Clinical Abstracts-With Comments by Adriane Fugh-Berman, MD
June 2000; Volume 2; 47
Caregiving Kills
Source: Schulz R, Beach SR. Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. JAMA 1999;282:2215-2219.
Design and Setting: Prospective population-based cohort (a random sample stratified by age group from Health Care Financing Administration Medi-care enrollment lists) between 1993 and 1998 in four U.S. communities: Forsyth County, NC; Washington County, MD; Sacramento County, CA; and Allegheny County, PA. Average follow-up was 4.5 years.
Subjects: 392 caregivers and 427 non-caregivers aged 66-96 years old who were living with their spouses.
Outcome Measures: Four-year mortality by categories of caregiving status: spouse not disabled (control subjects); spouse disabled but not caregiving; spouse disabled and caregiving but with no reports of caregiving strain; spouse disabled and caregiving with reports of caregiving strain.
Results: After four years of follow-up and adjustments for sociodemographic factors (age, sex, race, education, stressful life events), prevalent disease, and subclinical cardiovascular disease, participants who were providing care to a disabled spouse and experiencing caregiver strain had mortality rates that were 63% higher than non-caregiving controls (relative risk 1.63; 95% CI 1.00-2.65). Compared to controls, the other two groups (participants who were providing care but not experiencing strain and non-caregiving participants) did not have elevated adjusted mortality rates.
Funding: Supported in part by grants R01 MH46015, R01 MH52247, and T32 MH19986 from the National Institute of Mental Health; grant AG13305 and AG01532 from the National Institute on Aging; grant P50 HL65112 from the National Heart, Lung, and Blood Institute; and Petersen endowed chair scholar award from Oregon State University, Corvallis. The cardiovascular health study is supported by contracts N01 HC85079 through N01 HC85086 from the National Heart, Lung, and Blood Institute.
Comments: This striking study has important public health implications. There is a growing literature on the stresses of caregiving on mental health; this appears to be the first study that indicates that caregiving is an independent risk factor for mortality. As pointed out in an accompanying editorial, these data probably underestimate risks for those dealing with a severely physically or cognitively disabled spouse; in this study quite a broad definition was used for caregiving (the impaired spouse must have difficulty with at least one activity of daily living "due to physical or health problems or problems with confusion").1
Mortality rates were higher among those with prevalent disease, certainly not a surprise, but the combination of caregiving and prevalent disease was quite lethal; 33% of strained caregivers with prevalent disease in this sample died within the four-year follow-up period. As the investigators put it "primary care physicians who care for community-residing older adults may be in the best position to identify caregivers at risk. Older married couples should be evaluated as a unit, both in terms of their health status as well as the caregiving demands that exist in the home environment... In general, it is essential that we develop treatment approaches for older marital dyads that focus on the needs of both individuals simultaneously." My only quibble would be with the emphasis on married couples; stresses on non-married couples or non-spousal relatives can be expected to be similar.
References
1. Kiecolt-Glaser J, Glaser R. Chronic stress and mortality among older adults. JAMA 1999;282:2259-2260.
June 2000; Volume 2; 47
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