Vulnerability to winter mortality in elderly people in Britain: population based study
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.38167.589907.55 (Published 16 September 2004) Cite this as: BMJ 2004;329:647All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Presumably our milder climate reduces the dangers of death from
spells of hot weather such as that which affected France so badly last
year. If more of our elderly die in winter I presume less do so in summer
compared to other countries. Of course I wish to reduce avoidable deaths
and find the hypothesis of avoiding the excesses of outdoor cold exposure
attractive but wonder how much we are seeing the glass half empty rather
than half full.
Competing interests:
None declared
Competing interests: No competing interests
The great difference between us in the UK and those in colder climes
is our inability to dress appropriately for cold weather. On a sub-zero
day last February I walked from Waterloo Station to BMA House studying
headgear as I went. 1 person in 43 was wearing a hat. Age seemed to make
little difference. I would contend that short trips out in cold weather
are more likely to be undertaken by women, and that they are more likely
to feel unfashionable if they wear hats. They are also more likely to
develop respiratory illness.
I am disappointed that Dr Wilkinson and his colleagues did not include the
wearing of appropriate clothing amongst the personal behaviours noted.
Possibly a further study could be undertaken, and the fashion industry
persuaded to make hat-wearing "cool"!
Competing interests:
None declared
Competing interests: No competing interests
Sir,
The study by Wilkinson et al reporting a lack of effect
socieoeconomic gradient on excess winter mortality contributes
significantly to the debate seeking the best means to address this major
public health issue.
Currently, the UK government make a significant financial payment to
elderly persons, 'the winter fuel payment', in an attempt to address fuel
poverty, but it is becoming increasingly clear that other personal
factors, such as outdoor exposure to low temperature may play a
significant role in determining risk.
I would ask the research team two hypothetical questions: could the
excess mortality in women by related to their being more likely to spend
time outdoors in low temperature, as in this age group it is still likely
that they would bear the brunt of domestic tasks such as shopping? Second,
does the measure of air temperature used accurately reflect the
temperature experienced by the individual, given that windchill is a major
component of environmental exposure? If the data were re-analysed to
include windchill effects for each region, how would this affect the data?
Congraulations on a timely and interesting piece of research.
Competing interests:
None declared
Competing interests: No competing interests
Editor - Despite smaller fluctuations in seasonal mortality in
general (1,2), we obtained similar results for our analysis of excess
winter mortality in Denmark as Wilkinson et al (3) for Britain: an
increase of seasonality with age, higher excess winter mortality for women
- especially for respiratory diseases and a lack of a social gradient
related to mortality in winter.
Our analysis used Danish register data and was based on all women and
men being 65 years and older in Denmark between 1980 and 1998. These 1.8
million people survived on average about 100 months during the observation
period (186,271,440 person-months lived).
Using logistic regression, we obtained the following results: the
odds-ratios showed that winter mortality from all causes was 17.9% higher
for women and 15.7% higher for men than during summer. The disadvantage of
women was even more pronounced for respiratory diseases with an excess of
55.4% (men: 36.5%). The increase of seasonality with age was similar for
women and men until the age-group 85-89 years. At higher ages, men
surpassed women in excess winter mortality. We could not detect any social
gradient in vulnerability to excess winter mortality - regardless whether
socio-economic status was measured via highest completed education or via
wealth on the family level. We found, however, that people living alone
faced higher excess
winter mortality than women and men who shared their household with at
least one more person.
Our results support thus the findings of Wilkinson et al (3) that
fighting fuel poverty might not significantly reduce the annual cold-
related death toll. Policies aiming to reduce winter excess mortality as
suggested by Keatinge et al (4) should aim at all elderly, in particular
at women and people who are living alone.
1. Healy JD. Excess winter mortality in Europe: a cross country
analysis identifying key risk factors. J Epidemiol Community Health.
2003;57:784-9.
2. McKee M. Deaths in Winter: Can Britain learn from Europe? Eur J
Epidemiol. 1989;5:178-82
3. Wilkinson P, Pattenden S, Armstrong B, Fletcher A, Kovats RS,
Mangtani P, McMichael AJ. Vulnerability to winter mortality in elderly
people in Britain: population based study. BMJ. 2004;329:647-0.
4. Keatinge W, Donaldson G. Winter deaths: warm housing is not enough
(Letters). BMJ 2001;323:166
Competing interests:
None declared
Competing interests: No competing interests
Editor-The paper by Wilkinson et al, on people over 75, makes a
useful addition to the evidence that winter mortality in Britain is now
not caused primarily by deprivation and failure to heating homes. In
addition to other evidence they quote, a recent study on younger people
provides positive indications that cold exposure outside the home causes
winter mortality regardless of economic status (1). Manual workers
(social class 5) of working age (50–59) in Britain had low cold related
mortality compared with any other class. This was not the case with their
wives of similar age, nor for men of the same class after retirement age
(65–74). It suggests that internal heat production from manual work
protected class 5 men of working age against daytime cold stress and
consequent mortality. Elderly people in sheltered housing that was fully
heated, but who often went outdoors, had as much winter mortality as the
general elderly population (2).
Despite considerable evidence on these lines, reduction of outdoor
cold stress has been largely ignored in official campaigns to control
winter mortality. Heating of waiting areas for public transport, and at
least windproof shelters on bus routes subject to unscheduled delays, are
obvious measures that would help. Another is to broadcast warnings when
cold weather is forecast, that dressing warmly, with hats and with
windproofs and waterproofs when necessary, can prevent not only discomfort
but often illness and death. Keeping moving while outdoors is also
important
Surveys in Europe and Siberia provided statistical evidence that such
behaviour, as well as warm homes, is associated with low winter mortality
(3,4). We have found advice on these lines to avoid outdoor cold stress,
given via the media, well received by elderly people provided they are
also given the evidence that outdoor cold accounts for much of Britain’s
winter mortality.
William R Keatinge emeritus professor
Gavin C Donaldson lecturer in respiratory medicine
Barts and the London School of Medicine and Dentistry, Queen Mary
College, University of London, Mile End Road, London E1 4NS.
1. Donaldson GC, Keatinge WR. Cold related mortality in England and
Wales; influence of social class in working and retired age groups. J
Epidemiol Community Health. 2003;57:790-1.
2. Keatinge WR. Seasonal mortality in people with unrestricted home
heating. BMJ 1986;293:732-33.
3. The Eurowinter Group. Cold exposure and winter mortality from
ischaemic heart disease, cerebrovascular disease, respiratory disease, and
all causes in warm and cold regions of Europe. Lancet 1997;349:1341-6.
4. Donaldson GC, Tchernjavskii VE, Ermakov SP, Bucher K, Keatinge
WR. Winter mortality and cold stress in Yekaterinburg, Russia: interview
survey. BMJ 1998;316:514-8.
Competing interests:
None declared
Competing interests: No competing interests
If the lipid shift hypothesis (1) is correct I would have expected
there to have been a compensatory lipid shift in the winter relative to
summer possibly accompanied by a paradoxical rise in body temperature. If
so the increase in mortality in winter might be due to an energy
demand/supply mismatch provoked by uncoupling.
An alternative hypothesis is that the increased mortality in winter
is due to hypobaric hypoxia relative to that in summer, low pressures
being known to be associated with other diseases.
In the absence of a socioeconomic association the second hypothesis
would seem the more credible.
Successful evolutionary adaptation to environmental stress?
Richard G Fiddian-Green
Heart Online, 14 Jul 2004 eLetter r: D A Lawlor, G Davey Smith, R
Mitchell, and S Ebrahim
Temperature at birth, coronary heart disease, and insulin resistance:
cross sectional analyses of the British women’s heart and health study
Heart 2004; 90: 381-388
Competing interests:
None declared
Competing interests: No competing interests
A prospective study including 3034 consecutive hip fracture patients
admitted to a single unit in the United Kingdom over a 12-year period
showed more hip fractures occurred during the winter compared to summer
(P=0.002)and tendency to a higher mortality for those patients admitted in
the winter months(Crawford JR, Parker MJ, Injury. 2003 Mar;34(3):223-
5).Increased risk of hip fracture and associated high mortality may also
be kept in mind while taking additional measures to reach all those at
risk.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
respiratory infection is the killer.
Common Cold interferes with Coagulation, Complement and
Calcification.
People suffer from thrombosis and arthritis, induced by these three
innate immunity reactions.
Penicillin and heparin are the two drugs to stop the rapid downhill
course - in the beginning of the cascades!
Sincerily Yours
Friedrich Flachsbart
Competing interests:
None declared
Competing interests: No competing interests
Study conundrum
The report by Wilkinson et al (1) that economic deprivation is not a
predictor of winter mortality echoes a finding we made in 2001 that the
social class gap in hospital admissions is narrower in winter (2)
In our paper we discussed a number of possible explanations - for
example that winter excess morbidity and mortality might result not from
increased mortality and morbidity in winter but reduced morbidity and
mortality in summer, which might be experienced most by those with the
resources to use leisure opportunities or protect themselves from the
effects of heat-waves. However we did say that we thought our data was
probably wrong. It was the preparatory study result only and was the
opposite of what we expected. (We only published it out of scientific
integrity.)
We fully expected a better larger study to refute our finding but
instead it has been supported. This is a challenging intellectual
conundrum. The idea that poverty is not a predictor of the likelihood of
succumbing to the consequences of ambient cold is so counterintuitive that
it seems hard to believe.
Competing interests:
None declared
Competing interests: No competing interests