Meaning-making of dementia caregiving: A systematic review of qualitative studies

BACKGROUND

Being the backbone of informal care for people living with dementia, caregivers suffer overwhelming physical and psychological challenges in their daily caregiving experience. Proactive coping strategies to alleviate the caregiving burden are of utmost importance. Meaning-making emerges as an effective coping approach to benefit caregivers and mitigate their care burden. However, the conceptualisation of meaning-making on its dimensions and process has been ambiguously identified.

OBJECTIVES

To synthesise the qualitative research evidence on meaning-making in a dementia context to identify: (1) the situational dimension in making sense of caregiving scenarios, and (2) how the meaning-making process evolves during dementia caregiving.

METHODS

This systematic review identified 62 qualitative studies published between 1969 and 2022 from the major databases. Eligible studies met the following inclusion criteria: (1) having informal caregivers of people living with dementia; (2) involving meaning-making of care experience; (3) adopting qualitative design; and (4) full-text of research articles. The risk of bias was evaluated using the Clinical Appraisal Skills Programme checklist. By using Qualitative Evidence Synthesis, themes relevant to critical dimensions and phases of meaning-making were generated from the extracted data.

RESULTS

Sixty-two studies involving 2487 subjects were synthesised investigating the critical dimensions and process of meaning-making of dementia care experience. Results indicated that the dementia care experience can be made sense of in several folds: (1) it involved complicated demands from people living with dementia and requires customised care; (2) the dynamics of dyadic interactions with dilemma and ambivalence; and (3) adaptive coping encapsulating perceptions of loss and growth, complied and integrated values, balanced expectations of care and self, and improvement in self-efficacy. The meaning-making process underwent phases of meaning creation (meaning created in initial encounter with dementia symptoms), meaning appraisal (assimilation and accommodation pathways for appraisal), and meaning adherence (integration of the appraised meanings).

CONCLUSION

Findings suggest meaning-making of dementia caregiving is a multi-faceted and multi-phased recursive process. Future implications give directions on the facilitation of meaning-oriented interventions to enhance the awareness of caregiving role and the knowledge of dementia care, learn techniques of reframing and restructuring, and seek meaningful perspectives; and to adopt strategies to overcome the barriers for meaning-making by empowering self-identity, roles and expectations, and the dyadic relationship. In addition, our findings inform future advancement in the conceptualisation and measurement of meaning-making in the context of family caregiving. Optimisation of the meaning-making process inspires professional assistance to enhance caregivers' coping for dementia care experience.

The Relationship Between Adult Attachment and Complicated Grief: A Systematic Review

Attachment insecurity, including attachment anxiety and attachment avoidance, is proposed as a key factor disrupting adaptive recovery following bereavement, resulting in complicated grief. However, findings are inconsistent across studies. This review aimed to synthesise existing research on attachment patterns in adults experiencing complicated grief to better understand this relationship. 22 cross-sectional and longitudinal studies (5149 participants), published between 2003 and 2020, met inclusion criteria. Higher levels of attachment anxiety were consistently associated with symptoms of complicated grief. Higher levels of attachment avoidance were associated with symptoms of complicated grief, although this relationship was less consistent. The review has implications for clinical practice as bereaved adults with insecure attachment histories may be particularly vulnerable to experiencing complicated grief. The research is limited by the reliance on mainly cross-sectional studies. Future research should focus on longitudinal studies, and studies that explore men's experiences, and of individuals living in non-Western countries.

Can a global score be derived from the Integration of Stressful Life Experiences Scale-Short Form (ISLES-SF)? Empirical support for a bi-factor model

The Integration of Stressful Life Experiences Scale-Short Form (ISLES-SF) is a popular, two-factor measure of meaning-making. Although researchers have used this instrument to calculate a global index of meaning-making, there has been little evidence to support this practice. Therefore, the objective of this study was to examine the validity of this approach by analyzing data from 2,380 American adults during the beginning of the COVID-19 pandemic. A series of confirmatory factor analyses, reliability analyses, and concurrent validity analyses support a bi-factor model of meaning-making. These results affirm the practice of not only using the ISLES-SF to measure meaning-making at a global level, but also to interpret its two specific dimensions (Comprehensibility and Footing in the World) as well.

Validation of the Portuguese version of the Integration of Stressful Life Experiences Scale (ISLES) in a sample of bereaved individuals

The Integration of Stressful Life Experiences Scale (ISLES) evaluates the ability to integrate stressful experiences into one's meaning system. The present study developed and validated a version of this scale for a bereaved Portuguese-speaking population, utilizing a sample of 242 adults who had lost a significant other to diverse causes of death. The sample was predominantly female, educated, married, or in consensual unions, and actively employed. Confirmatory factor analysis revealed a two-factor structure, consisting of 13 items, showing adequate local and global goodness-of-fit and supporting the proposed original structure. Convergent evidence based on internal structure was found for the two dimensions (Comprehensibility and Footing in the World). Regarding reliability, Cronbach's alpha and McDonald's omega computed for each factor showed good internal consistency and the average inter-item correlation was considered satisfactory. This psychometric support for ISLES underscores its relevance in enhancing the knowledge of meaning-making processes in the Portuguese context.

Prolonged grief, reconstruction of meaning, and posttraumatic growth in nursing home residents who have lost loved ones

AIM

This study was conducted to determine the relationship between sociodemographic characteristics, prolonged grief, meaning reconstruction, and posttraumatic growth of elderly individuals who have lost loved ones.

METHODS

A total of 122 elderly individuals who had lost loved ones were included in the research conducted in a nursing home.

RESULTS

The levels of Prolonged Grief Inventory (PG-13), Grief and Meaning Reconstruction Inventory (GMRI), and Posttraumatic Growth (PTG) scale were found to be high among the individuals in the study. While the PG-13 scores of single individuals who have lost their spouses are statistically significantly higher compared to married individuals, the scores for GMRI are higher for elderly individuals with chronic illness and expected death compared to those who have experienced sudden loss. A significant negative correlation was also determined between PG-13, GMRI, and PTG scores.

CONCLUSION

Counseling to reconstruct grief and meaning is recommended for at-risk groups. Geriatr Gerontol Int 2024; 24: 364-370.

The associations of grief-related rumination with prolonged grief and posttraumatic stress symptoms: A longitudinal study of bereaved after the 2011 terror attack in Norway

After the sudden and violent death of a loved one, many bereaved experience symptoms of prolonged grief (PG) and posttraumatic stress (PTS). The present study investigated the cross-sectional and longitudinal associations of grief-related rumination with PG and PTS symptoms among bereaved parents and siblings after the Utøya terror attack in Norway on 22 July 2011 (N = 110, Mage  = 43.2 years, 59.1% female). Participants' responses on the Rumination Scale, the Inventory of Complicated Grief and the Impact of Event Scale-Revised 28, 40 and 102 months after the loss were analysed. Cross-sectionally and longitudinally, grief-related rumination was positively and strongly linked with PG and PTS symptoms. When controlling for the baseline levels of PG and PTS symptoms and demographics of the sample, grief-related rumination predicted PG symptoms after 12 months but not after 74 months. Further, grief-related rumination predicted significantly the PTS symptoms of avoidance after 12 and 74 months and hyperarousal after 74 months beyond sample demographics and baseline symptoms. The results suggest that grief-related rumination is an important factor in PG and PTS symptoms after traumatic bereavement.

Do insecure attachment styles predict prolonged grief symptoms? Significant null findings

Insecure attachment is proposed to be a risk factor in the development and persistence of severe grief. Although prior research demonstrates positive cross-sectional and longitudinal correlations between attachment styles and prolonged grief symptoms, controlled longitudinal analyses yield fewer convincing results. Therefore, we sought to further clarify the concurrent and longitudinal associations between these constructs. A sample of 225 bereaved Dutch adults (87% women; Mean age: 48.86 years) participated in a three-wave longitudinal survey including measures of attachment anxiety and attachment avoidance at baseline and prolonged grief symptoms at baseline and 6- and 12-month follow-up. Attachment anxiety and attachment avoidance were significantly positively correlated with prolonged grief symptoms at all time-points. However, multiple regressions, controlling for baseline symptoms, showed that attachment anxiety, attachment avoidance, and their interaction did not predict residual change in prolonged grief symptoms. These findings cast doubt on the proposed role of insecure attachment styles in prolonged grief.

Testing the latent structure of ICD-11 prolonged grief disorder symptoms in the U.K. adult population: An exploratory structural equation modeling approach

The latent structure of ICD-11 prolonged grief disorder (PGD), as measured using the International Prolonged Grief Disorder Scale (IPGDS), was assessed in a large general population sample of bereaved adults from the United Kingdom. Data were derived from Wave 5 of the COVID-19 Psychological Research Consortium Study (C19PRC-UK). Exploratory structural equation modeling (ESEM) was used to assess the latent structure of the IPGDS. Identified factors were explored in relation to known correlates (i.e., gender, age of the bereaved, income, bereavement timeframe, age of the deceased) and functional impairment. Three factors-Loss, Emotional Numbing, and Emotional Reactivity-emerged in the best-fitting ESEM model, χ2 (92, N = 1,763) = 273.70, p < .001, CFI = .97, TLI = .96, RMSEA = .048, SRMR = .020. All factors were significantly associated with bereavement timeframe, βs = -.15--.20, and age of the deceased, βs = -.22--.31. Lower income predicted both Loss and Emotional Numbing; younger age of the bereaved predicted both Loss and Emotional Reactivity; and female gender was a unique predictor of Loss. Functional impairment was associated only with Emotional Numbing, β = .89. The findings highlight the multidimensional structure of PGD. However, the patterns of factor/cross-factor loadings observed in the present study indicate that a "simple" structure was not attainable. Associations between factors and covariates attest to the discriminant validity of the factors, and the association between Emotional Numbing and functional impairment may afford clinicians an opportunity to better understand and target the most disruptive features of grief.

Complicated Grief Following the Traumatic Loss of a Child: A Systematic Review

Complicated grief is a disabling condition that occurs when the natural grief process is disturbed or prolonged. Research demonstrates that complicated grief is more prevalent following the sudden or violent loss of a child. Despite the high incidence of accidental death worldwide, little research has focused on parental grief trajectories following this form of traumatic loss. A systematic review was conducted to explore parental bereavement outcomes following accidental death. Studies were included if they specifically examined complicated grief in parents bereaved by the accidental death of their child. A total of 767 articles were identified and seven studies met the eligibility criteria for review. Poorer outcomes were identified in relation to the mode of death, relationship type, time post-loss, perceived support, perceived justice and comorbidities. Results of the current study may be used to inform the development of clinical practice guidelines for the treatment of complicated grief.

Measurement of Risk Factors Associated With bereavement Severity and Deterioration by COVID-19: A Spanish Validation Study of the Pandemic Grief Risk Factors

The present study translated and evaluated the psychometric evidence of the Pandemic Grief Risk Factors (PGRF) in a sample of 363 people from the general population of Peru who suffered the death of a loved one by COVID-19 (63-4% women and 36.6% men, where 78.5% were between 18 and 29 years old). The findings indicated that the PGRF is a unidimensional and reliable measure. The PGRF items can differentiate between individuals with different levels of risk factors and thus cover a wide range of the latent construct. Also, a greater sense of distress for each of the risk factors for pandemic grief is necessary to answer the higher response categories. Risk factors significantly and positively predict COVID-19-associated dysfunctional grief. The results indicated that the PGRF in Spanish is a measure with adequate psychometric properties to measure risk factors for pandemic grief.

Continuing Bonds after Loss by Suicide: A Systematic Review

The concept of continuing bonds as an alternative to detachment from the deceased person has gained traction in grief literature over the years. Those bereaved by suicide are likely to experience various grief reactions and may be at-risk for adverse grief and mental health outcomes. However, it remains unclear how those bereaved by suicide experience continuing bonds. To address this gap, we conducted a systematic review according to PRISMA guidelines. Searches of peer-reviewed literature in Medline, PsycINFO, Embase, Emcare, EBM Reviews, and Scopus identified 15 studies (2 quantitative and 13 qualitative) reporting on 12 samples, published between 2010 and 2021. The study quality of the quantitative studies was poor, but it was fair amongst the qualitative studies. People bereaved by suicide experienced continuing bonds across a variety of domains and reported mostly positive experiences. Factors that tended to have an impact on the expression of continuing bonds included time since bereavement, relationship to the deceased, social expectations, sex of the bereaved, and the ability of the bereaved to make meaning of the death. The review concludes that most participants reported positive experiences with continuing bonds. However, discrepancies between males and females and between those bereaved by suicide and those bereaved by other causes warrants further investigation. In addition, longitudinal community-based research involving representative samples is needed to understand the evolution and experience of continuing bonds over time in those bereaved by suicide and to inform future efforts in supporting them.

Grief and ruminative thought after perinatal loss among Turkish women: one-year cohort study

BACKGROUND

Among women who have suffered loss of pregnancy, the level of grief decreases gradually. Age, mental health status and childlessness are the factors known to mostly affect women's levels of grief.

OBJECTIVES

To assess the levels of grief among women who experienced perinatal loss and the changes in their ruminative thought styles over the first year after their loss.

DESIGN AND SETTING

One-year follow-up study carried out in a university hospital in Turkey.

METHODS

The study population included 70 women who experienced loss of pregnancy in the hospital. The sample size was calculated using G*Power V3.1. Data were collected at 48 hours, at the third month, at the sixth month and at one year after pregnancy loss, between June 2018 and June 2019. A personal information form, the Perinatal Grief Scale and the Ruminative Thought Style Questionnaire were used for data collection.

RESULTS

The women's highest levels of grief and ruminative thought style were in the first 48 hours. Their tendency towards grief and ruminative thought styles decreased over the repeated measurements during the follow-up. Women aged 20-29 years had the highest levels of grief at the third month after perinatal loss.

CONCLUSIONS

Nursing assessments regarding grief and ruminative thought style over the first 48 hours after perinatal loss should be integrated into nursing care for these women. Grief follow-up programs for these women can be developed through nursing research.

Social isolation and the mitigation of coronavirus anxiety: The mediating role of meaning

This study examined core belief violation and meaning making as mechanisms mediating the relationship between adherence to social isolation policies for mitigating coronavirus transmission and reduced coronavirus anxiety (CA). Adherence to social isolation policies (social distancing, sheltering in place, and cessation of long-distance travel), use of nonsocial precautionary measures (handwashing, wearing a mask), core belief violation, meaning made of the COVID pandemic, and CA were assessed in a sample of 408 North Americans. Process analysis revealed that adhering to social isolation policies predicted lower levels of CA and that this effect was largely mediated by conservation of core beliefs (e.g., in predictability, control, and self-agency) and ability to make meaning of the pandemic. In contrast, exclusive reliance on nonsocial protections such as handwashing and mask wearing was associated with high levels of CA. These results suggest that social isolation policies support the integrity of adherents' meaning systems, thereby mitigating distress, which carries useful implications for both policy and psychological intervention.

Investigation of the relationship between continuing bonds and adjustment after the death of a first-degree family member by using the Multidimensional Continuing Bonds Scale

OBJECTIVES

The study aims to develop a continuing bonds scale, investigate the relationship between continuing bonds and adjustment after loss, and test the moderating role of meaning reconstruction in this relationship.

METHODS

Data were collected from two different samples of 306 (Study 1) and 271 (Study 2) bereaved adults.

RESULTS

The four factors structure of the Multidimensional Continuing Bonds Scale (MCBS) was explored and confirmed. Hierarchical regression analysis revealed that continuing bonds showed a significant relationship with prolonged grief symptoms after controlling the risk factors such as gender, age of the deceased, time since loss, and cause of death. Meaning reconstruction moderated the relationship between continuing bonds and prolonged grief symptoms.

CONCLUSION

The results revealed that the MCBS can be used as a valid and reliable scale to assess the continuing bonds construct. The relationship between continuing bonds and prolonged grief symptoms varies according to the levels of meaning reconstruction.

Circumstances of the death and associated risk factors for severity and impairment of COVID-19 grief

This study examined the relationship between reactions of the bereaved to conditions of the pandemic and severity of their grief and levels of impairment. A total of 831 American adults who lost a loved one to COVID-19 responded to validated measures of dysfunctional grief and functional impairment, as well as items assessing unique complications associated with the pandemic (e.g. resentment toward doctors, social isolation). In combination, circumstantial risk factors accounted for 59% of the variance in social impairment and fully 71% of the variance in pandemic grief, leading to the development of an inventory of Pandemic Grief Risk Factors (PGRF), which displayed a unified factor structure, high reliability and strong convergent validity. Implications for psychological screening and intervention for those bereaved by COVID-19 are briefly noted.

Narrating ambiguous loss: Deficiencies in narrative processing and negative appraisal of consequences

OBJECTIVE

To compare narrative coping with physical and psychological ambiguous loss (AL) and definite loss in terms of distancing (vs. narrative immersion), meaning-making, and subjective biographical consequences.

METHODS

Thirty adults who had lost a parent to death, to going missing, or to Alzheimer disease (N = 90, 67 females; mean age 36.73 years, SD = 7.27; mean time since loss 9.0 years) narrated two loss-related and three control memories.

RESULTS

Individuals with AL were not more immersed in the loss experience, but less successful in finding meaning and in evaluating the loss and its consequences positively compared to those with a definite loss. These group differences were not due to differences in depression, posttraumatic stress disorder, and protracted grief.

CONCLUSIONS

Ambiguity of loss renders meaning-making and coherently narrating loss more difficult, leading to more negative affect, suggesting interventions that help narrating loss coherently in a self-accepting way.

Experiences of Parental Suicide-Bereavement: A Longitudinal Qualitative Analysis Over Two Years

Limited research exists on the experiences of parents bereaved by suicide. Our earlier qualitative analysis examined the experiences of parents’ suicide bereavement at 6 and 12 months after their loss. The current study aimed to extend the analysis over 24 months, outlining the key themes of parents’ suicide bereavement experience. In the frames of a longitudinal study of suicide bereavement in Queensland, Australia, parents were interviewed at 6, 12, and 24 months after their loss. Thematic analysis was used to further explore new themes and three key themes identified in earlier analyses: searching for answers and sense-making, coping strategies and support, and finding meaning and purpose. Results at 24 months revealed a clearer differentiation between strategies adopted by mothers and fathers. Anger and blame had changed towards feelings of depression. A polarization was observed between parents still oscillating in brooding rumination and those who have shifted towards sense-making. The former more frequently reported depression symptoms, and the latter reported a more positive attitude towards life and acceptance of their loss. Consistent with the dual-process model, parents managed to reach acceptance after oscillating between sense-making and meaning making. Findings provide insights how suicide loss affects parents, with implications for postvention.

Pandemic Grief Scale: A screening tool for dysfunctional grief due to a COVID-19 loss

Millions of people are grieving the loss of someone who died of COVID-19. However, there have been no screening tools developed to identify individuals who may be suffering from dysfunctional grief during the pandemic. Therefore, the objective of this study was to develop and evaluate the properties of the Pandemic Grief Scale (PGS), which is a brief mental health screener to identify probable cases of dysfunctional grief associated with a COVID-19 death. This 5-item scale, which was based on 831 adults who lost someone to COVID-19, demonstrated solid reliability (αs = 0.86), factorial validity (PCA and CFA support), and construct validity with strong correlations with suicidal ideation and substance use coping. The PGS measures COVID-19 grief equivalently across demographic groups, and discriminates well between persons with and without dysfunctional grief using an optimized cut score of ≥ 7 (87% sensitivity and 71% specificity). An alarming 66% of the sample scored in the clinical range. The PGS also demonstrates incremental validity by explaining 18% additional variance in functional impairment due to a COVID-19 loss beyond measures of depression and generalized anxiety. These results support the PGS as an efficient and valid screening tool for clinical research and practice during a pandemic.

Modeling pandemic depression and anxiety: The mediational role of core beliefs and meaning making

Background

Methods

Limitations

Conclusions

Regret and unfinished business in parents bereaved by cancer: A mixed methods study

BACKGROUND

Prior research has demonstrated that the presence of regret and unfinished business is associated with poorer adjustment in bereavement. Though there is a growing literature on these constructs among caregivers of adult patients, the literature on regret and unfinished business in bereaved parents has been limited.

AIM

The aim of this study was to examine regret and unfinished business in parents bereaved by cancer, as well as their associations with caregiving experiences and prolonged grief.

DESIGN

This was a cross-sectional mixed methods study that utilized self-report questionnaires with open-ended items.

SETTING/PARTICIPANTS

The multisite study took place at a tertiary cancer hospital and pediatric cancer clinical research institution. Participants were 118 parents (mothers = 82, fathers = 36) who lost a child aged 6 months to 25 years to cancer between 6 months and 6 years prior.

RESULTS

Results showed that 73% of the parents endorsed regret and 33% endorsed unfinished business, both of which were more common among mothers than fathers (p ⩽ 0.05). Parents were on average moderately distressed by their regrets and unfinished business, and both regret-related and unfinished business-related distress were associated with distress while caregiving and prolonged grief symptoms.

CONCLUSION

Findings have implications for how providers work with families, including increasing treatment decision-making support, supporting parents in speaking to their child about illness, and, in bereavement, validating choices made. Grief interventions that use cognitive-behavioral and meaning-centered approaches may be particularly beneficial.

Association Between Prolonged Grief and Attitudes Toward Reconciliation in Bereaved Survivors of the Khmer Rouge Regime in Cambodia

BACKGROUND

During the Khmer Rouge regime in Cambodia, about a quarter of the population died, resulting in many individuals losing close relatives. Still today, many individuals are suffering from the psychological consequences of these losses, which might also affect the process of reconciliation within the Cambodian society. The aim of this paper is therefore to investigate the association between symptoms of prolonged grief and attitudes toward reconciliation.

METHODS

A sample of 775 survivors of the Khmer Rouge regime who lost relatives during the conflict were interviewed about their losses and traumatic events, prolonged grief (PG; Complicated Grief Assessment Self-Report, CGA-SR), posttraumatic stress disorder (PTSD Checklist - Civilian Version) and attitudes toward reconciliation (Readiness to Reconcile Inventory, RRI).

RESULTS

A higher symptom severity of PG was significantly associated with readiness to reconcile even when controlling for other relevant variables (β = -0.22; p <.001). Persons who met caseness criteria for PG were significantly less ready to reconcile, t(773) = 5.47, p <.001, than persons who did not meet caseness for PG.

CONCLUSION

PG seems to be a relevant mental health correlate of attitudes toward reconciliation. The results of the current study underline the importance of also considering PG with regard to the reconciliation process in Cambodia and possibly also in other post-conflict regions.