Table 2.
Study design, sample characteristics, and study results for articles on widow(er)s
| Authors (year) | Quality | Study Design; Length of Observation (years) | Reference Group | Time Since Loss | Total N (% female) n Reference Group; n Widow(er)s | Mean Age (SD) or Age Range or % 65+ | Cognitive Assessment(s) | Cognitive Domain | Results | Controlled for age, sex, SES? |
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| Aartsen et al. (2005) | 3 | Longitudinal; 6 | Married subjects | 37 months | 1164 (40.7%) 940 (36 %); 204 (66 %) 2089 (59.9 %) | 60–85 | AVLT | Memory | Widow(er)s had greater memory decline than control | Yes |
| Amieva et al. (2010) | 3 | Longitudinal; 15 | Married subjects | nr | 1267 (nr); 679 (nr) | 73.7 (6.0) | Dementia diagnosis (clinician) | Incident dementia Verbal memory, | Being widowed was not associated with greater odds of dementia or AD than being married Widow(er)s had poorer cognitive function than married | Yes |
| Barragán- García et al. (2021) | 3 | Cross-sectional | Married subjects | 0–11+ years | 6898 (59.3 %) 4349 (50 %); 1624 (76.8 %) | 70.86 (7.43) | CCCE | Verbal memory, visuospatial ability/ memory | Widow(er)s had poorer cognitive function than married adults, with longer widowhood duration associated with lower overall cognition. | Yes |
| Bickel and Cooper (1994) | 3 | Longitudinal; 7.5 | Married subjects | nr | 314 (65.0 %) 133 (nr); 149 (nr) | 73.8 (6.0) | Dementia diagnosis (clinician, patient records, proxy report) | Incident dementia | Being widowed was not associated with increased odds of dementia | No |
| Biddle et al. (2020) | 3 | Longitudinal; 3.1 | Married subjects | nr | 257 (59.5 %) 145 (45.5 %); 35 (88.6 %) | 73.5 (6.1) | Preclinical Alzheimer Cognitive Composite included: MMSE, LMDR, DSST, FCSRT | Overall cognitive function, memory, executive function | Widow(er)s declined in cognitive performance compared to married subjects | Yes |
| Brenowitz et al. (2014). | 3 | Prospective; 3.2 | Married subjects | nr | 5335 (67.1 %) 3106 (nr); 1263 (nr) 10,940 (48.4 %) | 83.7 % | MCI diagnosis (clinician) | nr | Widowers had lower risk of MCI than controls. | Yes |
| Brown et al. (2020) | 3 | Longitudinal; 14 | Married subjects | 1–14 years | 9951 (53.2 %); 419 (79.5 %) | 50–65 | TICS-m | Global cognition; cognitive impairment | Widowed men had higher rates of cognitive impairment than married/re-partnered men. Widowed women did not show differences in cognitive function compared to married women. | Yes |
| Byrne and Raphael (1997) | 1 | Cross-sectional | Married subjects | 6 weeks | 114 (0%) 57 (0%); 57 (0%) | 74.94 (nr)* | MMSE | Global cognition | Widowed men did not differ from married men on overall cognitive performance. | Yes |
| Espinosa del Pozo et al. (2020) | 2 | Cross-sectional | Married subjects | nr | 80 (67 %) 48(nr); 16(nr) 7964 (50.5 %) | 100% | MMSE, AD8 | global cognition, self-report dementia symptoms | Widow(er)s did not differ on global cognition or risk for dementia than married adults. | Yes |
| Fan et al. (2015) | 2 | Cross-sectional | Married subjects | nr | 5111 (nr); 2471(nr) 2874 (nr) | 75.69 (nr)* | CDR, MMSE | Global cognition; cognitive impairment | Being widowed was associated with increased odds of dementia. | Yes |
| Farr on et al. (2020) | 2 | Cross-sectional | Married subjects | nr | nr; nr 2498 (56.6 %) 1857 (56.6 %); | 68.6 (nr) | Summary cognition score of 18 cognitive tests: WR, animal naming, MoCA CDT, HMSE, DSF, symbol cancellation, LM, constructional praxis, hand sequence, token test, judgment, problem solving, CSI-D, CPM, GNG | Overall cognition: memory, retrieval fluency, language, visuospatial skills, executive function, orientation, attention/speed, judgment | Widow(er)s had worse overall cognition than married adults. | Yes |
| Feng et al. (2014) | 2 | Cross-sectional | Married subjects | nr | 414 (90.8 %) | 66.0 | MMSE (cognitive impairment = <24) | Global cognition | Widowed men had greater odds of cognitive impairment than married men. No differences were found between widowed and married women. No differences found when widow (er)s were compared with married adults. | Yes |
| Forbes et al. (2019) | 3 | Longitudinal; 1.9–8 | Married subjects | 0–5 years | 247,586 (65.7 %) 123,793 (65.7 %) 123,793(65.7%) | 74.2c | Dementia diagnosis (patient records) | Incident dementia | Losing a spouse is associated with receiving a dementia diagnosis within 3 and 6 months of the loss but not associated with long-term risk of dementia | Yes |
| Guaita et al. (2015) | 2 | Cross-sectional | Married subjects | nr | 1321 (54.1 %) 872 (nr); 325 (nr) 1999 (72.4 %) 1157 (56.4%); | 71.69 (1.45) | Diagnosis of dementia or cognitive impairment no dementia (clinician) | incident dementia or mild cognitive impairment | Being widowed was not associated with increased odds of dementia or cognitive impairment Those who were widowed at midlife were more likely to show cognitive impairment later in | Yes |
| Hakansson et al. (2009) | 3 | Longitudinal; 21 | Married/cohabiting subjects | nr | 116 (95.7%) 3633 (nr) | 50.4 (6.0)d | Incident dementia | Incident dementia | life than those cohabiting with a partner in mid-life. Still widowed individuals had 3× risk of cognitive impairment thaan married/cohabiting people. | Yes |
| Hatch (2013) | 3 | Longitudinal; 13 | Nonbereaved subjects | nr | 2395 (47.2 %); 1088 (42.0 %) | 74.5 (nr)* | Dementia diagnosis (clinician) | Incident dementia | There was no association between widowhood and risk of dementia. | Yes |
| Helmer et al. (1999) | 3 | Longitudinal; 5 | Married subjects | nr | 3675 (58 %) 2106 (nr); 1287 (nr) | 100 % | Dementia diagnosis (clinician) | Incident dementia | Widowed adults did not differ from married adults in dementia risk. | Yes |
| Jia et al. (2020) | 3 | Cross-sectional | Married subjects | nr | 39,938 (nr); 3676 (nr) 6476 (61.3 %) | 70.26 (7.51) | Dementia diagnosis (clinician) | Incident dementia | Being widowed was associated with greater risk of dementia or mild cognitive impairment. | Yes |
| Karlamangla et al. (2009) | 3 | Longitudinal; 9 | Married subjects | nr | 3354 (nr); 2583 (nr) | 77.1 (nr) | TICS | Global cognition | Widow(er)s had faster declines on total cognition and recall than married adults. Baseline marital status was not associated with baseline cognitive function. Widow(er)s had greater | Yes |
| Kim et al. (2019) | 3 | Longitudinal; 2 | Married subjects with diverse social networka | nr | 1960 (48.2 %) 781 (36.5 %); 321 (80.7 %) 923 (62.0 %) | 72.05 (5.35) | MMSE | Global cognition | cognitive decline than married adults who had close contact with social groups. Widow(er)s have higher rates of cognitive impairment than married adults. Widowed | Yes |
| Kramer et al. (1985). | 2 | Cross-sectional | Married subjects | nr | 395 (41.0 %); 393 (83.7 %) 2618 (58.6 %) | 65–74 | MMSE (severe impairment = 0—17) | Global cognition | females have higher rates of cognitive impairment than married females. No differences across males by marital status. | No |
| Lee et al. (2019). | 3 | Longitudinal; 4 | Married subjects | nr | 2072 (51.5 %); 546 (85.5 %) 2462 (50.4 %) | 51–93 | Total cognition: WR, SS7, Backward counting | memory, working memory, attention and processing speed | There were no significant association between widowhood and cognitive function across a 4-year period. | Yes |
| Li et al. (2018) | 2 | Longitudinal; 30 | Married subjects | 2131 (nr); 61 (nr) | 40–65 | Dementia diagnosis (clinician) | Incident dementia | Widowhood was associated with increased risk of dementia for those aged 50 +. | No | |
| Liu et al. (2019) | 3 | Longitudinal; 7 | Married subjects | nr | 7508(58.2%) 3609 (41.1%); 2542 (81.2%) 15,379 (54.97 %) | 100% | Overall cognition and independent domains assessed using the following assessments: WR, CDT, time orientation. If unable to complete the tests, cognitive status measured by AD diagnosis or AD8. Overall cognitive score was categorized into 3 groups: dementia, cognitive impairment, normal cognition. | Memory, orientation, executive function | Widow(er)s had greater cognitive impairment in memory, executive function and orientation than married adults. They also had higher prevalence rates of cognitive impairment (not dementia) and dementia. | Yes |
| Liu et al. (2020) | 3 | Longitudinal; 14 | Married subjects | nr | 10,105(46.2%); 3007 (81.9 %) 1145 (63.4%) | 65.91 (9.88) | TICS, proxy assessment of memory and IADLs | Global cognition/ dementia category | Widowed respondents (and all unmarried groups) had higher odds of dementia than married respondents. The transition into widowhood, but not to divorce or remarriage, is associated with higher odds of dementia. | Yes |
| Lopes et al. (2007) | 1 | Cross-sectional | Married subjects | nr | 660 (nr); 315 (nr) 3660 (42.5 %) | 70.9 (60–100) | MMSE (< 26), FOME (< 35), IQCODE (> 3.40), B-ADL (> 3.19) | global cognition: language, attention, memory, verbal fluency, verbal and tactile recognition; activities of daily living | Widowhood was not associated with cognitive and functional impairment | Yes |
| Lyu et al. (2019) | 3 | Longitudinal; 8 | Married subjects | 0–6+ years | 3266(nr); 394 (nr) 3329 (nr) | 68.5 (6.16) | MMSE | Global cognition | Widow(er)s bereaved for 4—6 years had steeper declines in global cognitive functioning than nonwidowed individuals. Widowed women had lower initial levels of cognitive | Yes |
| Monserud (2019). | 3 | Longitudinal; 17 | Married men | nr | nr; nr 1882 (54.5 %) 1422 (47.3 %); | 65–109 | MMSE | Global cognition | Widow(er)s bereaved for 4—6 years had steeper declines in global cognitive functioning than nonwidowed individuals. Widowed women had lower initial levels of cognitive | Yes |
| Mousavi-Nasab et al. (2012) | 3 | Longitudinal; 5 | Married or single subjects | nr | 242 (86.8 %) 77 (72 %) 32 (68.8 %); | 35–85b | Free/cued recall and recognition tests, vocabulary and fluency tests | Episodic memory, semantic memory | divorced adults. Older widow (er)s had poorer semantic memory performance (vocabulary) than older married people. Widow(er)s showed no differences in recall or fluency from married, divorced, single adults. Widow(er)s with complicated | No |
| O’Connor and Arizmendi (2014) | NA | Cross-sectional | Married subjects | nr | 45(73.3%) | 71.85 (nr)* | e-Stroop, MMSE, DSB, WCST | Global cognition, working memory, executive function, emotional inhibition | grief had poorer overall cognitive performance and exhibited greater interference (slower reaction times) to emotional words, than nonbereaved group. No | No |
| Paul et al. (2010). | 2 | Cross-sectional | Married or single subjects | nr | 1268(70.4%) 704(nr); 442(nr) 9171 (52.8 %) 5586 (33.8 %); | 70.3 (8.7) | MMSE | Global cognition | differences in working memory or executive functioning. Widow(er)s did not have higher rates of cognitive impairment than nonbereaved group (single or married). Widows and widowers had worse memory performance than married counterparts. When widowhood duration was | No |
| Perkins et al. (2016) | 2 | Cross-sectional | Married subjects | 0–10+ years | 3585 (82.5 %) | 64.9 % | WR | Memory | accounted for, men bereaved for 5—9 years had lower memory ability than married men. Women bereaved for 0—4 years or 10+ years had lower memory ability than married women. Being widowed was not | Yes |
| Ribeiro et al. (2013) | 2 | Cross-sectional | Married subjects | nr | 683 (70.9 %) 284 (nr); 279 (nr) 211 (85.3 %) 84(nr); | 78.24 (6.95) | Dementia diagnosis (clinician) | Incident dementia | associated with greater odds of dementia than being married. Being widowed was not associated with cognitive | Yes |
| Rosnick et al (2010). | 3 | Cross-sectional | Nonbereaved subjects | 6 months | 127(nr) | 69.97 (6.33) | SR, disc positioning on a board, BNT, WAIS-R Similarities subtest, copying objects, overall cognitive score (summary statistic of all assessments) | Episodic and spatial memory, visuospatial skills, verbal ability, reasoning | outcomes. Bereaved men did worse than nonbereaved men on immediate story recall task. Bereaved younger adults did worse on immediate and delayed story recall compared to nonbereaved younger adults. | Yes |
| Saha et al. (2010) | 1 | Cross-sectional | Married subjects | nr | 179 (100 %) nr; nr | 64 (7.6) | MMSE (cognitive impairment<24) | Global cognition | Being widowed was associated with cognitive impairment | No |
| Shahar et al. (2001) | 2 | Cross-sectional | Married subjects | 2.9 months | 126 (82 %) 58 (82 %); 58 (82 %) 6766 (51.01%) | 77.6 (nr) | Combined score: MMSE, digit symbol substitution | Global cognition | No significant difference in cognitive functioning between widowed and married subjects. Widow(er)s had lower global | No |
| Shin et al. (2018) | 3 | Longitudinal; 17 | 0-16 years | Married subjects | 4040 (nr); 2726 (65.1 %) 240 (62.5 %) | 72.79(5.46) | Total cognition score (WR, mental status summary score) | Global cognition | cognition than married subjects. Cognition scores also declined significantly as time since spousal loss increased. Being widowed was associated | Yes |
| Subramanian et al. (2021) | 2 | Cross-sectional | Married subjects | nr | 160 (nr); 80 (nr) 1177 (57.4 %) | 63.9 (7.1) | HMSE (cognitive impairment <26) | Global cognition | with greater prevalence of cognitive impairment than being married. Being widowed was associated | Yes |
| Sun et al. (2021) | 2 | Cross-sectional | Married subjects | nr | 402(nr); 775(nr) 2,288,489 (51 %) | 81.25 (nr)* | MCI (clinician) | Cognitive impairment | with greater risk of severe cognitive impairment Being widowed was associated | No |
| Sundstrom et al. (2016). | 3 | Longitudinal; 10 | Married subjects | nr | 1,484,754 (48.6 %); 191,401 (79.8 %) | 60.5 (7.3) | Dementia diagnosis (patient records) | Incident dementia | with increased odds of dementia for young-old (50—64 yrs) and middle-old (65—74 yrs) | Yes |
| 3 | Married subjects | nr | 74.74 (nr)* | Dementia diagnosis (clinician) | Incident dementia | No | ||||
| Sundstrom et al.(2014b) 524 (nr) | Longitudinal; 8.6 | 1609 (56.12 %) 926 (nr); 4370 (45.6 %) 3007 (45.1 %); | Widow(er)s have an increased risk of dementia compared to married adults. | |||||||
| Vidarsdottir et al. (2014) | 3 | Longitudinal; 25 | Married subjects | 0–10+ years | 1363 (74.9 %) 537,513 (46.4 %) | 76.68 (nr) | composite cognition score (CVLT, DSST, Figure comparison test, Stroop, DSB, SWM of CANTAB); dementia diagnosis (clinician), MCI diagnosis (clinician) | Memory, processing speed, executive function | Widow(er)s did not differ on cognitive performance than married individuals and did not have greater risk of dementia or mild cognitive impairment. Widowed women had lower executive functioning performance than married women but no differences were seen across widowed and married men. | Yes |
| Wandell et al. (2020) | 3 | Longitudinal; 5.4 | Married subjects | nr | 292,736(36.0 %); 133,627 (74.3 %) 50 (72 %) 25(72 %); | 77.1 % | Dementia diagnosis (patient records) | Incident dementia | Widowed men had lower risk of dementia than married men. No differences in dementia risk between widowed and married women. | Yes |
| Ward et al. (2007) | NA | Cross-sectional | Non-bereaved subjects | < 18 months | 25(72 %) 1269 (42%) 850 (nr); | 65–80 | WTAR, MMSE, AVLT, Benton VRT, TEA subtests: elevator counting and visual elevator, TMT, RCFT, COWAT, SDMT MMSE, Coding task, CPM, AVLT MMSE | Intelligence quotient, global cognitive ability, memory, attention, information processing, visuospatial ability, verbal fluency | Widow(er)s performed worse on tests of attention, processing speed, and verbal fluency than nonbereaved group but after depression, stress and anxiety were accounted for, these differences were no longer significant. | Yes |
| Worn et al. (2020) | 3 | Longitudinal; 20 | Married subjects | 0–4+ years | 419 (64.4 %) 5872 (55.81 %) 3267 (nr); | 75.98 (6.60) | MMSE, Coding task, CPM, AVLT | MMSE, Coding task, CPM, AVLT | Global cognition, processing speed, reasoning, memory Bereaved women performed showed decrease in reasoning performance compared to married women; no differences in memory, global cognitive functioning, and processing speed were found. No cognitive differences between bereaved men and nonbereaved men. Widow(er)s were more likely to experience cognitive decline than married subjects. When stratified by gender, widowhood negatively impacted cognitive function in men but did not impact women. | Yes |
| Xiang et al. (2021) | 3 | Longitudinal; 9 | Married subjects | nr | 2605 (nr) | 80.64 (10.32) | MMSE | Global cognition | When widowhood was divided into 5 categories of widowhood duration, men bereaved for 5 years or less, 16—20 years, or 21+ years were more likely to have lower cognitive scores than married men. Women bereaved | Yes |
| Xu et al. (2020) | 2 | Cross-sectional | Married subjects | nr | 1018 (50.20 %); 285 (70.53 %) 5897(51%) | 71 (60–94) | MMSE | Global cognition | for 21+ years had worse cognitive function than currently married women. Window(er)s did not differ from married adults on global cognitive functioning. No effect of gender. | Yes |
| Yin et al. (2020) | 3 | Longitudinal; 5.32 | Widowed individuals | nr | 2448(nr); 3253(nr) 5550 (55.5 %) | 81.7 (9.7) | MMSE | Global cognition, cognitive impairment | Married individuals have lower risk of developing cognitive impairment than widowed individuals Widowed men have greater odds | Yes |
| Zhang et al. (2019a) | 2 | Cross-sectional | Married subjects | nr | 940 (61.2 %); 352 (64.8 %) | 73.30 (7.56) | MMSE, CDR, cognitive impairment (clinician) | Incident cognitive impairment no | of cognitive impairment than married men. No differences | Yes |
| 352 (64.8 %) | dementia | between widowed and married women | ||||||||
| Zhang et al. (2006) | 2 | Cross-sectional | Married subjects | nr | 34,807 (53.8 %) 25,910 (nr); | 56.3 % | Dementia diagnosis (clinician) | Incident AD or incident vascular dementia | Widowed adults had higher prevalence of AD cases and lower prevalence of vascular | Yes |
| Zhang et al. (2019b) | 3 | Longitudinal; 2 | Married subjects | nr | 1293 (72.2 %o) | 40.9 % | WR, TICS (orientation and subtraction) | Memory, orientation, calculation | continually married adults. Newly widowed adults did not differ from continually married adults in episodic memory changes | Yes |
| Zhang et al. (2021) | 3 | Longitudinal; 16 | Married subjects | nr | 14,788 (55.2 %) 9700 (nr); 2975 (nr) 30,578 (nr) 27,732 (49 %); | 65.89 (nr) | TICS, proxy assessment of memory and IADLs | Global cognition/ dementia category | Being widowed was associated with greater odds of dementia in both blacks and whites. Being widowed was negatively associated with global cognition, objective memory, crystallized | Yes |
| Zhao et al., 2021 | 3 | Longitudinal; 18 | Married subjects | 0–4+ years | 2846 (69 %); | 67.49 (nr)* | Cognitive constructs formed from: WR, backward counting, SS, TICS | Global cognition, memory, mental status | cognition and fluid cognition. Being widowed was not associated with backward counting, subjective memory, or date naming. | Yes |
Notes: nr = not reported; NA = not applicable; CE 8 = Eight-item Informant Interview to Differentiate Aging and Dementia; AVLT = Auditory Verbal Learning Test; B-ADL = Bayer-Activities of daily living scale; BNT = Boston Naming Test; CCCE = Cross Cultural Cognitive Examination; CDR = Clinical Dementia Rating Scale; CDT = clock drawing test; COWAT = Controlled Oral Word Association Test; CVLT = California Verbal Learning Test; DSB = Digit Span Backward; DSF = Digit Span Forward; DSST = Digit Symbol Substitution Test; e-Stroop = emotional counting-Stroop; FOME = Fuld Object Memory Evaluation; FCSRT = Free and Cued Selective Reminding Test; GNG = Go-No-Go Test; HMSE = Hindi Mental State Exam; IADLs = Instrumental Activities of Daily Living; IQCODE = Informant Questionnaire on Cognitive Decline in the Elderly; LMDR = Logical Memory Delayed Recall; MCI = mild cognitive impairment; MMSE = Mini Mental State Exam; RCFT = Rey-Osterrieth Complex Figure Test ; CPM = Raven’s Coloured Progressive Matrices; TEA = Test of Everyday Attention; TICS = Telephone Interview for Cognitive Status; TMT = Trail Making Test; SDMT = Symbol Digit Modalities Test; SS = Serial 7 Test; SR = Story Recall (immediate and delayed); TICS-m = modified TICS; WAIS- R = Wechsler Adult Intelligence Scale Revised; WR = Word recall (immediate and/or delayed); VRT = Visual Retention Test ; WCST = Wisconsin Card Sorting Task; WTAR = Wechsler Test of Adult Reading.
a
Reference group is widowed network (mostly widowed individuals) but reported results are based on comparison between widowed network and married couples with diverse networks.
b
Age was divided into two cohorts, 35–60 and 65–85.
c
Value is median age.
d
Age at mid-life/baseline.
*
Indicates estimates calculated by Wu et al. based on information provided by authors.