Excess winter mortality and Excess winter mortality and morbidity in the elderly morbidity in the elderly

in Ireland: has a change in in Ireland: has a change in the fuel allowance the the fuel allowance the

potential to affect it?potential to affect it?

Dr. Anne O’Farrell and Dr. Davida De Dr. Anne O’Farrell and Dr. Davida De La Harpe, La Harpe,

Health Intelligence Unit, HSE.Health Intelligence Unit, HSE.

Background:Background:

• Excess winter mortality has been observed in Ireland Excess winter mortality has been observed in Ireland and in other European countries.and in other European countries.11

• The fuel allowance, which is means tested, can be The fuel allowance, which is means tested, can be regarded both as a proxy measure for poverty and as regarded both as a proxy measure for poverty and as a real contributor to ameliorating the effects of a real contributor to ameliorating the effects of poverty. poverty.

• The increase in fuel prices together with the reduction The increase in fuel prices together with the reduction of the fuel allowance from 32 weeks to 26 weeks of the fuel allowance from 32 weeks to 26 weeks could impact on the numbers suffering fuel poverty 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:Recent Headlines:

Older people going to bed at 7pm to save on fuel bills.SOURCE: The Irish Times – Sept. 2011.

Fuel Allowance cut toFuel Allowance cut to hurt the poorest of older peoplehurt the poorest of older people. . SOURCE:SOURCE: Age Action, Jan. 2012 Age Action, Jan. 2012

Struggle of Irish people to pay Struggle of Irish people to pay bills revealed in Credit Union bills revealed in Credit Union

survey. “survey. “The increases in energy The increases in energy and fuel costs have affected and fuel costs have affected

85pc of people and 8pc said it is 85pc of people and 8pc said it is impossible to pay their bills each impossible to pay their bills each

month”.month”.SOURCE:SOURCE: IRISH INDEPENDENT, IRISH INDEPENDENT,

Monday 9th January, 2012Monday 9th January, 2012

Gas price increases Gas price increases to add €150 to to add €150 to

household bills.household bills.SOURCE: The Irish SOURCE: The Irish Times, Oct. 2011Times, Oct. 2011..

Households receiving fuel Households receiving fuel allowance:allowance:

Source: Dept of Social Protection, Sligo and Dept. of Environment, Community and Local Government.

15.3% 14.9% 14.9% 14.7% 15.0%

18.7%

23.7%

0%

5%

10%

15%

20%

25%

2005 2006 2007 2008 2009 2010 2011

N=264,400N=264,400 N=274,00N=274,0000

N=286,200N=286,200 N=290,000N=290,000 N=300,000N=300,000N=376,000N=376,000 N=400,000N=400,000

AIM:AIM:

• The aim of this study was to determine The aim of this study was to determine whether the excess in winter mortality and whether the excess in winter mortality and inpatient hospital emergency admissions inpatient hospital emergency admissions among the elderly is continuing in recent among the elderly is continuing in recent years 2005-2010.years 2005-2010.

• To describe the causes of death and reasons To describe the causes of death and reasons for hospital in-patient admissions among the for hospital in-patient admissions among the elderly in winter vs. summer months.elderly in winter vs. summer months.

Method:Method:• Persons aged ≥65 years who died in Ireland in Winter Persons aged ≥65 years who died in Ireland in Winter

months (i.e.Nov-Jan) versus Summer months (i.e. May-Jul) months (i.e.Nov-Jan) versus Summer months (i.e. May-Jul) extracted from the CSO for years 2005-2009. extracted from the CSO for years 2005-2009.

• Patients aged Patients aged ≥65 years who were admitted to acute ≥65 years who were admitted to acute hospitals as emergency admissions during winter months hospitals as emergency admissions during winter months vs. summer months extracted from HIPE database.vs. summer months extracted from HIPE database.

• Statistical analyses were carried out in JMP, Stata and Statistical analyses were carried out in JMP, Stata and StatsDirect. StatsDirect.

Age standardised mortality rate for all cause mortality for all ages and those aged 85+ years by

year.

y = -20.648x + 823.53

y = -455.97x + 19526

0100200300400500600700800900

Year of death

Rate

per

100,0

00

po

pu

lati

on

0

5000

10000

15000

20000

25000

Rate

per

100,0

00

po

pu

lati

on

All Ages 85+ Linear (All Ages) Linear (85+)

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

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

Age standardised mortality rate for older age groups by year.

0

50

100

150

200

250

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year of death

Rate

per

1000 p

op

ula

tio

n

60-64

65-69

70-74

75-79

80-84

85+

No. of deaths in elderly (aged 65+ yrs) No. of deaths in elderly (aged 65+ yrs) by season of death (winter vs. by season of death (winter vs. summersummer)(All deaths))(All deaths)

5136 5211 5065 5379 5315

26106

5969 5895 5823 5640 6012

29339

02000400060008000

1000012000140001600018000200002200024000260002800030000

2005 2006 2007 2008 2009 2005-2009

Year

No

. o

f d

ea

ths

Summer months Winter months

N= 3,233 excess deaths in winter months vs. summer months over 5 year studyN= 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.winter compared to summer.

Deaths from respiratory illness Deaths from respiratory illness in those aged 65+ yearsin those aged 65+ years

784 849661 671 740

1079 1043867

943 996

0

200400

600

8001000

1200

No.

of d

eath

s

Summer months

Winter months

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 Deaths from circulatory illness in those aged 65+ yearsin those aged 65+ years

2015 2006 1964 2027 20212438 2324 2365 2463

2213

0

500

1000

1500

2000

2500

3000

No

. of

De

ath

s

Summer

Winter

1,770 excess deaths in elderly due to circulatory diseases in winter vs. summer months Over the 5 year study period.

Results:Results:

• Excess deaths due primarily to:Excess deaths due primarily to:– Respiratory diseases: 1,770/3,233 Respiratory diseases: 1,770/3,233

(54.7%)(54.7%)– Circulatory diseases: 1,223/3,233 Circulatory diseases: 1,223/3,233

(37.8%) (37.8%)

• Dr. Elizabeth Cullen will present data on Dr. Elizabeth Cullen will present data on other countries’ experience and on the other countries’ experience and on the biological effect of lower temperatures.biological effect of lower temperatures.

Moving on to hospital Moving on to hospital admissions:admissions:

• HIPE dataHIPE data

• over 65s emergency onlyover 65s emergency only

• comparing winter admissions with comparing winter admissions with summer admissionssummer admissions

No. of emergency hospital in-patient No. of emergency hospital in-patient admissions in elderly (aged 65+ yrs) admissions in elderly (aged 65+ yrs)

by season (winter vs. summer):by season (winter vs. summer):

27601 28615 29650 29633 3040128943

30316 3034232926

31413

0

5000

10000

15000

20000

25000

30000

35000

2005 2006 2007 2008 2009

Summer Admissions Winter Admissions

N= 8,040 excess emergency in-patient hospital admissions in winter N= 8,040 excess emergency in-patient hospital admissions in winter months vs. summer months over 5 year study period.months vs. summer months over 5 year study period.

Results:Results:

• Excess hospital admissions due Excess hospital admissions due primarily to:primarily to:

– Respiratory diseases: 7,129/8,040 Respiratory diseases: 7,129/8,040 (88.6%)(88.6%)

 

2005-2009 SummerAdms

2005-2009 WinterAdms

Diff.% Diff

I00-I99 Diseases of the circulatory system 32424 33447 1023 3.2%

J00-J99 Diseases of the respiratory system 23312 30441 7129 30.6%

R00-R99 Symptoms, signs and abnormal clinical findings 19475 19796 321 1.6%

K00-K03 Diseases of the digestive system 15332 14682 -650 -4.2%

S00-T98 Injury and poisoning 14288 15436 1148 8.0%

C00-D48 Neoplasms 9642 9349 -293 -3.0%

N00-N99 Diseases of the genitourinary system 7752 7620 -132 -1.7%

G00-G99 Diseases of the nervous system 4370 4721 351 8.0%

M00-M99 Diseases of the musculoskeletal system 4130 3712 -418-

10.1%

E00-E89 Endocrine, nutritional and metabolic diseases 4123 4071 -52 -1.3%

L00-L99 Diseases of the skin and subcutaneous tissue 3274 2743 -531-

16.2%

D50-D89 Diseases of the blood and blood-forming organs 2592 2464 -128 -4.9%

A00-B99 Certain Infectious and Parasitic Diseases 2587 2648 61 2.4%

F00-F99 Mental and Behavioural Disorders 1216 1405 189 15.5%

H00-H59 Diseases of the eye and adnexa 668 628 -40 -6.0%

Z00-Z99 Factors influencing health status 350 367 17 4.9%

H60-H95 Diseases of the mastoid process 320 361 41 12.8%

Q00-Q99 Congenital malformations 45 49 4 8.9%

TOTAL 145900 153940 8040 5.5%

Winter vs. Summer Winter vs. Summer Admissions:Admissions:Length of Stay:Length of Stay:• Winter seasonWinter season = 1,842,691 bed days = 1,842,691 bed days

• Median LOS Winter = 7 days (range 1-850 days)Median LOS Winter = 7 days (range 1-850 days)

• Summer seasonSummer season = 1,689,663 total bed days = 1,689,663 total bed days

• Median LOS = 6 days (range 1-892 days)Median LOS = 6 days (range 1-892 days)

• Excess bed days used in Excess bed days used in winter seasonwinter season vs. vs. summer season = 153,028 bed days.summer season = 153,028 bed days.

Winter vs. Summer Winter vs. Summer Admissions: Estimated Acute Admissions: Estimated Acute

Care Costs: (emergency Care Costs: (emergency admissions only)admissions only)

€ €2005 159,066,230.90 172,223,977.142006 166,194,326.85 178,388,950.962007 173,171,915.31 184,676,111.812008 184,180,783.00 192,154,259.002009 159,542,568.00 175,857,058.00

2005-2009 inclusive 842,155,824.06 903,300,356.91

Hospital in-patient Costs Summer Winter

Excess costs winter admission vs. summer admission = €61 million Excess costs winter admission vs. summer admission = €61 million

Discussion:Discussion:

• Winter excess mortality and Winter excess mortality and morbidity still present in elderly morbidity still present in elderly although it has reduced over time. although it has reduced over time.

• Respiratory diseases and circulatory Respiratory diseases and circulatory diseases over-represented.diseases over-represented.

Discussion:Discussion:

• This study has found that more households This study has found that more households than ever are in receipt of the fuel allowance.than ever are in receipt of the fuel allowance.

• The numbers of those assessed as suffering The numbers of those assessed as suffering fuel poverty are increasing.fuel poverty are increasing.

• Although the direct overall cost has increased Although the direct overall cost has increased for the exchequer, the possible long-term for the exchequer, the possible long-term cost of reducing the allowance and the wider cost of reducing the allowance and the wider consequences require further monitoring. consequences require further monitoring.

Discussion:Discussion:

• The causes of the excess mortality still need The causes of the excess mortality still need further research as it is likely to be multi-further research as it is likely to be multi-factorial.factorial.

• Many of these deaths are likely to be Many of these deaths are likely to be avoidable and an hypotheses is that they avoidable and an hypotheses is that they are linked to poor housing, and temperature are linked to poor housing, and temperature

• Socio-economic factors come into play.Socio-economic factors come into play.

Discussion:Discussion:

• Further research into the link Further research into the link between housing standards and in-between housing standards and in-adequate heating and excess winter adequate heating and excess winter mortality needs to be carried out.mortality needs to be carried out.

• However, a cut in the fuel allowance However, a cut in the fuel allowance has the potential to exacerbate the has the potential to exacerbate the problem among the elderly. problem among the elderly.

Excess winter mortalityExcess winter mortalityin Irelandin Ireland

Energy Action Fuel Poverty Energy Action Fuel Poverty ConferenceConferenceDublin CastleDublin Castle

February 6February 6thth Feb 2012 Dr Elizabeth Feb 2012 Dr Elizabeth CullenCullen Department Community Health Department Community Health HSEHSE

Outline of presentationOutline of presentation

• 1. Excess winter mortality1. 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 countries4. A look at other countries

• 5. Conclusions5. Conclusions

1: Excess winter mortality1: Excess winter mortality

•We have seen from Anne’s slides, that we have We have seen from Anne’s slides, that we have

excess winter mortality and hospital admissions in excess winter mortality and hospital admissions in

those aged 65 years and over during the study period those aged 65 years and over during the study period

2005-2009.2005-2009.

•Majority due to respiratory and circulatory diseases.Majority due to respiratory and circulatory diseases.

•However, countries with warmest winters (over 5However, countries with warmest winters (over 5ooC) C)

tend to have highest ratestend to have highest rates

•‘‘Paradox of excess winter mortality’ Paradox of excess winter mortality’ Shah and Peacock 1999Shah and Peacock 1999

2: How do cold temperatures 2: How do cold temperatures affect health?affect health?

• Through the cardiovascular and respiratory systemsThrough the cardiovascular and respiratory systems

• Cardiovascular disease is declining as a cause of Cardiovascular disease is declining as a cause of mortality, but still causes a third of deaths in Irelandmortality, but still causes a third of deaths in Ireland

• Respiratory mortality has shown no fall, causing Respiratory mortality has shown no fall, causing approximately 14% of deaths in Irelandapproximately 14% of deaths in Ireland

• Almost a half of mortality in Ireland is Almost a half of mortality in Ireland is temperature sensitivetemperature sensitive

CardiovascularCardiovascular

Exposure to cold results in Exposure to cold results in significant and significant and

prolonged changes prolonged changes in the general population in the general population

Constriction of blood vessels leading to higher Constriction of blood vessels leading to higher

blood blood pressurepressure

Immediate changes in levels of chemicals Immediate changes in levels of chemicals

which which increase the tendency of blood to form increase the tendency of blood to form

clots. clots. (Donaldson Keatinge and Allaway 1997)(Donaldson Keatinge and Allaway 1997)

After six hours of mild cooling After six hours of mild cooling

• Packed cell volume by 7%Packed cell volume by 7%

• Platelet count increased to produce a 15% increase in the count increased to produce a 15% increase in the fraction of plasma volume occupied by platelets. fraction of plasma volume occupied by platelets.

• Whole blood Whole blood viscosityviscosity increased by 21%; increased by 21%;

• Arterial pressure rose on average from 126/69 to 138/87 mm Arterial pressure rose on average from 126/69 to 138/87 mm Hg. Hg.

• Plasma Plasma cholesterol cholesterol concentration increased, in both high concentration increased, in both high and low density lipoprotein fractions, but values of total and low density lipoprotein fractions, but values of total lipoprotein and lipoprotein fractions were unchangedlipoprotein and lipoprotein fractions were unchanged. .

• Fibrinogen increased increased• The increases in platelets, red cells, and viscosity The increases in platelets, red cells, and viscosity

associated with normal adjustments to mild surface associated with normal adjustments to mild surface cooling provide a probable explanation for rapid cooling provide a probable explanation for rapid increases in coronary and cerebral thrombosis in cold increases in coronary and cerebral thrombosis in cold weatherweather. . (Keatinge et al 1984; Neild et al 1995)(Keatinge et al 1984; Neild et al 1995)

RespiratoryRespiratory

• Cold temperatures Cold temperatures

Can induce constriction of the airways.Can induce constriction of the airways.

Cause delayed changes in increase in clotting factors in Cause delayed changes in increase in clotting factors in

bloodblood

Also associated with indoor crowding, contributing to both Also associated with indoor crowding, contributing to both

cross-infection and a lowering of the immune systems cross-infection and a lowering of the immune systems

resistance to respiratory infection.resistance to respiratory infection. (Eurowinter, 1977; Donaldson et al 1998).(Eurowinter, 1977; Donaldson et al 1998).

3: Who is most vulnerable in 3: Who is most vulnerable in Ireland?Ireland?

• People suffering from cardiovascular People suffering from cardiovascular

and respiratory diseaseand respiratory disease

• The older populationThe older population

2520151050-5-10

Mean temperature

1.2

1.0

0.8

0.6

0.4

Mortality rate per 100,000

QuadraticObserved

Mortality from Ischaemic heart disease per 100,000 Irish population 1981-2004

2520151050-5-10

Mean temperature

0.8

0.7

0.6

0.5

0.4

0.3

0.2

Mortality rate per 100,000

QuadraticObserved

Mortality from respiratory disease per 100,000 Irish population 1981-2004

20151050-5-10-15

Minimum temperature

0.8

0.6

0.4

0.2

Mortality rate per 100,000

LinearObserved

Relationship between lagged minimum temperatures and mortality from respiratory disease per 100,000 R square 0.892 p<0.000

2520151050-5-10

Mean temperature

1.0

0.8

0.5

Morta

lity

rate

per 1

00,0

00

Mortality from cancer per 100,000 population 1981-2004

Increase in mortality below Increase in mortality below threshold temperature in Irelandthreshold temperature in Ireland

15-6415-64 0.7%0.7%

65-7465-74 2%2%

75-8475-84 2.4%2.4%

Over 85Over 85 3.9%3.9%

TotalTotal 2%2%In accordance with national and international research (e.g. Aylin et al 2002, Eurowinter, 1997; Boulay et al,1999; Huynen et al, 2001; Moran et al, 2000; Goodman et al, 2004).

4 A look at other countries4 A look at other countries

• Yakutsk is the world's coldest city, with temperatures Yakutsk is the world's coldest city, with temperatures

averaging only −26.6°C during October to Marchaveraging only −26.6°C during October to March

• In Yakutsk, in the age groups studied: people aged 50-In Yakutsk, in the age groups studied: people aged 50-

59 and 65-74, mortality from cardiovascular disease 59 and 65-74, mortality from cardiovascular disease

and all causes was unchanged as temperature fell to - and all causes was unchanged as temperature fell to -

48.2°C48.2°C

• Mortality from respiratory disease only increased as Mortality from respiratory disease only increased as

temperatures fell below −20°C temperatures fell below −20°C (Donaldson et al 1998)(Donaldson et al 1998)

YakutskYakutsk

• High winter mortality in such regions is High winter mortality in such regions is largely preventable by warm housing and largely preventable by warm housing and clothingclothing

• Room temperatures were 19.1°C at outside Room temperatures were 19.1°C at outside temperatures of -42°Ctemperatures of -42°C

An average of 4.2 layers of clothing were An average of 4.2 layers of clothing were worn worn (Donaldson et al 1998)(Donaldson et al 1998)

A comparison: Norway and IrelandA comparison: Norway and Ireland

1986-19951986-1995 IrelandIreland NorwayNorway

Smoking Smoking prevalenceprevalence

32%32% 33%33%

ObesityObesity 10%10% 9%9%

CholesterolCholesterol HighHigh HighHigh

Both countries are demographically similar(Clinch and Healy 2000)

A comparison: Norway and IrelandA comparison: Norway and Ireland

IrelandIreland NorwayNorway

Roof insulationRoof insulation 100mm100mm 200mm200mm

Wall insulationWall insulation 40mm40mm 125mm125mm

Floor insulationFloor insulation 25mm25mm 150mm150mm

January temperatureJanuary temperature 55ooCC -1.1-1.1ooCC

Average internal Average internal temperaturestemperatures

1515ooCC 2121ooCC

A comparison: Norway and IrelandA comparison: Norway and Ireland

IrelandIreland NorwayNorwayCrude mortality rate from cardiovascular Crude mortality rate from cardiovascular disease/1000 populationdisease/1000 population 4.14.1 4.94.9

Crude mortality rate from respiratory Crude mortality rate from respiratory disease/1000 populationdisease/1000 population 1.31.3 1.11.1

Excess winter deaths per day from Excess winter deaths per day from cardiovascular diseasecardiovascular disease 39.639.6 6.36.3

Excess winter deaths per day from Respiratory Excess winter deaths per day from Respiratory diseasedisease 24.324.3 4.34.3

Clinch and Healy Clinch and Healy 20002000

(Walsh 2008 Statistical and Social Enquiry Society of Ireland)

Excess winter mortality is clearly modifiable

Recent reductionRecent reduction

Mortality Mortality 1973-19991973-1999 2000-20062000-2006

RespiratoryRespiratory 82%82% 58%58%

Ischaemic heart Ischaemic heart diseasedisease

27%27% 23%23%

CrudeCrude 27%27% 18%18%

Walsh 2008 Statistical and Social Enquiry Society of Ireland

Reduction in the peak to trough variation in winter mortality

Maximizing Ireland’s Energy EfficiencyMaximizing Ireland’s Energy Efficiency

MeasureMeasure Number of Number of homes homes deficientdeficient

Measures Measures made to 2008made to 2008

Wall insulationWall insulation 60,83660,836 3,8073,807

Draught Draught proofingproofing

74,52474,524 13,40113,401

Roof insulationRoof insulation 54,75254,752 17,98217,982

HomesHomes 18,46518,465

(Dept. Communications, Energy and Natural Resources 2009-2020)

Figures related to lowest income quintile

Factors associated with excess Factors associated with excess winter mortalitywinter mortalityWarmer housing Warmer housing Increased spending on health careIncreased spending on health careReduced air pollutionReduced air pollutionImpacts of better socioeconomic conditionsImpacts of better socioeconomic conditions

“ “Remains a puzzle”Remains a puzzle”

Merits further researchMerits further research

(Walsh 2008 Statistical and Social Enquiry Society of Ireland)(Walsh 2008 Statistical and Social Enquiry Society of Ireland)

Discussion:Discussion:

We know the importance of:We know the importance of:

good quality housing, good quality housing, heating, heating, nutrition nutrition and clothing in counteracting the impact of and clothing in counteracting the impact of

cold in the Irish and international contextcold in the Irish and international context

(Moran (Moran et alet al, 2000; Middleton , 2000; Middleton et al,et al, 2000; Donaldson 2000; Donaldson et al, et al, 2001(a)).2001(a)).

5. Conclusion:5. Conclusion:

A proportion of excess winter mortality A proportion of excess winter mortality is avoidableis avoidable

As you can see, we can monitor itAs you can see, we can monitor itWe have the opportunity now to track We have the opportunity now to track

the effects of socio-economic changes the effects of socio-economic changes and other variables on excess mortalityand other variables on excess mortality

Further research needs to be done Further research needs to be done Avoidable mortality is a tragedyAvoidable mortality is a tragedy