Spousal bereavement, mortality and risk of negative health outcomes among older adults: a population-based study

Abstract

Abstract Objective to examine whether spousal bereavement increases the risk of death and negative health outcomes and among older people. Design cohort study and self-controlled cohort crossover study Setting routinely collected administrative and healthcare data with individual-level linkage between several national registries in Sweden. Participants older persons (≥65 years) living in the community whose spouse died in 2013–2014, individually matched with controls. Main outcome measures death from any cause (primary outcome), acute cardiovascular events, pneumonia, hip fracture, and intentional self-harm (secondary outcomes). In the cohort study, incidence rate ratios were estimated with conditional fixed-effect Poisson regression models adjusted for potential confounders. In the self-controlled cohort crossover study, relative incidence ratios were estimated over the 12 months before and after spousal loss with unadjusted conditional fixed-effect Poisson regression including a bereavement-by-time interaction. Results 42 918 bereaved older spouses were included and matched to an equal number of married controls (mean age 78.9 [SD 7.2] years, 68% women). During the first year of follow-up, the risk of death from any cause was 1.66 (95% confidence interval 1.53 to 1.80) times higher for bereaved cases than for married controls, and bereaved cases survived on average 4.2 days shorter than married controls. Bereaved cases also experienced an increased risk of acute cardiovascular events (incidence rate ratio 1.34, 1.24 to 1.44), hip fracture (1.48, 1.30 to 1.68), pneumonia (1.14, 1.04 to 1.25), and self-harm (3.49, 2.11 to 5.76). These associations were strongly time-dependent, increasing sharply immediately after spousal loss and weakening as time elapsed. In the self-controlled cohort crossover study, the relative incidence ratios increased for all four secondary outcomes, starting already during the 6-month period preceding spousal loss. Conclusion Among older persons, the association between spousal bereavement and the risk of negative health outcomes and mortality is most likely causal. Our finding that the risk of adverse health consequences increases already during the 6 months prior to spousal loss indicates that palliative care services have an important role to play in providing timely bereavement care to spouses and other family caregivers. What is already known Bereavement is associated with an excess risk of mortality in the surviving spouses. There is some evidence that spousal loss is also associated with acute cardiovascular events. Previous studies have often focused on young and relatively healthy groups of people, although bereavement of a spouse typically occurs as we reach older ages. What this study adds Spousal bereavement comes with a rapid and substantial increase in mortality, acute cardiovascular events, hip fracture, pneumonia, self-harm, non-elective hospitalisation and nursing home admission. The excess risk of negative health events observed already during the months before spousal loss indicates the influence of an ‘anticipatory effect’. Although sudden spousal deaths expose surviving partners to especially high excess mortality, longer and more predictable illness trajectories do not shield spouses from the adverse health consequences of bereavement. Implications for clinical practice and health policy Bereavement support should be offered without delay to mitigate short-term hazards and then maintained over a sufficiently long period of time. Such support should be provided not only to recently bereaved individuals, but also to the spouses of seriously ill older people with poor 6-month prognosis. Palliative care services could have an important role in providing bereavement support to older adults.