Are advanced dementia staging and severity of neuropsychiatric behavioral symptoms associated with the likelihood of divorce or separation in older adulthood?

By Tarun Sai LomteMar 2 2023Reviewed by Danielle Ellis, B.Sc.

In a recent study posted to Preprints with The Lancet*, researchers evaluated associations between neuropsychiatric behavioral symptoms, dementia staging, and divorce/separation.

*Important notice: Preprints with The Lancet publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Background

Divorce is increasing among older adults. Generally, divorce has negative consequences for individuals' financial and psychological well-being, although it might be beneficial and a matter of safety in the case of abuse. A recent study reported a 45% decline in the standard of living of women after divorce. By contrast, men experienced a 21% decline in their standard of living post-divorce that lingered despite re-partnering.

Meanwhile, the prevalence of dementia has also increased among older adults, with evidence suggesting a strain on close relationships. Research has demonstrated the negative impact of dementia caregiving on spouses. Still, it remains unknown whether neuropsychiatric behavioral symptoms and dementia staging are associated with divorce/separation for older couples.

About the study

In the present study, researchers explored whether advanced dementia staging and severity of neuropsychiatric behavioral symptoms were associated with divorce/separation in older adults. They used data from 37 Alzheimer's Disease Research Centers in the United States. Selected participants were married or living as domestic partners at the initial visit.

Cases were defined by the first divorce/separation during the follow-up. Five age-matched controls, married or living as married, were assigned to each control. At each visit, the team assessed marital status (married, widowed, divorced, separated, unmarried, and living as a married/domestic partner).

Necessary information for the clinical dementia rating (CDR) was obtained through semi-structured interviews with the patient, reliable informants, or a family source. The primary exposure was 12 symptoms from the Neuro-Psychiatric Inventory (NPI) – anxiety, agitation/aggression, appetite, apathy/indifference, depression/dysphoria, delusions, motor disturbance, hallucinations, euphoria/elation, nighttime behaviors, disinhibition, and irritability.

Symptoms present in the last month were rated as none, mild, moderate, or severe. Covariates included age, sex, ethnicity, years of education, the relationship between participant and informant, and whether the informant lived with the participant. Conditional logistic regression, adjusted for covariates, was applied to examine the association between CDR score, NPI score, and case/control status. Moreover, separate analyses were performed for each NPI symptom, adjusted for multiple comparisons. 

Findings

The study included 264 cases and 1,250 matched controls. The mean age of participants was 68.8 years; females represented 45% of subjects in both cohorts. Around 77.3% of cases and 88.5% of controls were White. Most informants were spouses, 48.9% for cases and 86.3% for controls. One-third of informants for cases and 7.3% (of informants) for controls were neighbors, friends, or siblings.

Nearly 19% of cases and 6.4% of controls had child informants. Informant reports were obtained before divorce/separation. Cases were less likely to live with informants than controls. Dementia staging measured by CDR score revealed that 53% of cases and 48.5% of controls had no functional impairment.

The three most reported symptoms for cases and controls were anxiety, depression, and irritability. Adult children of cases/controls reported irritability less frequently than other informants, while spouses of cases reported depression more frequently. In contrast, for controls, spouses and adult children reported depression more frequently than other informants.

More than 20% of cases were reported as anxious by all their informants. Elation, delusions, and hallucinations were infrequently reported for both groups. The association between divorce/separation and CDR score was insignificant without the NPI score in the model. Contrastingly, there was a significant association between the NPI score and divorce/separation without the CDI score in the model.

Intriguingly, when CDR and NPI scores were considered in the model, the association between dementia staging and divorce/separation was significant. Specifically, the earlier stage of dementia, but not the later stage, was associated with divorce/separation. In addition, significant associations were evident for the severity of NPI symptoms - aggression, depression, and disinhibition with divorce/separation.

Conclusions

The researchers found that a higher NPI score was associated with greater odds of divorce/separation. In addition, the severity of disinhibition, aggression, and depression was associated with divorce/separation. Divorced or separated cases presented with earlier stages of dementia.

The findings suggest that treating aggression, disinhibition, and depression in older adults may help them and their spouses/family and society. In the future, studies should assess the benefit of treating NPI symptoms. Further, the initial stages of dementia represent a sensitive time for older couples when additional relationship support could be helpful.  

*Important notice: Preprints with The Lancet publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.