Protection From Increased Risk of Death After Bereavement
Protection From Increased Risk of Death After Bereavement
An increased risk of death in persons who have suffered spousal bereavement has been described in many populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. The authors followed 171,120 couples 60 years of age or older in a United Kingdom primary care database between 2005 and 2010 for an average of 4 years. A total of 26,646 (15.5%) couples experienced bereavement, with mean follow up after bereavement of 2 years. In a model adjusted for age, sex, comorbid conditions at baseline, material deprivation based on area of residence, season, and smoking status, the hazard ratio for mortality in the first year after bereavement was 1.25 (95% confidence interval: 1.18, 1.33). Further adjustment for changes in comorbid conditions throughout follow up did not alter the hazard ratio for bereavement (hazard ratio = 1.27, 95% confidence interval: 1.19, 1.35). The association was strongest in individuals with no significant chronic comorbid conditions throughout follow up (hazard ratio = 1.50, 95% confidence interval: 1.28, 1.77) and in more affluent couples (P = 0.035). In the first year after bereavement, the association between bereavement and death is not primarily mediated through worsening or new onset of chronic disease. Good health and material circumstances do not protect individuals from increased mortality rates after bereavement.
Death of a spouse or partner is a common major life event for older people. The adverse impact of bereavement on health has been long recognized, with an increased risk of death described in several populations. The increase in mortality has been most consistently described in the first year after bereavement, and a recent meta-analysis estimated a 41% increase in mortality in the first 6 months after bereavement in all age groups. The consistency of findings and robustness to adjustment suggest that the impact of bereavement is causal, but mechanisms and modifying factors are not well understood. In particular, it is not known whether good physical health and high socioeconomic status protect individuals from the adverse effects of bereavement, and neither is the relative contribution of acute events or worsening of chronic disease to excess mortality after bereavement known.
Most large studies on bereavement have relied on census databases or follow up of community surveys. The recording of chronic disease in such sources is often limited or self-reported, and few studies have used validated morbidity measures, such as the Charlson Index (3–5). Larger studies with well-recorded comorbid conditions have limited their analyses to baseline comorbid conditions and have not considered whether those conditions mediate or modify the impact of bereavement on mortality. Two studies have explicitly examined the modifying influence of pre-existing health on the increased risk of death after bereavement. They suggest, paradoxically, that good health before bereavement increases the adverse impact of bereavement rather than providing protection, but these findings are limited by sample size or limited information on comorbid conditions. Analysis of causes of death in bereaved individuals provides some insights into whether worsening of pre-existing chronic disease or acute events contribute to excess mortality, but the evidence is unclear, with both sudden unexpected deaths and chronic conditions contributing to excess mortality.
In the present study, we used a large United Kingdom primary care database with detailed recording of comorbid conditions to examine the modifying and mediating impact of physical comorbid conditions and material socioeconomic circumstances on mortality in the first year after bereavement. Unlike existing studies on bereavement, we were uniquely able to take account of changes in comorbid conditions before and after bereavement.
Specifically, we tested whether adjustment for physician-recorded chronic comorbid conditions before and after bereavement attenuated the association between bereavement and mortality; such attenuation would suggest that increased mortality is mediated through worsening or new onset of chronic conditions rather than unexpected acute events. Furthermore, we tested whether individuals with good health and higher socioeconomic status were protected from increased risk of death after bereavement.
Abstract and Introduction
Abstract
An increased risk of death in persons who have suffered spousal bereavement has been described in many populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. The authors followed 171,120 couples 60 years of age or older in a United Kingdom primary care database between 2005 and 2010 for an average of 4 years. A total of 26,646 (15.5%) couples experienced bereavement, with mean follow up after bereavement of 2 years. In a model adjusted for age, sex, comorbid conditions at baseline, material deprivation based on area of residence, season, and smoking status, the hazard ratio for mortality in the first year after bereavement was 1.25 (95% confidence interval: 1.18, 1.33). Further adjustment for changes in comorbid conditions throughout follow up did not alter the hazard ratio for bereavement (hazard ratio = 1.27, 95% confidence interval: 1.19, 1.35). The association was strongest in individuals with no significant chronic comorbid conditions throughout follow up (hazard ratio = 1.50, 95% confidence interval: 1.28, 1.77) and in more affluent couples (P = 0.035). In the first year after bereavement, the association between bereavement and death is not primarily mediated through worsening or new onset of chronic disease. Good health and material circumstances do not protect individuals from increased mortality rates after bereavement.
Introduction
Death of a spouse or partner is a common major life event for older people. The adverse impact of bereavement on health has been long recognized, with an increased risk of death described in several populations. The increase in mortality has been most consistently described in the first year after bereavement, and a recent meta-analysis estimated a 41% increase in mortality in the first 6 months after bereavement in all age groups. The consistency of findings and robustness to adjustment suggest that the impact of bereavement is causal, but mechanisms and modifying factors are not well understood. In particular, it is not known whether good physical health and high socioeconomic status protect individuals from the adverse effects of bereavement, and neither is the relative contribution of acute events or worsening of chronic disease to excess mortality after bereavement known.
Most large studies on bereavement have relied on census databases or follow up of community surveys. The recording of chronic disease in such sources is often limited or self-reported, and few studies have used validated morbidity measures, such as the Charlson Index (3–5). Larger studies with well-recorded comorbid conditions have limited their analyses to baseline comorbid conditions and have not considered whether those conditions mediate or modify the impact of bereavement on mortality. Two studies have explicitly examined the modifying influence of pre-existing health on the increased risk of death after bereavement. They suggest, paradoxically, that good health before bereavement increases the adverse impact of bereavement rather than providing protection, but these findings are limited by sample size or limited information on comorbid conditions. Analysis of causes of death in bereaved individuals provides some insights into whether worsening of pre-existing chronic disease or acute events contribute to excess mortality, but the evidence is unclear, with both sudden unexpected deaths and chronic conditions contributing to excess mortality.
In the present study, we used a large United Kingdom primary care database with detailed recording of comorbid conditions to examine the modifying and mediating impact of physical comorbid conditions and material socioeconomic circumstances on mortality in the first year after bereavement. Unlike existing studies on bereavement, we were uniquely able to take account of changes in comorbid conditions before and after bereavement.
Specifically, we tested whether adjustment for physician-recorded chronic comorbid conditions before and after bereavement attenuated the association between bereavement and mortality; such attenuation would suggest that increased mortality is mediated through worsening or new onset of chronic conditions rather than unexpected acute events. Furthermore, we tested whether individuals with good health and higher socioeconomic status were protected from increased risk of death after bereavement.
