Winter Joys….Winter Hazards!

Once again, the winter season is upon us. We have all changed our clocks back 1 hour, and those of us who are facing a colder climate have gotten our winter coats and shoes out of storage and will now have to deal with the consequences of this time of the year. As every season approaches, I like to consider what season-specific special messages and concerns I need to incorporate into my patient care activities. While the winter can be a magical and joyous time of the year, for many it brings life-changing concerns and realistic problems that can have major potential consequences. Winter is a particularly challenging time for older persons. Social isolation, changes in diet, exposure to cold temperatures, increased risk of falls, added cost of heating one’s home, reduced sunlight, and a greater chance of being exposed to individuals who are ill, among other winter issues, each present their own concerns and risks.

The holiday season often brings families and friends together and provides activities that may help occupy the older person’s time as well as serve as a distraction from everyday boredom. It also serves as a reminder of past experiences. It is the time period immediately after the holiday excitement is over, however, that concerns me the most. Many older persons must now adjust to their usual nonholiday lifestyle; depression, alcoholism, and even suicide occur at higher rates at this time. Be aware of and anticipate these circumstances. Openly discuss with your patients how best to approach the time that follows the holidays.

Shorter days mean less daylight, and this may lead to psychological problems, especially depression. Some countries in the northern parts of the world use artificial light to deal with this issue. While I do not advocate going to the tanning salon, as it has its own set of risks, well-lit environments are suggested. If depression does set in, counseling may be required, and, yes, there are even some people who do benefit from prescribed light treatments. Vitamin D levels are also at their lowest during this time of the year, and attention to taking supplements to maintain an adequate level in the blood may be wise.

Winter brings cold weather, snow, and ice in many areas of our country. For the older person living in this environment, prevention of hypothermia is key! Wearing proper clothing, both when going outside and when staying at home, is essential. Older persons cannot sense a change in environmental temperature to the same degree as they could when they were younger, and may not readily seek shelter or raise the temperature in their homes until they have been exposed to a lower temperature for a prolonged period of time. Shivering thermogenesis is less efficient in the elderly, with older persons having less muscle to generate body temperature. Non-shivering thermogenesis may also be impaired in the elderly due to medications, age effects, and age-prevalent illness. Remember, even a room temperature set at 70°F is below body temperature and a person in this setting would require thermogenesis to maintain a normal body temperature. It is no surprise that older persons develop hypothermia at a much higher rate than younger persons. The cost of heating one’s home is an increasing challenge, and the appropriate referral of persons at highest risk to social agencies for assistance in paying for fuel may go a long way in preventing hypothermia. Once again, I believe the physician’s job is not only to address the patient’s medical conditions, but also to anticipate problems before they arise and to consider the many social, economic, and environmental issues that can negatively impact the older person’s well-being.

While it is not advised for the older person to walk on snow and ice and risk a fall, for many persons living in the snow-belt, this is an impossible challenge, with the alternative often being to stay indoors for prolonged periods of time. Clearly, attention must be given to wearing proper shoes, common sense as to when and where to walk, and fall prevention strategies. Shoveling snow is ill-advised as one gets older. Although aerobic exercise is advised for those who are able to participate, shoveling is an isometric activity that causes the body to work against a resistance and results in an increase in end-diastolic function. In addition, the cold temperature may result in vasoconstriction, further compromising cardiac flow. Caution is advised!

Winter brings an increased chance of developing a respiratory illness. Paying careful attention to hand washing, avoiding crowds as much as possible, keeping away from obviously ill persons, and getting the annual flu shot is advised. A pneumonia vaccine can also prevent pneumococcal pneumonia, a common complication of viral-induced respiratory illness, and should be considered part of every older person’s routine care.

We hear people say, “Eat plenty of fresh fruits and vegetables.” The winter makes this increasingly difficult, especially for an older individual who may have limited flexibility in where he or she may be able to shop or who is on a fixed income and cannot afford the increased premiums that often accompany these foods during the “off-season.” The use of canned and frozen fruits and vegetables may be more realistic for some, with a daily vitamin taken to ensure that any lost nutrition is provided. The older person should clearly be prepared for not being able to leave his or her home during this time of year or have others bring him or her fresh food for at least 1 week out of the month. Unfortunately, many nonperishable foods lack adequate protein and are also high in salt. Depending on the older person’s dietary needs, careful thought should be given as to what foods can be stored for the winter that will provide proper nourishment in times of need with minimal risk.

I could go on with many other examples of winter hazards, but I think my point is clear. Winter can be fun and provides a much-needed change of pace. I enjoy having four distinct seasons where I live. As I too get older, however, I can appreciate why many older persons become “snowbirds,” fleeing the northern climate in search of “better weather.” We must all be prepared for our own circumstances, whatever they may be—summer weather also has its own risks. As physicians, however, we can make a difference for our patients by taking the time to help them identify issues that may impact their health and safety and to help them prepare in advance to ward off any unwanted effects.

Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor of Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.