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Can You Die of a Broken Heart?

Can You Die of a Broken Heart?. Morbidity and Mortality in Bereaved Spouses. Couple died on same day. Sunday Mercury (Birmingham, England) February 02, 2003

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Can You Die of a Broken Heart?

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  1. Can You Die of a Broken Heart? Morbidity and Mortality in Bereaved Spouses

  2. Couple died on same day. Sunday Mercury (Birmingham, England) February 02, 2003 A DEVOTED couple married for 55 years have died apart - on the same day. And neither Ted nor Sheila Aston knew about the other's death. Death graces couple with brief separation Margaret Dee dies as her husband, Jimmy, lies in the hospital. Less than a day later, he joins her. By BRADY DENNIS, Times Staff WriterPublished November 6, 2003

  3. Objectives: • Fact or Fiction: Is there an increased risk of death following the death of a spouse? • If so, what groups are most at risk? • What are the major causes of death? • Is there risk with other types of bereavement? • Are there other factors that are protective? • What can we do as physicians to intervene?

  4. Fact or Fiction? • 1959 – Kraus and Lilienfeld, Journal of Chronic Disease • Statistics: All deaths in Continental US 1949-1951 and 1950 US Census • Lower death rate in married vs. single, widowed, or divorced at every age • Outstanding excess risk in young widowed was noted

  5. Fact or Fiction? • 1969 – Parkes, Benjamin, and Fitzgerald, British Medical Journal • 4,486 widowers aged >55 followed for 9 years • 213 died in first 6 months, 40% above expected rate for married men at same age • At >6 months, rate falls gradually to that of married man • 5% of men died within 6 mo. of their wives

  6. Fact or Fiction • 1977 – Jacobs and Ostfeld, Psychosomatic Medicine • Review article of epidemiological literature • Discusses 14 published retrospective and cohort studies • “A basic pattern of excess mortality in the widowed, especially in males, is discernible in the studies summarized.”

  7. Effect lasts no more than 2 years for both men and women • Peak rise for men: 6 months • Peak rise for women: 2nd year • Prospective studies did not confirm this peak, apparent in work based on death certificates

  8. Fact or Fiction • 1987 – Kaprio, Koskenvuo, and Rita, American Journal of Public Health • Mortality of 95,647 Finnish widows/widowers followed from 1972-1976 (5 years) • 7,635 deaths occurred – 6.5% greater than expected number for entire cohort

  9. Fact or Fiction? • 1995 – Shaefer, Quesenberry, and Wi, American Journal of Epidemiology • Cohort of 12,522 spouse pairs belonging to health plan in N. California from 1964-1987 • 440 bereaved men and 510 women died • Mortality significant elevated, with highest relative risk during 7-12 mo. period after loss • RR then declines but is >1 for 2 years

  10. Fact or Fiction • 1996 – Martikainen and Valkonen, American Journal of Public Health • 1.58 million Finnish married persons (aged 35-84) were followed from 1986-1991 • Total excess mortality for widowed: 21% for men and 9% for women • 0-6 months: 29% men and 22% women • > 6 months: 19% men and 7% women • Authors published again in 1996, controlling for bias: accidents common to spouse, socioeconomic environment, common lifestyles • Total excess mortality 17% in men and 6% in women

  11. Probably not fiction!

  12. Objectives: • Fact or Fiction: Is there an increased risk of death following the death of a spouse? • If so, what groups are most at risk? • What are the major causes of death? • Is there risk with other types of bereavement? • Are there other factors that are protective? • What can we do as physicians to intervene?

  13. Does age matter? • Census data from 1959 showed excess mortality greatest in young widowed (aged < 35) • Relative mortality rates – Finnish data (1996) of married persons:

  14. Sex Matters! • 1987 Finnish article – mortality natural causes • Men < 65 – remains high until 3rd year • Men > 65 – remains high through 6 months • All Women – increases only during 1st month • Review article (1977) : “The risk of mortality is greater for men at all ages.”

  15. Greatest risk:Men < 65

  16. Objectives: • Fact or Fiction: Is there an increased risk of death following the death of a spouse? • If so, what groups are most at risk? • What are the major causes of death? • Is there risk with other types of bereavement? • Are there other factors that are protective? • What can we do as physicians to intervene?

  17. Causes of Death • From 1969 British study (men > 55) – diseases of heart and circulatory system accounted for 2/3 of increase in mortality

  18. Causes of Death • 1987 Finnish study: Overall mortality increase 3.2% natural causes vs. 93% violent causes • Ischemic Heart Disease • During the first week: 2.3-fold increase for men, 3.5-fold increase in women • After that, no increase except men < 65 in 2nd year • Cerebrovascular Disease • 1.9-fold increase for men during 1st month and 4-fold increase in men < 65

  19. Causes of Death • Increase in mortality from suicide during the 2nd to 12th month: • Men – 3.1-fold increase [2.19-4.30] • Women – 2.16-fold increase [1.30-3.37] • Suicide rate remained high during all 5 years of study

  20. Causes of Death • 1996 Finnish study • Highest relative mortality in men: alcohol-related diseases (2.40), suicide (2.31), other accidents and violence (1.92), MVA (1.45), chronic ischemic heart disease (1.36), lung cancer (1.24), MI (1.11) • Highest in women: alcohol-related diseases (2.22), suicide (1.74), other accidents and violence (1.47), chronic ischemic heart disease (1.30) • Mortality rates are higher for every cause of death in younger age group, except CA in women

  21. Causes of mortality with greatest increase:Violence (especially suicide)Chronic Heart Disease Deaths from alcohol-related diseases and lung cancer may also be significantly increased.

  22. Objectives: • Fact or Fiction: Is there an increased risk of death following the death of a spouse? • If so, what groups are most at risk? • What are the major causes of death? • Is there risk with other types of bereavement? • Are there other factors that are protective? • What can we do as physicians to intervene?

  23. Other Sources of Loss • Not much data • Rees and Lutkins (British Medical Journal, 1967) followed 903 survivors of 371 deceased people for 6 years – matched with controls • Widowed persons had a 10-fold increase in mortality compared to parents, siblings, children • Stroebe and Stroebe (Handbook of bereavement: Theory, research and intervention, 1999) show that individuals dealing with the loss of a child exhibit more intense and persistent levels of depression

  24. ?

  25. Objectives: • Fact or Fiction: Is there an increased risk of death following the death of a spouse? • If so, what groups are most at risk? • What are the major causes of death? • Is there risk with other types of bereavement? • Are there other factors that are protective? • What can we do as physicians to intervene?

  26. Are the rich protected? • 1969 British study suggests not: excess mortality greater in Classes I-III than IV-VI • In 1998, Martikainen and Valkonen published again, focusing on socioeconomic status • Relative mortality broadly similar • Because of high absolute levels of mortality, however, burden of excess mortality is heavier in lower social strata

  27. Can these protect you? • Previous good health • 1995 N. California study showed men with few health problems (RR 2.12) had greater risk than men with many (RR 1.56) • Spouse’s death resulted after long-term illness • 1977 review article quotes 3 studies that found no salutary effect • Remarriage • Not studied directly, but 1987 Finnish study noted that the proportion of deaths coded as “married” increased with time of follow-up

  28. Objectives: • Fact or Fiction: Is there an increased risk of death following the death of a spouse? • If so, what groups are most at risk? • What are the major causes of death? • Is there risk with other types of bereavement? • Are there other factors that are protective? • What can we do as physicians to intervene?

  29. Hospice • Christakis and Iwashyna (Social Science and Medicine, 2003) conducted retrospective cohort study of 61,676 elderly couples – half used hospice, half did not: • By 18 months, • Without hospice, 5.4% widows and 13.7% widowers had died • With hospice, 4.9% widows and 13.2% widowers had died • OR women 0.92 [0.84-0.99]; OR men 0.95 [0.84-1.06]

  30. Therapy and Meds • 2005 review article: • “Although results to date have not shown reduction in CVD events or mortality rates from psychosocial or pharmacologic antidepressant therapy, such treatments do reduce depressive symptoms.” • However, this article focused on studies conducted on an elderly surviving spouse.

  31. Hospice may positively affect survival in the bereaved.

  32. Conclusions • Fifty years of research indicate that there is increased mortality for the recently widowed, with the greatest risk seeming to come in the first 6 months. • Men less than 65 years of age seem to be at greatest risk. • The causes of death most increased seem to fall into two categories: violent and chronic diseases (i.e. heart disease, cirrhosis, lung CA). • Increased mortality seems to hold true despite socioeconomic class, previous good health, prolonged spousal illness, and remarriage. • Hospice has been shown to positively affect mortality rates in widows and widowers, although effect is only significant in women.

  33. Sources • Christakis N, Iwashyna T. The health impact of health care on families: a matched cohort study of hospice use be decedents and mortality outcomes in surviving, widowed spouses. Soc Science & Med 2003;57:465-475. • Jacobs S, Ostfeld A. An epidemiological review of the mortality of bereavement. Psychosom Med 1977;39:344-357. • Kaprio J, Koskenvuo M, Rita H. Mortality after bereavement: a prospective study of 95,647 widowed persons. Am J Public Health 1987; 77:283-287. • Kraus AS, Lilienfeld AM. Some epidemiological aspects of the high mortality rate in the young widowed group. J Chronic Dis 1959;10:207-217. • Martikainen P, Valkonen T. Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. Am J Public Health 1996;8:1087-1093. • Martikainen P, Valkonen T. Do education and income buffer the effects of death of spouse on mortality? Epidemiol 1998;5:530-534.

  34. Sources • Parkes CM, Benjamin B, Fitzgerald RG. Broken heart: a statistical study of increased mortality among widowers. Br Med J 1969;1:740-743. • Rees WD, Lutkin SG. Mortality of bereavement. Br Med J 1967;4:13-16. • Shaefer C, Quesenberry CP Jr, Wi S. Mortality following conjugal bereavement and the effects of a shared environment. Am J Epidemiol 1995;141:1142-1152. • Stroebe MS, Stroebe W. The mortality of bereavement: A review. In Stroebe MS, Stroebe W, Hansson R. eds. Handbook of bereavement: Theory, research and intervention. New York: Cambridge University Press;1999:175-195. • Williams JR Jr. Depression as a mediator between spousal bereavement and mortality from cardiovascular disease: appreciating and managing the adverse health consequences of depression in an elderly surviving spouse. South Med J 2005;1:90-95.

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