Dr. Anne O’Farrell and Dr. Davida De La Harpe, Health Intelligence Unit, HSE.

1. Excess winter mortality and morbidity in the elderly in Ireland: has a change in the fuel allowance the potential to affect it? Dr. Anne O’Farrell and Dr. Davida De La Harpe, Health Intelligence Unit, HSE.

2. Background: • Excess winter mortality has been observed in Ireland and in other European countries.1 • The fuel allowance, which is means tested, can be regarded both as a proxy measure for poverty and as a real contributor to ameliorating the effects of poverty. • The increase in fuel prices together with the reduction of the fuel allowance from 32 weeks to 26 weeks could impact on the numbers suffering fuel poverty  • McAvoy H. (2007) All-Ireland Policy paper on Fuel Poverty and Health. Dublin: Institute of Public Health of Ireland.

3. Recent Headlines: Fuel Allowance cut to hurt the poorest of older people. SOURCE: Age Action, Jan. 2012 Older people going to bed at 7pm to save on fuel bills. SOURCE: The Irish Times – Sept. 2011. Struggle of Irish people to pay bills revealed in Credit Union survey. “The increases in energy and fuel costs have affected 85pc of people and 8pc said it is impossible to pay their bills each month”. SOURCE: IRISH INDEPENDENT, Monday 9th January, 2012 Gas price increases to add €150 to household bills. SOURCE: The Irish Times, Oct. 2011.

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

5. AIM: • The aim of this study was to determine whether the excess in winter mortality and inpatient hospital emergency admissions among the elderly is continuing in recent years 2005-2010. • To describe the causes of death and reasons for hospital in-patient admissions among the elderly in winter vs. summer months.

6. Method: • Persons aged ≥65 years who died in Ireland in Winter months (i.e.Nov-Jan) versus Summer months (i.e. May-Jul) extracted from the CSO for years 2005-2009. • Patients aged ≥65 years who were admitted to acute hospitals as emergency admissions during winter months vs. summer months extracted from HIPE database. • Statistical analyses were carried out in JMP, Stata and StatsDirect.

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

8. Mortality coming down in all age-groups:

9. No. of deaths in elderly (aged 65+ yrs) by season of death (winter vs. summer)(All deaths) N= 3,233 excess deaths in winter months vs. summer months over 5 year study period, average 650 excess deaths per year in elderly during winter compared to summer.

10. Deaths from respiratory illness in those aged 65+ years 1,223 excess deaths in elderly due to respiratory diseases in winter vs. summer months over the 5 year study period.

11. Deaths from circulatory illness in those aged 65+ years 1,770 excess deaths in elderly due to circulatory diseases in winter vs. summer months Over the 5 year study period.

12. Results: • Excess deaths due primarily to: • Respiratory diseases: 1,770/3,233 (54.7%) • Circulatory diseases: 1,223/3,233 (37.8%) • Dr. Elizabeth Cullen will present data on other countries’ experience and on the biological effect of lower temperatures.

13. Moving on to hospital admissions: • HIPE data • over 65s emergency only • comparing winter admissions with summer admissions

14. No. of emergency hospital in-patient admissions in elderly (aged 65+ yrs) by season (winter vs. summer): N= 8,040 excess emergency in-patient hospital admissions in winter months vs. summer months over 5 year study period.

15. Results: • Excess hospital admissions due primarily to: • Respiratory diseases: 7,129/8,040 (88.6%)

17. Winter vs. Summer Admissions:Length of Stay: • Winter season = 1,842,691 bed days • Median LOS Winter = 7 days (range 1-850 days) • Summer season = 1,689,663 total bed days • Median LOS = 6 days (range 1-892 days) • Excess bed days used in winter season vs. summer season = 153,028 bed days.

18. Winter vs. Summer Admissions: Estimated Acute Care Costs: (emergency admissions only) Excess costs winter admission vs. summer admission = €61 million

19. Discussion: • Winter excess mortality and morbidity still present in elderly although it has reduced over time. • Respiratory diseases and circulatory diseases over-represented.

20. Discussion: • This study has found that more households than ever are in receipt of the fuel allowance. • The numbers of those assessed as suffering fuel poverty are increasing. • Although the direct overall cost has increased for the exchequer, the possible long-term cost of reducing the allowance and the wider consequences require further monitoring.

21. Discussion: • The causes of the excess mortality still need further research as it is likely to be multi-factorial. • Many of these deaths are likely to be avoidable and an hypotheses is that they are linked to poor housing, and temperature • Socio-economic factors come into play.

22. Discussion: • Further research into the link between housing standards and in-adequate heating and excess winter mortality needs to be carried out. • However, a cut in the fuel allowance has the potential to exacerbate the problem among the elderly.

24. Excess winter mortalityin Ireland Energy Action Fuel Poverty Conference Dublin Castle February 6th Feb 2012 Dr Elizabeth Cullen Department Community Health HSE

25. Outline of presentation 1. Excess winter mortality 2. How do cold temperatures affect health? 3. Who is most vulnerable in Ireland? 4. A look at other countries 5. Conclusions

26. 1: Excess winter mortality • We have seen from Anne’s slides, that we have excess winter mortality and hospital admissions in those aged 65 years and over during the study period 2005-2009. • Majority due to respiratory and circulatory diseases. • However, countries with warmest winters (over 5oC) tend to have highest rates • ‘Paradox of excess winter mortality’ Shah and Peacock 1999

27. 2: How do cold temperatures affect health? • Through the cardiovascular and respiratory systems • Cardiovascular disease is declining as a cause of mortality, but still causes a third of deaths in Ireland • Respiratory mortality has shown no fall, causing approximately 14% of deaths in Ireland • Almost a half of mortality in Ireland is temperature sensitive

28. Cardiovascular Exposure to cold results in significant and prolonged changes in the general population • Constriction of blood vessels leading to higher blood pressure • Immediate changes in levels of chemicals which increase the tendency of blood to form clots. (Donaldson Keatinge and Allaway 1997)

29. After six hours of mild cooling Packed cell volume by 7% Platelet count increased to produce a 15% increase in the fraction of plasma volume occupied by platelets. Whole blood viscosity increased by 21%; Arterial pressure rose on average from 126/69 to 138/87 mm Hg. Plasma cholesterol concentration increased, in both high and low density lipoprotein fractions, but values of total lipoprotein and lipoprotein fractions were unchanged. Fibrinogen increased The increases in platelets, red cells, and viscosity associated with normal adjustments to mild surface cooling provide a probable explanation for rapid increases in coronary and cerebral thrombosis in cold weather. (Keatinge et al 1984; Neild et al 1995)

30. Respiratory • Cold temperatures • Can induce constriction of the airways. • Cause delayed changes in increase in clotting factors in blood • Also associated with indoor crowding, contributing to both cross-infection and a lowering of the immune systems resistance to respiratory infection. (Eurowinter, 1977; Donaldson et al 1998).

31. 3: Who is most vulnerable in Ireland? • People suffering from cardiovascular and respiratory disease • The older population

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

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

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

35. Mortality from cancer per 100,000 population 1981-2004

36. Increase in mortality below threshold temperature in Ireland 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).

37. 4 A look at other countries Yakutsk is the world's coldest city, with temperatures averaging only −26.6°C during October to March In Yakutsk, in the age groups studied: people aged 50-59 and 65-74, mortality from cardiovascular disease and all causes was unchanged as temperature fell to - 48.2°C Mortality from respiratory disease only increased as temperatures fell below −20°C (Donaldson et al 1998)

38. Yakutsk • High winter mortality in such regions is largely preventable by warm housing and clothing • Room temperatures were 19.1°C at outside temperatures of -42°C An average of 4.2 layers of clothing were worn (Donaldson et al 1998)

39. A comparison: Norway and Ireland Both countries are demographically similar (Clinch and Healy 2000)

40. A comparison: Norway and Ireland

41. A comparison: Norway and Ireland Clinch and Healy 2000

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

43. Recent reduction Reduction in the peak to trough variation in winter mortality Walsh 2008 Statistical and Social Enquiry Society of Ireland

44. Maximizing Ireland’s Energy Efficiency Figures related to lowest income quintile (Dept. Communications, Energy and Natural Resources 2009-2020)

45. Factors associated with excess winter mortality • Warmer housing • Increased spending on health care • Reduced air pollution • Impacts of better socioeconomic conditions “Remains a puzzle” Merits further research (Walsh 2008 Statistical and Social Enquiry Society of Ireland)

46. Discussion: • We know the importance of: • good quality housing, • heating, • nutrition • and clothing in counteracting the impact of cold in the Irish and international context (Moran et al, 2000; Middleton et al, 2000; Donaldson et al, 2001(a)).

47. 5. Conclusion: • A proportion of excess winter mortality is avoidable • As you can see, we can monitor it • We have the opportunity now to track the effects of socio-economic changes and other variables on excess mortality • Further research needs to be done • Avoidable mortality is a tragedy