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Commentary on: Shah SM, Carey IM, Harris T, et al. The mental health and mortality impact of death of a partner with dementia. Int J Geriatr Psychiatry 2016;31:929–37.
Implications for practice and research
As caring for a partner with dementia has a negative impact on caregivers’ health, supportive interventions need to be offered to active caregivers.
Patients with dementia are less likely to receive palliative care, so these services need to be made more accessible to patients with dementia and their caregivers.
Comparisons between dementia bereaved partners and non-dementia bereaved groups need to be extended to other bereavement-related health problems, including complicated grief.
It has been consistently documented that caring for a family member with dementia is associated with multiple health impairments. Coping with predeath grief, providing end-of-life care and experiencing the death of the care recipient are particularly stressful, but the impact of bereavement on caregivers’ health still needs to be better understood. For that purpose, Shah and colleagues (2016) have analysed the difference in the prevalence of depression, use of psychotropic medication in the year before and after bereavement and use of palliative care services between those whose partners died of dementia and those whose partners died from other diseases.
Data from a demographically representative UK primary care database collected between 2005 and 2012 were used. Two thousand six hundred and twenty-four persons aged ≥60 who had a partner die from dementia were matched with 7512 persons whose partner’s death was caused by other diseases. For the year before bereavement, any diagnosis of depression and the prescription of psychotropic medication were identified. Receipt of palliative care services and contact with primary care were also compared. For the year after bereavement, only those partners without psychotropic prescription before the death were analysed. Mortality rates were also compared between the two groups. Methods for data analysis included conditional logistic models, Kaplan-Meier estimates and Cox proportional hazards survival models or conditional Poisson models.
In the year before bereavement, partners of people with dementia had a greater likelihood of being diagnosed with depression (OR 2.31) and being prescribed psychotropic drugs (OR 1.34), compared with partners of those with other diseases. Receipt of palliative care services was lower in patients with dementia (OR 0.47). Psychotropic drug initiation in the 12 months after bereavement was lower when a partner had died from dementia (HR 0.81). Regarding mortality, men who had experienced dementia bereavement had lower rates (HR 0.68), while no significant differences were found for women (HR 1.02).
This study makes a significant contribution to caregiver research. By drawing on data from a primary care data base, it extends the findings of previous studies that mostly relied on self-report.
Shah and colleagues again demonstrated the detrimental effects of caregiving on health. By analysing diagnosis of depression and drug prescription, the study might even underestimate the impact, because many caregivers do not find or take the necessary time to contact primary care for themselves. The large number of a new depression diagnosis in the year before bereavement is particularly striking and draws attention to the increase in carer burden before the death of the care recipient. It is, however, also possible that a diagnosis might in fact reflect heightened predeath grief, because many caregivers are themselves not aware that they are grieving.1 Nonetheless, the need for supportive interventions during caregiving is clearly highlighted. For example, a cognitive-behavioural intervention can successfully reduce the burden of predeath grief.2
The present study further showed that dementia caregivers generally adapt well to bereavement, thus supporting the ‘stress relief’ and ‘anticipatory grief’ hypotheses.3 Yet, there is also a large number of caregiving-related risk factors for the development of complicated grief4 and previous studies showed that a substantial number of bereaved caregivers experiences symptoms of depression and complicated grief5 or need additional bereavement services.6 While these findings were obtained with support-seeking samples and might therefore include more distressed individuals, the present results could be more representative for caregivers in general. To confirm this, the results need to be extended to other bereavement-related outcomes, including complicated grief.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.