Understanding the impact of cold weather on older people has become imperative for healthcare professionals, particularly community nurses, who support an ageing population(Goodwin, 2007; Reis da Silva, 2023a). This article comprehensively analyses the physiological, psychological and social implications of cold weather on older individuals, and highlights the indispensable role of community nurses in providing holistic care.
During the winter months, vulnerable adults in care homes face greater risks of health problems, including respiratory conditions, falls because of snow or ice and gastrointestinal infections such as norovirus. Adhering to key infection prevention and control practices (IPC) can help prevent illness and protect patients from common infections (Department of Health, 2013; Aziz, 2018).
The high rate of winter deaths in the UK has been a persistent issue since 1841, with an estimated 20 000 to 50 000 more people dying each winter than in other seasons—most of these are older adults (Office for National Statistics (ONS), 2023). Most of this mortality rate is attributed to poorly insulated homes, leaving vulnerable populations exposed to the dangers of cold weather (Age UK, 2016). Tragically, in England and Wales, one older person dies approximately every seven minutes from cold-related illnesses. During the winter of 2014–15, some 40 800 excess winter deaths occurred among people aged 65 years or more, with the highest mortality rates seen in those aged 75 years and older (Age UK, 2016) (Box 1).
Excess winter deaths
Excess winter deaths (EWDs) are the difference between the average daily deaths in the winter months compared to other months in England. These deaths are primarily caused by hypothermia, respiratory and circulatory conditions, dementia and Alzheimer's. EWDs occur across all ages and represent a significant health inequality, with those experiencing greater socioeconomic deprivation more likely to be affected. Factors contributing to EWDs include seasonal factors such as weather and infectious diseases, individual vulnerability to cold, attitudes towards cold, and housing and economic factors including inadequate heating and energy inefficiency.
The NHS faces substantial financial burden from cold-related illnesses caused by inadequate housing, with an annual cost of £1.36 billion. Meanwhile, rising energy costs—up by about 150% over the past decade—have created a fuel poverty gap nearing £900 million, making it increasingly difficult for many households to afford adequate heating (Age UK, 2016). Although 6 million low-income households in the UK have homes rated B to D, or lower, in energy efficiency, only 1.8 million energy efficiency improvements have been implemented to date (Age UK, 2016). Public Health England (PHE) (2020) underscores that cold homes lead to approximately 35 000 excess winter deaths, often because of hypothermia, and exacerbated by conditions among those facing fuel poverty, low income or homelessness. Although the government's cold weather plan and cold weather alert service aim to address these risks, they fall short of tackling fuel poverty—a key driver of cold, damp housing.
In December 2022, this crisis reached a devastating peak, with over 1000 people in England dying as a result of living in cold, damp homes (End Fuel Poverty Coalition (EFPC), 2023a). This represents a sharp increase from December 2021 and matches the high mortality levels seen during the COVID-19 pandemic in December 2020. In total, December 2022 had 1047 excess winter deaths, up from 768 in the previous year (EFPC, 2023b). Across the winter of 2021-2022, England recorded 2731 excess winter deaths, while there was an average of 7409 preventable deaths in the UK each winter over the past decade because of poor housing conditions (ONS, 2023).
The enduring scale of this issue has spurred action from advocacy groups. Members of the National Pensioners Convention and Fuel Poverty Action held a minute's silence and a funeral march in memory of those lost to winter deaths. Fuel Poverty Action continues to mobilise through ‘warm up’ protests to raise awareness and demand effective solutions (PHE, 2020; EFPC, 2023b). These figures illustrate a public health crisis compounded by escalating energy prices and inflation, highlighting the urgent need for policy reform. Addressing fuel poverty with enhanced social support, improved energy efficiency in low-income housing and increased access to affordable heating could prevent avoidable deaths, particularly among older and vulnerable populations (Box 2).
Vulnerable groups
Cold weather poses a significant risk to certain groups:
Source: Public Health England, 2020
Cold weather can be particularly difficult for older people, as it can exacerbate existing conditions and expose them to respiratory tract infections (Age UK, 2016, 2018; Aziz, 2018). Cold-related mortality and morbidity remain a significant public health issue in the UK and other countries around the world (Hajat, 2017; Aziz, 2018). Slippery pavements during winter pose a hazard; falls can be catastrophic for older and vulnerable individuals (Reis da Silva, 2023b; 2024a) causing skin tears and immobility issues that result in costly wound care (Jones, 2017; Aziz, 2018). Community patients often rely on staff for dressings and wound care (Frykberg and Banks, 2015; Aziz, 2018).
Causes of excess winter deaths
Excess winter deaths are primarily caused by primarily as a result of low environmental temperature, a fact that has been recognised since 400 BC (Goodwin, 2007). Bull and Morton (1978) identified the relationship between temperature, age and mortality. Curwen informed that for every 1°C below the average, there are 8000 more deaths (Collins et al, 1985; Curwen, 1997; Goodwin, 2007; Bunker et al, 2016, Phung et al, 2016; Song et al, 2017). Hypothermia is not the main cause of winter deaths, with less than 1% deaths associated with it (Goodwin, 2007; Bunker et al, 2016, Phung et al, 2016; Song et al, 2017).
The main causes of excess death are respiratory illnesses, myocardial infarction and stroke. Infectious diseases such as influenza play a small role in these deaths (Goodwin, 2007; Bunker et al, 2016, Phung et al, 2016; Song et al, 2017). Climate change is not expected to cause an acute reduction in winter deaths and a significant decline in older people dying in winter. The physiological mechanisms that support the pathological processes brought on by exposure to cold are often ignored (Goodwin, 2007). The physiological threshold for cold ambient temperature effects begins as high as 12°C and the risk of death rises acutely as the temperature falls below this threshold (Goodwin, 2007).
The number of older people dying from heat-related causes in the UK is relatively low as compared to deaths from cold. Despite a slow decline in excess winter deaths (EWD), the problem is likely to continue for the foreseeable future (Goodwin, 2007; PHE, 2020). Humans often use behavioural thermoregulation in cold environments, such as migration, shelter building and physical activity, to maintain thermal balance and protect against cold-related injuries. However, in some situations, these behaviours are insufficient and physiological responses are required to maintain thermal balance (Castellani and Young, 2016). Humans lose heat two to five times faster in cold water than in air at the same temperature (Hong, 1984) because water has higher conductive and convective heat-loss properties (Castellani and Young, 2016). Water has 25 times higher thermal conductivity than air (Castellani and Young, 2016). Therefore, cooling is extremely effective, even in moderately cool water, resulting in rapid heat dissipation through conduction and convection from deeper tissues.
Physiological responses to cold weather in older people
Acute physiological responses
Cold exposure triggers primary cold thermoregulatory responses, such as vasoconstriction and shivering, also called thermoeffector responses (Castellani and Young, 2016). These responses occur when peripheral temperatures decrease, primarily skin and core temperatures (Castellani and Young, 2016). Cold exposure triggers peripheral skin vasoconstriction, reducing skin blood flow and convective heat transfer between the body's core and shell. While this increases insulation by the body's shell, heat is lost faster than it is replaced, leading to a decline in skin temperature (Castellani and Young, 2016). Vasoconstriction begins when skin temperature falls below 35°C and becomes maximal when it is 31°C or lower.
This vasoconstriction response helps prevent heat loss and protects core temperature (Castellani and Young, 2016). The preoptic area of the anterior hypothalamus senses afferent signals from the skin, causing cutaneous vasoconstriction and/or shivering thermogenesis (Castellani and Young, 2016). The threshold is the temperature point where the effector response is initially activated and the sensitivity of the response is denoted by the slope of the mean body temperature-effector response (Castellani and Young, 2016).
Cardiovascular and respiratory effects
Older individuals are more susceptible to cardiovascular challenges exacerbated by cold weather. This section explored scientific literature to explain the physiological responses of the cardiovascular system to low temperatures, emphasising the increased risk of adverse events and the need for vigilant monitoring by community nurses (Skinner et al, 2009; Song et al, 2017).
The association between temperature and cardiovascular disease has been extensively studied, with evidence suggesting that physiological regulation occurs through sympathetic reactivity, the renin-angiotensin system (RAS), dehydration and the systemic inflammatory response (Liu et al, 2015; Song et al, 2017; Reis da Silva, 2024b). Cold temperatures can increase the risk of hypertension and cardiovascular disease in overweight individuals (Park et al, 2012; Song et al, 2017) and increased angiotensin-II levels in plasma (Zhang et al, 2014; Song et al, 2017).
While the exact mechanism for this phenomenon is still unclear, it has been suggested that 25-hydroxy (OH) vitamin D deficiency promotes positive cardiovascular effects, such as improved endothelial function and lower blood pressure (Papandreou and Hamid, 2015; Bromage et al, 2016; Stewart et al, 2017). Exposure to ultraviolet light has been associated with a significant increase in 25(OH)D levels and a concurrent decline in blood pressure (Verdoia et al, 2014; Degerud et al, 2016; Stewart et al, 2017).
The respiratory system of older individuals faces heightened challenges during the colder months. The biological link between temperature and respiratory disease may stem from the impact of higher temperatures on allergen growth and virus transmission, both primary causes of respiratory illnesses (Pica and Bouvier, 2014; Song et al, 2017). Studies have shown that influenza virus transmission in temperate climates correlates with low temperatures and that high rates of respiratory syncytial virus infection are associated with colder weather (Basnet et al, 2016; PHE, 2017; Aziz, 2018; D'Amato et al, 2018).
Air pollutants such as fine particulate matter, ozone and carbon monoxide have been observed to cause or exacerbate respiratory diseases and have often been linked to high environmental temperatures (Amegah et al, 2016; Song et al, 2017; Aziz, 2018; D'Amato et al, 2018).
Cold exposure can cause both acute and chronic physiological changes leading to detrimental cardiovascular consequences (Skinner et al, 2009; Stewart et al, 2017). These changes depend on age, sex and individual characteristics, including fitness and ability to combat thermoregulatory fatigue (Manou-Stathopoulou et al, 2015; Stewart et al, 2017). The primary thermoregulatory responses to a drop in peripheral and potential core temperatures are peripheral vasoconstriction, which minimises heat loss through the skin, and shivering, which boosts metabolic heat production (Stewart et al, 2017).
These responses, mediated through sympathetic activation, can lead to increased heart rate and blood pressure (Castellani and Young, 2016; Stewart et al, 2017), platelet activation (Zhang et al, 2004; Stewart et al, 2017), and elevated inflammatory blood markers (Halonen et al, 2010; Stewart et al, 2017). Such physiological changes are provocative and may negatively impact individuals with subclinical or established cardiovascular disease. Older adults may exhibit a diminished cold response, affecting their ability to maintain thermoregulation (Stewart et al, 2017), or even recognise the need for behavioural adaptations to cold (Stewart et al, 2017).
Psychological and mental health implications of cold weather on older people
Behavioural changes and seasonal variations in activity patterns contribute to a higher risk of cardiovascular disease events during specific times of the year (Castellani and Young, 2016; Stewart et al, 2017). Studies have shown that regional and sociocultural differences in preserving heat, such as indoor heating, wearing thermo-protective clothing and modulating exercise levels, may explain why individuals living in milder countries are more exposed to the effects of cold weather. Seasonal variations in behaviour, such as dietary patterns and physical activity, can also contribute to cardiovascular disease events (Marti-Soler et al, 2014; Basnet et al, 2016, Stewart et al, 2017).
Cold weather is often linked to seasonal affective disorder (SAD), impacting the mental health of older individuals (Stewart et al, 2017). A distinct pattern of major depression, caused by SAD, is particularly common in people living at higher latitude, who are exposed to longer, darker winter months (Melrose, 2015; Sandman, et al, 2016; Stewart et al, 2017). Community nurses can offer valuable support through effective communication and emotional care, addressing the psychological aspects of SAD.
This highlights the importance of healthcare professionals possessing emotional awareness and emotional intelligence (da Silva, 2022; Reis da Silva, 2024c; Reis da Silva, 2024d). The social implications of cold weather on older people are profound, contributing to increased isolation and loneliness (Reis da Silva, 2024d). Community nurses are pivotal in addressing these social determinants of health, fostering community engagement and establishing support networks to enhance the overall wellbeing of older individuals (Reis da Silva, 2024e).
Health impacts of exposure to cold weather
Cold weather exposure can have significant health impacts including: increased blood pressure, clotting risk, immune suppression, lung capacity reduction and airway narrowing. Direct effects include heart attacks, strokes, respiratory diseases, influenza, falls, injuries and hypothermia. Indirect effects include poor mental health, reduced education and employment success, carbon monoxide poisoning, poor hygiene and poor diet and nutrition. These effects can occur even at mild outdoor temperatures (4−8°C).
Source: Public Health England, 2020
Weather, healthcare and caregiving
The relationship between weather and health is a critical area of concern, particularly in the context of service delivery and caregiving. Despite the significance of this relationship, the complexities involved are often under-represented in existing literature (Skinner et al, 2009).
Landeg et al (2019) highlighted that while adverse weather conditions were frequently cited as barriers to accessing health services, especially in rural and remote areas, the explanations provided were largely anecdotal. There is a significant lack of comprehensive studies that examine the implications of weather on the provision and reception of healthcare services. This gap in research underscores the need for a more nuanced understanding of how weather impacts health outcomes, particularly for vulnerable populations such as the elderly and those with pre-existing health conditions.
Geographic studies focusing on the intersection of climate, weather and health have a longstanding history (Skinner et al, 2009; Landeg et al, 2019). Medical geography has traditionally sought to clarify the links between climate and disease ecology, health system planning and the health status of individuals and populations. This field of study emphasises the importance of understanding how environmental factors, including weather patterns, influence health outcomes and healthcare delivery. For instance, extreme weather events can disrupt health services, hinder access to care and exacerbate existing health disparities among vulnerable populations (Skinner et al, 2009; Oldman, 2018). The implications of these disruptions are profound, as they can lead to increased morbidity and mortality rates, particularly among those who are already at risk because of socioeconomic factors or geographic isolation (Skinner et al, 2009; Oldman, 2018).
Climate-related health policy concerns are multifaceted and encompass a range of issues, including temperature-related morbidity and mortality, the impact of extreme weather events, air pollution and the spread of vector-borne diseases. Additionally, the socioeconomic impacts of climate change on community health and the vulnerabilities faced by populations in both rural and urban settings are critical considerations for policymakers. This highlights the urgent need for health systems to incorporate climate resilience strategies into their planning and service delivery frameworks (Skinner et al, 2009; Oldman, 2018).
The challenges posed by weather-related disruptions to healthcare services are not limited to physical access; they also extend to the psychological and emotional wellbeing of individuals affected by such events. Studies have shown that extreme weather can lead to increased levels of stress, anxiety and depression among populations that experience disruptions to their daily lives and healthcare access (Skinner et al, 2009; Oldman, 2018; Landeg et al, 2019). This is particularly relevant for individuals with chronic health conditions who rely on consistent access to healthcare services for management and treatment (Reis da Silva, 2024e). The interplay between weather, health and caregiving necessitates a comprehensive approach that considers both the physical and mental health implications of environmental factors.
The role of community health workers and caregivers becomes increasingly vital in the face of weather-related challenges. These individuals often serve as the first point of contact for vulnerable populations and play a crucial role in navigating the complexities of healthcare access during adverse weather conditions. Their ability to provide support, education and resources can significantly mitigate the negative impacts of weather on health outcomes.
However, as noted by Landeg et al (2019), the resilience of healthcare systems in the face of climate-related challenges is often tested, revealing gaps in preparedness and response capabilities. This underscores the need for targeted training and resources for healthcare providers to enhance their capacity to respond effectively to weather-related health challenges.
The role of community nurses in cold weather care
Jones and Mays (2016) revealed a clear distinction between the thermal comfort experienced by participants living in social housing that was newer, had efficient heating, was well-insulated and well-maintained and that of owner-occupiers living in older difficult-to-heat homes, which are often not connected to mains gas. Participants were largely unaware of the cardiovascular risk associated with low temperatures and their greatest concern was falling (Jones and Mays, 2016; Reis da Silva, 2023b), which they avoided by staying indoors during icy conditions. However, when deemed safe, people went outside for shopping, exercising, socialising or simply to get out of the house (Jones and Mays, 2016). Most of them relied on public transport and faced long and arduous journeys involving a combination of walking and taking buses to access facilities. The habit of venturing outdoors when possible, and the nature of journeys for those who relied on public transport, were important sources of exposure to cold temperature. Many received practical support from family during cold weather, such as car journeys for shopping or hospital trips, delivering groceries, cooking meals, help with household repairs, using the internet and using heating technology (Jones and Mays, 2016).
Wilkinson et al (2004) found that cold-related mortality and morbidity did not exhibit a socioeconomic gradient, indicating that the risk of winter deaths was broadly distributed among older individuals. This may limit the effectiveness of health initiatives focused solely on low-income households. One reason for the absence of a socioeconomic gradient is that housing standards are often higher in the social sector compared to the private sector (Jones and Mays, 2016). Local agencies face challenges in identifying vulnerable individuals during cold weather, because this information is not always available to services (Jones and Mays, 2016).
Budget pressures have reduced the number of people receiving services, with a 39% decrease in older people receiving state-funded services since 2005 (Fernandez et al, 2013; Jones and Mays, 2016). The ability of managers to influence front-line staff is also impacted by the transfer of services to the private sector (Jones and Mays, 2016). Winter deaths are a challenge for health and social care agencies in many countries with similar climates and housing stock. While Jones and Mays (2016) provided a nuanced picture of vulnerability during cold weather, revealing that older people in hard-to-heat homes were at risk of adverse outcomes, this is not necessarily linked to socioeconomic deprivation. Social support plays a key role in mediating vulnerability in both cases (Jones and Mays, 2016). Policy implications include directing resources toward individuals in poorly insulated homes and those who are socially isolated, as well as reducing isolation and fostering community resilience (Jones and Mays, 2016).
Community nurses play an essential role in health promotion and education, particularly when it comes to educating older individuals about the potential risks associated with cold weather. People in this demographic are particularly vulnerable to cold-related health issues, including hypothermia, frostbite and exacerbation of chronic conditions. Community nurses are uniquely positioned to assess the health needs of older adults and intervene effectively, given their frequent interactions and established trust within the community (Kasa, 2023; 2024). Their role extends beyond mere education; they actively engage in health promotion strategies, which can mitigate the risks posed by cold weather, enhancing the overall wellbeing of older individuals (Marcus-Varwijk et al, 2018).
The effectiveness of nurse-led interventions in managing the health of older adults during cold weather is well-documented. For instance, systematic reviews have shown that nurse-led programmes can significantly improve health outcomes by addressing frailty and promoting independence among community-dwelling older adults (Kasa, 2023; 2024). These interventions often include personalised health assessments, education on recognising cold weather risks and strategies for maintaining warmth and safety during the colder months. Such proactive measures are critical in empowering older adults to take charge of their health and reducing the possibility of hospitalisations and other adverse outcomes (Kasa, 2024).
Community nurses are instrumental in implementing comprehensive health literacy interventions that enhance older adults' understanding of health risks associated with cold weather (Geboers et al, 2018). By using models that focus on patient-provider interactions, community nurses can effectively communicate vital information regarding health management during the winter months. This includes educating older individuals on the importance of adequate clothing, nutrition and hydration, as well as the need for regular health checks to monitor chronic conditions that may be exacerbated by cold temperatures (Geboers et al, 2018; Reis da Silva, 2024b; 2024f). The integration of health literacy into nursing practice improves individual health outcomes and fosters a culture of preventive care within the community (Geboers et al, 2018).
In addition to direct education, community nurses often collaborate with other healthcare professionals to develop and implement community-wide health promotion programmes. These programmes are designed to address the multifaceted needs of older adults, particularly during the winter months when social isolation and mental health issues may become more pronounced (Lapena et al, 2022; Tucker et al, 2022). Initiatives that promote social engagement and physical activity can significantly reduce feelings of loneliness and depression among older adults, which are exacerbated during the colder months when outdoor activities are limited (Lapena et al, 2022; Tucker et al, 2022). Community nurses can facilitate these programmes by organising group activities, providing transportation and ensuring that older adults have access to necessary resources (Lapena et al, 2022; Tucker et al, 2022).
The role of community nurses in assessing the environmental factors that contribute to health risks during cold weather cannot be overstated. They are often involved in evaluating the living conditions of older adults, identifying hazards, such as inadequate heating or insulation, and advocating for necessary modifications to the household (Shimoda et al, 2020; Reis da Silva, 2023c). By addressing these environmental factors, community nurses can help create safer living conditions that protect older adults from the adverse effects of cold weather (Shimoda et al, 2020). This holistic approach to health promotion is essential for fostering resilience among older adults, enabling them to maintain their health and independence despite the challenges posed by seasonal changes (Kasa, 2024).
Community nurses also play a pivotal role in the dissemination of information regarding available community resources and services that can assist older adults during cold weather. This includes connecting them with local organisations that provide heating assistance, meal delivery services and transportation options for medical appointments (Kasa, 2024). By acting as a bridge between older adults and these resources, community nurses enhance the capacity of individuals to manage their health effectively and reduce their vulnerability during colder months (Kasa, 2024).
The importance of culturally tailored interventions is another critical aspect of community nursing in the context of cold weather health risks. Older adults from diverse backgrounds may have unique cultural beliefs and practices that influence their health behaviours and perceptions of risk (Siddiq et al, 2023). Community nurses are well-positioned to develop and implement culturally sensitive educational materials and interventions that resonate with the specific needs of these populations (Siddiq et al, 2023). This tailored approach improves engagement and ensures that health promotion efforts are relevant and effective (Siddiq et al, 2023).
Material deprivation can lead to winter hypothermia in older people because of outdoor cold exposure, lack of private transportation, inappropriate winter clothing and culturally determined behaviours (Romero-Ortuno et al, 2013). Fuel poverty in older people is influenced by income and the National Fuel Poverty Index could be an effective tool to address this issue (Romero-Ortuno et al, 2013). However, the study by Romero-Ortuno et al (2013) used a continuous time frame for data analysis and was not limited to the coldest months, which may have underestimated inner city temperature extremes. Their findings suggested that measures to alleviate fuel poverty should consider the wider social meaning, particularly through improved socioeconomic circumstances and more equitable income distribution (Romero-Ortuno et al, 2013).
Collaboration with multidisciplinary teams
The complex nature of the impact of cold weather on older individuals necessitates collaboration with multidisciplinary teams (Age UK, 2016; Aziz, 2018). Community nurses can foster partnerships with physicians, social workers and other healthcare professionals to provide holistic and integrated care, tailored to the specific needs of older individuals (Age UK 2016; Aziz, 2018).
A key finding from the study by Jones and Mays (2016) was the way an individual's risk (based on age or the presence of pre-existing illness) was mediated by social support. Social support has an influence on health outcomes across a range of conditions, such as managing chronic health conditions and being an important determinant of survival after a major health event, such as a myocardial infarction.
Conclusions
This article provides a comprehensive analysis of the impact of cold weather on older people, underscoring the indispensable role of community nurses in addressing the associated challenges. By integrating advanced concepts, research methodologies and academic theories the article contributes to the understanding of the intricate interplay between environmental factors and the health of older individuals. Further research and collaboration between academia and healthcare practitioners is essential to refine and expand the evidence base, which will ultimately improve the care and wellbeing of older individuals during the colder months.