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Association between mid-life marital status and cognitive function in later life: population based cohort study

BMJ 2009; 339 doi: (Published 02 July 2009) Cite this as: BMJ 2009;339:b2462

On mid-life marital status and cognitive function in later life: notes inspired by a journal club discussion

We discussed with considerable interest in our monthly journal club
presentation the implications of the study findings presented by Håkansson
and colleagues in their article on mid-life marital status and cognitive
function (1). We believe the interpretation of these findings needs take
into account a number of considerations. Most important of these will be
summarized here.

First, cognitive assessments were only performed at the “follow-up”,
but not at baseline. As the cognitive status of participants at age 50 is
unknown, the study is, strictly speaking, not a prospective study. Thus,
the authors cannot infer that being widowed for instance preceded
cognitive dysfunction. Håkansson and colleagues argue that reverse
causation seems unlikely as baseline measurements were taken at a mean age
of 50 and 21 years before cognitive assessments. As they acknowledge, the
pre-clinical period of dementia may span over nine years. However, it has
been suggested that cognitive performance may be associated with the
development of AD symptomatology over a period of 22 years (2) over even
longer (3).

Second, a previous study has suggested that the risk of Alzheimer’s
disease associated with contact with children may be higher if those
contacts are perceived as not satisfying (5). Satisfaction with one’s
marriage may modify the association between being married and cognitive
function in a similar fashion.

Third, engagements in social activities, living arrangement, contact
with friends or relative provide protective effect against dementia both
for singles, widowed or divorced (5). However, the benefit is likely to be
reduced in widowed and divorced. Being widowed is an imposed involuntary
transition considered to be traumatic as stated by the authors (1), while
being divorced though not involuntary imposed, is associated with divorced
-related emotional difficulties (6). In contrast to singles, both widowed
and divorced have experienced loss of their spouse. This might be a
possible explanation for the specific increased risk for widowed and
divorced reported by the authors.

Finally, it seems likely that the public perception of and attitude
towards singles or divorced adults was different in the 70s and 80s as
compared to nowadays. It is likely that our present day society more
readily accepts single life styles in mid-life. If so, then public health
interventions targeted towards preventing the development of Alzheimer’s
and dementia in later life need to take these into careful consideration.

1. Håkansson K, Rovio S, Helkala EL, Vilska AR, Winblad B, Soininen
H, Nissinen A, Mohammed AH, Kivipelto M (2009) Association between mid-
life marital status and cognitive function in later life: population based
cohort study. BMJ 339; b2462.

2. Elias MF, Beiser A, Wolf PA, Au R, White RF, D'Agostino RB (2000)
The preclinical phase of alzheimer disease: A 22-year prospective study of
the Framingham Cohort. Arch Neurol 57: 808-813.

3. Snowdon DA, Kemper SJ, Mortimer JA, Greiner LH, Wekstein DR,
Markesbery WR (1996) Linguistic ability in early life and cognitive
function and Alzheimer's disease in late life. Findings from the Nun

4. Berkman LF (2000) Which influences cognitive function: living
alone or being alone? Lancet 355: 1291-1292
5. Fratiglioni L, Wang HX, Ericsson K, Maytan M, Winblad B (2000)
Influence of social network on occurrence of dementia: a community-based
longitudinal study. Lancet 355: 1315-1319.

6. Sbarra DA, Law RW, Lee LA, Mason AE (2009) Marital dissolution and
blood pressure reactivity: evidence for the specificity of emotional
intrusion hyperarousal and task-rated emotional difficulty. Psychosom Med.

Competing interests:
None declared

Competing interests: No competing interests

23 July 2009
Adrian Loerbroks
Nasir Umar
Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim, Heidelberg University