Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho

Eric 00:11

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have with us today? I heard it’s a disruptive group.

Alex 00:18

It’s disruptive. We’re delighted to welcome back to the GeriPal podcast Lauren Hunt, who’s a hospice and palliative care nurse, researcher and associate professor at the Institute for Health Policy Studies at UCSF. Lauren, welcome back to the GeriPal Podcast.

Lauren 00:34

Great to be here.

Alex 00:35

And we’re delighted to welcome Rebecca Rodin, who is a palliative medicine physician researcher at Mount Sinai School of Medicine in New York City. Rebecca, welcome. Good to have you. And we’re delighted to welcome Tsai-Chin Cho, who’s an epidemiologist, recently grad, her PhD woo, and research specialist at the University of Michigan in the School of Public Health. Tsai-Chin, welcome to Geripal.

Tsai-Chin 01:02

Thank you. Glad to be here.

Eric 01:04

We’re going to be talking about disruptive events before we jump into what actually is a disruptive event and what do we know about that from the research studies that we’ll be going over? I think somebody has a song request. Is it you, Rebecca?

Rebecca 01:20

I do. I do have a song request for you as a huge Leonard Cohen fan. It’s one of his all time classics. So it’s Who by Fire by Leonard Cohen. And he’s a fellow Canadian who lived in Montreal where I used to live. And he actually apparently lived in the same neighborhood and used to go to the same bagel shop, but I never got a chance to meet him.

Eric 01:42

That’s wonderful.

Alex 01:43

And did you say that this is based on like a chant or something?

Rebecca 01:48

Yeah. So the song was released actually in 1974. It’s directly inspired by the Jewish prayer Unatanetoke, which is probably like a more solemn prayer that’s recited during the high holidays of Yom Kippur and Rosh Hashanah. And this song is just really a reflection on mortality and fate and it really discusses kind of who will live and who will die. And it lists various ways by which that could actually happen. So thought it related to our theme of disruptive events about different ways in which you may experience an early demise.

Eric 02:18

I just want to acknowledge the other disruptive event because when you said Leonard Cohen, I’m all, she’s going to pick Hallelujah. Like that is. But you did not pick Hallelujah. That is very disruptive. Yeah, that’s which I think is probably our most requested song.

Alex 02:32

Probably. Yeah. It’s certainly up there. Okay, here’s a little bit.

Alex 02:36

(Alex singing)

Eric 03:16

That was excellent. Great song, Rebecca. Now I gotta listen to that. I’ve never heard that song.

Alex 03:21

Yeah, Leonard Cohen’s great. So ominous.

Eric 03:25

Yeah. You gotta go deeper.

Lauren 03:29

Yeah, I liked Alex’s version. It was a little more upbeat.

Eric 03:33

Yeah, I know.

Rebecca 03:35

Hard to be darker than Leonard Cohen.

Eric 03:38

Yeah.

Alex 03:41

Okay, so today we’re going to talk about disruptive events. And let’s start it off with Lauren. Big picture. What’s a disruptive event?

Eric 03:52

Lauren, thank God you’re starting out with this question. I have no idea what that is.

Lauren 03:57

Yeah, thanks for that question, Alex. Disruptive events are medical, surgical. They can be social events that really change the trajectory that a person has been on. Sometimes people call them health shocks, but we kind of all, like, clinically, intuitively know what these things are. They’re like a major health event that happens to somebody and their situation has really. Has really changed. That’s how. That’s how I think about.

Eric 04:36

Can I ask why? How do you choose between…because I like the term health shock. Like, I get a good idea what a health shock is with a disruptive event. I think I get it. Like, how did you choose between those two? Or has everything just coalesced around disruptive events?

Lauren 04:54

That’s a great question. I actually. Can I turn that back to Alex? Because Alex is the one who originally came up with it.

Alex 05:03

Okay. Do you remember I was heavily involved in the projects that Lauren and Rebecca resulted in? The papers that we’re going to discuss today, including the grant.

Eric 05:14

Tell me, Alex, why not health shock?

Alex 05:17

I like the term health shock. I don’t think that we have to, you know, coalesce around one singular term. I think we’re talking about the same concept here. And I think that, you know, health shock. Health shock is really dramatic. Right. And maybe that sort of drama is warranted. But I think, as Lauren will talk about, some of these disruptive events can occur frequently. And. And then, you know, sometimes people have more than one type of disruptive event. Whereas health shock, you know, maybe you could have several health shocks. But it’s so dramatic. To me, it comes across as being like, maybe, you know, it’s a once in A lifetime kind of event. But I don’t know.

Lauren 05:58

I think it also ignores the idea that these events can be social, which we’re going to talk about. So we’re going to talk about, you know, widowhood and wealth shocks. And so if you’re only talking about health shocks, then you miss out on all those really other important events.

Alex 06:13

Yeah, that’s great. So, Rebecca, you were really interested in this idea of disruptive events and for people with different conditions like dementia, cancer, other conditions. Could you say a little bit more about your interest in this area?

Rebecca 06:30

Yeah, absolutely. I think part of this does stem from a clinical experience and also some of the theoretical models that have evolved around serious illness, you know, to think specifically about dementia. And the classic model being one of slow, progressive decline in function and cognition with a pretty unpredictable death. And so that’s been the classic model we think of for dementia. And then when you see clinically patients coming into hospital, they’ll have, you know, they’ll be admitted for aspiration pneumonia.

And perhaps that actually initiates a cascade of events that dramatically accelerates their decline or alters their trajectory. And so I got very interested in this idea that there are these, you know, signal events that can really dramatically alter a clinical trajectory beyond what’s been really taught in some of the classic paradigms.

Alex 07:21

Yeah, I think that’s great. And a couple of classic articles in this area. June Lunney wrote one with, I think Jack Grolnick was a senior author. Joanne Lynn was involved, that describe these different trajectories of end of life. And you can just sort of see the figures, if anybody’s seen them before, they’ll probably be seared into your brain. It’s things like cancer. You have a relatively gradual decline, then you kind of fall off a cliff in terms of function.

Right. And then for dementia, it’s really a slow dwindle over time. And Tom Gill in a subsequent paper, found that indeed, dementia was kind of the only predictable trajectory at the end of life. Most people who had dementia had this slow dwindle. I think what you’re pointing out is that maybe for people with dementia, it’s not just the slow dwindle there might be punctuated by these disruptive events.

Rebecca 08:13

Yeah, And I’ll just add to that, Alex. I think that’s very much true for what we were thinking about in terms of dementia. And part of what made me think about other serious illnesses is that, you know, with cancer and even with organ failure, organ failure, you get this, you know, acute exacerbations that Bring you almost to the point of death, and then you can kind of recover and go home sometimes maybe not exactly to where you were before, but then you have this unpredictable demise.

But, you know, even with cancer, we say, okay, once your function starts to decline, that initiates a trajectory, but we don’t really look one step even more upstream, like, what created that change? And so trying to think a little bit more about what could be driving some of those alterations in the trajectory for all kinds of serious illness.

Eric 08:54

And I love that because I actually love the Tom Gill article because it made perfect sense to me is that, you know, there is no one type of cancer. The functional trajectory with prostate cancer, breast cancer is going to be very different than pancreatic cancer. And I think into my head, oh, it’s cancer, cancer, cancer. But I love this idea, like, what the heck else is going on in their lives? What else is going on? Their health. Most of these people have more than one thing going on with their health, and they have the rest of their lives. Is that what you’re kind of getting at, Rebecca?

Rebecca 09:24

Yeah, definitely. And, you know, I think it’s very interesting. I think intuitively we may have a sense that medical or surgical events can impact your health, but I think it’s maybe less intuitive or perhaps just a little bit more interesting that some of these social events can have a direct, potentially have a direct effect on your medical and overall health as well.

Alex 09:44

That’s a perfect segue. So, Tsai Chen, you’re really interested in social events like the impact of wealth shock, that there’s a difference, dear listeners, from health shock, wealth shock. This is like a dramatic loss of wealth. Saichin, tell us how you got interested in this topic.

Tsai-Chin 10:04

So I think, like, speaking of, like, when Alex, speaking of health shock, that I agree, like, this sounds a drastic term. And then like the wealth shock in our papers do have really, like drastic loss of 75% or greater in household wealth. So it is drastic financial losses. So back to the question about, like, how I get to this idea to look into this specific social, economic, disruptive events. So I recently got my PhD degree and like a few years ago, I was in this desperate need to find my dissertation topic and I was doing this literature review.

And then I see Dr. Lindsay Pool’s paper about, like, so she developed this measurement of a negative oshock, and that measures exactly the same definition as I mentioned, in a very short period of time, two years. And then I was pretty fascinated 26% this. About of the US people that had this experience of such a great financial loss. And then as Rebecca just mentioned, that the process of dementia, the cognitive decline, can take years. And there is this bidirectional relationship between wealth and health shocks. And health shocks. And then I was inspired by this paper and then really interested in looking at the bidirectional relationship between the two of them.

Alex 11:44

Right. And we’ll get more into this when we get into your paper, because this is a very interesting question. Does the wealth shock result in the loss of cognition, cognitive function, or is it that the decline in cognition leads to a loss of wealth? So let’s put a pin in that.

Eric 12:03

I’m interested in that because I hear a lot about people losing their, like, one way, like people get health issue and then lose all their finances, especially in the U.S. but. Oh, that’s parking lot, that one.

Alex 12:14

Yeah, that’s a good one. And I know, Eric, you’ve written about financial insecurity and such as. Well, so we’ll be interested in your thoughts about this. But before we get into the specific articles and we want to dive in, can we just name some different types of disruptive events? So, Lauren, say which ones you’ve focused on?

Lauren 12:34

Yeah. So in our studies, we focused on hospitalization for pneumonia and hip fracture and widowhood, but there’s a lot of other events that we considered using, like things like a heart attack or a stroke, another major surgery.

Eric 13:01

Were those just like exemplar events? Like, why did you choose those three?

Lauren 13:06

Yeah, I mean, I think there was a combination of reasons for choosing them. So one of them was just practical in terms of we could measure them in the Medicare data and they had high enough frequency of events that we could get decent sample sizes to assess them. So those were some of the big reasons why we chose those. And I think that those are like, you know, people can at face value, say, oh, yeah, like having hip fracture is probably going to affect somebody’s health.

Alex 13:41

Outcomes, and hip fracture is kind of like a surgical event. And hospitalization for pneumonia is like a medical event. And then widowhood, Rebecca, is a social event. Any other social events? I mean, certainly loss of wealth would be a social event. Could we just brainstorm for a moment before we dive into the articles, other types of social shocks or social disruptive events people can think of?

Rebecca 14:05

Yeah, I mean, I think there’s still, I mean, they’re related kind of events, but, you know, you think about loss of any important person in one’s life, perhaps somebody who’s also involved in caregiving, you know, also changes in residential Status. Maybe you lose your home or you get evicted from where you’re living or you’re suddenly, no, you no longer have stable housing. Those are all things that could dramatically be a major health shock for an individual.

Alex 14:28

Yeah, yeah. Tai Chen, any other social disruptive events?

Tsai-Chin 14:34

So I do look at widowhood and divorce or separation. So. So that’s also related to marital status.

Alex 14:43

Yeah. Great.

Lauren 14:43

I’m also thinking about, like, natural disasters.

Alex 14:47

That could be another one, like presidential election shock. Yeah, yeah.

Lauren 14:54

Political unrest.

Eric 14:56

Yeah, Political.

Lauren 14:57

Big politics, Lauren.

Alex 15:00

Yeah, right, right. What’s happening to the older adults in Ukraine? Yeah, good question. Well, let’s dive into the articles because we have several articles to discuss. We’ll have links to all of them in our show notes. I think there are four. Lauren, you’re going to talk about the first two, and I think in the first one you’re going to talk about, like, how common are these disruptive events that you examined, hip fracture, hospitalization for pneumonia, and widowhood. How common are these events?

Lauren 15:29

Well, they are very common. And so let me just go back a step and talk a little bit about why we wanted to do this study. So Rebecca talked about how people think about the clinical course of dementia as being this long, slow, dwindling decline. But we all know intuitively as clinicians and as people in the community, we see people have these events and then we see them have a much faster decline after that. The goal of doing these studies was really trying to, as we often talk about the meticulous, as research, as the meticulous documentation, as the blatantly obvious.

But we really wanted to quantify how often these events occur and then what happens to people afterwards, which is the subsequent paper. In this paper, we wanted to understand how often events of hospitalization for pneumonia and hip fracture and widowhood are occurring for people with dementia. And compared to people without dementia, we found,

Lauren 16:43

not surprisingly, people with dementia had a much higher rate of events than people without dementia. So for pneumonia, a way to think about this is that if you followed 1,000 people for a year, about 115 of them would have a hospitalization for pneumonia. And for those without dementia, there was about 60. So there were about 80 people with dementia, about 80% more likely to have a hospitalization for pneumonia than those without. And for hip fracture, it was about 12 people in 1000 in a year and versus 8 in those without dementia. And for widowhood, actually, we’re pretty similar, about 25 versus 22.

Eric 17:37

So about 1 in 10 people with dementia will develop a pneumonia requiring hospitalization yes. And then, yeah, about half as much for people without dementia. But those are matched people for dementia because not that many older adults get hospitalized for pneumonia every year. Is that because that they were, they were matched to this dementia group?

Lauren 18:00

So these people actually weren’t. In the other paper, we, we matched them and we adjusted for some characteristics like age and sex. So in that sense, they’re kind of sort of matched. Yeah, but they weren’t like fully matched.

Eric 18:13

Okay.

Lauren 18:14

But yeah, it’s really. I mean, pneumonia in particular is quite common.

Alex 18:18

I would say pneumonia is extremely common. Yeah, we’re talking about hospitalization for pneumonia. There are probably other pneumonias that don’t are treated as patients or patients are in hospice at the time that they develop the pneumonia and they’re not hospitalized.

Lauren 18:33

Yeah.

Alex 18:34

Okay. So these events are particularly pneumonia, fairly common, followed by hip fracture. And then widowhood was less common.

Lauren 18:45

I mean, still somewhat common. But they were pretty similar in how often they occurred for people with. Without dementia.

Alex 18:51

Okay. So I guess the reason is, the thing is, like, why should we care? You know, so what happens to people who experience a disruptive event?

Lauren 19:01

Yeah, so in our second paper, we asked that exact question. We focus on function and mortality because these are outcomes that really are important to patients and families. What is your function? How are you functioning in your life after an event? And do you die? Those are the outcomes that we focus on. In this paper, we looked at hospitalization for pneumonia and hip fracture, and Rebecca’s going to talk about widowhood later. Then in this paper, we actually matched people with an event to those without an event, using very fancy statistics that we’re not going to get into here.

Alex 19:45

Our listeners will appreciate that.

Lauren 19:48

Then we also compared people with and without dementia. Basically what we found is that for people with dementia who are hospitalized for pneumonia, about half of them will die within one year. This is actually still pretty high. For those without dementia was about 40%. Then for those with hip fracture, it was about 35% die within one year versus 24% for those without dementia. Having one of these events is pretty serious in terms of your risk of mortality. Pretty good prognostic indicator, actually.

Eric 20:32

Are these people in the. In the community? Nursing homes all over the place?

Lauren 20:37

Yeah. So we focused on community dwelling population in the study because some other people have studied nursing home residents actually found pretty similar findings in terms of rates. But also one of the reasons we want to focus on the community was that actually most people with dementia live in the community. It’s like 60 to 70% of them. We felt like, this was a gap we wanted to address. Then I could talk about function.

Alex 21:05

Yes.

Lauren 21:09

These events also had a really big impact on people’s function. What we found is that people with dementia, they were starting at a lower place in terms of their. Their function, and they were declining faster before these events. They had kind of a similar drop at the time of events, but then were more likely to have no recovery or to continue to decline than people without dementia. The thing that I think is really interesting from this finding is just the scores we were getting, the function scores that we’re seeing on these figures, if you want to go look at this, we made some really cool figures. If you want to look up the paper.

People’s function was dropping to scores of around three or four after having these events. This is a really profound level of functional impairment. What this means is we talk a lot about activities of daily living and instrumental activities of daily living in geriatrics. Somebody with this level of functional impairment, the only things that they can really still do are probably, like, they can feed themselves and maybe they can transfer, but they’re not able to dress themselves. They’re not able to get up and go to the toilet by themselves.

They’re not able to shower or bathe by themselves. So this is a really, really profound level of impairment that people are experiencing afterwards. And so having this information is really important as clinicians, when we are caring for patients who’ve had these events, to really help them understand what their future might look like so that we can help guide them through understanding what services and supports they might need, how their caregivers can help care for them, and how to make best use of the time that they have left.

Alex 23:20

And the big picture, just to reiterate for our viewers, is that people who have dementia, who experience a disruptive event, like a hospitalization for pneumonia or hip fracture, they have higher rates of mortality than people who don’t have dementia and experience a disruptive event. And they have a big loss of function and never and don’t recover as well compared to people with that. And as you said, research is the meticulous documentation of the blatantly obvious. And this is really important for people to know because clinicians may have that intuition that this is true, and this is important confirmation that that intuition is indeed backed by. By evidence. And so they should feel more comfortable when they’re talking with patients and doing anticipatory planning, as you say, about what might lie ahead.

Lauren 24:15

Yeah. And I think. And it’s also really important in thinking about our patients with dementia, because so oftentimes, a lot of times, people actually aren’t thinking about this in the context of dementia. You know, they’re seeing their patient in the hospital, and they don’t. May not even know that the patient has dementia, or they might think that, but it’s not been diagnosed. But we really need to be understanding this more within the specific context of dementia.

Alex 24:38

That’s terrific. And maybe we’ll turn now from these medical and surgical events to start talking about social events. Rebecca, you studied widowhood, and you studied the impact of widowhood on people who have dementia and other conditions. Can you say more about what you studied and what you found?

Tsai-Chin 24:59

Sure.

Rebecca 25:00

This is really a continuation and expansion of the papers that Lauren was talking about, looking at cohorts of older adults, but really expanding this to different populations of older adults with serious illness and looking at the impact of widowhood on similar outcomes of their physical function and mortality. We wanted to include those three archetypal serious illnesses that we mentioned, which would be dementia, cancer, and organ failure, because those really are sort of the different. They have different clinical trajectories with high caregiving needs, but with different burdens at different points in time.

And so spouses are typically the ones for patients who provide most of the caregiving support. And that may include treatment, navigation, nursing care, personal hygiene, meal preparation, and medical decision making. And that’s in addition to the financial, emotional companionship, and psychosocial support that spouses typically provide. And so we really look to see what the impact of that might be on these populations with serious illness. And we focused specifically on people who had the older adults who had these serious illnesses, but who already had a little bit of functional impairment. So we wanted to capture people who were probably already requiring a little bit of caregiving support, but who weren’t so far along in their clinical trajectory that we would really lose the ability to measure the impact of widowhood on this population.

We looked at this kind of function like sort of mildly functionally impaired group of older adults with serious illness to see the impact of widowhood. And we had pretty similar findings to Lauren, although not quite as pronounced, but still actually markedly dramatic, considering it’s a social event. We found that in older adults with serious illness in the year following widowhood, there was a drop in function of one of your ADL or IDLs, your activities of daily living, or instrumental activities of daily living. We found that for cancer and for dementia, we had a similar trend in organ failure, but it wasn’t statistically significant. That group was Also a lot smaller in sample size, but there may be something different potentially about that group as well. But just to put that in context, that’s akin to losing the ability to toilet independently or take medication spikes.

Eric 27:16

Can I ask, so is that a 1 drop difference compared to the group that didn’t have widowhood, or is this just natural progression of, of decrease in function with age and a serious illness?

Rebecca 27:27

Yeah, that’s a great question. So we did kind of a couple of sets of comparisons and we compared to people who had each of these serious illnesses, but no event. And so this was really compared to the people with no event whatsoever. So you have this.

Eric 27:39

No event is widowhood, widowhood, loss of a spouse.

Rebecca 27:44

And then we also looked at people who didn’t have a serious illness and said, okay, what happens to the people who do and do not experience widowhood? And we interestingly did not really see any change in function in those individuals, which has somewhat been reported in some places elsewhere, which makes one wonder if they maybe weren’t accounting for serious illness in some of those populations. And you know, the effects are also somewhat similar with mortality. We found a fairly significant increase in one year mortality for people with cancer.

So you’re 47% more likely to die in the year following widowhood if you have cancer compared to if you didn’t have widowhood. And similarly with dementia, you were 14% more likely, which when you don’t have many prognostic tools available for dementia, that’s actually pretty dramatic. We had a similar trend again with organ failure that wasn’t statistically significant.

Eric 28:35

I always thought about the widowhood effect, and my wife is an estate tax attorney, so we’re death and taxes. If we combine ourselves together, the only important topics. Yeah, but you know, one thing you notice is when the guy dies first, you know, oftentimes the women continue to live, but when the woman dies first in a married heterosexual couple, the guy dies pretty quickly afterwards, not infrequently. And there’s this idea of widowhood effect where the mortality for men is actually higher than women if their corresponding spouse dies. Did you break it down in gender at all? Like, are you seeing that?

Rebecca 29:20

I will say what we had a lot of fun thinking about different happy couple versus unhappy couple theories of this outcome. But, you know, perhaps that relates to the effect that, you know, there are studies that show that marriage is protective for like that marriage is protective for men but not for women. And so maybe it’s the loss of.

Lauren 29:37

That protective depends on how fast they get remarried. Yes.

Rebecca 29:45

I Do think it’s interesting because you have the component of there’s grief and loss and then there’s all these material losses in terms of caregiving support. But what was interesting to me is that when you think with the functional changes that we saw, it wasn’t just that people who had existing functional impairment, for example, they just needed somebody else to fill that role or they had to get. Maybe they had to move to a different residential situation because to get the same support, they actually lost additional capacity. So things they were previously able to do, they no longer were able to do. So I just found that an interesting way of thinking about what it means to actually lose a spouse. There’s direct material loss and then there’s a whole other component of psychosocial components and grief and loss and whatever it is that make a spouse potentially beneficial or detrimental to oneself.

Eric 30:33

But you didn’t break it down by gender at all.

Rebecca 30:37

So we didn’t in this study. I mean, I believe at some point we did do a check for gender to see if there were major differences, which there were not. But I mean, they were masked on gender as well.

Eric 30:46

Okay.

Alex 30:47

And I love how this work builds on a couple of giants in the field. The first is Nicholas Christakis, who published a whole series of articles on mortality after death of a spouse. I think the lead article was in the New England Journal. And the other giant whose footsteps you stand on is Amy Kelly, who developed sort of a definition of who are the people with serious illness. Right. And it was her conceptual, like incorporation of functional decline, some measure of functional decline along with a serious illness diagnosis that you’re utilizing here. Rebecca, any final thoughts about the implications of this for clinicians as our audience are primarily clinicians before we move on to Tsai Chen?

Rebecca 31:33

Yeah, you know, I would just, you know, I think that people, when they, I think many people understand that widowhood is an acutely disruptive social event. I think that’s not news. I think having an awareness that in people with serious illness this can come with profound implications for what happens to their function and their chances of survival in the course of a serious illness. For example, a change in function for someone with cancer can determine your treatment eligibility for anti cancer therapies and may initiate that whole cascade we talked about where you drop off the curve.

And so being, I think, a mindful and also using this as a moment to potentially mobilize community resources, home supports, rehabilitation, or other kind of transitional supportive resources to support individuals during this time to help them get through a really critical Period following loss of a spouse.

Alex 32:23

Yeah, and really important here that this is a connection between the social circumstances of patients and their health, their function and their prognosis. And this is like such a key important insight and a great transition into Tsai Chen’s work which has looked at wealth as a predictor of cognitive decline and across countries here in health systems that might provide different levels of support for people experiencing wealth shocks. Cai Chin, can you tell us more? I mean you gave the intro in the beginning saying a wealth shock is like loss of 75% or greater of wealth, which is a tremendous, tremendous shock. Right. That is certainly, I think anybody face validity tremendous. That’s definitely a wealth shock. Tell us more about what you did in this study and what you found.

Tsai-Chin 33:20

So before diving into this, I want to echo a little bit on Lawrence and Rebecca’s work. So in another paper we do have these changes in marital dissolution and that includes separation, divorce and widowhood. And that is a risk factor for a well shock, the 75% or greater financial loss. And in a prior study that a well shock is also linked to mortality. So maybe well shock, it may be a dot IN between widowhood and mortality. And if I get back to the paper that Alex, you just mentioned. So in this cross national comparative study that we study a whale shock over a short period of time, I think it’s three to four years, so it’s a drastic financial loss.

And we look at this whale shock in relation to cognitive function in United States, England, China and Mexico. So two high income countries and two upper middle income countries. And then we find this significant association that a negative shock is associated with a lower level of cognitive function in United States and China, but not in England and Mexico. It’s a little bit surprising because we would have that assumption that maybe we will see this connection in middle income countries rather than high income countries. So some hypothesis we have about this findings is that so in England actually first it’s a rare event for them to have this negro shock in this population.

And a second hypothesis that we have is perhaps the social safety net has done is invisible but important role in preventing this association association for example that in Mexico they have this non contributory pension program introduced in 2007 especially for those aged 70 years old and older and that would reduce the income inequality among older adults. And this expanded pension income in Mexico has been found to promote the memory function of the older population in Mexico. So there may be a reason that the the social safety net plays a role in preventing the negative effect of a negative workshop. It’s repetitive a bit here. So yeah, that’s what we found.

Alex 36:08

This is fascinating. And can you say a little bit more, I think you mentioned a little bit about England. Can you say more about why you hypothesize you didn’t find this decrement in cognitive function in England?

Tsai-Chin 36:25

So first like it’s rare, it’s a rare event. And in England. So in comparison to United states there’s about 26% of the population in the States that have this experience of a negative road shock. I think there’s about only I think less than 10%.

Eric 36:45

And how much is that is because people with health. So England has national health care system. You know, they don’t get bankruptcy from having these health effects which means that they’re not getting the wealth shock that comes after the health shock or are they getting wealth shocks that leads to these health shocks? Goes to the question that was posed parking lotted which is coming first. Is this a check in and an egg.

Tsai-Chin 37:13

So. So actually I think it’s a. There, there’s a practical like datability thing here that we don’t have that much data to make conclusions in England. And then. But, but, but we did another paper focusing on the United States and like we actually find so, so like the exposure still the same, the negative shock. And then we. So this paper is still under review. But like we find this like long term effect of memory decline would potentially lead to a negative offshock which further leads to an acute effect on memory function. So still we have this bidirectional relationship. But there may be a difference between the long term effect and the short term effect.

Alex 38:02

Interesting. So you could have a decline in cognitive function that might lead to a wealth shock that might lead to a further acceleration of decline in cognitive function.

Tsai-Chin 38:17

In memory function for the lower level in memory function as well as in general cognitive function.

Alex 38:26

Wow.

Eric 38:27

I guess a question for Rebecca then. I’m going to ask the same parking lot question. I guess your study was a little different because you have some timeline. Because I always think that caregivers may have a higher mortality rate as their spouse’s functional status worsens as they’re dealing with needing more and more support. I think there is past studies increased mortality for spousal caregivers. How much are you seeing is the functional process is getting worse. Increasing mortality, I guess increasing chance that the spouse is actually going to. I guess this is. No, this is widowhood. Widowhood. Right. So the widow dies and then it just worsens things like Is there a chicken and an egg concern at all with your study?

Rebecca 39:10

Also, great question. And I think you know what I found interesting. There’s a lot of literature on the health, as there should be, on the health of caregivers, and there is relatively little attention to what happens in bereavement for the person who actually has a serious illness. We tend to think about bereavement as something that can only occur to the caregiver, not occur to the patient. But with widowhood, we did, as we were going through various iterations of our data and manipulating it, there’s moments where we thought, are there some populations for whom widowhood might be protective? And perhaps this goes back to this bad, unhappy couple.

But I think when we actually got more clarity in our data and we did many, many extremely thorough and multiple sensitivity analyses to show that we’re looking at people’s function before the widowhood event happens. So we’re not seeing that there are major differences before these widowhood events. It’s really after that they occur. And that’s what that timeframe was.

Alex 40:08

Helpful.

Rebecca 40:09

At the same time, with observational data, you can never be 100% sure about causal inference with anything. So take that with a grain of salt.

Eric 40:16

But I want you to do another study looking at. It’s not uncommon that we see hospice patients who are with us for a while, and then they’re getting all their care in the hospice unit. Their spouse dies and like a couple days later, they die. So there’s the.

Lauren 40:32

I do recall us having, like, some conversations about murdering your spouse that came.

Rebecca 40:38

Up during our research meeting. We’ll never repeat what happened.

Eric 40:41

Okay, lightning question. I see Alex pulling out his guitar. Like if you had a magic wand, you had healthcare providers, like, one thing they. You want them to do differently with the information from your study.

Lauren 40:56

Lauren, I think it’s what I’ve already said. I’m going to repeat what I said. It’s when you have. When you’re taking care of a patient who’s had one of these events, hip fracture, pneumonia, or something else, this is an opportunity to talk about goals of care, provide anticipatory guidance, really sit down with patients and talked about the realities of what the recovery is going to look like.

Eric 41:25

Great. Rebecca.

Rebecca 41:27

I would say just to build on that. I think bereavement support, like I was saying, is often given mainly to caregivers and having a thought about what it means to provide that to patients with serious illness. I think many of us think a patient loses a spouse. Oh, that’s Terrible. I’m sure that will be difficult and maybe don’t for the implications for what bereavement support could do in terms of function and mortality.

Eric 41:49

I love that. TTsai-Chin.

Tsai-Chin 41:51

Well, in general, I think Lauren and Rebecca have both have good thoughts already and just add to the individual or household level, maybe the government level, because I’m also working on whale sharks. So that’s the macro environment and the role in this government policies, how this could play a role.

Eric 42:13

What do you want the government to do? You got a magic wand? You got to pick something.

Tsai-Chin 42:17

Stabilizing the economic environment.

Eric 42:20

Great.

Alex 42:21

In general, yeah. And that’s something that clinicians like. Our audience are mostly clinicians they could advocate for. If we had a system that was, say, more like England’s, then these health shocks might not only occur less frequently, but have less deleterious outcomes when they do occur.

Eric 42:38

All right, Alex, take us away.

Alex 42:41

(Alex singing)

Eric 43:20

Tai Chi, Lauren, Rebecca, thanks for joining us on this podcast.

Lauren 43:24

Thank you so much for having us.

Eric 43:26

And thank you to all of our listeners for your continued support.

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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guests Lauren Hunt, Rebecca Rodin, and Tsai-Chin Cho have no relationships to disclose.

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