded reform and a reduction in death due to thispreventable problem.

CLAUDE PEPPERChairmanSubcommittee onHealth & Long-Term Care

RALPH REGULARanking Minority MemberSubcommittee onHealth dc Long-Term Care

INTRODUCTION

Cold weather and the hazard it presents to the health,safety, and welfare of every American, especially the elderly,is a national problem.

It is a national disgrace that thousands "freeze todeath," or die as a result of "cold weather," and that so littleis done to prevent their demise or further our understandingof this problem.

In cold weather, older adults are the most vulnerableof our population. Over 60,000 older Americans are strickeneach year during the winter months and die quietly in theirown homes, in emergency rooms, and even while shovelingtheir own sidewalks the victims of neglect, inflation, risingfuel costs which they are unable to turn around.

Unfortunately the death toll due to cold weather isincreasing each year. For this reason, Chairman ClaudePepper and Ranking Minority Member Ralph Regula asked theSubcommittee staff to begin to examine the problem.Preliminary inquiries confirmed earlier suspicions.

What follows is the first comprehensive examination ofthe topic of cold weather and its impact on olderAmericans. It explores a very hidden, little explored problemwhich has tremendous and far-reaching implications for theelderly and all who one day will be old.

Section I of this paper attempts to measure thedimension of the problems associated with cold weather inthe United States, concluding that over 60,000 lives are lostannually; that cold weacaer deaths are increasing annually;that the excess in deaths in winter months is increasing; thatmost deaths are attributed to cardiovascular failure inindividuals over the age of 65; that the steady increase indeaths has been noted for generations in the United States;and that although preventive steps can be taken to reduce orcurb excess winter deaths -- no concerted federal or non-federal action has been taken.

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Section II describes the most common types of healthhazards associated with cold weather, including hypothermia,fires, carbon monoxide poisoning, influenza, pneumonia andother infectious diseases.

Section III explores the federal and non-federalinterest in this area, and Section IV summarizes the paper'sprimary conclusion that the increasing incidence of deathsdue to cold weather exists in dimensions few would haveimagined possible; that the means of prevention exist; and,that no cocrdinated effort at either the public or privatelevel exists to curb the increase in this deadly phenomenon.

Lastly, Section V provides the Congress and the Stateswith a number of suggestions for reform which might beadopted to deal with this pervasive problem.

It is hoped that this paper and the information itcontains will lead not only to further discussion but to abrightened awareness on the part of the media and the publicto a problem which has too long been ignored. It is hope thatreform will follow and that lives will be saved.

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SCOPE OF THE PROBLEM

The winter of 1981-2 left people of virtually everyState reeling from one of the harshest cold spells in memory,stunned by unrelenting snowfall, high winds, and much humantragedy. Indeed, the weather and its calamitousconsequences made banner headlines.

Saddest of the stories were those of elderly peopleliving alone in their own houses, slowly giving themselves upto a threat they could not see and knew little about: thethreat of hypothermia. There were people, like an elderlycouple in New York, both of whom were deaf and mute frombirth. He was 90; she was 86. They could not tell anyonethat their apartment was too cold. There were those likeAnna Dolan, age 84, of Washington, D.C., who perished fromhypothermia in temperatures many would consider livable.

These stories and others like them led theSubcommittee to convene a hearing on February 3, 1982,entitled, "The Preventable Tragedy of Hypothermia." Areport released by the Subcommittee on that day revealedthat hypothermic conditions may affect all persons, yet, it isthe elderly who are particularly susceptible. The NationalInstitute on Aging estimated that more than 2.5 million olderAmericans are vulnerable to the hypothermia threat.Particularly at risk among the elderly are those withillnesses, or those using alcohol or certain types ofprescription drugs (such as antidepressants, sedatives, andtranquilizers). Hunger and fatigue can also increase the riskof hypothermia. Hypothermia means low body temperaturecaused by exposure to cold. For medical purposes anytemperature below 95°F is considered hypothermia.

The 1982 Subcommittee report provided a descriptionof the causes of hypothermia, the signs and symptoms andpotential methods of treatment. The report concluded thatthe lack of public and professional education about the risk ofcold weather exposure coupled with the absence of the means(low reading thermometers) for properly diagnosinghypothermia, made it difficult to reduce excess deathsassociated with this cold weather hazard. As a result ofSubcommittee interest with reducing unnecessary deaths dueto hypothermia, various administrative and legislative

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activities were undertaken which are discussed in greaterdetail in Appendix I of this paper, which is entitled"Hypothermia: A Preventable Tragedy: A Cold Weather Guidefor the Elderly."

In November of 1983, with predictions of another harshcold spell facing the Nation, the Subcommittee sought toidentify those health hazards likely to confront olderAmericans during cold weather. The Subcommittee consultednumerous public and private agencies with an interest in coldweather effects, including but not limited to the NationalCenter for Health Statistics, the Center for Disease Control,the Environmental Protection Agency, the National Heart,Lung, and Blood Institute, the National Institute of Aging, theNational Oceanic and Atmospheric Administration, theAdministration on Aging, the U.S. Office of ConsumerAffairs, the American Gas Association, the AmericanAssociation of Retired Persons, the Center for EnvironmentalPhysiology, the Washington Area Agency on Heat and ColdStress, the National Association of Regulatory UtilityCommissioners, the D.C. Office on Aging, the PotomacElectric and Power Company, Washington Gas LightCompany, and the International Hypothermia Association,among others.

The Subcommittee found that:

The problem of hypothermia specifically due to coldweather, although important and in need ofeffective action, was but one of a number of healthhazards brought on by cold weather.Thousands of lives are lost during cold weather.According to the National Center for HealthStE tistics, approximately 60,000 lives are lostannually by problems associated with cold weather,including fires, carbon monoxide poisoning,pneumonia, influenza, and other infectious diseases,and, of course, hypothermia;

More lives, especially elderly lives, were lost thiswinter than last winter. There was a substantialincrease in deaths, especially for those over the ageof 65, associated with the intense cold wave duringthe later part of December 1983. The Center for

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Disease Control monitors weekly reported deaths in121 cities in the United States. For the last 2weeks of December and first week of January 1982-3, there were 17,876 deaths among individuals 65+.During the same time period in 1983-4, 19,205deaths, an excess of 1,329, were reported in thoseareas primarily affected by the cold wave. Thisapproximately 7% excess, if related to the totalU.S. deaths age 65+, would indicate over 2,000 moredeaths during the cold wave of 1983-4 as comparedto 1982-3. (See Appendix II, Table 1);

There are many more deaths in the United Statesduring the winter months than in the spring andsummer. For example, in 1978 (Appendix II, Table2) there were 690,000 deaths from December -March and 614,000 from May through August, anexcess of 76,000 or 11%. Only epidemics of flu orpneumonia are associated with similar excesses inmortality, especially among older individuals;

The excess in winter deaths has been noted forgenerations in the United States (Appendix II,Table 3);

There is no evidence of any improvement orreduction in the excess of winter deaths in theUnited States, at least between 1964 and 1980(Appendix II, Table 3);

There is a widening of the differential mortalitybetween winter and summer deaths (Appendix II,Table 3);

The excess deaths occur in many cities even in thetemperate areas of the United States. The excess,in fact, appears to be worse in those areas in whichthere are irregular cold spells in a relativelytemperate environment and the heating systems andinsulation of homes, as well as the individualresponse, is inadequate. Only the extreme southand southwestern parts of the United States areusually spared (Appendix II, Table 4);

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A study by the National Environmental ResearchLaboratory of the Environmental Protection Agency(EPA) measured the death rates in twenty cities inthe United States in relationship to temperaturebetween 1962 and 1966. In most cities, the lowestnumber of deaths were at temperatures around 65-70° (Appendix II,Table 5);

The study also examined two cold waves in theUnited States. During the January 25 to February 3cold wave and excess deaths were in Florida, Texas,Georgia and Mississippi (Appendix II, Table 6);

A second cold wave analyzed from January 6-15,1973, resulted in a possible 950 excess deaths. Inthis cold wave the south was partially spared andthere were little or no excess deaths in southernstates (Appendix II, Table 7);

According to a National Heart, Lung and BloodInstitute study, on excess deaths due to cold, it wasfound that there was a substantial excess ofcardiovascular deaths during cold weather. Therewas an increase in the number of cardiovasculardeaths up to temperatures of 45 or 50°F in manymajor cities in the United States. The combinationof snowfall and temperature increased the numberof cardiovascular deaths. The effects were notedboth for those over and under age 65, but themagnitude of the effect was greater in th!group (Appendix HD;

We can expect that this year's cold wave will beassociated with a substantial increase in the numberof deaths;

British investigators have noted that there is asubstantial increase in the number of hospital-izations for heart attacks during the winter andperiods of low temperature. The increase in heartattack death was not primarily related to secondaryinfluenza and pneumonia;

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The reason for the excess mortality in cold weatherand the best approaches to reducing these deaths,have not been adequately addressed. The majorcause of death is probably cardiovascular disease.Most of the deaths occurred in individuals over theacre of 65. Cold temperature affects thecardiovascular and pulmonary function and couldresult in excess risk of heart attack and deaths.

The following section is an effort to catalog mostcommon effects of cold weather identified by theSubcommittee.

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A PANOPLY OF COLD WEATHER HEALTH HAZARDS

Approximately 60,000 are lost annually byproblems associated with cold weather, including fires,carbon monoxide poisoning, pneumonia, influenza and otherinfectious diseases, and, of course, hypothermia. Thefollowing summarizes in greater detail how these variouseffects of cold weather threaten older Americans.

HYPOTHERMIA

Hypothermia develops when body heat is lost to a coolor cold environment faster than it can be replaced. This heatloss causes the body temperature to fall below the normal98.6°F, resulting in a life-threatening physical and mentaldeterioration. Without medical treatment and rewarming,the victim of hypothermia will die.

Although most people associate hypothermia withexposure to severe outdoor cold, indoor cold exposure isconsidered by experts to be the most common cause ofhypothermia in the United States, and older Americans are itsmost frequent victims. Indoor temperatures do not have tofall below freezing to cause hypothermia in the elderly; mostolc'er victims become ill at temperatures between 50 and 65°,as a result of mild cold exposure which would only producediscomfort in younger people. The National Institute onAging has estimated that over 2.5 million older Americansare especially at risk of developing hypothermia during thewinter season.

Older individuals and others at risk may be exposed tocold outdoor temperatures when going to the store to getfood, to visit friends, etc. The risk ell an adverse healtheffect may be related to the temperature, wind speed,amount of snowfall or other participation and to the length oftime that they are exposed. The availability of adequatetransportation systems may be an important if not criticalfactor. Warning systems that alert individuals to the hazardsof "cold weather" would also be important.

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INADEQUATE HEATING AND INSULATION: FIRES ANDCARBON MONOXIDE POISONING

Many older individuals live in houses which may nothave adequate heating or insulation. This is especially trueamong low-income individuals and in areas of the countrysuch as the south in which cold fronts are less frequent.

Low fixed incomes, poverty, and the increased cost offuel for heating and cooling the home create conditions inwhich many of the most vulnerable members of ourcommunities are forced to make dangerous tradeoffs betweenenergy and health. Energy conservation programs whichencourage elderly people to reduce room temperatures below70°F directly endanger the health and safety of those who arevulnerable to hypothermia. It is of critical importance thatsuch suggestions for energy conservation be accompanied bysafety information on cold stress and the importance ofpersonal insulation. It is of little value to insulate the homewithout also providing information on how to insulate theperson, particularly when economic conditions force theoccupant to live in cool surroundings. The public health costof hypothermia is very high, and experts estimate that tens ofthousands of older Americans die in their own homes eachwinter as a result of exposure to cold.

Previous energy conservation programs have focusedalmost exclusively on structural insulation, and specialconservation techniques for seniors with less physical

stamina. The concept of personal insulation is vital to thesafety of vulnerable older Americans who live in homeenvironments cooler than 70°F.

A large number of older individuals live in houses builtprior to 1940. Many have inadequate heating especially inrural areas. Second, the cost of heating an apartment orhome may be substantial for older individuals having marginalincomes. For example, in Appendix II, Table 8, the averagecost of heating by gas in the Northeast United States was$1035. However, one third of elderly individuals havehousehold incomes less than $10,000. These individuals maytry and minimize their fuel costs by keeping the temperaturein the home or apartment as low as possible rather than a

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minimum of 65°. In the worst case inability to pay for fuelenergy could result in a termination of service and severe riskduring a cold spell. The laws which regulate tha terminationof service and the effects on the health of the elderly havenot been quantified.

A. Fires

There is a substantial increased risk of fire duringwinter months in homes and housing with poor, inadequateheating systems. Death rates due to fires are greatest inyouth, children, and in the 65+ age group (Appendix II, Table9). A recent report from the State of Georgia noted thatapproximately 83% of fire deaths occur in private dwellings(Appendix II, Table 10). In 1978, there were 1,696 deaths dueto fires in the United States among persons aged 65+. Thiswas 27.5% of all fire deaths. The death rates due to fires inhomes ;gas changed very little in recent years.

A study by Baker et al., in Baltimore, further notedthat fire deaths are more likely to occur in the lowest incomeand rent areas of the city and that 20% of the deaths weredirectly related to faulty electrical and heating systems andthat half occurred between 2 and 6 a.m. Fire deaths werenine times more frequent in low than high income areas,especially in the southern states. Furthermore, in 1977, therewas a minimum of 360,000 days of hospital care for burnedindividuals over the age of 65 at an approximate cost of $131million. It has been estimated that smoke detectors wouldprevent 90% of these deaths and severe burn injuries. Atleast some of the excess mortality related to cold weather isdue to fire deaths.

13. Carbon Monoxide

A second problem is related to the use of unsafeheating equipment. This con obviously result in a risk of firebut also to increased levers of carbon monoxide and otherpollutants. Carbon monoxide is produced by the incompletecombustion of any carbon-containing substance. The majorsource of carbon monoxide is from cigarette smoking. Othersources of carbon monoxide are in transportation, from autoexhaust, occupational exposure and from home heating.

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Carbon monoxide is an odorless, tasteless gas. It interfereswith the ability of the blood to carry oxygen to the tissues.High levels of carbon monoxide are usually fatal for mostindividuals. Relatively low levels that would be found inhomes with defective heating systems, may have a veryadverse effect on the health of individuals who have pre-existing heart or lung disease. Radford, et al., demonstratedin a national sample of the U.S. population that the meancarbon monoxide levels in blood (COHB) were higher in winterthan summer months. The precise contribution of carbonmonoxide exposures to increased heart attack deaths duringcold spells needs to be determined. Individuals at particularhigh risk would be users of space heaters especially ifunvented and old and defective central heating systems,poorly ventilated fireplaces and use of coal or woodburningstoves as extra sources of heat. Carbo i. monoxide monitorsare now available that can be placed in individual homes todetect possible increased carbon monoxide levels. The costof the monitors is low $1.50-2.00 and have been shown tosave lives.

INFLUENZA AND PNEUMONIA

At least part of the excess mortality in cold weather isdue to a higher frequency of influenza, pneumonia and otherinfectious diseases in the winter since 1970 (Appendix II,Table 11). The Center for Disease Control maintains aneffective influenza and pneumonia surveillance system. ThePublic Health Service Advisory Committee on ImmunizationPractices, recommends vaccination for individuals over 65years of age. An update of specific vaccine recommendationsis published annually.

Unfortunately, the costs of influenza vaccine are notcovered by the Medicare program. Pneumococcal vaccine iscovered under Medicare. There appears to be only limiteduse of pneumococcal vaccine in the United States.Pneumonia and influenza continue to cause the deathhospitalization and disability for many individuals. (AppendixH, Table 12)

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AN ANALYSIS OF FEDERAL AND NON-FEDERALEFFORTS TO REDUCE EXCESS MORTALITY

ASSOCIATED WITH COLD WEATHER

The Subcommittee identified numerous governmentagencies that had an interest in the health effects of coldweather.

The National Center for Health Statistics publishestabulations of the number of deaths and death rates by monthof year for the United States and each State. The NationalCenter is the major source of health statistics in the UnitedStates.

The Center for Disease Control has monitored deathsdue to hypothermia. The Center publishes a weekly report ofdeaths in 121 U.S. cities. The Center also monitors influenzaand pneumonia deaths. Recommendations for the use ofinfluenza vaccine are published annually by the Center. TheCenter does not presently have a specific program to preventthe excess cold-related deaths. No federal program toincrease the use of influenza vaccine for the elderly wasfound by the Subcommittee.

The Environmental Sciences Research Laboratory ofthe Environmental Protection Agency had a major interest ininvestigating cold- and heat-related deaths. They havepreviously documented excess mortality during "coldwaves." Their activities are currently dormant.

The National Health, Lung, and Blood Institute of theNational Institutes of Health, has studied the relationshipbetween cold weather, snow, and excess heart attack andstroke deaths. Although they found an excess of heart attackdeaths in winter, no further follow up studies are being doneto -investigate the reasons for the excess and theirprevention.

The National Institute on Aging held a workshop onAccidental Hypothermia and the Elderly on December 11-12,1979. Other than these activities, the NIA does not have aformal program related to the adverse effects of coldweather on the elderly.

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The National Oceanic and Atmospheric Administration(NOAA) produces a Climate Impact Assessment Report thatincludes estimates of excess deaths due to cold as well asother weather-related events.

Recently, the Administration on Aging has taken aninterest in cold weather and the elderly and supported ahealth education and information program about the risks,diagnosis, and treatment of hypothermia. On October 4,1983, a national symposium was convened in Washington,D.C. by the Administration on Aging, the U.S. Office ofConsumer Affairs, the American Gas Association, theAmerican Association of Retired Persons, and the Center forEnvironmental Physiology to focus r ,ention on

hypothermia. The Administration on Aging is continuing tofund health education efforts.

Most non-federal action has been in the area of healtheducation. The Center for Environmental Physiology hasreceived financial support from the Administration on Aging

to develop educational materials related to hypothermia. The

Washington Area Project on Health and Cold Stress is thefirst of its kind in the country. It was begun in the winter of

1981 with seed money from the D.C. Office on Aging,

Potomac Electric and Power Company and Washington GasCompany. This program is now being expanded intosurrounding counties in Maryland.

There is also an International Hypothermia

Association. The primary function of the Association is tocoordinate research and educational activities related tohypothermia, especially as it is related to water submersion.

The National Association of Regulatory UtilityCommissioners publishes a Survey of Natural Gas and ElectricUtility Uncollectible Accounts and Service Disconnections for

1982 (see Appendix IV).

Although many federal agencies have a related

interest, there is no coordinated Federal or non-Federalactivity related to the adverse effects of cold weather.Given the large number of deaths in winter compared to

summer, the potential for prevention in this area is apparent.

SUMMARY AND CONCLUSIONS

There is a substantial public health problem due to thecold weather. It is the greatest environmental healthproblem of the elderly and along with influenza andpneumonia represents the two major reasons for excessmortality from year to year, and within a single year, acrossthe United States. There is little evidence that the excessmortality due to cold weather is decreasing in the UnitedStates. Rather, the Subcommittee found that deaths due tocold weather are increasing annually.

Unfortunately, although excess winter deaths havebeen noted for generations in the United States, there is littleevidence of an organized, public health response.

The Subcommittee found that many of the problemsdue to cold weather are remedical and suggests that avigorous and coordinated public health effort be developed tocurb this increasing problem.

(13)

SUGGESTIONS F014. REFORM

It is apparent that a coordinated and comprehensiveattack is necessary if there is to be any hope of limiting theincreasing number of excess deaths in the United States dueto cold weather. Obviously the problems associated with coldweather can never be eliminated altogether. However,because so little is being done at the present time at eitherthe State or the Federal level, even a modest reform effortcan have significant and far-reaching results. In short, theexcess deaths in the winter and related to cold weathershould not be accepted as an unsolvable problem. The excess60,000 deaths are only a reflection of the increasedhospitalization, disability and severe discomfort that occurswhen individuals, especially senior citizens, are unpreparedfor the cold weather.

First, no specific government agency has a primaryresponsibility for monitoring the adverse effects of coldweather and implementing a treatment and preventionprogram. Recurrent cold waves will occur and continue tokill more people unless a coordinated effort to combat thisproblem is begun. The key steps needed should include:

(1) Better monitoring of cold-related morbidity isneeded. The frequency of abnormally low bodytemperatures ("hypothermia") among the elderlyshould be determined, and the relationship ofwinter temperatures in their homes to type andadequacy of heating systems;

(2) The National Weather Service should develop anearly warning system for "cold waves." Thiswarning system will have to be specific fordifferent areas of the country. Along with thewarning system, health information messagesshould be provided about the potential dangersof cold weather and preventive actions thatmay be required;

(3) Local, State and Federal health organizersshould develop an energy response program topossible "cold waves." This response systemshould be in place prior to the winter season.

(15)

23

16

The education of the public about "cold" shouldbe a major component of this program;

(4) A major effort should be made in eachcommunity to ensure that all older individualshave adequate heating in their homes before thewinter season and "cold waves." The frailelderly living alone in older houses and theelderly poor are at greatest risk. An agencywithin each community should have primaryresponsibility for identifying "at risk" housesand apartments. Adequate federal funds shouldbe made available to provide proper insulationand adequate heating. The alternative will beincreased risk of illness, costly hospitalizationand institutionalization and possibly death. Anemergency response system, well publicized inthe community, should be available forsituations in which adequate temperatures inthe home cannot be maintained, and theresidents have a high risk of hypothermia andother complications of cold temperatures,

Health organizations should work closelywith Gas and Electric Companies to prevent gasand electric shutoffs to residential customers.Shutoffs during the wintertime should not beallowed without adequate warning and

notification of a responsible healthdepartment. A list of current regulations isincluded in Appendix IV of this paper.

Inexpensive wall thermometers thatcould be kept in the bedroom or living room ofan older individual may be an importantpreventive step especially if combined with aspecific and simple message about what to do ifthe temperature goes below a certain level, i.e.,less than 65° for several hours.

(5) Accidental carbon monoxide deaths in the homeare preventable. The Consumer ProductsSafety Commission should monitor theproduction of carbon monoxide by space heaters

24

17

and other portable types of heating equipment.Inexpensive monitors are available to check forincreased levels of carbon monoxide in thehome. Health education programs descrii)ingthe risks of carbon monoxide poisoning shouldbe widely distributed. All deaths due toaccidental carbon monoxide inhalation,especially in the home, should be reported andinvestigated, and the specific reason for thecarbon monoxide exposure determined in orderto prevent subsequent similar accidents.

(6) The excess in fire deaths, especially among theelderly, is a tragedy. Many of these deathsoccur in older homes, rural areas, and amonglower income groups. Safe heating systems,smoke detectors and adequate fire escapesshould be mandatory in all multi-dwelling homesand hopefully in all houses in the community.Fire prevention and especially prevention ofburns and deaths should be an importantcomponent of the national health educationefforts. The Consumer Products SafetyCommission and other government agenciesshould carefully monitor space and otherportable heaters for potential fire hazards.

(7) The Center for Disease Control hasrecommended the use of influenza vaccine forindividuals over the age of 65. In spite of thisrecommendation, there is no concerted effortto immunize the elderly population and excessmortality and morbidity due to influenzacontinues. The Medicare program does notcover the costs of influenza immunization. It ispuzzling that the government agency mostresponsible for prevention, the Center forDisease Control, has recommended a specificimportant preventive action and yet, noeffective implementation of thisrecommendation has occurred in either thepublic or private sector.

25

18

Federal policy with regard to the influenzavaccine and implementation of public healthprograms should be coordinated.

(8) Most physicians are unaware of the potentialhazards of "hypothermia" and methods oftreatment especially for the elderly. More

professional education about hypothermiaincluding diagnosis and treatment should beprovided. This probably should include anincreased availability of low-readingthermometers.

26

APPENDIX I

"HYPOTHERMIA:A PREVENTABLE TRAGEDY"

A Cold Weather Guide for the Elderly

PREFACE

John S. was a robust and active man. On a clearDecember morning, as every norning, he rose precisely at7:00 a.m. Taking his walk he noticed others clothed in heavycoats and mufflers. He had only a light fall jacket on. Hisskin was taunt and shiny, with a strange pink glow. He feltfine. All those years of exercise were paying off.

That evening John was rushed to a local hospital,confused, his speech slurred, his breathing slow and shallow.Accidental hypothermia had struck another victim.

Mr. S. was lucky. His case was diagnosed correctlyand his life was saved. Not all persons are that fortunate.

As the body ages it becomes less able to adjust toextremes in temperature. Experts agree that the menace ofhypothermia is particularly great for the aged. Ill informedon the nature of this ailment many older Americans areaffected without realizing their condition. Efforts must bemade to make the elderly aware of those precautions to betaken in dealing with the threat. Otherwise this silent killerwill continue to be responsible for thousands of deaths eachyear.

Mortality from accidental hypothermia reaches 50% indocumented cases of elderly victims. Chances for recoverydepend upon a number of factors, such as the patient's age,degree of internal chilling, as well as the patient's previousphysical condition. However, early detection in addition tothe duration of hypothermia and the method of treatment ofparticular importance upon the victim's ability to survive thisillness.

(19)c,

2730-482 0 - 84 - 4

20

Studies have shco.vn that the degree of internal chillingappears to he of greater significance than the relative age of

the elderly victim. The lower body temperaturesdramatically decrease survival chances. For example, onestudy showed a 75% mortality for elderly victims admitted tothe hospital with temperatures below 86° Fahrenheit ascompared with 39% whose temperatures were between 86°

and 95° Fahrenheit. Early detection greatly improves thechances for eventual recovery.

Both body temperature and age appear to be lesssignificant in determining recovery than the presence of anunderlying disease. In those cases where hospital admission

takes place, the most important condition for survivalappears to be the general health of the victim. Consequentlythe frail, the debilitated, and the sick are at far greater risk.

It is, however, particularly important to rememberthat many otherwise healthy elderly victims die in their ownhomes without ever reaching the hospital. Hypothermia dulls

the mental faculties to such a degree that the victim is neveraware of the condition and is entirely dependent upon the

awareness, knowledge and action of others. Unfortunately,accidental hypothermia is often overlooked and dismissed assimple disorientation, lack of coordination or confusion.Without recognition, the eldely victims lack even a chance ofrecovery, and death is inevitable.

Accidental hypothermia can worsen preexistingconditions such as heart disease and diabetes. Fall of thebody's temperature below 90° Fahrenheit is dangerous becausecold slows the normal body processes and important bodyfunctions are often disrupted. Complications increase as thetemperature falls to lower levels, and heart, blood, liver,

kidney pancreas and gastric problems may develop.Pneumonia is also a common complication for hypothermiavictims.

Nlany of these problems are treatable by properrewarming, but some require special attention, especially in

older adults with pre-existing conditions. Hypothermia has

been reported to cause permanent damage in some

individuals, but further research is needed to determine therisk of permanent damage in otherwise healthy older adults.

28

21

The most serious complication of a low body temperature is avulnerable heart. Cold slows and weakens the heart, and it isvery important that the victim be handled gently.

The key to avoiding hypothermia is increasedawareness. It is usually an accidental death. Indoor exposureis the most common form of the condition. Attempting toconserve energy, many elderly turn their thermostats down toan unsafe level. Unknowingly, they place their lives injeopardy. The older populace must be better informed aboutthis threat.

It is the purpose of this document to provide olderAmericans and service providers with practical informationon accidental hypothermia. We believe it can make adifference this winter and in the years to come.

If one life is saved the Subcommittee will haveaccomplished its goal in publishing this booklet.

Claude Pepper, M.C.Chairman

Ralph Regula, M.C.Ranking Minority

Member

Subcommittee on Health and Long-Term Care

22

INTRODUCTION

With escalating fuel costs many of America's poor, andthose on fixed incomes, are forced to conserve energy in

order to buy food and clothing. Winter poses a life-threatening situation for these people. This plight is

aggravated by the fact that most adults are unaware of the

danger and unfamiliar with physical techniques for reducing

or preventing cold stress.

The poor elderly are extremely vulnerable to this cold

weather threat. It is essential the aged take advantage of all

resources and programs to maintain an acceptable room

temperature. If a home is heated at 50 to 65° Fahrenheit itmay be lethal to its elderly inhabitants. "Safe" energyconservation must be exercised.

The National Institute on Aging estimates that morethan 2.5 million older Americans are vulnerable to thehypothermia threat. Also at high risk are newborns and

infants.

Information is the safeguard of the young, aged, anddisabled against the silent killer. Emphasis has been placed

upon energy conservation, fuel savings, and America's energy

independence. Both financial and patriotic reasons havespurred on citizens to lower their thermostats. But little has

been said of the inherent risks.

Potential hypothermia victims must be made aware of

the danger. The focus of this booklet is to provide data so

that an informed decision can be made in reducing thetemperature in your home. It is also an information sourcefor those persons providing supportive services to potential

victims.

30

23

WHAT IS HYPOTHERMIA?

Hypothermia is an abnormally low body temperaturecaused by exposure to the cold. It is a state of rapid heatloss. Simply put, the rate of body heat production can nolonger keep pace with the rate of heat loss. Typically, aninner body temperature of 95° Fahrenheit (35° Centigrade) orunder is hypothermic. The normal body temperature is 98.6°Fahrenheit. A simple drop in skin temperature is nothypothermia. Rather it is a lowering of the inner body heatlevel.

Hypothermic conditions may affect all persons, yet, itis the elderly who are particularly susceptible. Conservativesources estimate that nearly 25,000 older citizens die eachyear from this condition. Particularly at risk are elderlypersons with illnesses, or those using alcohol or certain typesof prescription drugs (such as antidepressants, sedatives, andtranquilizers). Hunger and fatigue can also increase the riskof hypothermia.

It is important to remember that hypothermia is notlimited to extremely cold weather outdoors. Temperaturesdo not have to be below freezing, or even near that level.Prolonged exposure to cool temperatures indoors may alsolower the body temperature to an unsafe level. A simple dropin skin temperature is not hypothermia. Rather it is alowering of the inner body heat level.

24

FACTORS INCREASING THE RISK OF HYPOTHERMIA

Older Americans are at a greater risk than mostgroups due to their tendency to develop a lew bodytemperature. Coupled with the natural effects of aging theelderly are subjected to numerous other factors that affectthe body's control over heat loss and production.Approximately 10% of all elderly have some form oftemperature regulating disorder.

1. NUTRITION

Good nutrition is very important in maintaining anormal body temperature. Food is the fuel used by the bodyto generate heat. An inadequate diet will will make it moredifficult for the body to maintain normal temperature.

An adequate diet refers to a nutritionally balanceddiet. That is why it is important that the elderly maintaingood eating habits which provide sufficient amounts ofvitamins and minerals and an adequate intake of calories.

2. ILLNESS

Certain diseases or disorders can markedly increasethe body's vulnerability to temperature change.

A. MENTAL ILLNESS

Frequently, persons who suffer from mental disordersare unaware of environmental changes. Exposure to a coldenvironment simply goes unobserved. The situation is furthercomplicated by the presence of many therapeutic drugs whichimpair the body's regulation over heat production.

B. HYPOTHYROIDISM

Reduced thyroid function lowers metabolic rate and

32

25

consequently brings about a decrease in body heat production.

C. STROKE AND NERVOUS SYSTEM DISORDERS

Persons with strokes or nervous system disorders havean impaired temperature sense as well as a reduced capacityto respond with shivering and other heat conservationmeasures.

3. ALCOHOL

The risk of hypothermia is magnified by the use ofalcohol. Alcohol dilates blood vessels; depresses the nervoussystem, and decreases blood sugar. Concealed by the dullingeffect of this depressant a lethal drop in body temperaturecan go unnoticed.

It is important to note that alcohol decreases sensationin relationship to the quantity consumed. It follows thatdrunkenness is not a prerequisite for being unaware of alowerei body temperature. Whenever a person uses alcoholthey should be cognizant that such consumption will affecttheir level of physical sensation to some degree.

4. DEFECTS IN SKIN BLOOD FLOW

Skin is the body's first line of defense against thecold. In response to cold, blood vessels near the skin shouldconstrict and reduce the flow of warm blood near thesurface. This makes the skin appear pale. Muscles tightenand cause shivering. A signal is given to add clothes or find awarmer environment. If a defect is present in this skin-bloodflow relationship the victim may continue unaware of hisdeclining body temperature.

5. PRIOR CASE-HISTORY OF HYPOTHERMIA

Persons who have experienced hypothermia often areunable to maintain a normal temperature if they are latersubjected to even mildly cold temperatures.

33

26

6. MEDICATIONS

It has long been known that many drugs can precipitateboth hypothermia and hyperth'rmia, or abnormally hightempe,qture. The normal mechanisms that compensate forvariations in temperature in our environment are generallyless efficient in the elderly. For these susceptableindividuals, the combined effects of cold weather and drugscan rapidly induce hypothermia, often with devastatingresults.

Some common drugs often prescribed for the elderlywhich can seriously impair the body's ability to adjust are:barbiturates, sedatives, tranquilizers, antihypertensives,vasodilators, and antidepressants.

Once again, the watchword for hypothermia is

awareness. Any physical or mental disorder which inhibits anindividual's senses increases the risk of hypothermia. Ifconscious of this fact, however, a person can take necessaryprecautions to decrease its effect.

34

27

SIGNS AND SYMPTOMS

One of the most drastic problems of accidentalhypothermia is the non-specific signs of the illness. Usually,the first thought is that the person has had a stroke or othermental disorder. It is not obvious to the family, friends,physician, and least of all not to the patient, that the patientis hypothermic.

Most older adults develop accidential hypothermiaover a period of three days to one week. Although theclinical picture is non-specific, there are warning signals,which should be heeded, that hypothermia may be eminent.

Outward Signs and Symptoms

Confusion Confusion or reduced alertness is one ofthe first apparent signs of hypothermia. These signsusually worsen in a rapid fashion as body temperaturefalls. Logical thinking becomes impossible and theperson may become completely disoriented. Memory isaffected and familiar things are often forgotten.

Coldness If the victim complains of cold it is usuallyduring the early stages when the body temperature isbetween 95° Fahrenheit and 97° Fahrenheit. Once bodytemperature falls below 95° Fahrenheit, response to coldis diminished or eliminated.

Shivering and Trembling In the early stages,shivering gripes the hypothermic victim indicating thebody is having trouble keeping warm. This will cease asthe hypothermia becomes more severe. Tremblingusually ensues on one side of the body or in one arm orleg.

Breathing Rhythm and Heart Rate Both becomereduced and they may become difficult to detect whenhypothermia is severe.

35

28

Sleepiness If the victim's hypothermic condition isnot discovered, this sleepiness may progress to comaover a one-half day to three day period. Coma may be

accelerated by the presence of an additionalcomplicating acute illness.

Skin The skin becomes pale and dry due toinadequate constriction of the blood vessels. However,the skin may also have large, irregular blue or pink

spots. The skin also fecds cool or cold, even in coveredareas such as the abdomen and back

Muscles The muscles become unusually stiff,particularly in the neck, arms and legs.

Swelling Swelling of the face is most common andbecomes an important sign of hypothermia, especiallywhen found in combination with cold skin and signs of

confusion.

Coordination The individual often has difficultywalking and has problems with balance.

Bruises Bruises and blistered lesions may also befound and are most likely related to pressure.

Kidney Excretion The cold forces the kidney toexcrete large volumes of body fluid which could lead todehydration.

Attitude Apathy is comon in a hypothermia victim.The individual may also become irritable, hostile andaggressive.

Speaking Difficulty in articulating will occur.

Unconsciousness

36

29

TREATMENT

The obvious goal of treatment for a victim ofhypothermia is to rewarm the body. The usual method ofraising the body temperature back to normal is Rapid ActiveRewarming (RAR) which is accomplished by providing thevictim with a warm bath. However, this means of treatmentis usually used for young, previously healthy victims ofexposure. RAR is strongly advised against in assisting anelderly hypothermic victim.

RAR in elderly victims often times produces aperplexing and lethal syndrome of worsening metabolicabnormalities such as a further fall in the body's coretemperature and a profoundly low blood pressure reading.

For an elderly hypothermia victim, treatment shouldbe administered by a physician who is familar withhypothermia in a hospital or clinical setting wheneverpossible.

A person suspected of having hypothermia should havehis/her rectal temperature taken with a special, low readingthermometer, if possible. The 'normal' thermometer's lowestreading is between 94° and 95° Fahrenheit and, therefore, willnot usually cause one to suspect hypothermia.

Slow Spontaneous Rewarming (SSR) should beadministered by the medical staff. During SSR body heat isconserved with blankets and the core temperature ismonitored. The core temperature is allowed to rise no morethan 1° Fahrenheit per hour to avoid a worsening of metabolicabnormalities.

If emergency medical help is slow to arrive, furtherheat loss can be prevented by wrapping the victim in a warmblanket. Food and drink can pose dangers for a hypothermicperson and should be avoided.

If blankets are not available the body heat of anotherperson lying close to the victim will aid in rewarming. Careshould be taken in handling a victim of hypothermia. Rubbingof limbs can worsen the condition and cause injury. Sudden

37

30

movement or rough handling can easily cause a fatal heartattack (ventricular fibrillation).

It is best that the victim not try to walk or movearound because he or she might fall and suffer furtherinjury. Care should be taken in moving and handling thevictim since the heart muscle is very weak when the body iscold.

The victim should not be placed in a hot bath orshower because it could cause fatal rewarming shock orafterdrop in body temperature. Additionally, the victimshould not be placed in an electric blanket and should not begiven a hot water bottle. These actions would have the sameeffect on the victim as a hot bath or shower.

The victim's feet should not be raised if they areunconscious. This will cause the cold blood to flow from thelegs into the body core and further depress the bodytemperature.

38

31

REMEMBER

The elderly hypothermia victim MUST:

be given slow spontaneous rewarming (SSR)be given professional attentionbe handled gently

The hypothermia victim must NOT:

be rapidly rewarmedbe given food or drinkbe rubbedbe moved suddenly or handled roughlybe placed in a hot bath or showerwalk or move aroundbe given a hot water bottlebe placed in an electric blankethave their feet raised if the victim is unconscious

Seniors can prevent hypothermia by following a fewvery basic rules.

TEMPERATURE IN THE HOME You should havethermometer in your house especially in rooms where yousleep and relax. The temperature should not go below 65°degrees Fahrenheit for any prolonged period while you are inthe room.

Homes are often colder at night, and it is veryimportant to make sure that the bed is warm, becausehypothermia can begin during sleep. Hot water bottles, extrablankets and quilts, heating pads, and electric blankets can allhelp to keep the body warm at night. Extra clothes,particularly a nightcap, long underwear and socks may beworn for additional protection, but special care must be takento make sure clothes are absolutely dry.

Insulate your home properly. There are variousmethods to be used in insulation. Install storm windows orpolyethelene sheeting; caulking and weatherstripping; closethe closet doors and close off unused rooms; close windows,curtains and shades during the nights and unusually cold days;

39

32

install aluminum foil radiator reflectors, insulate waterheaters, attics, and attic doors; and seal bypasses andopenings in walls.

Not only will this assist in preventing hypothermia butin most homes it may reduce your heating bills by as mush as20 to 30 percent. This may also make you eligible for anEnergy Tax Credit on your Federal Income Tax check withyour local Internal Revenue Service (IRS). Additionally,contact your local state energy office or local communityservice agency for information on special financialassistance.

CLOTHING Clothing should be worn in severallayers. Avoid tight clothingloose cloths will trap muchmore warm air around your body. Heavy clothing is not asheat efficient as many layers of thin cloths. A Windproofouterlayer should be worn when you are outdoors.

Wool and most synthetics will keep you warmer than

cotton because they absorb moisture and allow it toevaporate. Cotton holds moisture against the skin which mayexacerbate the on-coming hypothermia.

Dark colors absorb heat and will, therefore, keep youwarmer.

Tight shoes cut down the warm blood supply to thefeet and are, therefore, a major cause of frostbite. It wouldbe much better to have one less pair of socks and the shoes alittle loose, rather than three pair of sox, tight shoes andreduced circulation.

If you are wasting heat, the body will try to conserveon its own by reducing the flow of warm blood to the skin,

hands and feet. Wearing a hat will cause your body to sendmore warm blood to the hands and feet. A warm scarf tocover your neck should be worn.

Mittens are warmer than gloves because they allowfingers to warm one another.

40

33

Some publications have recommended that plastic bagsbe worn over clothes for additional insulation during homeheating emergencies. This is bad advice because clothing willbecome damp from body moisture.

DAILY CHECK-IN If you live alone, arrange for adaily check-in call with a friend, neighbor, relative, etc.Although this may seem unnecessary remember, mostindividuals do not realize hypothermia is emniment becausethey do not realize they are cold. Therefore, it is a good ideato make sure someone will be there each day to ensure theirhealth.

GOOD NUTRITION It is important to rememberthat good nutrition is vital to the prevention ofhypothermia. Liquids are- very important for energy andadequate blood volume for circulation. Although liquidsshould not be given to the victim of hypothermia, liquids areimportant in the prevention of hypothermia.

Smoking or coffee may cause a reduction in the flowof warm blood to the hands and feet. Moderation must beexercised.

DRUGS Drugs are thought to be a majorpredisposing factor to hypothermia in older adults. Manydrugs can directly impair the body's ability to regulatetemperature, and many also increase the rate of heat loss.Your physician should be consulted and questioned as towhether or not any medication you are taking will have theseeffects. Make sure the medication is taken properly.

EXERCISE During the waking hours, exercise willproduce more body heat, and therefore, you will be warmer ifyou are more active during the day. More insulation isneeded if you are stationary.

AVOID FATIGUE Your body needs energy to fightthe cold and fatigue makes you more vulnerable to submormalheat and cold.

AVOID EXCESSIVE DRINKING OF ALCOHOLContrary to popular belief, alcohol does not increase bodyheat. Alcohol greatly increases body heat loss by relaxing

34

skin blood vessels and allowing a greater supply of warmblood to flow near the cold surface. You feel warmer for ashort period of time, but cool faster. Therefore, alcoholintake should be limited during the winter months of the year.

AVOID WETNESS Moisture from perspiration, rainor melting snow can seriously reduce or destroy the insulatingvalue of clothing because water conducts body heat over 25times faster than air. The hair, body and clothing must bekept dry. Many individuals believe that snow at 15°Fahrenheit is more dangerous than rain at 40° Fahrenheit.This assumption is false. Snow at 15° Fahrenheit is dry andeasy to work in if you are properly dressed more so than rainat 40° Fahrenheit which is very cold.

APPENDIX II, TABLE 1

Deaths:

A Ccoparison:

Last Two Weeks December 1982, First Week January 1982

Last Big Weeks December 1983, First Week January 1983

1983 - Age 65+ 1982 - Age 65+

Dec, 24 Dec. 31 Jan, 7 TOTAL Dec, 24 Dec. 31 Jan, 6 TOTAL

NEW ENGLAND 480 476 504 1,460 465 363 498 1,326

MID-MIMIC 1,755 1,772 2,164 5,691 1,845 1,810 2,050 5,705

EAST NORTH

CENTRAL 1,499 1,655 1,516 4,670 1,410 1,390 1,407 4,207

WEST NORTH

CENTRAL 499 465 456 1,420 486 451 406 1,343

SOUTH ATLANTIC 898 739 744 2,381 702 744 709 2,155

EAST SOUIH

MIK 447 501 394 1,342 479 354 402 1,235

WEST SOUTH

CENTRAL 841 801 599 2,241 741 633 531 1,905

TOTAL 6,419 6,409 6,377 19,205 6,128 5,745 6,003 17,876

43

1,127 EXCESS

36

APPENDIX II

Table 2"Number of Deaths in the United States

Due to Cold vs. Heat"

Tear

Numbers of deaths In theUnited States

Excessive heat Excessive cold All Causes

1962 154 423 1,756,449

1963 196 457 1,813,199

1964 195 287 1,797,528

1965 106 298 1,827,776

1966 531 365 1,862,985r

1973 182 383 1,972,827

1974 143 348 1,934,154

1975 194 360 1,892,674

1976 102 427 1,909,294

1977 315 635 1,899,476

44

APPENDIX II

Table 2A

"Deaths and Death Rates by Month:

United States, 1977 to 1978"

talk DIPS AM DIAN 11011,1Y !OMNI WITS ITAT1k1117 AND 1111

Ilia OA mud hi ow 1,011 pepoeils, Dili v' proviloul Nolo *NW spollihi

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Feb Nil MINIIIIIIHOWNNIINONSIIIMMION14.11#0

hosolsomnielowoommffiliMmeNIONINIMs

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06:6(4001.1wommoutoomplOONNOIR440141Now

Are/vensfilsimilablibenwslOwammtalagialirliMIRAWMIRMINNOMOMMINOM

1178 1177

1,114,000 11898,000

1977 . .117?1111 191

111m1I , Ifir411'

111,917 18 U

189p411 -173,000 173,237 1013 0.5

16,000 181,003 163250 10,1 17

170,000 188,000 181,271 92 1110

111,000 157p00 1%1122 8.0 8.8

111,000 158,000 157,732 8,8 8.1

ip,coo imp 148,038 8.8 8.5

113,030 159,030 157,117 813 8.8

113001 149,000 150,481 811

101,000 147,000 148,901 13 113

161,000 151,000 160,252 14 U154,03 113,000 1540 8,5 818

112,003 184/4 114,12 17 1,1

Aimmismilmilossommolomomallw

1,3

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8.4

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8,7

8,7

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APPENDIX II

Table 3

"Death Rates by Month:

United States: 1964 to 1978"

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I 1(111 1

1 illii 11

I i Iiiil 1111iI hi!00 il

i III ii

ill 1' ii

1 Ili 11

iffil 11 ,

Hip i1111iz, .!

II il

11

lil

1111

ii 1

i

i :

1 1

1

I 1

1

ggh iti; N1:1 gli; iiiii MR arii 10 iii:t iiiii 1 1

dills dig iiiii iiial ;tiff dill iiiii 1%4. ilea Milli i I 1

'Mil :lid eiiii iiiii tag Ifni ;MI Hof tali hid j 1

:Hilt did alai efiti phi iiiii Ilia Ifni gash hid i / 1

'fait did diii siiii iiiii Mil :diii iftef !at i iiiii i i

tiiiit sil=l &if gild slid iiiii !NH %If foil iiiii i I

411!. %fief alai titti nisi iiiii Iiiii Hid hull Mai i i

:Wig did diii did Hid Mil till= full leaf hid i 1

tiff% dill iiiii giti :aid iiiii mill lisai inii Mai i 1

glint did difi siisi Hid Mil iiiii fill! huh ifigi i I

shift dill iiiii did slid iffil iiiii Hui iiiii Wei I I

din' efisi afiii did ttiti iiiii tail Hui iii!: iiiii i I

dine diii .sill Mei Iiiti ifiii iiiii iisai lull fiiii i I

cmrc cco, "-eo

m

=I Esr7 co,

40

APPENDIX II

Table 5"Death Rates in 20 Cities in Relation to

Temperature, 1962-1966"

art 111114111.212.1re 1041141

aMl 011110. 114110011

aft imAt11 .1 II a

7. sr. l44 7.17 tit 7.41 EA Lie Lit Ln R.* to LW 24 SI1. 0w*, L 7.4 7.4 4.11 7.11 7.77 7.4 7.17 7.47 717 1.77 7.73 7 11 4.11

1. Ms Poles, a 7.4 /11 IN 7.4 717 7.111 7.4 7.111 1.111

1. M4111141, 01 l.a 44 1411 7.a 1411 ill IA, JD LIS 1.12 1.11 /ADP

I. MY.II.II L/1 LP? 7.10 3.4 7.10 7.0 711 3.33 7.21 7.11 7.111 7.11 1.41

LIS 7.12 7.4 7.4 LSD LIS 1.11 1.n IA III LW7. 1110/24, SD 714 tit LSD LIS Lift LSD 1.4 2.14 LIS III 2.111

PlIp. 17 ID 7.11 7 IS 7.11 1.11 7 Y 7.4 LSD IA LW 1.11 1.11

I. Ipmvsto, UL 1.4 7.11 3.0 7.11 7411 7.77 S.17 1.17 7.IS 7.11 74

It. tiod, Lit tit LIP .1.01 1.13 LIS LSI I N Ill 2.4 LW LIS 4.11

II. 1.1177174111. IS 1.01 7.111 LS an III 7.14 7.4 Ca 7.11 1.11 1.4 7.11 1.14

Y. m114& at ma am 8.0 Ls asa CIO I.11 1.14 1/7 IA /. a.asIL on mmar, a me am am 7.11 III 7.711 La 7.11 4.47

7.111 1,16 1.11 1.111 1.111 1.4 1.0310 8448, 111 LIS

II. 14 41201. 11 1.31 1.11 tA /AV 1.411 11 1.11 gm la I 111 1.0

111. 1N14 .a 2.11 La &II 4.111 OA 7M 1./1 IA 1.41 LW 7.4 4.4

II. 11414. It 1.4 1111 7A 111 11.111 1.7/ IA 1.13 lA 1.11 3.4 1.111

Y. N. WA.. 4.0 1411 SAS 4.0 4.4 4.14 4.0 CA 1.4 4.11 4.111 4.11 La 11.P

N. Sp Mom. a 3.0 4.11 411 7.11 1.4 MS LSI 1-70 7.7/ 11711

Y. 11401s. 11 LSI to LIS LIS CO 11.07 l.r 1411 1.4 LS

48

41

APPENDIX II

Table 6"Daily Total Mortality in Relation to

Temperature for Selected Statesin the U.S. for the period of

January 25 - February 3"

1962 -196511 a4 0

State Mean 95%

1966 - Cold WaveIi-ici

Mean E.C. Excess

NE 34 43 31 0 0VT 14 21 13 0 0NH 22 29 19 . 0 0MA 175 218 185 0 0RI 28 38 27 .0 0CT 76 95 84 0 6

NY 537 599 551 1 28NJ 191 226 194 2 7PA 366 400 382 6 22DE 13 21 15 1 7

MD 92 124 97 4 0DC 26 36 30 1 1VA 109 135 119 ! 10 0WV 54 66 56 . 3 9

NC 119 142 136 10 22SC 66 80 74 4 18GA 112 139 137 6 52FL 159 183 194 1 156AL 95 117 108 5 43.MS 69 85 84 5 63LA 89 105 104 1 37TX 245 300 271 0 69OH 278 317 291 4 14KY 92 106 97 1 19TN 104 126 107 8 3MI 201 242 214 1 0IN 135 158 135 1 1IL 317 345 329 4 63

MO 151 174 157 2 3AR 58 70 61 3 13OK 72 87 78 0 4MN 93 110 93 1 2'MI 111 137 112 3 0IA 84 100 . 85 1 0NO 1 5 24 16 2 0SO 18 28 15 1 0NB 42 50 42 1 8KS 66 82 65 0 0

4,528 4.807. 97 670

, 49

Pin. I1

-24.-28.9128.3-16.1-16.7-15.6-13.9-14.4-23.3-15.0-13.9-12.8.16.1-22.8-1 6.1...,,,- 21.1`-20.0-11..7

-21.-9--14.4-10.6-21.1

-23.3-24.4-23.3-24.4-23.9-28.9-254-16.7-17.2-35.0-31.7-32.2-40.0-34.4-27.8- 23.91.

42

APPENDIX II

Table 7"Daily Total Mortality in Relation to

Temperature for Selected States in theUnited States, for the Period

January 6 to 15"

1974-1977N40

State Mean 95:

1973 - Cold WaveN10

Mean E.C. Excess.

Min.T(C)

ME 29 40 31 0 0 -74.4VT 12 17 13 0 4 -27.2NH 22 30 21 C 0 -27.8MA 164 191 191 1 33\ -17.2RI 27 35 32 0 16 '. -15.6CT 76 89 85 1 18 -17.2

NY 501 551 571 2 230 -11.7Nd 193 213 225 1 138 -11.1PA 360 405 400 4 102 -11.1DE 14 20 16 0 2 -10.6

MO / 96 113 103 0 18 -11.1DC 22 32 26 0 0 -15.0VA 117 140 127 0 5 -15.0WV 57 70 63 1 6 -15.0

NC 139 159 154 7 27 -15.0SC 74 90 79 3 0 - 7.8GA 128 149 140 3 18 - 8.9FL 261 303 264 2 0 - 1.7AL 105 128 109 0 6 -10.0MS 69 85. 79 0 .3 -10.6.LA 100 116 119 1 53 - 6.1iTX 306 346 337 3 58 -10.0

OH 283 311 300 0 64 -12.8KY 103 125 101 1 1 -11.7TN 117 142 116 2 0 -13.3MI 219 239 236 2 32 -13.9IN 144 169 152 1. 2 -15.6IL 318 354 357 1 100 -17.2MO ,154 178 164 3 1 -17.2AR 68 81 68 0 0 - 9.4OK 87 100 85 3 0 -18.3

MN 99 129 97 2 0 -28.9WI 118 142 125. 3 3 -20.0IA 89 116 85 1 0 -23.3NO 16 25 . 15 0 0 -35.0jSO 19, 30 19 3 0 , -28.31NB 44 56 47 0 0 -25.0KS 70 84 73 1 10 -21.7

4,820 5,225 .1 950

50

43

APPENDIX II

Table 8"Average Annual Home Heating Costs:

1983"

Average annual home heating costs

J 01EI ,... ..,.

c...k.

,..4. 1,,,U P 41el..

1.4mw, .i.,.,..,:zi,

% 0 01111"144ALASKA

MI HAWAII, r

'Based on a 1,000 square foot home withaverage insulation and weatherizatIon. 1883 fuel prices. Local climateand fuel price difference will cause costs tovary.

1 2 3 4 5FUEL: ZONE:

OIL $210 $520 $730 $875 $1040 .

GAS 265 665 755 1035 1375ELECTRICITY 465 1150 1610 1950 2290COAL 190 340 480 585 690WOOD 150 345 520 620 730SOURCE UnRonuly of Connecticut

t inloOmphles1110

APPENDIX II

Table 9

"Average Annual Death Rates for Burn Victims,

by Age, Sex, and Race

Geoqia, 19804981"

t TAM!. Agathatilla

ofteroftwilllimolsonamemenrimorwallarir

(11.4

5.9

10.19

20.29

30.44

45.64

16.74

075

0.0 0,0

4.4

1.8 0,7

1.2 0.9

4.0r 0.7

2.4 1.2

7,2 . 2.6

11,9 3,1

18,2 8.2

5 2

3,2

161

6.8

13

4.5

10.9

22.0

47.5

821

113

18,4

7.7

1,9

1.3

3.3

7.7

11.4

211

APPENDIX II

Table 10

"Distribution of burn-associated deaths

and death rates, by cause category

Georgia, 1979-1981"

TAILI 1, Distdbulle bimesmIstoi dMtho and do* me, by oium Mop1170111

IOM 1CD MI WO Porto MOMyths of deithe tell'

1410 Coders* In private king 104 121 3111111.2 Othroonfbindoo 20 1.7 0.12

1111 halite* by Ignition of *thing 31 41 011

!NO °the( end osoeciflol fin 53 7.3 0.32

1114 Accident alai by hot oubstence or object,

Rustic r Qom* MAL and atom 19 21 0.12

Al *eve court 731 woo totemationel Clessilioetion of Dios*, 9th

duths11001000populitionly,r.

53

46

APPENDIX II

Table 11'Trends of Crude Mortality Rates from

Influenza and Pneumonia, Summer and Winter, by Sex-Color,U.S., 1968-78, Rate per 4-Month Period"

Trends of Crude Mortality Rates from Influensa and PtAmenels

(ICD 470- 474, 480 -486), Sommer and Winter by Sex- Color,

Sated States, 1968-78, Rate per 4 -Month Period

Tear

WhiteMen

ElateMoro

lbaulate

toe

Ileaddite

Veers All

Jon-Sept.

DOC.torch

June-Sept.

Dec.-March

JeerSept.

DOC...

Mend.Jame-Sept.

Dee.-Horeb

Jess-.

Sept.pee. -

March

1168 1.0 20.1 6.6 17.1 12.4 30.1 8.5 21.4 11.2 19.4

1168 11.7 17.6 6.6 14.3 11.7 26.2 7.5 17.2 7.4 16.3

1970 8.7 15.6 6.4 12.0 12.0 234 6.8 14.7 7.1 14.4

11171 74 12.4 6.1 10.5 10.3 17.6 6.2 10.8 7.2 11.6

11172 1.0 16.1 6.2 13.2 10.3 20.6 5.5 12.8 7.2 144

473 8.4 144 6.4 124 91.91 18.5 6.0 11.7 7.6 134

474 7.6 11.7 6.0 10.2 9.2 13.1 5.0 8.1 6.1 10.8

475 7.4 13.6 5.6 114 8.5 14.0 4.3 9.0 6.5 12.5

476 7.0 15.1 5.4 14.8 7.9 144 4.2 9.6 6.1 14.6

1977 7.2 10.4 5.8 1.3 7.8 12.0 4,4 7.0 6.4 9.8

11178 7.2 13.2 5.7 124 7.6 13.6 4.2 8.2 6.4 12.7

Chug 1968-78 -1.8 -6.9 -0.9 -4.2 -5.2 -17.2 -4.3 -13.2 -1.1 -6.7

Peranet Chose -20.0 -34.3 -11.6 -24.6 -40.6 -55.8 -50.6 -61.7 -22.0 -34.5

Slope 11168-73 -0.0198 -0.0570 -0.014 -0.0509 -0.0520 -0404 -0.0790 -0.1204 -0.0200 -0.0625

Stamina Error 0.0095. 0.0327 0.0065 0.0358 0.0094 0.0265 0.01511 0.0327 0.042 0.0338

31014. 1973-73 -0.0390 -0.0464 -0.0302 -0.0282 -0.0629 -0.0737 -0.045 -0.0857 -0.0452 -0.0398

Standard Error 0.0121 0.0524 0.0162 0.0655 0.0073 0.044 0.0288 0.005 0.0156 0.0568

54

47

APPENDIX II

Table 12"Pneumonia and Influenza Deaths in the

United States by Age, 1980"

AGE

TOTAL 54,619

65+ 30,212

65-74 8,668

75-84 17,003

85+ 19,841

ALL DEATHS

65+ 1,341,848

% INFLUENZA ANDPNEUMONIA DEATHS 2.2%

48

APPENDIX III

"Average Temperature on Day of Deathfor 32 Selected Cities:

1962-1966"

a

I.44 4.1

41111311.111111111 11304111111MI4)-11-1 4112731A...I 4111/ SC

NEM swami

house 1. Average daily deaths hum CHI) byaverap temperature aa day of death far 32 selected

SMOKE US, 19 * -19M.

56

50

APPENDIX IV - page 1

I000ICI 01000MSCTIOM AND WON...C.10M POLICITS

uthogity Which Pciona0..... Seguin. attic.

mem pia D:iftsvit:;*Tagil! ..... .

AuchogitySpecial Notice CoProCalu.th Reconne 000000

Thied party mat- PSCHutton.

Altai, Ova u Ctlea ammo; death. thirdiiiiii es. party wall-Cos wagon calm. elba-antra tland ameba.

AA cun .F CC 7 Thl.d pyty oath= CC

utiitty

Arians. PO NSF 7

Additionalnopaolt

.:gtaPor:.1":111Nan-r.r,to I months bill.

N.p gap,. gtttt to I month.billing.

7.0 llmo t ttttmonthly bill If quica.

Cilltainli ourecarlar.-00

Mules.e,i1.,arr7ue DC--T1

C.nnezticur5GOC

Third potty Doll- Pa

%1.d Pegiy mai-n. militias-

al meta.Sin. Petty 0000- PM

iiiii ion, notice in7h

liay be requigW,EtTIT-001 yeed the Btimated bill for 2 pagodatttttttttttt i Yndsgeritshall not aaaaaa thelb 0111 for ono

potIcal before aaaaa istndatd, 'lull not aaaaatho stlmtod bill for sixperiod. plus po.ntlIde... to equipment ifaaaaaa for the donee!' I.

bottled or Hand

RC.utAlisy tot111.

-6A

to 077 cill-----tayabla in 1 monthly

nto.

11C

oili;Mui 11r r1!.C"--YitIT/--Millin"71TtliT second PICiii iii must be

i II i mailed nd0.1 ttmptod tole.iiiii c11 lf. phone collo ono

altar 4,00p,._!,_Aisiirti niTTa-ifybrInlla PSCCaumbls PSC

to connect the0t004f, AO

In weltInq &ant laIna.

r ThIrajliity Darter 110

c

No

ttttttt hay PLC.

special noticepun patinae.

Ar service his bathdiler nonpayment withinthe pest 12 .onchs.deposit is J/12 el esti-mated 1

Pneounr-Will to actualog estimated coot or

tot 10 -del periodof maabram aaaa or 1100hinagt 1. lay.

Shell not exceed-inmtmot quol to twicethe aaaaaa charge logaaaaaaa ler the IImonth aaaaa to dicon-nction. ocag23geede.777. lf-a7am. *et towood 2 1/2 times thebill - electric.

maaITICE-- nc. .uaym gust top., to PVCday. befog. ter-

n,idegly and haul% -

nth...1 custom

FUT7W------Unt lee. than 15765"---and net Silg than thbantam^ tlmatdchanty for 1 coo-. months ol

57

Imewent PyInetsileentsr OutetendIng Peconnection

below. Cheri.117.00 -

U7.001

TZ: IFFrol y il].00Marini Lumina.. bow.awl 170:00 dwrimg P0n .brain... hours.

pecimily dm/porous tobeeith.

de sy be cccccc sa, T. bay Sodepends on delayed tar elderly andremson tor krd ic.ppea ccccc ortermination. bend on governmental

51

Aomtrictiow. on Service illcanneOmte

In. ccccc ed1reiorraireslh utility. 1,111711131cccccccc during peri-od. of anther.

payment.Moyle. .nail not be tor -.insted November through00000 11 minimum temer.tor. predicted le 13. orIolaw. No trmlnetioneAplii through Octobermmsimum tempo ,.... pre-dicted I. 115. or ebove.

Carle. No113.70.$$.001

Carle.

tee ITS during wortins hour., Additionsel 110 ccccc normalworking howns.

ohring any roan i771/glr----fa. terminetion wouldccccc mental to

health s cer ccccc dby licensed phi/0:010nand inab ccccc to P.Ohas been cccccNo di cccccc <Slone for 10/1/10

1p ccccc (roNov. I to ccccc 05.

iono/11--

Ye VIT se may not beMO-9151 terminated when im-

ps cccccc 4 torscstedto be 31. or belowduring the .et 34hours.

P to utility.

1374351

V115-1101

r ectr a- lctg"mention. Monne - Ge.-11/31/71 ...-Stat0"bar IS and March II If...tomer agree. to payPeet doe by Oct. IS,

Par *II ccccby dee dote nd temperc.-twr for 34 boo, period letareceNted below 33..Co. No di eta.loos teepe forecestedSelvv 33. during beet 34hour *erica

58

52

APPENDIX IV page 2teVICS DISCOMMCCIION Otto MCCOWN:410M POLIO'S

Mot to sasse

Pit 110 f Mo PSC My be requires sadcorer sore rata 7 in

months of

brrylt4 bSC

14 1c days =ft0 roc--

rair:rh 740 0PI7Isco party aoreeNit,satia11. lot SiliMfiV costae..

sN 010

II.

59

Mot to sasse

II.

war: i 4 ttttttt ar------ii-if ..nar----w. . ...nay apt. ROC Mot to 00003 1 month. b11 t.

7 if yarrow fiof if ..trice 1.0.1.-

ally delivered. aced Oataker IS to.11 $

kIrrilmolplil-PLC b p to aaely14.1 .1 ty a0

ki rine---T12-7-1-1II 00 iiii" Not to eammel 2 kis. lathe.tali. mat aaaaa la bill of tIms lest lb moot..

. wilier aaaaa watt..

finTr-T. r 00105.

.11 $

kIrrilmolplil-PLC b p to aaely14.1 .1 ty a0

ki rine---T12-7-1-1II 00 iiii" Not to eammel 2 kis. lathe.tali. mat aaaaa la bill of tIms lest lb moot..

.wilier aaaaa watt..

0.0.1.1 ISO --PIC 11 car 1SC Ma

Pro broprldra 1111Z---1 117,rt aaaaaaa &dun #1.1C 3 [twos ..tone -Via/est

.1,sae peat or 0111 If gequirmt.sFeted sate wink la....Wm. on recta-. aaaaa .

oirvolr aaaa b/d all 7:111.gairlTilia17--Tara.. Ora C...Mol [to iiiii ...

I.C.

finTr-T. r 00105.

wow PSC

W.. ilia -Its. 112 pSC.Ot4ists,

IS

t..1ff. nest of iiiiii 0111e.

NliNTa7rifaili as It----13173 I 1/111....74EITmo.I ...et blIt.

Ifiiiirjarrnlica, , Mecoil weather rotas, PSC

o roilaai swirlooryr tariffs.iiiii ly am Sledded.aaaaa to ramrly,spacial aotioa.

0.0.1.1 ISO --PIC 11 car 1SC Ma

Pro broprldra 1111Z---1 117,rt aaaaaaa &dun #1.1C 3 [twos ..tone -Via/est

.1,sae peat or 0111 If gequirmt.sFeted sate wink la....Wm. on recta-. aaaaa .

oirvolr aaaa b/d all 7:111.gairlTilia17--Tara.. Ora C...Mol [to iiiii ...

I.C.

59

t..1ff. nest of iiiiii 0111e.

NliNTa7rifaili as It----13173 I 1/111....74EITmo.I ...et blIt.

Ifiiiirjarrnlica, , Mecoil weather rotas, PSCoroilaai swirlooryr tariffs.iiiii ly am Sledded.aaaaa to ramrly,spacial aotioa.

.dhroAl Syllllll bras)1 OWmod Perlommectlea

1251411..ac0

I No

sesstioll *ma .0 to lllll Dl000sseatioos is blaset

Dale

Ila term iiiii on duties booth.o l December.. )..wry mdPilmosser whims. sIsseam iiiii y that Aker. Oil maothers. allarly at lolls..

1n1:1I11 "'V"

lionesoolitalcoo Oa Kea II. I...- 1/0/13osatiol tease for theloliewling 311 Mato will Is. 33..

ICC

Isctric Vt ratio. -Cuotopera al-10de 1alatace say mOt be &Is-n't...clod Deoeobet 1 throughP asch IS.

Vas lb dr000lustitlie from devember1 to Affil 1 11 owlemof V.1'-11.1 lor i -tone. funds.

Igo V MO 4liscoasoetloo Megroaborga catch Ii osateeer

gra ttttt oottIllcoto of need.P ort 1/3 of 6111 modto tpileant chedulo.

On coe-y comabeat..

Mo term bottoms whoa It would 11/3/10 PSCboo esp., lllll ibiegorou. toh ealth sad ossitomot I.to pay for llll co of le ableto pay only Is ttttttt 6411ns.

ff. val.. Decest I through April IS 1)/7/01 PUC,00000y p#S0114, requitalto diecoolowl.

et November A t1.loo911 111/17/1 VICCatch )1, us131sy Poet pro-ride so tttttt all to PlCthat totalmottoe rill notand

--Tie :. le. yammer 5-ksrch 0t. DIM spores.' 5/SI105-1151 tttttt ad for Seat tttttt A accouate.

11 customer below 1501 ol pa

Vas litaltla=1:::t:nret lugs Pre---111-1011 Omtttt1.4 Co100111Cobet 1through Catch 31.

----Vasthrough

tabor IS to April IS. (1110 ttt le115-1301

Va.

es WI. /flatlet one impolemi.0% NW ttttt el

RIsCono. eoly Ibooe owe.

Isith attempt to vs! 4

11/I/77 ICoaf Nebo good

Masomhet IS sod mach 31.

ea Vertes he Ter 'nation bet,.., Mersa- 1/1/1111110.1101 bar I end spill 1 without PSC

--bilni-iell.lith11-117oonsitailois for ttttt 10IIIutility. 1111.130/ lobe that 1175 ler soaheslegat 1300 lot Matta, customer.

V.. 11KIT10 Mo Ol.oann.etlon DemoidoetC-V through Nicer, II 11 ,,.t..1too ttttt Apo11to or ttttt pub.

rila saaletsnea.

atios So

yir-gi-j--------1167iibli)1)E4116gh April isspecial puttee lo requital.Olconaocslom pre01011o4 11 Itroll Oases Sons.. Impltmentto ttttt or wordily or 11becoups of phyalcol or basalhandicap cutooet it wash**to baoo taootes.

11/34/111110

30/111/01 tt

60

AuLno,ItyG 000000 Smaylco

;3:Tie tue 21041" la"

CC

Who. 1SC PA

I._. tte

t smimAli

ce

54

APPENDIX IV page 200000 CI diSCOtoECTION AMU ntruloltf ION POLICIES

ItiotMOSS. 11.4011 Notico91111.--.. 'tutted..

gltd dottynotification.001.04.1 0001001In mint..

00140111/Guy.s.lxy Satoh. Ad11::!:111

11.conoacalons pot Sacco...alio.onawoimith 011.

.0001 of 00000000 lywan 00000 AV IOC 040 yonost aussnt cccccc ameteml,

to :n llow 01 doWat.MoI /----11117311171-01-

nailed. Mattoon. o

0001.01 In *lilt.d roc I notice

o pettyCatieo, ettoodt Cl4444444 by 14441.400.of in 4

cc

rlO

CC

El shell 001 04C0Z77,1777.--ttttt at estimated tttttt bill-ing. Cas-a0t to ..c.00 ao:! notimott4 sandal

14.wilnt fie Ile

nlno Oat toe--rPSC--Ple

Ma

II "ay. no cm totooants.

16.

/ 0. time Es 0 urr---not soots sort than 1 1/1month. of

OM mo

ttiotich- POottr.

h Ichl4a0

actIca.11.110.1notica-1If

gg,41:1.

fot aldarly outlawsnol adtwOvalIn w c .

gifltdplity malice. ne Mot to olccood

hinii5ti rut ref .11.4 au co Des y .tots- ilk Not to aacoad 1 oontgi-gn17----

1 if ptied it imotice tocsin-

ally doll td IS to

mllii1P1 1fC ---SEg I ::11! lad utility

Reif.1 1 11CThe I negria :.tty folticat

000 to coad I time. hilhaat

motto* *oat cantatabill of the innt Ii months.

speollie ttttt attioa.

Sontan PSC 1Se--10--------ThTirlriTy noun. uo 1010.. 114

Vt --1 6-To Ile do

.:tsPgIt tg I AZ. can so do E---1121.o. e.comi-iighost

Putmacaroni at ttttt bill II osquiond.

O 50100 Rota with in-letguctions 00 gocon-asetion.

W ad tt i t ;I artiirlf----rtaragfirrapatty walla..

10.C.

n.+'nOoloti

mom YOit Eta-I-SSC PSC,

010,t

"WeGesutsuffNicient to Pe/.wont of t

'hi-Aria-ay .0110., 1...anal concoct.hlo17.711-, sorra. It ttttt ,

cold waathet guise, PSC,

o ejtcei oestioncy. tootles.1411y ot dloonisa,

ttttttt focoly.pneisi aotioa.

p 0. I l/ld ass moo owntgly.

Ma

61

.ylosn% tv

11 Ow J 040noselloa111.11-.112.b J21/91.

fee -----WrI1111.

55

n eetrietioas 00 torvioe 01.000*

Imo N.

Ma IOrnInstIoo duriny Booth.

oo b0s.u0.y 8. unto... tOo yumud

41

e telly that tttt a no

1. 1401.mAL7.71/IS

Gastod 16004 000th for thefallout., 14 Mug. will be le.

Dat

ICC

Cuero.. .11,101. for tttttwry 001 L. dis-

co/erected Orreambee I throughP arch II.

11/1/11

Vas Vag1sS 110 JIoeon..otles iron November I/i/Ot1 to April 1 If cumtower lllll -Ries fOr .lour Onoripy lllll Gteneo funde,_

Yem V No dIecoonect as MovolloWleowonor -1112Notch II t

lllll nte ccccccc cote of nead.paye I/1 et bill ewe ogre.to repayseAt schedule.

CC

plc

On or.s. lisrlem No terolostIons when it voold 11/1/110 PSCby on. bo ooparlolly deny uuuuu toLeelm. beelth and ...tom. 10

to pep for service or In siglsto pay Only la 1aaaaaamonis.

Irr VallesSe 11 through IS 11/1/S1 WCpone

lto dIy eop cnet... Vol MI etymon vsubel 1 t0cough-------1171771 Innoreh 11. u iiiiii meet plu-Olds ma o iiiiiiii to 'SCthat tagalastlos ..111 notnod boeltb.

es -ii7lie bov.rl r reh IS. birippc Thr---Ttillit:(10.110) requited far here relied seeounks.

If eurI00er below ISO% of po

Val ii-----'-ageillifighl: ;r:.1 lOP------1T717------"SW----Ili.1601 Surliflod eumOwele Doesnber 1thrOugh March 11.

Vogl. Oc ttttt 11 to...April IS. ISIS"---------Trarair

Y..

---Yes

110.1311

Soot ii t Inioe

----9:71:7------V.71.. isetriet ... .....n..!d.Ofd ttttt basis odditionsi

P LefonaloC nly taunt MIN- 11/1/I7 SICtoners who do mot metes gooddeith pt to per ti tttttN aysaboe IS end Meet/ 11.

3s0 Ihriis No t.o.In.tion osn Nov..- IWO Statute1110 -1101 bee 1 end A011l I without SIC

"Trp'slikliis 167 noonsetIoa ton peeutility. 1110.1101 lose the.. 1111 for 000 -hOr 1100 for ovetosees.

Slos 1174-1Te:IloCss.

e.

115.1101

No dieconnactios Deomeber. 11/71711-11VTthrowoh March IS If cuotoaerreceives pub.Ilc ttttttt nee.Po

-11o171a7T111M3611 !poll IS.peel! natio@ la required.01.eonesetion p Aged If Itmould sssss eeriove 10.to ssssss Or .misty Or If*.cove. 01 phy.lcst of monistlendlcap customer I. usubleto ramege remourceo.

10/11/111

O

62

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