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

Lucas Morin; Jonas W Wastesson; Stefan Fors; Neda Agahi; Kristina Johnell

One such hypothesis is that the effect of bereavement is mediated by enhanced inflammatory responses to psychophysiological stress and depressive symptoms. 62-64 This exacerbated inflammation may be triggered not only by loss and grief after spousal loss, but also by 'anticipatory grief', namely that soonto-be widows and widowers face substantial emotional and psychological distress before the death of their loved one actually occurs. 65 A second hypothesis is that the "widowhood effect" stems partly from a shared health disadvantage among spouses, which could be explained both by assortative mating and by unfavourable living conditions throughout adulthood such as insufficient material resources, poor housing quality, and high-risk diet. Hence, social scientists have suggested that the excess risk of negative health events around the time of bereavement is driven either by selection mechanisms (those who become widows and widowers tend to have a lower socioeconomic position) or by the substantial reduction in material resources already before spousal loss. Although our data shows that bereaved cases have, on average, a lower level of education and income and tend to live in more socially deprived areas compared with married controls, we found no evidence of a socioeconomic gradient in the association between bereavement and mortality. We acknowledge that this may very well be specific to the study population at hand, namely older people whose main source of income was retirement pensions rather than work-related earnings, in a country where the financial toll of widowhood is automatically compensated by a specific pension scheme. Finally, a third hypothesis is that the observed health disadvantage among bereaved relatives is partly due to the caregiving burden, which is well documented among spouses of older people with advanced illness (e.g. cancer, heart failure, dementia). 66,67 Caregiving burden is hypothesised to have a direct impact on mental health and cognition, and to affect physical health through poorer self-management of pre-existing diseases, including lower adherence to essential medicines, and postponing of routine clinical appointments. 68 In a large cohort of 12 722 older people with chronic cardiovascular conditions in the United Kingdom, Shah and colleagues showed that during the year prior to spousal loss there was a lower uptake of basic care processes (e.g. blood pressure and HbA1c measurements) among soon-to-be widows and widowers than among their continuously married counterparts. 69 Similarly, they found that adherence to statins, platelet antiaggregants and renin-angiotensin drugs started declining already during the months preceding spousal death. In the present study, we hypothesise that a large part of the observed increase in the risk of fall-related injuries already during the 6 months before spousal loss can be attributed to the use of sedatives, anxiolytics and hypnotics that are often prescribed to help relatives cope with the psychological stress of caring for someone at the end of life. 70, 71 This suggests that palliative care services could have an important role in detecting high-risk caregivers, providing bereavement counselling already before spousal loss, and signposting to relevant health services (including GPs and other primary care professionals) to ensure adequate management of existing conditions.