Widowhood and mortality: a Danish nationwide register-based cohort study

Widowhood status, morbidity, and mortality in India: evidence from a follow-up survey

A known health effect of widowhood is an increased mortality risk among surviving spouses, with gender- and age-specific observations. While morbidity conditions with socio-economic factors may exacerbate the effect of widowhood on mortality, no research has attempted to predict mortality among the widowed over the married population with the presence of morbidity in India. Thus, the present study concurrently examines marital status and health in the Indian setting, bringing substantial empirical evidence to explore the link between marital status, morbidity, and mortality. The study used prospective data from India Human Development Survey (IHDS) wave 1 (2004-2005) and wave 2 (2011-2012). In total, 82,607 individuals aged 25 years and above were considered for the analysis. To present the preliminary findings, descriptive statistics and bivariate analysis were used. Using multivariable logistic regression, the interaction effect of marital status and morbidity status was estimated to predict the likelihood of mortality. Across all socio-economic groups, widowed individuals reporting any morbidity had a higher mortality proportion than married people. Young widowers with any morbidity are more susceptible to increased mortality. Asthma among young widowers and cardiovascular diseases among elderly widowers significantly elevate the probability of mortality. However, older widowed women with diabetes had a lower probability of mortality than older married women with diabetes. The widowers' disadvantage in mortality and morbidity may be attributable to less care-receiving and the greater incidence of unhealthy lifestyle practices during the post-widowhood period, indicating the need for more research.

Widowhood and mortality risk in Taiwan: a population-based matched cohort study

BACKGROUND

Studying the causes of death among deceased spouses and surviving partners may provide insights into the underlying mechanisms of the association between widowhood and mortality. This study investigated the mortality risk of widowhood in Taiwan, examined the association of the cause of death between widowed individuals and their deceased spouses and explored potential modifying effects by age, gender and duration after widowhood.

METHODS

This matched cohort study utilized Taiwan's National Health Insurance claims database and National Death Registry. In total, 204 010 widowed men and 596 136 widowed women were identified with a mean follow-up period of 6.9 and 7.9 years, respectively, and 816 040 comparison men and 2 384 544 comparison women were selected.

RESULTS

Widowhood was associated with an increased mortality risk, with widowed men having a 1.32 increased risk and widowed women having a 1.27 increased risk. Age at spousal death and duration modified the associations after widowhood. The widowed individuals are more likely to die by the same cause as the deceased spouse if they died by suicide, accident, endocrine, gastrointestinal disorders or infection.

CONCLUSIONS

The study suggests that healthcare policies and interventions should be developed to improve widowed individuals' health and overall welfare.

Impact of lifestyle and psychological resilience on survival among the oldest-old in China: a cohort study

Introduction

Healthy lifestyles and psychological resilience are important factors influencing the life expectancy of the oldest-old (≥80 years). Stratified by urban and rural groups, this study used a 10-year cohort to examine the mechanism of lifestyle and psychological resilience on the survival of the oldest-old in China.

Methods

This study used the China Longitudinal Healthy Longevity Survey datasets spanning from 2008 to 2018, and 9,250 eligible participants were included. The primary outcome variable was all-cause mortality, and independent variables included healthy lifestyle index and psychological resilience. Six covariates were included in the survival analysis and moderation-mediation model, such as gender and annual household income.

Results

This study found that the oldest-old with five healthy lifestyles had the longest survival time, averaging 59.40 months for urban individuals and 50.08 months for rural individuals. As the lifestyle index increased, the survival rate significantly increased. The Cox regression showed that for the urban oldest-old, the lifestyle index served as a protective factor for survival outcomes. However, this effect lost statistical significance among rural oldest-old individuals. For urban oldest-old individuals, psychological resilience significantly mediated and moderated the effect of the lifestyle index on survival status, but the moderating effect was not statistically significant for the rural ones.

Discussion

Overall, healthy lifestyles and psychological resilience can be effective in enhancing the survival of the oldest-old, and there are differences between urban and rural population, so different interventions should be adopted for urban and rural areas to achieve longer life in China.

Pair bonding and disruption impact lung transcriptome in monogamous Peromyscus californicus

Social interactions affect physiological and pathological processes, yet their direct impact in peripheral tissues remains elusive. Recently we showed that disruption of pair bonds in monogamous Peromyscus californicus promotes lung tumorigenesis, pointing to a direct effect of bonding status in the periphery (Naderi et al., 2021). Here we show that lung transcriptomes of tumor-free Peromyscus are altered in a manner that depends on pair bonding and superseding the impact of genetic relevance between siblings. Pathways affected involve response to hypoxia and heart development. These effects are consistent with the profile of the serum proteome of bonded and bond-disrupted Peromyscus and were extended to lung cancer cells cultured in vitro, with sera from animals that differ in bonding experiences. In this setting, the species' origin of serum (deer mouse vs FBS) is the most potent discriminator of RNA expression profiles, followed by bonding status. By analyzing the transcriptomes of lung cancer cells exposed to deer mouse sera, an expression signature was developed that discriminates cells according to the history of social interactions and possesses prognostic significance when applied to primary human lung cancers. The results suggest that present and past social experiences modulate the expression profile of peripheral tissues such as the lungs, in a manner that impacts physiological processes and may affect disease outcomes. Furthermore, they show that besides the direct effects of the hormones that regulate bonding behavior, physiological changes influencing oxygen metabolism may contribute to the adverse effects of bond disruption.

The association between adverse events in later life and mortality in older individuals

Background

Stress can have adverse impacts on health, particularly when it is chronic or resulting from major adverse events. Our study investigated whether relatively common adverse events in older individuals were associated with an increased risk of death, as well as cause-specific death and potential gender differences.

Methods

Participants were 12896 community-dwelling Australians aged ≥70 years at enrolment into the ASPREE (ASPirin in Reducing Events in the Elderly) study and without known life-limiting disease. A questionnaire administered in the year after enrolment, collected information on ten adverse events experienced in the past year. Mortality status was verified by multiple sources including health records and the National Death Index across a maximum of 10 years. Underlying causes of death were determined using clinical information by two adjudicators. Cox-proportional hazards regression models were used to estimate mortality risk.

Results

Two of the ten adverse events were associated with an increased risk of mortality in fully adjusted models. A 69% increased risk of mortality was observed in participants who reported their spouse/partner had recently died (95% CI: 1.19-2.39, P < 0.01). Cancer-related but not cardiovascular deaths also increased. Participants with a seriously ill spouse/partner also had a 23% increased risk of mortality (HR: 1.23, 95% CI: 1.02-1.48, P = 0.03). There was a tendency for these associations to be stronger among men than women.

Limitations

Perceived stress and cortisol were not measured, thus limiting our understanding of the psychological and physiological impacts of adverse events.

Conclusions

Experiencing adverse events in later-life, especially the death of a spouse/partner, may be a risk factor for earlier mortality. These findings may increase public health awareness and better inform initiatives for particular groups, including bereaved men.

Causes of death in individuals exposed to spousal, parental, and child suicide: a nationwide population-based cohort comparison study

Exposure to suicide is associated with higher mortality, and the health impact varies depending on the types of kinship. However, the moderating role of kinship remains unclear. Therefore, this study aimed to compare causes of death between individuals exposed to spousal, parental, and child suicide to those exposed to natural or unnatural death. In this study, 1,929,872 individuals were enrolled, of whom 1,726,846 individuals were exposed to natural death, 141,206 individuals were exposed to unnatural death, and 61,820 individuals were exposed to suicide. To compare causes of death between kinship, stratified analysis and moderation analysis were conducted by using the Cox proportional hazard model and the cause-specific hazard model. Although higher mortality from specific causes, such as suicide, homicide, and vascular and unspecified dementia, was observed in individuals exposed to suicide compared to those exposed to natural and unnatural death (adjusted hazard ratio: 1.69 to 23.26), we did not observe higher all-cause mortality when compared to those exposed to unnatural death. Some causes of death were moderated by kinship. When compared to unnatural death, parental or spousal suicide was associated with higher mortality from suicide and homicide than child suicide (adjusted hazard ratio: 1.70 to 15.67), and parental suicide was associated with higher mortality from accidents than spousal suicide (adjusted hazard ratio: 1.81). These findings provide an integral understanding of the role of kinship in the impacts of suicide exposure on causes of death.

Contribution of CKD to mortality in middle-aged and elderly people with diabetes: the China Health and Retirement Longitudinal Study : CKD was a chronic stressor for diabetics

BACKGROUND

The contribution of chronic kidney disease (CKD) to mortality in diabetic patients is unclear. This study aimed to explore the association between diabetics with CKD and mortality in middle-aged and elderly people of different ages.

METHODS

Data were obtained from the China Health and Retirement Longitudinal Study, including 1,715 diabetic individuals, 13.1% of whom also had CKD. Diabetes and CKD were assessed by combining the physical measurements and self-reports. We fitted Cox proportional hazards regression models to examine the effect of diabetics with CKD on mortality in middle-aged and elderly people. The risk factors for death were further predicted based on age stratification.

RESULTS

The mortality rate of diabetic patients with CKD (29.3%) was increased as compared to that of diabetic patients without CKD (12.4%). Diabetics with CKD were at a higher risk of all-cause mortality than those without CKD, with a hazard ratio of 1.921 (95% CI: 1.438, 2.566). Additionally, for participants 45 to 67 years of age, the hazard ratio was 2.530 (95% CI: 1.624, 3.943).

CONCLUSIONS

Our findings suggested that, for diabetics, CKD was a chronic stressor that led to death in middle-aged and elderly people, especially among participants aged 45 to 67 years.

Marital status and all-cause mortality rate in older adults: a population-based prospective cohort study

BACKGROUND

Living with a partner and separation is becoming more common among older people. Mortality disparities associated with marital status are significant in increasingly diverse aging populations. The link between marital status and all-cause mortality risk in older adults remains uncertain.

METHODS

This prospective cohort study included data from the US National Health and Nutrition Examination Survey (NHANES). We included NHANES participants ≥ 60 years of age (data from 1999 to 2014). Data for mortality follow-up beginning from the commencement date of survey participation to the last day of December 2015. Univariate- and multivariate-adjusted Cox proportional hazard models for marital status were estimated, and the findings were presented as regression coefficients and 95% confidence intervals (CI). Kaplan-Meier curves were reported.

RESULTS

Compared to never married individuals, the risk of all-cause mortality was 0.77 (0.50-1.18), 0.72 (0.56-0.93), 0.56 (0.36-0.88), and 0.84 (0.67-1.07) in those people living with a partner, married, separated, and divorced, respectively, after adjusting for demographics, socioeconomics, behavior, anthropometric variables, and medical history. The risk of all-cause mortality was 1.24 (0.97-1.59) in widowed participants.

CONCLUSION

This population-based cohort study included a large sample size followed by long-term follow-up. The association between marriage, health, and reduced mortality in older individuals has been illustrated in this study. Being married or separated was associated with a lower risk of mortality.

Effects of functional limitations and activities of daily living on the mortality of the older people: A cohort study in China

Introduction

Prevalence of functional limitations (FLs) and disabled activities of daily living (ADL) cause heavy burdens to the health of the older people. Stratified by gender, this study aimed to explore the effects of FL and ADL on the mortality of the older people in China, and the mechanism was then discussed.

Methods

We used survey data of a prospective 10-year cohort (2008-2018), from the China Longitudinal Healthy Longevity Survey (CLHLS). The primary outcome was all-cause mortality, and Independent variables included FL, basic ADL (BADL), and instrumental ADL (IADL). Covariates involved socio-demographic characteristics, health-related behaviors, and health status of the participants in the CLHLS project.

Results

There were 967 (19.20%) male and 2,235 (32.36%) female older people performed functional limitations, and their survival time was 60.98 (SE = 0.66) and 55.19 (SE = 0.55) months, respectively. Old adults with FL had significantly poorer survival than the ones without (Log-rank test, P < 0.001). Weibull regression suggested that FL (P < 0.001), abnormal BADL (P < 0.001) and IADL (P < 0.001) were negatively associated with the survival of the older people. Further analysis showed that BADL and IADL performed significantly mediating roles in the relation of FL and survival time in old adults; additionally, for female older people, BADL also exhibited a significant moderating role in the effect of FL on survival.

Conclusions

Prevalence of FL was serious among the older people in China, especially for the women. Disabilities of BADL and IADL and FL were negatively associated with the survival time of the older people in China. Regarding the effect of FL on survival, BADL and IADL performed significantly mediating roles, and the moderating role of BADL existed only for the female. These suggested evidence to implement strategies to maintain health in the older people.

Sex differences in health care expenditures and mortality after spousal bereavement: A register-based Danish cohort study

BACKGROUND

Spousal bereavement is a life event that affects older people differently. We investigated the impact of spousal bereavement on medical expenditures and mortality in the general population, emphasizing on age and sex.

METHODS

Data are from a population-based, retrospective cohort study following 924,958 Danish citizens over the age of 65 years, within 2011-2016. Changes in health care expenditures in those who suffer bereavement were compared with time matched changes among those who did not. Mortality hazards were analysed with time to event analysis.

RESULTS

A total of 77,722 (~8.4%) individuals experienced bereavement, 65.8% being females. Among males, bereavement was associated with increase of expenditures the year after, that was 42 Euros per week (95% CI, 36 to 48) larger than the non-bereaved group. The corresponding increase for females was 35 Euros per week (95% CI, 30 to 40). The increase of mortality hazards was highest in the first year after bereavement, higher in males than females, in young old and almost absent in the oldest old. Compared with the reference, mortality the year after spousal loss was 70% higher (HR 1.70 [95% CI 1.40 to 2.08]) for males aged 65-69 years and remained elevated for a period of six years. Mortality for females aged 65-69 years was 27% higher in the first year (HR 1.27, [1.07 to 1.52]), normalizing thereafter.

CONCLUSION

Bereavement affects older people differently with younger males being most frail with limited recovery potential.

The Widowhood Effect on Mortality in Older Patients with Hip Fracture

Objective

Widowed people have increased mortality than married people of the same age, a phenomenon known as the widowhood effect. This study aimed to investigate whether this effect exists in older patients with hip fracture.

Methods

Using our own hip fracture database, a total of 1101 hip fracture patients were consecutively included from January 2014 to December 2021. Marital status was stratified as married (n = 793) and widowed (n = 308). Patients survival status was obtained from medical records or telephone follow-ups, and the outcomes were all-cause mortality at 30 days, 1 year and at latest follow-up. Univariate and multivariate Cox proportional hazard models were used to assess the association between marital status and mortality, and subgroup analyses according to sex were also conducted.

Results

Compared with married patients, widowed patients were more likely to be older, female and intertrochanteric fracture, and were less likely to be urban area, smoking, drinking, and surgical treatment (P < 0.05). After a median follow-up of 37.1 months, the 30-day mortality was 4.3% (n = 47), 1-year mortality was 19.3% (n = 178), and total mortality was 34.2% (n = 376). Multivariate Cox analysis showed that widowed marital status remained an independent risk factor for 1-year mortality (HR = 1.437, 95% CI: 1.054–1.959, P = 0.022), and total mortality (HR = 1.296, 95% CI: 1.038–1.618, P = 0.022), whereas this association was not found in 30-day mortality (HR = 1.200, 95% CI: 0.607–2.376, P = 0.599). Moreover, subgroup analyses also found that the widowhood effect on mortality was present in both male and female.

Conclusion

Widowed marital status seems to be an independent risk factor for long-term mortality in older patients with hip fracture.

Can the internet mitigate the negative effect of widowhood on Quality of Life? A gender analysis

Widowhood often reduces the Quality of Life of individuals of advanced ages by negatively affecting their social network ties. Yet conversely, the Internet has also created new opportunities for communication and interaction, thus contributing to improved Quality of Life. This research analyses the role of the Internet in the relationship between widowhood and Quality of Life from a gender perspective.

This study focuses on 31,814 individuals aged 65 or over residing in 17 European countries who participated in Wave 6 of SHARE – the Survey of Health, Ageing and Retirement in Europe.

The linear regression analyses highlighted that the role of the Internet in the relationship between widowhood and Quality of Life varies according to gender. More specifically, in Europe, the Quality of Life for widowed women aged 65+ using the Internet is .414 higher (CI=.006 to .0822) than widows who do not use the Internet and married women or women in a de facto relationship whether or not they use the Internet. The results have relevant implications for the development of social policies and suggest a need to develop digital inclusion projects targeting older people, particularly widows, to help promote their Quality of Life.

Dynamical indicators in time series of healthcare expenditures predict mortality risk of older adults following spousal bereavement

BACKGROUND

The process of aging renders older people susceptible for adverse outcomes upon stress. Various indicators derived from complex systems theory have been proposed for quantifying resilience in living organisms, including humans. We investigated the ability of system-based indicators in capturing the dynamics of resilience in humans who suffer the adversity of spousal bereavement and tested their predictive power in mortality as a finite health transition.

METHODS

Using longitudinal register data on weekly healthcare consumption of all Danish citizens over the age of 65 from January 1st, 2011, throughout December 31st, 2016, we performed statistical comparisons of the indicators 'average', 'slope', 'mean squared error', and 'lag-1 autocorrelation' one year before and after spousal bereavement, stratified for age and sex. The relation between levels of these indicators before bereavement and mortality hazards thereafter was determined by time to event analysis. We assessed the added value for mortality prediction via the time dependent area (AUC) under the receiver operating characteristic curve.

RESULTS

The study included 934,003 citizens of whom 51,890 experienced spousal bereavement and 2862 died in the first year thereafter. Healthcare consumption is increased, more volatile and accelerating with aging and in men compared to women (all p-values < 0.001). All dynamic indicators before bereavement were positively related with mortality hazards thereafter (all p-values < 0.001). The average discriminative performance for the 1-year mortality risk of the model with only age as a predictor (AUC: 68.9% and 70.2%) was significantly increased with the addition of dynamical indicators (78.5% and 82.4%) for males and females, respectively.

CONCLUSIONS

Dynamic indicators in time series of health care expenditures are strong predictors of mortality risk and could be part of predictive models for prognosis after life stressors, such as bereavement.

Predictors of Family Caregivers' Depressive- and Prolonged-Grief-Disorder-Symptom Trajectories

OBJECTIVE

Depression and prolonged grief disorder (PGD) are related but distinct constructs with different risk factors and treatments. We aimed to determine commonality and differences in factors predicting membership in depressive- and PGD-symptom trajectories to highlight uniqueness of each construct to guide further care and treatments.

METHODS

We previously identified four shared trajectories for depressive- and PGD-symptom trajectories (endurance, transient-reaction, resilience, and prolonged-symptomatic) with unique trajectories of chronically distressed and potential recurrence for depressive and PGD symptoms, respectively. This secondary-analysis study examined pre- and postloss factors predisposing 849 bereaved caregivers of cancer patients to membership in depressive- and PGD-symptom trajectories from the integrative framework of predictors for bereavement outcomes by a multinomial logistic regression model (the "endurance" trajectory as reference).

RESULTS

Common factors predicted membership in depressive- and PGD-symptom trajectories: higher postloss personal coping capacity protected from more distressing symptom trajectories, spousal relationship with the patient predicted membership in the transient-reaction trajectory, while financial hardship and preloss depressive symptoms predicted for the resilience trajectory. Yet, accurate prognostic awareness protected caregivers from more distressing depressive-symptom trajectories only. Higher preloss subjective caregiving burden protected caregivers from the four more distressing depressive-symptom trajectories but only from the transient-reaction and resilience trajectories for PGD symptoms.

CONCLUSION

Commonality and differences in factors predicting membership in PGD- and depressive-symptom trajectories confirm that PGD and depression are related but distinct constructs. Interventions should be tailored to caregivers' unique risk profile for depressive- and PGD-symptom trajectories to reduce the likelihood of suffering both or individual symptom trajectories.

Modifiable predictive factors and all-cause mortality in the non-hospitalized elderly population: An umbrella review of meta-analyses

OBJECTIVE

This umbrella review aimed to summarize the association between modifiable predictive factors and all-cause mortality in the non-hospitalized elderly population, and estimated the credibility and strength of the current evidence.

METHODS

PubMed, Embase, Web of science, and EBSCOhost were searched up to February 28, 2022. Random-effect summary effect sizes and 95% confidence intervals (CIs), heterogeneity, small-study effect, excess significance bias, as well as 95% prediction intervals (PIs) were calculated. Methodological quality was assessed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool. The credibility of the included meta-analyses was graded from convincing to weak using established criteria. This umbrella review was registered with PROSPERO, CRD 42021282183.

RESULTS

In total, 32 predictive factors involving 49 associations extracted from 35 meta-analyses were analyzed. Forty-three of the 49 (87.8%) associations presented nominal significant effects by the random-effect model (P < 0.05), of which 34 had harmful associations and nine had beneficial associations with all-cause mortality. Frailty (FRAIL scale), low short physical performance battery (SPPB) score, and fewer daily steps carried a more than three-fold risk for all-cause mortality. Convincing evidence showed that weight fluctuation, prefrailty and frailty status, sarcopenia, low SPPB score, fewer daily steps, and fatigue increased the risk of all-cause mortality, while daily moderate-to-vigorous physical activity (MVPA) duration and total physical activity participation reduced the risk of death. There were twenty, nine, five, and six associations that yielded highly suggestive, suggestive, weak, and non-significant grades of evidence. Thirty-four (69.4%) of the associations exhibited significant heterogeneity. Twenty-two associations presented 95% PIs excluding the null value, two indicated small-study effects, and three had evidence for excess significance bias, respectively. The methodological quality of most meta-analyses was rated as low (37.1%) or critically low (42.9%).

CONCLUSIONS

A summary of the currently available meta-analyses suggests that a broad range of modifiable predictive factors are significantly associated with all-cause mortality risk in the non-hospitalized elderly population. The most credible evidence indicates that physical function represented by frailty and sarcopenia, as well as physical activity, are significant predictors for all-cause mortality. This umbrella review may provide prognostic information to direct appropriate diagnostic evaluation and treatment goals in the future. More solid evidence is still needed coming from moderate-to-high quality meta-analyses.

Persistent effects of pair bonding in lung cancer cell growth in monogamous Peromyscus californicus

Epidemiological evidence suggests that social interactions and especially bonding between couples influence tumorigenesis, yet whether this is due to lifestyle changes, homogamy (likelihood of individuals to marry people of similar health), or directly associated with host-induced effects in tumors remains debatable. In the present study, we explored if tumorigenesis is associated with the bonding experience in monogamous rodents at which disruption of pair bonds is linked to anxiety and stress. Comparison of lung cancer cell spheroids that formed in the presence of sera from bonded and bond-disrupted deer mice showed that in monogamous Peromyscus polionotus and Peromyscus californicus, but not in polygamous Peromyscus maniculatus, the disruption of pair bonds altered the size and morphology of spheroids in a manner that is consistent with the acquisition of increased oncogenic potential. In vivo, consecutive transplantation of human lung cancer cells between P. californicus, differing in bonding experiences (n = 9 for bonded and n = 7 for bond-disrupted), and nude mice showed that bonding suppressed tumorigenicity in nude mice (p<0.05), suggesting that the protective effects of pair bonds persisted even after bonding ceased. Unsupervised hierarchical clustering indicated that the transcriptomes of lung cancer cells clustered according to the serum donors' bonding history while differential gene expression analysis pointed to changes in cell adhesion and migration. The results highlight the pro-oncogenic effects of pair-bond disruption, point to the acquisition of expression signatures in cancer cells that are relevant to the bonding experiences of serum donors, and question the ability of conventional mouse models to capture the whole spectrum of the impact of the host in tumorigenesis.

Experiences of becoming widowed in old age - a cross-countries study with qualitative interviews from Denmark and quantitative measures of association in a Swedish sample

Purpose: Becoming widowed is a stressful health-threatening event causing major life changes. We explored how widowed people experience becoming widowed and examined if these experiences are quantitatively associated with widowhood.

Methods: A multi-methods study using an exploratory sequential mixed-methods approach including a qualitative descriptive study with widowed people from Denmark and a Swedish cohort study. Qualitative interviews (n = 9) were analysed using qualitative content analysis, describing experiences as explained by the widowed people. The quantitative association of the experiences was examined by identifying proxies for the qualitative experiences of widowhood in the cohort study and examining the occurrence in widowed people compared to married people (n = 1,095).

Results: Six categories of experiences emerged: the circumstances around spousal death, mental health and well-being, physical health, social relations, activities and practicalities. The quantitative examination showed a significant association with widowhood regarding mental and physical health problems.

Conclusion: The circumstances around spousal death and the time before spousal death, in general, were important to how participants felt being widowed. Being ill negatively affected mental health and well-being, partly because of the inability to participate in activities and social relations. This is important, as health problems are more common among widowed people than married people.