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Vulnerability to winter mortality in elderly people in Britain: population based study

BMJ 2004; 329 doi: (Published 16 September 2004) Cite this as: BMJ 2004;329:647
  1. Paul Wilkinson (paul.wilkinson{at}, senior lecturer1,
  2. Sam Pattenden, lecturer1,
  3. Ben Armstrong, reader1,
  4. Astrid Fletcher, professor1,
  5. R Sari Kovats, lecturer1,
  6. Punam Mangtani, lecturer1,
  7. Anthony J McMichael, professor1
  1. 1 London School of Hygiene and Tropical Medicine, London WC1E 7HT
  1. Correspondence to: P Wilkinson
  • Accepted 3 June 2004


Objective To examine the determinants of vulnerability to winter mortality in elderly British people.

Design Population based cohort study (119 389 person years of follow up).

Setting 106 general practices from the Medical Research Council trial of assessment and management of older people in Britain.

Participants People aged ≥ 75 years.

Main outcome measures Mortality (10 123 deaths) determined by follow up through the Office for National Statistics.

Results Month to month variation accounted for 17% of annual all cause mortality, but only 7.8% after adjustment for temperature. The overall winter:non-winter rate ratio was 1.31 (95% confidence interval 1.26 to 1.36). There was little evidence that this ratio varied by geographical region, age, or any of the personal, socioeconomic, or clinical factors examined, with two exceptions: after adjustment for all major covariates the winter:non-winter ratio in women compared with men was 1.11 (1.00 to 1.23), and those with a self reported history of respiratory illness had a winter:non-winter ratio of 1.20 (1.08 to 1.34) times that of people without a history of respiratory illness. There was no evidence that socioeconomic deprivation or self reported financial worries were predictive of winter death.

Conclusion Except for female sex and pre-existing respiratory illness, there was little evidence for vulnerability to winter death associated with factors thought to lead to vulnerability. The lack of socioeconomic gradient suggests that policies aimed at relief of fuel poverty may need to be supplemented by additional measures to tackle the burden of excess winter deaths in elderly people.


  • We thank Chris Bulpitt, Dee Jones, and Alistair Tulloch, coinvestigators on the MRC trial of assessment and management of older people; the nurses, general practitioners, the other staff, and the patients in the participating practices; the MRC general practice research framework coordinating centre, particularly Madge Vickers, Jeannett Martin, and Nicky Fasey; the research team for the MRC trial of assessment and management of older people in the community—Elizabeth Breeze, Edmond Ng, Gill Price, Susan Stirling, Rakhi Kabiwala, and Janbibi Mazar at London School of Hygieneand Tropical Medicine, and Maria Nunes and Ruth Peters at Imperial college; Amina Latif and Elaine Stringer, University of Wales College of Medicine; and the trial steering committee, J Grimley Evans (chair), Andy Haines, Carol Brayne, Karen Luker, and Madge Vickers.

  • Contributors AJM, PW, BA, and AF designed the winter mortality study. PM and RSK collected data on flu vaccination, PHLS flu counts, and meteorological data. SP and BA carried out the statistical analyses. PW wrote the paper. All authors contributed critical comments to the paper. AF is the principal investigator of the MRC trial of assessment and management of older people in the community. PW is the principal guarantor of the paper.

  • Funding UK Medical Research Council grants G9900506 and G9223939; and Departments of Health and the Scottish office. PW was supported by a Public Health Career Scientist Award (NHS Executive, CCB/BS/PHCS031), and PM by project funding from the Wellcome Trust (No 051637).

  • Competing interests None declared.

  • Ethical approval The relevant local research ethics committees approved the study.

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