Building and Environment 120 (2017) 123e133

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Building and Environment

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10 Questions

Ten questions concerning thermal comfort and ageing

J. van Hoof a, *, L. Schellen b, c, V. Soebarto d, J.K.W. Wong e, J.K. Kazak f
a
Fontys University of Applied Sciences, Dominee Theodor Fliednerstraat 2, 5631 BN Eindhoven, The Netherlands
b
Maastricht University, Department of Human Biology, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
c
Avans University of Applied Sciences, School of Built Environment and Infrastructure, Professor Cobbenhagenlaan 13, 5037 DA Tilburg, The Netherlands
d
School of Architecture and Built Environment, The University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia
e
Department of Building and Real Estate, Block Z, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
f
Wrocaw University of Environmental and Life Sciences, Department of Spatial Economy, Grunwaldzka 55, 50-357 Wrocaw, Poland

a r t i c l e i n f o a b s t r a c t

Article history: This 10 Questions contribution provides an overview of thermal comfort in relation to ageing and the
Received 18 January 2017 way the indoor environment can contribute to and improve well-being and health of older adults to age-
Received in revised form in-place. The number of older people is increasing rapidly and these demographical changes put a large
2 May 2017
stress on the health care system. Furthermore, as most older people wish to age-in-place, adequate
Accepted 8 May 2017
ageing-in-place strategies become signicantly important. Housing impacts health, therefore appropriate
Available online 11 May 2017
and comfortable housing is a key determinant to facilitate older people to age-in-place. One of the as-
pects of concern is thermal comfort; however, the thermal requirements of older people differ from
Keywords:
Thermal comfort
those of young adults. They are also relatively vulnerable to thermal conditions outside the generally
Thermal sensation accepted range. This 10 Questions' contribution addresses issues related to thermal comfort and ageing
Aging and argues that the current models for assessing thermal comfort are not sufciently accurate to be used
Elderly for older adults. It also discusses approaches to facilitate ageing-in-place including the use of smart home
Temperature technologies. The paper is based on extensive literature review of numerous relevant studies relating to
Heat stroke thermal comfort, physiological differences between older and younger people, the relationship between
Climate change thermal environment, comfort and health, as well as housing design and smart home technologies for
Health
older people.
2017 Elsevier Ltd. All rights reserved.

1. Introduction
1.1. Ageing of the population
All over the world, populations are ageing. In 2015, the pro-
portion of people aged 60 years and above (often referred to as
older people1) was around to be 12.5% of the entire world popu-
lation [1]. This number is expected to rise to 16.7% in 2030 and 20%
in 2050 [1], with some of the developing countries experiencing a
high rate of increase in the population of older people as well (at
* Corresponding author.
E-mail addresses: joost.vanhoof@fontys.nl, jvhoof1980@hotmail.com (J. van
Hoof).
1
In some countries the term older people refers to those aged 65 years or over.
In this paper, we use the neutral and non-ageist term older adults or older people
interchangeably, instead of seniors or the elderly. In the literature relating to
thermal comfort and ageing, no further distinction is made between the various
cohorts of older people.
26% for developing nations versus 71% for developed nations).
Worldwide, the vast majority of older people prefer to age-in-
place and continue to live independently at home for as long as
possible [2,3]. Ageing-in-place or the ability to live in one's own
home for as long as condently and comfortably possible [2] is the
focus of government strategy, for example in Australia [4,5],
Singapore [6], Hong Kong Special Administrative Region (SAR),
China [7], Poland [8] and the Netherlands [9]. The Hong Kong SAR,
for example, has the second-fastest ageing population in Asia, and
the Government upholds the principle of ageing-in-place as the
core, institutional care as back-up in its aged-care policy [10]. For
most older people, ageing-in-place means staying in the family
home in which people have resided for many years, often a lifetime.
In their quest for ageing well and independently, a wide array of
home modications and technologies may be introduced in the
home environment in order to facilitate ageing-in-place and sup-
port activities of daily living [11e14].
Apart from people ageing-in-place, there are a substantial
number of older people in western societies, who reside in aged-

http://dx.doi.org/10.1016/j.buildenv.2017.05.008
0360-1323/ 2017 Elsevier Ltd. All rights reserved.
124 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
care facilities or nursing homes. Nursing homes provide an alter-
native place of residence with 24-h care and assistance offered by
professionals to people who can no longer reside in their own home
environment due to increasing need for assistance with activities of
daily living, complex health care needs and vulnerability [15].
Nursing homes have a dual nature: as a care institution and as a
place to live [16]. There is an increasing focus on the aspects of
living, which is most evident in so-called small group living facil-
ities for people with dementia [17]. In addition to nursing homes,
there are many other emerging housing arrangements for the
ageing society, including retirement villages or independent living
units [18]. This type of housing usually comprises of much smaller
residential units, with or without services such as cleaning and
meals being provided to the individual units. In other words, in this
type of housing, older people would still feel to be at home, but
without the burden of having to care for the house, which was
usually much larger than their new home in the retirement village.
Healthy ageing is one of the key topics of the World Health
Organization (WHO) and is included in the WHO's Ageing and
Health programme [19]. Ninety percent of our time (up to 100% for
the aged) is spent indoors; therefore, the indoor environmental
conditions that we are exposed to are a key determinant of health
[20,21]. With respect to the thermal environment, especially older
people are relatively vulnerable to thermal environmental condi-
tions outside the common temperature range, for instance, during
cold spells and heat waves [22,23]. Older people may perceive the
combined effects of indoor climate conditions differently from
younger people [24]. Many older people are more vulnerable to
extreme weather during summer or winter because they tend to be
frailer and have various health problems [25]. The likelihood of this
occurring tends to increase when they live alone, and on a wider
scale, this can lead to a societal economic burden not only to
themselves but also to their families and community.
When faced with reduced income, nancial resources of older
people play a part in relation to cooling and heating. In a recent
survey of a sample of older people conducted in South Australia,
most participants (78%) avoided using cooling and heating, as they
were not able, or not wanting, to spend the money to pay for the
electricity and gas bills from using heating and cooling equipment
[27]. Worldwide, there are important issues concerning the supply
and costs of energy and fuel poverty, and the health risks of cold
winters in community-dwelling people [28]. The availability of air-
conditioning systems in homes of older adults in order to provide
them comfort and to protect them against the risk of increased
mortality during long periods of (extreme) heat, as seen in the 2003
and 2006 heat waves in Europe [29], may not be evident for those
without sufcient nancial means. Ensuring that the homes are
reasonably comfortable without heavily relying on heating and
cooling through better building design and the use of smart home
technologies is, therefore, critical as in a society that propagates
energy-efcient ways of heating and cooling a building.
1.2. Thermal comfort
In order to provide older people with a thermally comfortable
environment we must understand their thermal comfort, or, in
other words, their thermal sensation and preference. As widely
known, the term thermal comfort is dened by the American
Society of Heating, Refrigerating an Air-Conditioning Engineers
(ASHRAE) as that state of mind which expresses satisfaction with the
thermal environment [30]. Within the built environment, the most
commonly used model for evaluating thermal comfort is the PMV-
model (Predicted Mean Vote) of Fanger [31]. The optimum condi-
tion according to this model, dened as the thermal neutral
condition, is a condition wherein a person does not prefer either a
colder or warmer environment (
0.5 < PMV < 0.5).
The model is included in standards regarding the assessment of
thermal comfort [30,32] that are widely used by heating and air-
conditioning engineers to prescribe and design the thermal envi-
ronment [33]. These thermal comfort standards aim to specify
conditions that provide comfort to all healthy adults [34]. Appli-
cation of these guidelines results in an optimum constant indoor
temperature without uctuations, both during the day and night.
However, it has been argued that the optimal thermal condition for
people is not necessarily equal to thermal neutrality since prefer-
ences for non-neutral thermal sensations are common [33,35].
Further, based on research by Fanger [31], Rohles and Johnson
[36], and Fanger and Langkilde [37] among others, ASHRAE [38]
states that the preferred thermal conditions of older adults do
not differ from those of younger adults. On the contrary, several
studies indicate that optimum thermal conditions for the older
people differ from those of young adults [24,39e43]. Gender also
plays a role in perceiving the thermal environment. In general, fe-
males are more sensitive for cold conditions and deviations from
the individual optimum conditions than males. Besides, females
frequently prefer higher temperatures [44e47]. These studies
reveal that the thermal conditions preferred by older people and
females can differ from those preferred by younger adults and
males.
Results from naturally ventilated buildings in practice reveal
that satisfaction with the thermal environment does not mean that
this environment has to be controlled at a constant indoor air
temperature [48]. These ndings lead to the adaptive thermal
comfort approach and cause a signicant paradigm shift away from
the heat balance-based approach [49]. The adaptive approach ac-
counts for the fact that humans adapt to seasonal variations in
environmental conditions. Application of the adaptive thermal
comfort approach therefore results in a more varied, depending on
the outdoor conditions, indoor thermal climate [48].
Compared to maintaining a constant temperature, allowing the
temperature to drift will reduce building energy-use [50]. The latter
is highly relevant since one-third of the primary energy in devel-
oped countries is used for heating, ventilation and air-conditioning
(HVAC) as well as lighting in non-industrial buildings such as
dwellings and hospitals [51]. A temperature drift is dened as a
transient temperature over time, depending on running outdoor
temperature.
In addition to energy-saving potentials, a recent study search
indicates that the adaptive temperature approach can have signif-
icant health effects [52]. While conventionally thermal comfort and
health are considered as synonyms and, therefore, the tightly
controlled PMV-approach is regarded as most healthy, recent
ndings suggest that it might be healthier to expose people to
temperatures outside the thermoneutral zone [52].
1.3. Structure of the paper
In line with previous Ten Questions papers [53e56], the
remainder of this paper is structured as follows. In Section 2, the ten
questions on thermal comfort and ageing are raised and answered
extensively. The questions are ordered according to the following
thematic structure:
 The differences in thermal comfort of young and old (Q1, Q2);
 Strategies of older people to achieve thermal comfort (Q3)
 Effects of thermal environment on health and well-being of
nancial of older (Q4, Q5, Q6);
 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
 How thermal environment, building design and services can
contribute positively to ageing-in-place (Q7, Q8);
 Generalisability (Q9);
 Future perspectives (Q10).
2. Ten questions (and answers) concerning thermal comfort
and ageing
2.1. Are there differences between young and older people in terms
of thermal comfort?
Answer: When exposed to the same thermal conditions older
people tend to have a different thermal sensation and preference
than younger people. They are also less responsive to changes in
their thermal environment, making them more vulnerable to
extreme thermal conditions.
In standards and guidelines, no distinction in age is made
regarding thermal comfort levels as it is assumed that older adults
do not perceive thermal comfort differently from younger college-
age adults [30]. ASHRAE Standard 55 was based on studies by
Fanger [31], who created his predictive model through climate
chamber research involving approximately 1300 college-age stu-
dents. These studies were followed by much smaller experiments
involving 128 older subjects to study the inuence of age and
ageing. He concluded that the neutral temperature did not differ
between young and older adults, and, therefore, no difference in
thermal preference was assumed between younger and older
people. It should be noted that the experiments conducted by
Fanger were conducted with identical clothing insulation values.
However, in daily life older people may be less active, and, there-
fore, they may prefer higher ambient temperatures.
However, already 20 years ago a number of studies found that
the optimum thermal conditions for older persons differ from those
for younger persons [39e42]. The 20e24  C comfort zone is not
warm enough for older adults [57] and older adults generally prefer
a warmer environment (2 K) than younger subjects [24]. Later,
Schellen et al. [43] also found that the optimum conditions for
healthy older adults (age above 67 years) differ from those of their
younger (age 18e30 years) counterparts. The thermal sensation of
older adults was in general 0.5 scale units lower on the PMV scale
than the thermal sensation of the young adults. The same trend was
found for the thermal comfort votes; older adults felt less
comfortable at lower temperatures than the young adults, indi-
cating that the older adults preferred a higher temperature than the
young adults did. Under the same environmental conditions, the
young adults were feeling neutral, while the older ones were
feeling slightly cold.
Another study however, showed the opposite, that the neutral
and preferred temperatures of older adults were lower compared to
the acceptable operative temperatures suggested by ASHRAE
Standard 55 [58,59]. In a study of a sample of older people in South
Australia by Bills [58], despite the high number of cold votes
during the winter period, almost 50% of the time the older adults in
the study did not prefer to be warmer even though the minimum
indoor temperature was as low as 12  C. On the opposite side, they
started to feel slightly warm and warm at the temperatures when
the ASHRAE Standard 55 suggests being neutral. In a study of older
people in Taiwan e Republic of China, Hwang and Chen [59] found
that the operative temperature range in which older subjects feel
thermal comfortable is narrower than that of young adults, both
during winter and summer.
In summary, older people tend to have a different thermal
sensation and preference than younger people. This, in turn, affects
the way older people respond to changes in the thermal conditions
around them.
125
2.2. What are the underlying causes of the differences in thermal
comfort between young and older people?
Answer: The underlying causes of these differences are: (1)
reduced efciency of, and ability to detect, cold and warm defence
mechanisms, (2) lower metabolic rate, (3) reduced vascular reac-
tivity, (4) decreased thermoregulatory response (especially the
vasoconstrictor response), (5) different body composition, i.e.,
reduced muscle volume and increased fat percentage (6) reduced
muscle strength hence reduced work capacity, and (7) lower car-
diovascular exibility and resulting lower cardiac output, in older
people [24,60,61]. These factors have impact on the older people's
thermal sensation and preference.
As a consequence of biological ageing, several sensory changes
occur in the sensory organs and their coupling to the nervous
system. These changes may change our perception of the envi-
ronment surrounding us [24,29]. Crucial in thermoregulation is the
maintenance of the heat balance, which can be achieved by two
physiological means: regulation of heat loss and heat production.
For heat loss, heat transport by blood perfusion from the core to the
surface of the body is the most important factor. In hot environ-
ments, sweat production is an additional necessity. For the regu-
lation of heat production, among most important organs are
skeletal muscle and brown adipose tissue. Many factors related to
thermoregulation are impaired in older adults. All factors listed are
known to be affected by age and ageing, and are of great impor-
tance with respect to dissipation of heat within the body and to-
wards the environment and the ability of keeping core temperature
stable and skin temperatures within a comfortable range.
The differences in thermal comfort between older people and
their younger counterparts are due to several factors, as reviewed
by Hoof and Hensen [24], van Hoof et al. [29] and Blatteis [60].
Older adults experience a decline in the efciency of their cold and
warm defense mechanisms and in the ability to detect, and
therefore respond to, temperature changes. In addition, Poehlman
et al. [62] revealed that the metabolic rate in older people is lower
than that of younger people due to a decrease in muscle mass,
which reduces both the basal and resting metabolic rate. The dif-
ference in thermal sensation may also be explained by a decreased
thermoregulatory response (especially the vasoconstrictor
response), indicated by the extent of vasomotion measured by the
differences in skin temperatures between the young adults and the
older adults [63,64]. For example, during the experiments of
Schellen et al. [43] the older adults were continuously more vaso-
constricted compared to the young ones. Although 20% of older
adults show no vasocontraction of cutaneous blood vessels, not all
of those 20% have a diminished control of body temperature.
In the aged population group, one of the most prescribed types
of medication are beta-blockers for the treatment of cardiac dis-
eases. This type of medication alters the cardiovascular and ther-
moregulatory responses. One important side effect of beta-blockers
is cold extremities (hands and feet) that, in turn, result in cold
discomfort, which could be reinforced by the thermal environment
[65].
Concluding, older adults seem to perceive thermal comfort
differently from the young due to a combination of physical ageing
and behavioural differences. Individual differences are too large to
draw an unequivocal conclusion on the requirements of older
adults regarding their preferred thermal environment. Therefore,
emphasis, with respect to the thermal environment, should be on
the individual level particularly because the indoor climate can
have impacts on the health of occupants.
126 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
2.3. How do older people achieve a thermally comfortable
environment?
Answer: In order to achieve thermal comfort older people
usually adjust their behavioural actions before adjusting their
thermal environment. They may add or reduce their clothing layer
or body cover and have a rest. Opening or closing windows is un-
likely unless they can easily operate them. Resorting to a heater or
cooler is unlikely as well, unless they can afford it.
Since older people are at greater risk of hypothermia and hy-
perthermia, it is often a tendency to advise older people to keep the
indoor temperature tightly controlled with hardly any uctuations,
both during day and season [26]. However, as discussed earlier,
satisfaction with the thermal environment can still occur when the
indoor temperature is allowed to drift. Schellen et al. [43] showed
that a signicant temperature drift up to 2 K/h in the range of
17e25  C will not lead to unacceptable thermal comfort conditions
for older adults.
A recent study in the UK showed that older people were sen-
sitive to variations in their thermal environment [66] but rather
than tightly controlling their thermal environment, they used the
variations to satisfy their thermal experiences. They moved around
the house or took up different sitting positions with a space, used
internal doors to regulate air movement, tted curtains and blinds
and operated them accordingly as well as adjusted the heating
system controls.
A study to investigate heat-adaptive behaviour involving nearly
1000 older adults in Victoria and South Australia at the end of
summer 2011 found that majority of the respondents also took
adaptive behaviours during hot conditions [67]. These included
reducing physical activities, staying inside, wearing cool light
clothing, and drinking more uids. While using an air-conditioner
was one of the strategies, it was not the main and only strategy
undertaken. Using air-conditioning or space heating can also be a
burden for older adults, whose income may be reduced, and can be
problematic during peak periods where power outages may occur.
Even when an air-conditioner is used, it is often not operated
appropriately, because older people often have difculties in un-
derstanding the control panel [68].
In summary, older people can achieve thermally comfortable
environment in two ways: by adjusting themselves or by adjusting
their thermal environment. Regardless of which way they choose,
the bottom line is, older people need to be able to control their
thermal environment accordingly to accommodate their physio-
logical needs, but this control does not need to make them live in a
static thermal environment by using air-conditioners or heaters. To
age well in place, older people should be able to control their own
thermal environment with their preferred strategies.
2.4. How does the thermal environment affect the health and well-
being of older people?
Answer: A comfortable living environment is shown to
contribute positively to older people to age-in-place, while health-
related complications such as heat stroke, hypothermia and
pneumonia among older adults were shown to be triggered by the
thermal environment, too.
Older people are usually more vulnerable to thermal environ-
mental conditions outside the generally accepted range, i.e., during
cold spells and heat waves [22,23]. Mortality due to hypothermia
during periods of cold is reported to be high, with death rates
increasing with age. Morbidity also increases signicantly during
hot periods and many who are hospitalised during these periods
are older adults. Extended periods of excessively cold and hot
weather are likely to occur more frequently and can further
increase the morbidity and mortality rates among older people
[26].
The impact of thermal environment on the ability of older
people to age-in-place becomes even more prevalent to those who
have reduced ability to pay their utility bills (Question 6). Barrios
et al. [69] found that many older people with low incomes in Spain
were unable to age well as they could not afford to retrot their
homes in order to be comfortable.
While for healthy older people a temperature drift will not lead
to unacceptable thermal comfort conditions [43], the effect of the
thermal environment on older adults is more prevalent when they
live in a care home particularly when they have dementia. In a
domestic environment, at least the occupants have the autonomy
and responsibility to control or adjust their thermal environment.
On the other hand, in a care home usually only staff have access to
the thermostat [70]. In a study by Wong et al. [71] in Hong Kong
SAR, the thermal environment in care home centres is generally
well established due to thermostatically controlled air-
conditioners, heaters and dehumidiers. In order to maintain a
comfortable indoor temperature for residents, room heaters are
turned on when the indoor temperature is below 15  C, and air
conditioners turned on when the temperature is above 28  C. The
study found that some behavioural and psychological symptoms of
people with dementia occur when the heaters or air-conditioners
are not on sufciently early enough to maintain a comfortable in-
door thermal environment.
Wong et al. [71] and van Hoof et al. [72] found that in addition to
the thermal environment, the acoustic environment (noise level)
and lighting are also the most important inuencing factors for
people with dementia. They are sensitive to sounds generated by
technology, including air-conditioners, which may trigger fear and
other negative feelings. Poor internal lighting results in hallucina-
tions, while dysphoria and insomnia occur with high indoor tem-
peratures and anorexia with low indoor temperatures [71]. In order
to combat these problems the indoor temperatures are usually
tightly controlled because such approach is regarded as providing
the healthiest condition for older people with dementia.
Environmental conditions that are within the comfort zone can
positively contribute to the health and well-being of people to age-
in-place. At the same time, conditions that fall outside of the
comfort zone are known as causes of a spectrum of health-related
complications, as older people are usually more vulnerable to such
thermal environmental conditions.
2.5. What are the implications of hot summers and cold winters on
health, well-being, and mortality/morbidity?
Answer: Hot summers and cold winters increase the risks of
older people having pneumonia, heat stroke, dehydration, hypo-
thermia and hyperthermia. As older people have a reduced ability
to maintain an adequate thermoregulatory system, hot summer
and cold winters can have a negative impact on their health and
well-being, including resulting in morbidity and mortality.
There are several studies that identify older people's vulnera-
bility to heat-related mortality and morbidity [67,73,74], but the
number of deaths among older people attributable to cold is not
small either. A study conducted in South Australia showed that
hospital admissions due to heart failure, changes in blood pressure,
arthritis, and respiratory diseases such as inuenza, pneumonia
and asthma peaked in winter and decreased in summer [75]. Un-
fortunately, the impact of living in cold conditions is often forgotten
because there is a cultural focus on summer [76] and much
attention is placed on global warming and heatwaves. In fact,
health symptoms that occur in winter can lead to deaths. Inglis et al.
[75] found mortality was highest in winter than in summer and
 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
those aged 75 years or older were the most vulnerable. This result
was consistent with a multi-country observational study of 384
locations in 13 countries [77]. This study found that temperature-
related deaths caused by cold outweighed those caused by heat
by more than 17 times (7.29% versus 0.42%).
In humid subtropical climate regions, such as Hong Kong SAR,
senior citizens as well as frail older people (including people with
dementia) have a high risk of developing skin disorders including
itchy scalps and fungal infections. Dehumidiers are installed in
many care homes to reduce relative humidity and promote a
comfortable indoor environment during spring and summer sea-
sons, but this leads to higher electricity consumption and associ-
ated energy costs, ultimately borne by the residents in the form of
increased accommodation fees [71] (Question 6).
In conclusion, thermal conditions that fall outside of the comfort
zone, particularly hot summers and cold winters can decrease the
sensation of comfort and well-being, and increase the mortality
rates among older people. Part of this is caused by the reduced
ability to maintain an adequate thermoregulatory system.
2.6. What are the nancial implications of age-specic thermal
comfort needs on the (affordability of) utility bills?
Answer: Hot summers and cold winters may force older people
to use cooling or heating more often and this can become a nancial
burden and lead to fuel poverty. This, in turn, can further worsen
their health condition, as less money is available to cope with the
effects or effective treatment of health problems.
With more occurrences of heatwaves and extreme conditions
during summer periods, which often extend to autumns or even
occur early during springs, people, particularly older people may
need to use air-conditioners more often than they used to do.
Similarly, as older people may experience increased blood pressure
and blood coagulation triggered by low temperatures during win-
ters, they may need to operate the heaters more often to keep their
homes warm.
Keeping their homes to meet their thermal and physiological
needs may not be a problem for older people who can afford paying
more electricity or gas use. The case will be different to those with
lower income, or those who live in fuel poverty, a term generally
referred to those who have to pay more than 10% of their incomes
for all energy services [78]. Older people with low incomes tend to
forfeit the need to retrot their homes to be more comfortable if
that would mean spending more money [79] and as a result, their
living condition could become worse, which impact negatively on
their ability to age-in-place and live well.
There is no one direct value that can describe a share of ex-
penses on heating or cooling in relation to average pension of
retired persons, as these gures depend on the purchase power of
individuals in different countries. Depending on climate conditions
or technical standards, it varies all over the world. However, in case
of Poland, the average cost of energy resources per household reach
approximately 20% of the average pension. Additionally, electric
energy costs (which are used not only for cooling but other pur-
poses as well) cover next to 7% of average pension [80,81]. In
Australia, it is estimated that older people pay between 10 and 20%
of their household income for energy (gas and electricity), which is
to be used for cooling, heating and cooking [82,83]. In the
Netherlands, according to Nibud, the National Institute for Family
Finance Information, the average gas use for ats and terraced
housing in the Netherlands ranges from 940 to 1310 m3, which
amounts to V 66 to 88 per month. This gas use encompasses gas
used for cooking, heating one's home and for heating water for
showering and bathing. The minimum nett basic pension in the
Netherlands for single-person households is V 876.24, which
127
means that at least 8% of the income is spent on the gas bill. The
gures do not provide a rst glance on the purchase power of older
people in an all-electric scenario, in which electrical systems are
used for heating and cooling. However, those expenses could be
reduced, for instance, by the implementation of appropriate and
energy-saving systems in the built environment [84,85].
In short, thermal conditions, which fall outside of the comfort
zone, compromise comfort and may pose health-related compli-
cations, leading to a higher demand for cooling or heating. The
increased use of building services technologies compared to
younger age cohorts goes together with higher energy demands,
and accompanying costs of energy. This may, in turn, affect the
purchase power of older people.
2.7. How can the indoor environment contribute positively to
ageing-in-place?
Answer: The indoor environment will contribute positively to
ageing-in-place, by improving well-being, health and comfort. This
can be achieved through a good building design and amenities that
can be easily adjusted or operated by older people.
It is argued is that by having slight variations in the thermal
environment, based on the adaptive thermal comfort approach, the
health of older people can be improved. In van Marken Lichtenbelt
et al. [52], it is suggested that it might be healthier for people to be
exposed to a wider range of temperatures, i.e., excursions outside
the so-called thermoneutral zone. Johnson et al. [86] indicated
furthermore that a causal relation might exist between the time
spent indoors under daily living circumstances in thermoneutral
conditions and increased adiposity. Recent studies conrm these
suggestions and show that excursions to ambient conditions
outside the thermoneutral zone can increase energy expenditure
and improve glucose metabolism, and subsequently may reduce
susceptibility to obesity and type 2 diabetes (which are major
health risks for older adults) [87,88]. This will result in a reduction
of the incidence of heat stroke and pneumonia as well as improved
hydration levels. On the other hand, mild temporal thermal chal-
lenges can also result in negative physiological responses. From
previous studies, we know that cold exposures can result in
increased systolic blood pressure levels in older people [89]. It is,
therefore, advisable to investigate the effects of mild dynamic
thermal conditions on older adults in more detail.
As green infrastructure solutions may have a positive effect on
the thermal conditions inside buildings, their positive inuence on
healthy ageing should also be highlighted. Having a contact with
green elements in a landscape affects health and well-being [90].
Hegetschweiler et al. [91] argued that green infrastructure solu-
tions give more benets to general health, self-reported mood or
well-being than to socio-economic factors.
In short, the thermal indoor environment that is comfortable
has a positive effect to ageing-in-place, though an improved well-
being and health and comfort. At the same time, slight variations
in the thermal environment outside of the thermal neutral zone can
have an additional positive effect on the health of older people.
2.8. How can the building and its HVAC systems be designed to
support older people thermal requirements now and in the future?
Answer: The architecture and the geographical location of a
building inuence the performance of a building in terms of ther-
mal comfort. In the home environment, thermal comfort can be
achieved through a balanced mix of passive, architectural solutions
and active technological solutions.
Passive architectural solutions often form an integral part of
traditional and modern buildings while allowing user interaction
128 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
with outdoor environment, such as shades, blinds, doors, operable
windows, and balconies. Most of these solutions do not use extra
energy and do not put a strain on the environment and the pur-
chase power of people, as these measures are often already in place.
There may be some recommendations concerning their use in case
of people with dementia [29], for instance, in relation to the safety
and security of these people or behavioural effects. There are
numerous passive strategies, which can help reduce the need for
the use of HVAC systems, thus lowering operating costs. These
include careful considerations for the building mass, solar shading,
building materials, and window-to-wall ratio. It is also possible to
apply green infrastructure solutions in a scale of single building.
Recent studies prove that by increasing the shadow effect from
some greenery systems on a building the cooling energy can be
reduced by 59% while no additional heating energy consumption
was noticed [84,85].
As households are the elements of a complex urban structure,
better thermal conditions inside a household can also be achieved
by improving conditions in a whole city. Smart decision-making
during a design process can provide for instance higher ratio of
shaded area, natural ventilation or reduction of heat island effect
[92]. Actions that can be implemented outside of a household, but
still inuence indoor thermal conditions, can be done in a scale of
neighbourhood or a whole city [93]. Fortunately, such solutions
have become increasingly popular in current urban policies. They
can be encountered in the form of green or blue infrastructure
developments [94,95].
In case of social housing, and a generally older housing stock,
measures to improve the energy efciency of housing may have a
relatively larger impact on the purchase power of older tenants.
Housing Europe, the European Federation of Public, Cooperative &
Social Housing, will have to account for similar scenarios. In
October 2014, the European Council agreed on the 2030 climate
and energy policy framework for the EU setting an ambitious
economy-wide domestic target of at least 40% greenhouse gas
emission reduction for 2030 [96]. The Commission's Clean Energy
for All Europeans proposals include the renovation of Europe's
buildings in the light of a clean energy transition. The package also
contains several measures aimed at protecting the most vulnerable
consumers. This provides the foundation stones for achieving en-
ergy efciency in the built environment and opportunities for
improving the purchase power of older people in relation to energy
expenses.
A focus on energy savings, thus cost savings, is criticised by
Vilches et al. [97]. They argue that such approach does not t within
the context of fuel poverty. For those living in fuel poverty, their
utility cost is already low (as they cannot afford to pay the bills), so
retrotting the building will not have much impact on their already
low utility bills (Question 6). Instead, they proposed to focus the
retrot on increasing the percentage of comfortable hours, termed
as Thermal Comfort Percentage, but within the budget that each
older household can afford. This can be in the form of sealing
windows, adding solar blinds, adding external insulation and
replacing existing windows with better performance windows.
Future dwellings can also be designed to respond automatically
to changes in weather conditions while optimising building energy
use simultaneously, for instance, by automatically closing windows
when outdoor temperature drops below the lower limit of thermal
comfort or turning off space heating when windows are opened.
Future housing of older adults are expected to increase user au-
tonomy, and provide optimum thermal comfort for everyone.
Supporting older people to age-in-place may also require
modication of their existing home settings. Smart home tech-
nology may be considered as a potential means of helping older
people to live well at home [98]. Smart home technologies, also
referred to as home automation; include all in-home devices and
infrastructures that use electronic information for measuring,
programming, and control of functions to the benet of the resi-
dents. The market for home energy products is currently large and
growing [99]. There are two main types of products for the ageing
population: home energy monitors and automated energy systems,
which are installed in dwellings for older adults in order to help
save energy. Sadly, Walker et al. [99] also identied a number of
serious usability issues which prevent these products from suc-
cessfully accessing the market place. Wong et al. [100] evaluated
key intelligent attributes of smart-home devices for senior citizens.
It suggests that future HVAC system devices hold intelligent attri-
butes, including autonomy, controllability for complicated dy-
namics, humanemachine interaction, and bio-inspired behaviour,
which can provide comfort, energy efciency and better quality
home environments [101]. Bottlenecks of current home technolo-
gies are inadequate control options for those people with a
decreased muscular, visual and auditory functioning, the limited
compatibility of various systems, and nancial aspects. Still, posi-
tive trends in society come to the fore. In The Netherlands, smart
home thermostats, were being launched on the market place in
2014 [102]. Smart thermostats can be controlled by manually
manipulating the thermostat, or controlled via smartphones, per-
sonal and tablet computers, and are said to offer better comfort and
provide a means for energy conservation. Some of these thermo-
stats offer options for the hourly control of the indoor (air) tem-
perature. Depending on the brand, a thermostat can be used for the
control of the entire home or for individual rooms. These smart
thermostats contain self-learning algorithms based on the presence
of occupants, which allow a room to be controlled according to
their wishes. In combination with radiator-mounted thermostats
and motion detectors, individual rooms can be controlled, based on
time and temperature. Based on the location of a mobile phone
(geo-fencing), some systems can detect if the occupant is close to
home, and the temperature of the home can be changed if needed.
Some more elaborate systems also allow the thermostats to be
combined with the control of electrical appliances and lighting
systems, using plug-in switches in order to monitor energy use.
Smart thermostats can be pre-set to have small control ranges,
which may be a solution for households with people with dementia
as they may have difculties operating thermostats [29].
In short, the architecture, the present building services tech-
nologies and the geographical location inuence the thermal per-
formance of a building. There is an increasing amount of energy-
efcient building services technologies that are being installed in
the homes of older people in order to control the indoor environ-
ment. The installation of actives means of thermal control goes
together with challenges in terms of costs of energy and the po-
tential for smart home technologies that can actively control the
indoor thermal environment to the needs and wishes of the
occupants.
2.9. How can national and regional differences between ageing
people be used to explain research ndings from across the world?
Answer: There are geographical differences in the thermal
perception and potential for controlling the thermal environment.
Climate, building traditions, clothing habits, family patterns, wel-
fare, and numerous other factors differ so much between countries
and continents that there are obvious differences between ageing
people. These differences are also based on the culture of a nation in
terms of options for thermal control, purchase power and attitudes
towards energy consumption.
A study by Hansen et al. [67] shows that older people in Ade-
laide, South Australia (warm arid climate, experienced more hot
 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
days per year) took more actions to keep themselves cool during
the 2009 heatwave compared to older people in Melbourne, Vic-
toria (cooler climate with less hot days). A more recent study of
thermal comfort of a sample of older people in South Australia
indicates that more than 60% warm and hot votes actually
occurred during the acceptable condition according to ASHRAE
Standard 55, between 20 and 27  C [103]. In winter, the minimum
temperature at which a number of respondents voted cold but
still did not want to change was as low as 12  C [27]. The preference
of older people in South Australia to be cooler in summer, or to
accept cool to cold conditions in winter (compared to other pop-
ulation), may relate to the older people's perception of the outdoor
climate; however, further studies are required to conrm this. In
general, Australia is within the temperate to tropical/equatorial
climate classications according to the Ko ppen classication sys-
tem, without any region located in the continental and polar clas-
sications. Anecdotal evidence suggests that most Australians
perceive Australia to be a hot place, thus more attention is directed
towards keeping (older) people cool particularly during hot sum-
mers and heatwaves.2 In reality, and on the contrary, studies found
that there are more hospitalisation and deaths among older people
in Australia during winter than in summer, mostly due to cardio-
vascular and respiratory diseases [75,77]. Not paying attention to
cool to cold weather in winter may lead to older people ignoring
the fact that the thermal condition in their homes in winter may
not be conducive to their health.
The above ndings indicate that in Australia it is crucial to
ensure that the homes of older people are thermally comfortable
during both summer and winter. Strategies to keep the house cool
in summer are no more important than the strategies to keep the
house warm in winter, even though the sensitivity towards cold (or
heat) among older people diminishes. Indeed, precisely because
their thermal sensitivity decreases, it is even more important to
ensure that the thermal condition in their homes is conducive to
their health because they may not take any action or adaptive
behaviour during extreme thermal conditions.
On the opposite side, European countries are located within the
temperate, continental and subpolar climate classications. Keep-
ing (older) people warm is, therefore, more prevalent than keeping
them cool. However, with increasing occurrences of heatwaves,3
including in 2003, which resulted in the deaths of more than
15,000 people in France, mostly older people, it is also critical to
avoid overheating and to keep the house cool in summer. The
projections by the European Environment Agency show extreme
heat events like those in 2003 in Western Europe will occur more
often and highly urbanised areas will be especially vulnerable such
conditions. Without adaptation and physiological acclimatisation
to new conditions, we can expect an increase in mortality related
with heat (between 60,000 and 150,000 deaths per year by the
2080s) and cold (between 60,000 and 250,000 deaths per year by
the 2080s). However, it is highlighted that cold-related mortality
may decrease due to better social, economic and housing condi-
tions in many countries in Europe [104].
Many cities in Asia are characterised by dense concentration of
2
In Australia, a heat wave is dened as ve consecutive days at or above 35  C, or
three consecutive days at or over 40  C.
3
In the Netherlands, a heat wave is dened as a period of at least 5 consecutive
days in which the maximum temperature exceeds 25  C, provided that on at least 3
days in this 5-day period the maximum temperature exceeds 30  C. In Poland, a
heat wave is dened as at least ve consecutive days with daily maximum tem-
perature above the long-term 90th percentile of daily maximum temperature. In
Hong Kong SAR, the Hong Kong Observatory will issue the Very Hot Weather
Warning when the Hong Kong Heat Index, which represents the combined effect of
temperature, humidity, wind speed and solar radiation, reaches around 30  C.
129
buildings, congested public spaces, and urban pollution; all of
which affect people's health, especially those who are socially and/
or physically vulnerable such as the older people. The physical
environment in a congested city like Hong Kong is likely to be
different from that of many other countries because of different
climatic conditions and space for both social interaction and pri-
vacy. The focus in such location is on providing fresh air while
maintaining thermally comfortable indoor environment at the
same time. The other aspect pertinent to cities like Hong Kong SAR
and many other cities in China and Asia, the issue around social
interactions. Strong families continue to be seen as the rst line of
support in Asia. Traditionally, lial norms are of particular impor-
tance in the East Asian region, including Hong Kong SAR, Taiwan e
Republic of China, Japan, the People's Republic of China, South
Korea, etc. Co-residence of older parents and adult children, the
traditional form of intergenerational relations, is still common in
Chinese society and is an excellent vehicle for social, emotional,
practical and nancial support [105]. Chen and Short [106] found
co-residence with immediate family to be associated with
improved well-being, including decreased loneliness and feelings
of social isolation of older adults in Chinese communities. It seems
reasonable to expect that intergenerational ties are highly valued
and that co-residence with adult children (or a maid/caretaker)
have a positive inuence on the psychological well-being of older
people [107e109]. Thus, even though the thermal environment of
their home may not be ideal, and they do get sick, the stronger
social cohesion and inter-generational relationships would possibly
offset the impacts of poor living environment - this is worth further
investigation. Some studies have suggested that social support
from family reduces the risk of chronic conditions, morbidity and
mortality of older people [110]. Older people with adequate social
relationships have a 50% greater likelihood of survival [111]. Having
said that, some studies argued that Chinese communities are now
transitioning from multigenerational co-residence as a standard
living arrangement to a more Westernised family lifestyle, with
heightened values of privacy and independence as well as of in-
dividuality [112].
Two things can be summarised from the above examples. First,
while the specic focus on keeping the homes of older people
thermally comfortable in each geographical region may be
different, the bottom line is, regardless of the location, it is
important to maintain a reasonable comfortable condition of their
homes throughout the year. Second, in order to develop the best
solutions for each circumstance, it is important to understand not
only the biological conditions of older people and the physical
constraints of the surroundings such as the climatic condition and
urban settings, but also the cultural factors including social in-
teractions and habits affecting older people's perceptions and ac-
tions towards their thermal environment.
2.10. What are the future perspectives for thermal comfort studies
related to the ageing population?
Answer: Future studies should focus on studying low-energy
building services in combination with thermal comfort, energy
use, and improvements on health and well-being. Moreover, future
research should expand the current study on smart home tech-
nology, in particular the adaptive thermal comfort approach and
smart thermostats, in enhancing thermal comfort of the older
people and promoting energy savings. An in-depth study should be
conducted that systematically evaluates the ability and compo-
nents of different smart home devices required to full quality of
life and ageing-in-place requirements of senior citizens.
A study of young subjects showed that mild thermal variations
could be benecial from both a health and comfort perspective
130 J. van Hoof et al. / Building and Environment 120 (2017) 123e133
[52]. However, such mild thermal challenges can result in both
positive as well as negative physiological responses. Kingma [87]
found that mild cold exposures could result in increased systolic
blood pressure levels in older adults. Therefore, it is advisable for
future studies to investigate the effects of mild thermal distur-
bances on older people in more detail, before strategies based on
the adaptive thermal comfort model (which may in some building
types and climate zones result in low energy buildings) are being
implemented in order to improve the thermal environment of a
space.
Furthermore, it is advisable to continue developing existing
thermophysiological models for older adults, such as the Fiala
model [113], the ThermoSEM [114e116], and others [117e119], in
order to adequately model and predict the thermoregulatory con-
trol and physiological response of older adults in response to a
designed indoor environment. A next step is to link these responses
to the thermal perception of older adults, as proposed in Schellen
et al. [120].
Although passive architectural solutions are preferred in
achieving thermal comfort, the rooms of frail older people or older
people with dementia may still need to be actively controlled [61]
based on a PMV-algorithm using real-time measured input data.
Foster et al. [121] suggested that impairment of thermoregulatory
functions due to diminished or absent transpiration is one of the
factors responsible for increased mortality among older adults
during hot summers [122]. This is even more critical for bed-ridden
or bed-bound (institutionalised) older adults, whose clothing
insulation is strongly increased by the bed and bedding [123], and,
therefore, need lower ambient temperatures (22.5e25.5  C)
compared to mobile people [124]. Adequate HVAC-systems at
home of the frail are of great importance in periods of extreme
weather conditions including hot summers. The cooling system can
reduce or eliminate the number of discomfort hours, depending on
its size, efciency and the control system [111]. There is, however,
no need for prescriptive standards if individual control is provided
to optimise the indoor environment to meet personal needs [125].
Additionally, individuals should be given direct control for ne
tuning environmental parameters, in time supported by intelligent
technology substituting frequent user intervention. Easily operable
technology, characterising future homes of older adults, are ex-
pected to increase user autonomy, and provide optimum thermal
comfort for everyone.
It is also important to note that uncertainties of the future
weather and climate would have a signicant impact on human
health especially of older people. Future studies should, therefore,
search for solutions that allow for more effective adaptation to
extremes. In order to support the decision making process in
choosing optimal ways of action to adapt to climate change and
weather extremes, it is necessary to investigate not only the qual-
itative but also the quantitative impact in terms of the prot and
loss in the social, environmental and economic aspects at once.
Doing so will convince relevant stakeholders to implement the
proposed solutions in order to reach targets and thresholds set in
policies, i.e., reduction of primary energy consumption in house-
holds [126].
The future perspectives for thermal comfort studies related to
the ageing population are manifold. Some will focus on studying
the effects of low-energy building services in combination with
thermal comfort, automated control, energy use, and improve-
ments on health and well-being. Other studies may further inves-
tigate the effects of mild thermal disturbances on older people
before strategies on health and well-being; as such strategies offer
the potential for improving the health of, and energy use by, older
people.
3. Summary
In this Ten Questions contribution, an overview was given of the
state of the art concerning thermal comfort in relation to ageing.
With the ageing of our populations, the demand for comfortable
and energy-friendly living environments and the wish to live
healthily and independently for as long as possible, make this
crossroads of disciplines a relevant domain for investigation. If the
scientic knowledge concerning ageing and thermal comfort is
applied in practice, this may open up a new range of opportunities
for the construction and building services industry. Understanding
the fundamentals of thermoregulation and physical ageing may
lead to new designs for HVAC services, passive solutions and smart
home technologies.
The following issues were discussed in this Ten Questions
contribution:
 Older people have different comfort needs compared to their
younger counterparts, although differences are not so large to
require different approaches to the design. The personal means
of adaptation or options of personal control among older people
may be limited in comparison with young adults, for instance,
when symptoms of dementia syndrome are present. In such
situations, building services technologies and smart controls
may be used as an auxiliary system to provide comfort.
 Conditions for thermal comfort of older people may not be met
if buildings and building services are not adequately designed,
i.e., provide comfort in a certain climate, or provide inadequate
means for control. Moreover, nancial limitations in terms of
reduced purchase power among some older people may lead to
suboptimal living conditions and may pose a risk in terms of
increased changes on morbidity and mortality, both in cold and
warm conditions. Cultural and regional differences in expecta-
tions may have an impact on the thermal needs of older people.
 An increased understanding of thermal comfort of the ageing
population offers directions for innovations in the building and
building services sectors. Equipping the homes of older people
with smart technologies as well as training older people to use
the technology may lead to a reduced need for energy to heat or
cool a space and saving operating costs.
4. Expertise of the authors
Joost van Hoof has a background in building physics and ser-
vices, and holds a PhD in the design of housing facilities for older
people with dementia. Lisje Schellen has a background in building
physics and services, and holds a PhD in thermal comfort differ-
ences between age groups and genders under different thermal
environments. Veronica Soebarto is an associate professor with the
School of Architecture and has published extensively on thermal
comfort and sustainable architecture and energy. Johnny Wong has
a background in construction management and quantity surveying,
and holds a PhD in smart building components selection and
evaluation. Jan Kazak has a background in sustainable solutions for
spatial management and adaptation to climate change, and holds a
PhD in environmental studies.
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