Context
Most deaths in the United States occur among older persons who have
1 or more disabling conditions. As a result, many deaths are preceded by an
extended period during which family members provide care to their disabled
relative.Objective
To better understand the effect of bereavement on family caregivers
by examining predeath vs postdeath changes in self-reported and objective
health outcomes among elderly persons providing varying levels of care prior
to their spouse's death.Design and Setting
Prospective, population-based cohort study conducted in 4 US communities
between 1993 and 1998.Participants
One hundred twenty-nine individuals aged 66 to 96 years whose spouse
died during an average 4-year follow-up. Individuals were classified as noncaregivers
(n = 40), caregivers who reported no strain (n = 37), or strained caregivers
(n = 52).Main Outcome Measures
Changes in depression symptoms (assessed by the 10-item Center for Epidemiological
Studies–Depression [CES-D] scale), antidepressant medication use, 6
health risk behaviors, and weight among the 3 groups of participants.Results
Controlling for age, sex, race, education, prevalent cardiovascular
disease at baseline, and interval between predeath and postdeath assessments,
CES-D scores remained high but did not change among strained caregivers (9.44
vs 9.19; P = .76), while these scores increased for
both noncaregivers (4.74 vs 8.25; F1,116 = 14.33; P<.001) and nonstrained caregivers (4.94 vs 7.13; F1,116
= 4.35; P = .04). Noncaregivers were significantly
more likely to be using nontricyclic antidepressant medications following
the death than the nonstrained caregiver group (odds ratio [OR], 12.85; 95%
confidence interval [CI], 1.02-162.13; P = .05).
The strained caregiver group experienced significant improvement in health
risk behaviors following the death of their spouse (1.47 vs 0.66 behaviors;
F1,118 = 20.23; P<.001), while the
noncaregiver and nonstrained caregiver groups showed little change (0.27 vs
0.27 [P = .99] and 0.46 vs 0.27 [P = .39] behaviors, respectively). Noncaregivers experienced significant
weight loss following the death (149.1 vs 145.3 lb [67.1 vs 65.4 kg]; F1,101 = 8.12; P = .005), while the strained
and nonstrained caregiving groups did not show significant weight change (156.2
vs 155.2 lb [70.3 vs 69.8 kg] [P = .41] and 156.2
vs 154.0 lb [70.3 vs 69.3 kg] [P = .12], respectively).Conclusions
These data indicate that the impact of losing one's spouse among older
persons varies as a function of the caregiving experiences that precede the
death. Among individuals who are already strained prior to the death of their
spouse, the death itself does not increase their level of distress. Instead,
they show reductions in health risk behaviors. Among noncaregivers, losing
one's spouse results in increased depression and weight loss.
Figures in this Article
More than 2 million persons die in the United States each year. The
large majority of these deaths occur among older persons with 1 or more disabling
conditions that compromise their ability to function independently prior to
death. As a result, a typical death is preceded by an extended period of time
during which 1 or more family members provide health and support services
to their disabled relative.1- 2
Although researchers have repeatedly documented the psychiatric and physical
health effects of family caregiving,3- 4
caregivers are rarely followed up long enough to assess the effect of the
death of the disabled relative on the caregiver.5
Similarly, bereavement researchers rarely explore the extent to which family
members were involved in care prior to the death of their relative as a factor
affecting bereavement outcomes. To better understand the role of caregiving
in adjustment to bereavement, we examine predeath to postdeath changes in
both self-report and objective health outcomes including depression symptoms,
antidepressant medication use, health risk behaviors, and weight among husbands
and wives providing varying levels of care to their spouse prior to death.
These outcomes were selected because of their known association with caregiving
and/or bereavement.
Although bereavement in the elderly is generally associated with increased
depression6 and weight loss,7
2 opposing hypotheses have been proposed to predict the effects of bereavement
in the context of caregiving: exposure to the chronic stresses of caregiving
depletes the emotional and social resources of caregivers and thus makes them
more vulnerable to negative outcomes when their spouses die; alternatively,
the loss of a disabled spouse may lead to an improvement in mental and physical
health outcomes because of the reduced caregiving burden. Studies addressing
these hypotheses are inconclusive because of a lack of appropriate comparison
groups,8- 11
small sample sizes with respect to the number of bereaved cases,10,12
or a focus on select subgroups such as caregivers of patients with the human
immunodeficiency virus.11 In addition, published
studies are often based on retrospective accounts of caregiving involvement.8
The Caregiver Health Effects Study (CHES), an ancillary study of the
Cardiovascular Health Study (CHS), a large population-based study of elderly
persons, affords a unique opportunity to examine the effects of bereavement
in the context of caregiving. It has a relatively large sample size (approximately
400 spousal caregivers and 400 matched controls) and measures of quality of
life and physical and psychological health outcomes. In this article we examine
prospectively the effects of spousal death on depression symptoms, antidepressant
medication use, health risk behaviors, and weight as a function of level of
involvement in caregiving prior to death. We examine bereavement effects among
noncaregivers, caregivers who report no strain associated with caregiving,
and caregivers who report strain.