Couple relationships and health and wellbeing in later life: a policy briefing from the Relationships Alliance. (Click here to download the PDF file)
- The older couple relationship has been largely invisible at all levels – policy-making, commissioning, local service provision.
- Indeed, while we have long recognised for more the importance of family relationships in outcomes for children (and this is reflected in health and social care policy) at the other end of the lifespan, in older adults’ services, the importance of relationships of many decades’ standing may be ignored, and partners separated. The human cost of this is immense and, as research indicates, is reflected in poorer outcomes.
- Over and above the cost in emotional terms, there is a significant economic cost attached to our failure to sufficiently target help to relationships which, if they could hold together, might provide care and containment that is otherwise very expensive to provide in institutional settings.
- There are perhaps signs of the beginnings of change, for example in older people’s IAPT and approaches to dementia care which focus on the couple relationship, but these are relatively sparse at present.
Commitments made by the Coalition Government in 2010 to ‘put funding for relationship support on a stable, long-term footing, and make sure that couples are given greater encouragement to use existing relationship support’ were naturally welcomed by all those who recognise the importance of good quality relationships to the health and wellbeing of children, adults and wider society.
While recent policy initiatives have tended to focus on couples who are about to have or have just had a child, or couples who are struggling with young children (The Three of Us and CanParent, for example), relationship support is relevant to all couples, whatever their life stage and the Relationships Alliance aims to adopt a cradle to grave approach.
With life expectancy increasing by five hours per day, and the number of people aged over 65 set to increase by 51% between now and 2030, many more couples will not only be facing challenges and encountering the kinds of difficulties which relationship support services are set up to address but there will be many more couples where one or more partner has a disability. The number of people in England with moderate or severe disabilities is projected to increase by 32% by 2022 (Nuffield Trust, 2012) and there will be over 50% more people with three or more long-term conditions in England by 2018, compared to 2008 (House of Lords, 2013). Both of these factors have a significant impact on couple relationship quality and functioning.
So while it is crucial that relationship support services are available to, and accessed by, young couples starting out in life together as well as couples across the working age span (support which we might, in terms of its preventative potential, think of as supporting couple relationships for later life), it is equally fundamental that we support couple relationships in later life itself. After all, personal relationships are a key factor in determining how happy our later years will be, with 9 out of 10 people believing that their relationship with their partner is very important to their happiness in retirement, a recent poll has shown (Relate, 2013).
How does our failure to support relationships during adulthood and in later life manifest itself?
While it is important to acknowledge that not everyone who lives alone is lonely (and, indeed, that not everyone who is lonely lives alone), research nevertheless shows that the absence of intimate relationships in particular fosters loneliness, but also highlights that it is the quality of relationships, not the quantity, that matters most to people (Kraus, 1993).
By 2033 4.8 million people over 65 will live alone (Communities and Local Government, 2010). Given that the percentage of divorce in the over 65s has doubled in the decade 2001-11, it is clear that significant numbers of people over 65 are projected to be living alone due to relationship breakdown. Translating the Government's aspirations – that couples are given greater encouragement to use relationship support services – into reality has the potential to reduce the numbers of older people who are lonely by lessening the incidence of relationship breakdown earlier in life.
Widening the uptake of relationship support services by people of working age and in later life may not only reduce the numbers of elderly people living alone however. It could also – given that relationship quality is associated with improved health in a range of areas – result in reduced levels of illness for those suffering from long-term physical health conditions and, as a consequence of this, improved well-being for their partners.
Physical health and long-term conditions
Getting older is not of course an illness in itself; nevertheless, it is associated with a range of long-term conditions such as cardiovascular disease, arthritis and depression. Links between relationship quality and long-term conditions are well-established (e.g. Kiecolt-Glaser, 2001). Research on cardiovascular disease, for example, shows that marital stress may increase the risk of recurrent coronary events (Orth-Gomer, 2000), while marital quality predicts patient survival among patients with chronic heart failure (Coyne, 2001). The quality of couple relationships also has a remarkable impact on survival rates after bypass surgery, with married people being 2.5 times more likely to be alive 15 years after coronary artery bypass grafting (CABG) than those who are not married, and those in high-satisfaction marriages being 3.2 times more likely to be alive 15 years after CABG compared with those reporting low marital satisfaction (King, 2011).
In relation to blood pressure, people with mild hypertension who report higher levels of marital satisfaction exhibit decreased left ventricle mass and lower diastolic blood pressure after 3 years than people with lower levels of marital satisfaction (Baker, 2003). In addition, relationship quality is a better predictor of daily blood pressure, affect and stress than partner status, with high relationship quality being linked to lower blood pressure (Grewen, 2005). Similarly, high marital quality is associated with lower ambulatory blood pressure, lower stress, less depression, and higher satisfaction with life; but that single individuals have lower ambulatory blood pressure than their unhappily married counterparts (Holt-Lunstad, 2008).
Depression, well-being and mental ill health
In the same way that research has shown that poorer relationship quality is associated with poorer cardiovascular health, research has shown that the quality of a person's relationships with a partner predicts the likelihood of major depression disorder in the future (Teo, 2013). And while the implications of these kinds of studies are largely to be still acted upon at a policy or clinical level, just as significant are findings from research which indicate that the physical and psychological health of older couples is dynamically linked. For example, researchers have found strong associations between depressive symptoms (unhappiness, loneliness, restlessness) and functional limitations (the physical inability to perform basic tasks of everyday living) in couples, with each spouse’s symptoms waxing and waning closely with those of their partner’s (Hoppmann, 2011). Such findings show how interdependent emotionally and physically older couples are; and highlights the need for a health and social care system that focuses on a patient and their significant relationship and not solely on an individual patient in isolation.
Furthermore, working on older people’s wellbeing is actually preventative for people developing depression in the longer term. It is encouraging therefore that ‘No health without mental health’, the Government's mental health strategy (Department of Health, 2011), supports both the provision of psychological interventions for people with long-term conditions and psychological interventions to improve older people’s mental health through the Improving Access to Psychological Therapies (IAPT) programme.
IAPT provides support predominantly to individuals rather than couples; however, given that some studies have estimated that over 60% of those with depression attribute relationship problems as the main cause for their illness (O‘Leary, Riso & Beach, 1990; Rounsaville et al., 1979) and that a meta-analysis has found marital dissatisfaction to be ‘associated with both depressive symptoms and diagnostic depression’ (Whisman, 2001), it is concerning that IAPT services have not seen the numbers of older people coming forward that it had hoped (only 5% of the 500,000 seen in IAPT have been older people). Much more work therefore needs to be done to increase the value put on late life relationships.
The health of carers
An area related to that explored in the previous paragraphs is the high incidence of stress resulting from the burden and isolation experienced by carers (950,000 people over 65 are carers (Carers Trust, 2013)). Carers who provide substantial amounts of care are over twice as likely to have mental health problems than those who provide more limited amounts, and over a quarter of those providing over 20 hours a week have mental health problems (Singleton, 2002).
Research also shows that loss of intimacy is associated with carer spouse depression, and that low levels of positive interaction between the partners in the marriages of people with dementia predict the move to residential care, and the death of that spouse with dementia two years later (Wright, 1991) (Wright, 1994).
Furthermore, research shows that closer relationships between carer and the person with dementia are associated with slower decline in Alzheimers’ Disease, and this effect is highest for couple relationships (Norton, 2009).
The care needs and health of people with dementia
In dementia, the importance of the couple relationship is thrown into sharp relief. 800,000 people are estimated to have dementia, according to the Alzheimer’s Society, while one in twenty-five between the ages of 70-79 will develop it, with this ratio increasing to one in six after the age of 80.
Research shows that what might look like small psychological gains in a condition that is progressive and incurable can nevertheless have very important consequences: studies show that the training of carers delays the admission to nursing home by an average of 20 months (Brodaty, 1997) and providing carers with emotional support delays admission to residential care by an average of 500 days (Mittelman, 2006).
An inadequate focus on the couple relationship in later life makes for a more poorly connected society. Research shows that parents’ relationships with their adult children are negatively affected by divorce, which means that older parents get less support (Kalmjin, 2012), something which is particularly worrying given the doubling in the percentage of divorce in the over 60s between 2001 and 2011 (ONS, 2011). Conversely, the loss of relationship with an older parent translates into a reduced availability of kinship care from grandparents (that is, a grandparent with whom an adult son or daughter has a difficult relationship is less likely to be someone whom that son or daughter can call on to help lighten the load when they are looking after small children). Indeed, it is clear that, at all stages of life, relationship distress has consequences that reach beyond the couple, particularly affecting children and grandchildren.
What interventions exist to support couple relationships in later life?
Older people’s IAPT
IAPT data since 2008 reveals that older people benefit as much, if not more, than younger people from this programme (and older people are more likely to complete the intervention). One of the NICE-recommended interventions available through this service is couple therapy for depression. This intervention is designed to treat mild to moderate depression where there is a distressed couple relationship that appears to be a factor in instigating, maintaining, or re-precipitating the depressive symptoms in one partner. It is also the intervention of choice where a close relationship might be a necessary support for treatment adherence (Hewison, 2011).
Living Together with Dementia: A psychosocial intervention for couples where one partner has a dementia
Developed by The Tavistock Centre for Couple Relationships with support from Camden Council’s Innovation Fund, this is a new approach to working with couples where one partner has a dementia. It comprises a brief, structured intervention, using everyday activities, delivered in participants’ homes; ‘Flip’ cameras are used to videotape the partners doing ordinary activities around the house and selected interchanges then played back to the couple as a way in to addressing dynamics between them.
The approach aims to increase shared activity, emotional contact and understanding between the partners - and to counter the tendency towards withdrawal and loss of contact, or the acting out of frustration and anger. The aim is to help people with dementia to manage the trauma of the diagnosis, the loss and the changes it brings and to maintain, or recover, the protective aspects of the relationship.
Changing the culture of care for people with dementia
Acceptance and acknowledgment that older people with dementia have a need for intimacy, love and sexual expression represents something of a challenge to the care sector. However, a guide on the topic of dementia, sexuality and relationships in care homes which was sponsored by the Department of Health and published in 2011 hopes to change this (ILCUK, 2011).
The guide covers the need for those providing care for older people with dementia to promote a culture of acceptance, dignity and privacy for all residents (while remembering not all relationships will be heterosexual), to educate care workers in their employment on the sexual and intimate needs of residents and to include, if possible and if volunteered, the social and sexual history of residents in care plans. Very few care plans address the sexual needs of individual clients, despite the benefits to person-centred care of this aspect of dementia planning; and many couples may wish to maintain a sexual relationship, experiencing sexual intimacy as a source of comfort, reassurance and mutual support (Bouman, 2007).
This briefing was produced by the Tavistock Centre for Couple Relationships on behalf of the Relationships Alliance. The Relationships Alliance, a corsortium comprising Relate, Marriage Care, One Plus One and the Tavistock Centre for Couple Relationships, exists to ensure that good quality personal and social relationships are more widely acknowledged as central to our health and wellbeing
Baker, B., Szalai, J. P., Paquette, M., & Tobe, S. (2003). Marital support, spousal contact and the course of mild hypertension. Journal of Psychosomatic Research, 55, 229–233.
Bouman W. P. (2007). Sexuality and Dementia. Geriatric Medicine. 35, 5, 35–41.
Brodaty, H., Gresham, M., & Luscome, G., (1997). The Prince Henry Hospital dementia caregivers training programme. International Journal of Geriatric Psychiatry 12, pp183-193.
Carers Trust (2013) Key facts and statistics
Communities and Local Government (2010). Updating the Department for Communities and Local Government’s household projections to a 2008 base. Final Report.
Coyne, J. C., Rohrbaugh, M. J., Shoham, V., Sonnega, J. S., Nicklas, J. M., & Cranford, J. A. (2001). Prognostic importance of marital quality for survival of congestive heart failure. American Journal of Cardiology, 88, 526–529.
Department of Health (2011). No Health Without Mental Health: a cross-government mental health outcomes strategy for people of all ages
Grewen, Karen M., Girdler, Susan S., Light, Kathleen C. (2005). Relationship quality: effects on ambulatory blood pressure and negative affect in a biracial sample of men and women. Clinical Methods and Pathophysiology, 10,3, 117-124.
Hewison, D. (2011). A guide to couple therapy for depression. Healthcare Practitioners Journal, April 2011, 32-33
Hoppmann, C., Gerstorf, D., Willis, S., & Schaie, K. W. (2011). Spousal interrelations in happiness in the Seattle Longitudinal Study. Developmental Psychology, 47, 1-8.
Holt-Lunstad, J., Birmingham, W. A., Light, K. C. (2008). Influence of a ‘warm touch’ support enhancement intervention among married couples on ambulatory blood pressure, oxytocin, alpha amylase, and cortisol. Psychosomatic Medicine 70(9), 976-85.
House of Lords Select Committee on Public Service and Demographic Change. (2013) Report of Session 2012–13 Ready for Ageing? Nuffield Trust, Reforming social care: options for funding, May 2012.
ILCUK (2011). The last taboo: A guide to dementia, sexuality, intimacy and sexual behaviour in care homes. International Longevity Centre – UK
Kalmijn, M. (2012) Long-Term Effects of Divorce on Parent–Child Relationships: Within-Family Comparisons of Fathers and Mothers. European Sociological Review, July, 2012
Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 12, 472–503.
Kraus, L. A., Bazzini, D., Davis, M., Church, M., & Kirchman, C. M. (1993). Personal and social influences on loneliness: The mediating effect of social provisions. Social Psychology Quarterly, 56, 37-53.
Mittelman M. S., Haley W.E., Clay O.J., Roth D.L. (2006). Improving caregiver wellbeing delays nursing home placement of patients with Alzheimer’s disease. Neurology 14;67(9), 1592-9.
Norton, M.C., Piercy, K.W., Rabins, P.C., Green, R.C., Breitner, J.C.S., Ostbye, T., Corcoran, C., Welsh-Bohmer, K.M., Lykefsos, C.G., & Tschanz, J.T. (2009) Caregiver-Recipient Closeness and Symptom Progression in Alzheimer’s Disease. The Cache County Dementia Progression Study. Journal of Gerontology: Psychological Sciences, 64B (5), 560-568.
Office for National Statistics (ONS) (2011). Divorces in England and Wales – 2011. http://www.ons.gov.uk/ons/rel/vsob1/divorces-in-england-and-wales/2011/stb-divorces-2011.html
O’Leary, K., Riso, L. P., Beach, R. H. (1990). Attributions about the marital discord/depression link and therapy outcome. Behavior Therapy, 21, 4, 413-422
Orth-Gomér, K., Wamala, S. P., Horsten, M., Schenck-Gustafsson, K., Schneiderman, N., & Mittleman, M. A. (2000). Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. Journal of the American Medical Association, 284, 3008–3014.
Partridge, L. (2009) – Rejuvenating Ageing Research. Academy of Medical Sciences
Relate (2013) - http://www.relate.org.uk/news/102/index.html
Rounsaville, B. J., Weissman, M. M., Prusoff, B. A., Herceg-Baron, R. (1979). Marital disputes and treatment outcomes in depressed women. Comprehensive Psychiatry, 20, 5, 483-490
Teo, A. R., Choi, H., Valenstein, M. (2013). Social Relationships and Depression: Ten-Year Follow-Up from a Nationally Representative Study. PLOS ONE, 10.1371/journal.pone.0062396
Whisman, M.A. (2001). The association between depression and marital dissatisfaction. In S.R.H. Beach (Ed.), Marital and family processes in depression: A scientific foundation for clinical practice (pp.3–24). Washington, DC: American Psychological Association.
Wright, L. (1991). The impact of Alzheimer’s disease on the marital relationship. The Gerontologist, 31, 224-326.
Wright, L. (1994) Alzheimer’s Disease afflicted spouses who remain at home: Can human dialectics explain the findings? Social Sciences and Medicine, 3, 8, 1037-1046.
Young, H., Grundy, E. (2009). Living Arrangements, Health and Well-Being, Understanding Population Trends and Processes, 1, 127-150
 For further information about this approach, see: http://www.tavistockrelationships.org.uk/relationship-help/living-together-with-dementia
The Relationships Alliance, a corsortium comprising Relate, Marriage Care, One Plus One and the Tavistock Centre for Couple Relationships, exists to ensure that good quality personal and social relationships are more widely acknowledged as central to our health and wellbeing.