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

Objectiveto examine whether spousal bereavement increases the risk of death and negative health outcomes and among older people. Designcohort study and self-controlled cohort crossover study Settingroutinely collected administrative and healthcare data with individual-level linkage between several national registries in Sweden. Participantsolder persons ([≥]65 years) living in the community whose spouse died in 2013-2014, individually matched with controls. Main outcome measuresdeath 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. Results42 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. ConclusionAmong 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. O_TEXTBOXWhat is already known O_LIBereavement is associated with an excess risk of mortality in the surviving spouses. C_LIO_LIThere is some evidence that spousal loss is also associated with acute cardiovascular events. C_LIO_LIPrevious studies have often focused on young and relatively healthy groups of people, although bereavement of a spouse typically occurs as we reach older ages. C_LI What this study adds O_LISpousal 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. C_LIO_LIThe excess risk of negative health events observed already during the months before spousal loss indicates the influence of an anticipatory effect. C_LIO_LIAlthough 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. C_LI Implications for clinical practice and health policy O_LIBereavement support should be offered without delay to mitigate short-term hazards and then maintained over a sufficiently long period of time. C_LIO_LISuch 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. C_LIO_LIPalliative care services could have an important role in providing bereavement support to older adults. C_LI C_TEXTBOX