摘要：Objectives. We investigated the risk of entering long-term institutional care after the death of a spouse in relation to the duration of widowhood among older Finnish men and women. We also examined whether high levels of education or household income buffered the effects of bereavement on institutionalization. Methods. We used linked register-based data on Finnish adults 65 years or older who were living with a spouse at the beginning of the study period (n=140902) and were followed from January 1998 to December 2002. Results. The excess risk of institutionalization was highest during the first month following a spouse’s death compared with still living with a spouse (adjusted hazard ratio=3.31 for men, 3.62 for women). This risk decreased over time among both men and women. The relative effect of the duration of widowhood on institutionalization did not significantly vary according to the level of education or income. Conclusions. Risk of institutionalization is particularly high immediately after the death of a spouse, demonstrating the importance of loss of social and instrumental support. Previous studies showed that older adults who live alone or without a spouse have an increased probability of entering institutional care, independent of baseline health status. 1 – 4 These findings indicate the importance of social and instrumental support provided by a spouse in reducing the need for institutionalization. In addition, never-married, widowed, and divorced older persons have been shown to have a higher probability of institutionalization than their married counterparts. 5 , 6 However, few studies have analyzed how the death of a spouse affects the probability of entering institutional care. The death of a spouse has been shown to be associated with poor mental health, such as depression and anxiety, 7 , 8 and with poor physical health. 7 Because poor mental and physical health have both been found to be associated with an increased risk of institutionalization, 1 , 2 it is likely that the death of a spouse also increases the need for institutional care. In addition, some studies have found an association between the death of a spouse and a decline in cognitive status (e.g., memory functioning), 9 which is shown to be an important risk factor for admission to institutional care. 1 , 10 Because mental health may improve again after despair and disorganization diminish with time following bereavement, 11 it is possible that the risk of institutionalization is highest immediately after the loss of a spouse and decreases over time. One study from the United States indicated that becoming widowed during a prospective follow-up was associated with an increased probability of nursing home admission, but the recency of widowhood, measured retrospectively at the time of the baseline interviews, was not. 12 The latter finding may be misleading, especially if the effect of widowhood is short term and a large proportion of the recently widowed were already institutionalized before the baseline interviews. However, we know of no large-scale prospective studies testing whether the effect of a spouse’s death on institutionalization varies according to the duration of widowhood, and the existence and the magnitude of these effects are unknown. The effect of widowhood and widowerhood on mortality is well established: the recently bereaved have been shown to have a higher risk of death than the currently married, 13 – 20 especially from alcohol-related diseases, suicides, and other accidents and violence. 19 Because both mortality and institutionalization are related to poor health (e.g., poor self-perceived health predicts mortality and institutionalization, 3 , 21 depression predicts mortality, 22 and depressive symptoms predict institutionalization among men 23 ), it is possible that the effect of the duration of widowhood is similar for both. Previous studies indicated that excess mortality is highest during the first weeks 18 , 24 or months 13 , 14 , 16 , 20 , 25 after a spouse’s death. Some studies found that excess mortality among the bereaved decreases to the level of the married with time from bereavement among men, 13 but others indicated that it continues, although at a lower level, for 10 years and longer. 15 The excess risk of death among the recently bereaved may be related to psychosocial mechanisms, such as emotional stress and grief, and to the loss of social, instrumental, and material support. 18 , 19 , 26 However, previous mortality studies suggested that the bereaved gradually adapt to the loss and learn to cope in their changed social environment. Furthermore, bereaved persons with disabilities may be more likely to be institutionalized immediately after the death of the spouse because there is no longer anybody to take care of them. High levels of education and income, as well as other social and economic resources, may buffer against the harmful effect of spousal loss on institutionalization and mortality. However, persons with higher education 20 , 27 , 28 and income 27 were not found to suffer less excess mortality after a spouse’s death in previous studies. Although high socioeconomic status is associated with lower mortality, it has not been shown to prevent or even buffer the harmful effects of spousal loss. On the contrary, a study of the Israeli Jewish population indicated that the relative excess mortality among those recently bereaved was higher for men with more education. 20 Perhaps socioeconomic buffering of the effects of bereavement is greater on institutionalization than on mortality, because the loss of spousal support and access to substitute assistance, such as home help services, are likely to be more effective predictors of institutionalization than of death. However, empirical evidence for this hypothesis is not available. Because older adults with savings and higher incomes may be better able to afford home help services, a high household income at the beginning of a study could also buffer the harmful effects of spousal loss. We used population-based survival data with a continuous time scale of institutionalization to assess the risk of entering institutional care after the death of a spouse in relation to the duration of widowhood and widowerhood among adults 65 years or older. We analyzed Finnish register-based data containing information on each individual’s dates of first admission into long-term institutional care and death and on the spouse’s date of death during a 5-year follow-up from January 1998 to December 2002. We sought to assess (1) whether recently bereaved older adults had a higher risk of entering institutional care than did those living with a spouse, independent of sociodemographic controls and preexisting medical conditions; (2) how the duration of widowhood was associated with the risk of entering institutional care; and (3) whether the relative effects of a spouse’s death were smaller among persons with a higher level of education or a higher household income. The first 2 analyses were performed separately for men and women.
