As I write this editorial, we are about to experience the coldest weather so far this winter. Temperatures are consistently dropping below freezing at night and remain low during the day. In Scotland, the mercury has dropped to -10 degrees Celsius. It seems timely, therefore, to consider the impact of cold weather on older people at home. The majority, we hope, have been vaccinated against the flu, but this is just the tip of the iceberg when it comes to preventing excessive morbidity and mortality in this age group in the winter months.
The impact of cold temperatures on older people is not widely known, but the statistics are stark. When the weather is cold, one older person dies every 7 minutes, and an average drop of 1 degree Celsius over the winter period will result in 5000 more deaths (NICE, 2015; Age UK, 2018).
It is commonly believed that hypothermia is the greatest risk associated with cold conditions, but this is a myth, and a dangerous one, too. When temperatures drop, there is a huge spike in heart attacks and strokes (because of poor circulation), exacerbation of chronic obstructive pulmonary disease and arthritic pain, and an increase in accidents and falls (NICE, 2015). These happen long before someone becomes hypothermic. Further, wounds heal more slowly in cold weather. Wounds need a moist, warm environment for optimal healing, and poor circulation and reduced blood flow lead to less oxygenation and regeneration of the wound bed (Winter, 1962; Hinman and Maibach, 1963). Inactivity from staying indoors will affect leg ulcers, which need calf muscle pump activity to encourage healing (Alimi et al, 1994). And then there are those blisters and burns from sitting too close to a gas fire.
So why are older people particularly vulnerable to cold weather and why do they find it difficult to maintain their body temperature? There are two main reasons. The first is that heat is generated by muscles, and muscle mass decreases dramatically with age. About 70–80% of our ability to maintain heat comes from our muscles, yet from the age of 55 years, we lose 1% of muscle mass per year. The second is low income and the inability to keep homes warm. Fuel poverty is when expenditure on fuel pushes the person's income below the poverty line, and a third of those experiencing fuel poverty in the UK are aged 60 years or above (NICE, 2015; Age UK, 2018).
District nurses dash from house to house and may not notice a cold home, but we need to recognise signs of fuel poverty, like not turning the heating on or heating just one room, skipping meals and staying in bed. A cold person is much more likely to feel anxious, depressed or lonely. So we need to ask: does the house feel damp and cold? Is the patient wearing many layers of clothing? Have they put the fire or heating on just for us? Is there evidence of unpaid energy bills? Do they have existing lung or heart conditions? Are they at risk of falls? Are they in the habit of keeping the bedroom deliberately cold, with the window open at night? (NICE, 2015).
NICE guidelines recognise the vital role of district nurses and the primary healthcare team in identifying patients living in hard-to-heat homes and those with low income (NICE, 2015). District nurses are ideally placed to assess patients' heating needs and ask how they keep their houses warm. Patients need easy-to-understand information on the effect of cold on older bodies and referral to the local health and housing service if needed. And finally, let's dispel some of those myths! A flu jab is an essential first step, but there is more to health promotion with older people in the coldest months. Hypothermia is not the greatest risk, and a cold bedroom or home is not healthy.