Can You Die of a Broken Heart

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Can You Die of a Broken Heart?

• Morbidity and Mortality in
• Bereaved Spouses

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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 Margare
t 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
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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?

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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

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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

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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.

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• 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

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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

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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

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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

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Probably not fiction!
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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?

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Does age matter?

• Census data from 1959 showed excess mortality
  greatest in young widowed (aged
• Relative mortality rates Finnish data (1996) of
  married persons

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Sex Matters!

• 1987 Finnish article mortality natural causes
• Men
• 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.

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Greatest riskMen 18
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?

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Causes of Death

• From 1969 British study (men 55) diseases of
  heart and circulatory system accounted for 2/3 of
  increase in mortality

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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 year
• Cerebrovascular Disease
• 1.9-fold increase for men during 1st month and
  4-fold increase in men

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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

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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

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Causes of mortality with greatest
increaseViolence (especially suicide)Chronic
Heart Disease

• Deaths from alcohol-related diseases and lung
  cancer may also be significantly increased.

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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?

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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

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?
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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?

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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

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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)
• Spouses 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

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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?

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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

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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.

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Hospice may positively affect survival in the
bereaved.
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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.

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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 200357465-475.
• Jacobs S, Ostfeld A. An epidemiological review of
  the mortality of bereavement. Psychosom Med
  197739344-357.
• Kaprio J, Koskenvuo M, Rita H. Mortality after
  bereavement a prospective study of 95,647
  widowed persons. Am J Public Health 1987
  77283-287.
• Kraus AS, Lilienfeld AM. Some epidemiological
  aspects of the high mortality rate in the young
  widowed group. J Chronic Dis 195910207-217.
• 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
  199681087-1093.
• Martikainen P, Valkonen T. Do education and
  income buffer the effects of death of spouse on
  mortality? Epidemiol 19985530-534.

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Sources

• Parkes CM, Benjamin B, Fitzgerald RG. Broken
  heart a statistical study of increased mortality
  among widowers. Br Med J 19691740-743.
• Rees WD, Lutkin SG. Mortality of bereavement. Br
  Med J 1967413-16.
• Shaefer C, Quesenberry CP Jr, Wi S. Mortality
  following conjugal bereavement and the effects of
  a shared environment. Am J Epidemiol
  19951411142-1152.
• 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 Press1999175-195.
• 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
  2005190-95.