Prolonged Grief and Cognitive Decline: A Prospective Population-Based Study in Middle-Aged and Older Persons

Loneliness and global cognitive functioning in racially and ethnically diverse US midlife and older adults

Introduction

Few studies have examined the association of loneliness and cognitive functioning in the US. We used two common measures of loneliness and examined their association in a large sample of US Black, Latino, and White adults (ages ≥ 50).

Methods

We analyzed Wave 3 of the National Social Life, Health, and Aging Project (N = 2,757). We examined loneliness using one item from the CES-D and the Felt Loneliness Measure (NFLM); cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA) tool, where higher scores indicated better functioning. We used weighted ordinary least squares regressions to examine the effects of loneliness (CES-D loneliness and NFLM in separate models) on MoCA scores. In exploratory analyses, we examined if these relationships varied by race and ethnicity. We adjusted all models for sociodemographic and other salient factors (e.g., chronic disease, depressive symptoms, living alone).

Results

Mean age was 63.49 years, 52% were female, and 9% were Black and 6% Latino persons. Approximately 54% endorsed feeling lonely on at least one measure; 31% (CES-D) and 46% (NFLM). The relationship between loneliness measures was positive and significant, X 2 (1, N = 2,757) = 435.493 p < 0.001. However, only 40% of lonely individuals were identified as lonely on both assessments. CES-D loneliness was inversely (βˆ = -0.274, p = 0.032) associated with MoCA scores and this association did not vary by race and ethnicity. Greater NFLM loneliness was positively associated (βˆ = 0.445, p < 0.001) with higher MoCA scores for Latino participants only.

Discussion

Loneliness appears to be an important predictor of cognitive functioning. However, the association of loneliness and cognitive functioning varied when using the CES-D loneliness item or the NFLM. Future work is needed to understand how loneliness and its clinically relevant dimensions (social, emotional, existential, chronicity) relate to global and individual cognitive domains. Research is needed with racially and ethnically diverse midlife and older adults, particularly to understand our counterintuitive finding for Latino participants. Finally, findings also support the need for research on interventions to prevent cognitive decline targeting loneliness.

Neuropsychological correlates of early grief in bereaved older adults

Prolonged grief disorder (PGD) is associated with impairments in cognitive functioning, but the neuropsychological correlates of early grief in older adults are poorly understood. This preliminary study cross-sectionally examined neuropsychological functioning in bereaved adults with high and low grief symptoms and a non-bereaved comparison sample and further explored the relationship between multidomain cognitive measures and grief severity. A total of ninety-three nondemented older adults (high grief: n = 44; low grief: n = 49) within 12 months post-bereavement and non-bereaved comparison participants (n = 43) completed neuropsychological battery including global and multiple domain-specific cognitive functioning. Linear regression models were used to analyze differences in multidomain cognitive measures between the groups and specifically examine the associations between cognitive performance and grief severity in the bereaved, after covariate adjustment, including depressive symptoms. Bereaved older adults with higher grief symptoms performed worse than those with lower symptoms and non-bereaved participants on executive functioning and attention and processing speed measures. In the bereaved, poorer executive functioning, attention and processing speed correlated with higher grief severity. Attention/processing speed-grief severity correlation was seen in those with time since loss ≤ 6 months, but not > 6 months. Intense early grief is characterised by poorer executive functioning, attention, and processing speed, resembling findings in PGD. The putative role of poorer cognitive functioning during early grief on the transition to integrated grief or the development of PGD remains to be elucidated.

An Examination of Cognitive Function Abilties in Bereaved Adults

Grieving individuals experience changes in cognitive function. The purpose of this study was to examine factors that are associated with a decline in cognitive function in grieving adults. Questionnaires for sleep, depression, anxiety, self-efficacy to manage emotions, and cognitive function were completed. 69% of the grieving adults (N = 134) reported a decline in cognitive function. Anxiety and self-efficacy to manage emotions were associated cognitive function abilities (RMSE = 6.32, AdjRSQ = .32, AIC = 486.12). Bereavement programs may want to consider adding existing interventions, to improve anxiety and self-efficacy to manage emotions.

Competitive Neurocognitive Processes Following Bereavement

Bereavement is a common human experience that often involves significant impacts on psychological, emotional and even cognitive functioning. Though various psychological theories have been proposed to conceptualize the grief process, our current understanding of the underlying neurocognitive mechanisms of grief is limited. The present paper proposes a neurocognitive model to understand phenomena in typical grief, which links loss-related reactions to underlying learning and executive processes. We posit that the competitive relationship between the basal ganglia (BG) and circuitry involving the medial temporal lobe (MTL) underlies common cognitive experiences in grief such as a sense of "brain fog." Due to the intense stressor of bereavement, we suggest that these two systems' usually flexible interactive relationship become imbalanced. The resulting temporary dominance of either the BG or the MTL system is then manifested in perceived cognitive changes. Understanding the underlying neurocognitive mechanism in grief could inform ways to best support bereaved individuals.

Attentional bias during acute grief predicts clinical outcome in suicide-related bereavement

BACKGROUND

Individuals who have lost a loved one to suicide are at increased risk for developing complicated grief (CG). It is unclear why only a subgroup of bereaved develops pathological forms of grief. Vulnerability may be related to the ability to regulate attention toward reminders of the deceased during the acute phase of grief. Using a longitudinal design, we determined whether loss-related attentional bias during acute grief predicts grief severity one year later.

METHODS

Thirty-seven participants grieving a first-degree relative or partner to suicide in the prior 6 months performed an emotional Stroop task using words related to the deceased, a living attachment figure, living non-attachment figure, and color congruent Stroop to quantify related attentional bias during the acute grief period. Clinical interviews were conducted at baseline (N = 37) and one year later (N = 35).

RESULTS

Participants showed greater attentional bias to deceased-related word trials compared with living attachment, non-attachment, and congruent trials, controlling for age, time since loss, depression, and psychiatric medication. A greater reduction in grief severity over time was associated with more deceased-related attentional bias at baseline. Self-reported grief avoidance was related to deceased-related attentional bias, with lower avoidance scores associated with greater bias.

LIMITATIONS

Lack of non-suicide grief control and small sample size.

CONCLUSIONS

Less deceased-related bias following the loss may hinder the transition from acute to integrated grief and result in poorer grief trajectories.

Grieving as a form of learning: Insights from neuroscience applied to grief and loss

Recent grief research suggests that the influential cognitive stress theory should be updated with evidence from cognitive neuroscience. Combining human and animal neuroscience with attachment theory, we propose that semantic knowledge of the everlasting nature of the attachment figure and episodic, autobiographical memories of the death are in conflict, perhaps explaining the duration of grieving and generating predictions about complications in prolonged grief disorder (PGD). Our gone-but-also-everlasting model emphasizes that grieving may be a form of learning, requiring time and experiential feedback. Difficulties before loss, such as spousal dependency or pre-existing hippocampal volume, can prolong learning and predict PGD. Complications such as avoidance, rumination, and stress-induced hippocampal atrophy may also develop after loss and create functional or structural mechanisms predicting PGD.

Why do mothers never stop grieving for their deceased children? Enduring alterations of brain connectivity and function

A child's death is a profound loss for mothers and affects hundreds of thousands of women. Mothers report inconsolable and progressive grief that is distinct from depression and impacts daily emotions and functions. The brain mechanisms responsible for this relatively common and profound mental health problem are unclear, hampering its clinical recognition and care. In an initial exploration of this condition, we used resting state functional MRI (fMRI) scans to examine functional connectivity in key circuits, and task-based fMRI to examine brain network activity in grieving mothers in response to pictures of their deceased child and as well as recognizable deceased celebrities and unfamiliar individuals. We compared nine mothers who had lost an adult child and aged-matched control mothers with a living child of a similar age. Additionally, we collected diffusion imaging scans to probe structural connectivity and complemented the imaging studies with neuropsychological assessments. Increased functional activation in Ventral Attention/Salience Networks accompanied by a reduced activation in the medial prefrontal cortex in response to the deceased child's picture robustly distinguished the grieving mothers from controls. Heightened resting-state functional connectivity between the paraventricular thalamic nucleus (PVT) and the amygdala distinguished the grieving mothers from the controls and correlated with subjective grief severity. Structurally, maternal grief and its severity were associated with alterations in corticolimbic white matter tracts. Finally, grieving mothers performed worse than controls on neuropsychological tests of learning, memory, and executive function, linked with grief severity. Reduced activation in cortical regions inhibiting emotions and changes in the PVT circuitry-a region involved in long-term emotional memories and decision making under conflict-distinguish grieving mothers from controls. Notably, the magnitude of neurobiological changes correlates with the subjective severity of grief. Together, these new discoveries delineate a prevalent and under-recognized mental health syndrome and chart a path for its appreciation and care.

Associations between life course marital biography and late-life memory decline

Late-life marital status is associated with cognitive aging; however, the influence of life course marital biography (i.e., changes in marital status) on late-life cognitive trajectories, as well as gender differences in the effects of marital biography, remain to be explored. Associations between (a) marital status at study baseline (currently married, previously married, never married) and (b) retrospectively reported life course marital biography (i.e., age at first marriage, time spent unmarried following initial marriage, history of divorce, history of widowhood) and up to 20 years of subsequent episodic memory trajectories were examined using latent growth curve models in 3,061 participants aged 51 + in the Health and Retirement Study 2017 Life History Mail Survey. Gender differences were examined with multiplicative interaction terms and stratified models. Participants who were married at study baseline demonstrated higher initial memory than previously and never married individuals. Older age at first marriage and shorter duration spent unmarried were each associated with better initial episodic memory among previously married individuals only; longer duration spent unmarried was associated with slower memory decline. Stratified models suggested that these associations may be driven by women. These results highlight the importance of considering multiple aspects of marital biography, not just current marital status, in cognitive aging research. Marital biography may have an enduring influence on cognitive aging, particularly among previously married older women. Future work is needed to identify mechanisms (e.g., socioeconomic resources, cognitive stimulation, self and spousal health, emotional support) through which marital histories influence cognitive aging. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Neuropsychiatric Complications of COVID-19: What is to be Expected

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Amygdala Functional Connectivity Features in Grief: A Pilot Longitudinal Study

OBJECTIVE

Acute grief, in an important minority of older adults, can become protracted, intense, and debilitating, leading to the development of complicated grief (CG). However, the neurobiologic mechanisms underlying a maladaptive grief response after an attachment loss are unknown. The current study aimed to examine the amygdala brain network features that cross-sectionally explain the symptom variance and longitudinally relate to grief symptom trajectories after an attachment loss.

METHODS

Baseline amygdala functional connectivity (Fc) was assessed using a seed-based resting-state functional magnetic resonance imaging method in 35 adults who were within 1-year after death of a loved one and 21 healthy comparison (HC) participants. Magnetic resonance imaging scans were obtained at baseline, and clinical assessments, including the inventory of complicated grief (ICG) were completed at weeks 0, 8, 16, and 26 (endpoint).

RESULTS

Relative to HC participants, grief participants showed increased amygdala Fc in the posterior default mode (bilateral medial temporal lobes and left precuneus) and thalamus. Amygdala Fc in the default mode and ventral affective regions positively correlated with ICG scores at baseline. Furthermore, increased baseline amygdala functional connections with the dorsal frontal executive control and salience network regions correlated with worsening ICG scores over time. These longitudinal findings persisted after controlling for covariates, including baseline depressive and anxiety symptoms.

CONCLUSION

These results provide novel preliminary evidence suggesting amygdala-based brain network measures to cross-sectionally explain symptom variance and longitudinally correlate with grief symptom trajectories in grievers. Amygdala brain network function measures may have the potential to serve as biomarkers of CG.

A Systematic Review of Treatment Options for Grieving Older Adults

Purpose of review

a)The purpose of this systematic review was to characterize the studies published on grief interventions for bereaved older adults in the last 5 years. Grief intervention studies were included that exclusively focused on older adults as well as those that included older adults in their samples, in order to summarize the most up-to-date treatment options available for bereaved older adults.

Recent findings

b)Twenty-four articles that investigated grief interventions in older adults were identified. Generally, findings suggest viable treatment approaches for bereaved older adults are those incorporating behavioral activation and guidance on restoration-oriented coping. However, similar to studies of broader adult populations, grief interventions had small effects on grief-related symptoms in older adults. Few studies examined age as a moderator of treatment effects. Studies varied greatly by study design, sample size, and outcomes measured, which all likely impacted the efficacy of results.

Summary

c)This review suggests that, while there has been a growing focus on older adults, who have unique vulnerabilities in bereavement, the evidence-base of efficacious interventions for this population is limited. Given the need for specialized bereavement support for older adults will increase in the coming years, future research should prioritize rigorous investigations of grief treatment options leveraging technology to increase access and incorporate techniques that enhance engagement in life and connectedness for this vulnerable population.

Objectives, design and main findings until 2020 from the Rotterdam Study

The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the city of Rotterdam, The Netherlands. The study aims to unravel etiology, preclinical course, natural history and potential targets for intervention for chronic diseases in mid-life and late-life. The study focuses on cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1700 research articles and reports. This article provides an update on the rationale and design of the study. It also presents a summary of the major findings from the preceding 3 years and outlines developments for the coming period.

Grief Before and After Bereavement in the Elderly: An Approach to Care

Grief is the natural response to the death of a loved one and is encountered frequently in clinical practice with the elderly; it can also precede the death. Knowledge about four distinct forms of grief can aid clinicians with the conceptualization of grief, and the assessment and care of grievers. First, predeath grief is experienced by many caregivers of terminally ill patients. Second, acute grief arises immediately after the death of a loved one; and third, this normally evolves to a permanent state of integrated grief after a process of adaptation. Finally, failure of adaptation results in Prolonged Grief Disorder (PGD) which has been recently included in ICD-11. The hallmark feature of PGD is intense longing for the deceased or persistent preoccupation with the deceased that lasts longer than 6 months after the death. Validated instruments are available to assist practitioners with assessment of predeath grief and screening for PGD, thereby enabling identification of patients in need of additional support. Increased risks of morbidity and mortality following bereavement are important health issues for clinicians to be aware of. All grievers can benefit from support focused on understanding their grief, managing emotional pain, thinking about the future, strengthening their relationships, telling the story of the death, learning to live with reminders of the deceased, and connecting with memories. A short-term evidence-based intervention for PGD is based upon these seven themes and is efficacious in the elderly. Caregivers of the terminally ill benefit from psychological support that validates and normalizes their grief experiences and helps them recognize and accept their losses.

Complicated grief knowledge, attitudes, skills, and training among mental health professionals: A qualitative exploration

The knowledge, attitudes, skills, and training of professionals regarding complicated grief influence their practice. We conducted 30 semi-structured interviews with psychiatrists, psychologists, and counselor/psychotherapists; the preliminary findings were contextualized via interviews with three experts in complicated grief research/practice. Findings suggest that professionals did not substantially rely on research evidence, favoring instead personal and professional knowledge. They expressed concern regarding the possible pathologization of normal grief that might arise from having a diagnosis of complicated grief. Deficits in professional training were evident. A need for an improved culture of collaboration between researchers and practitioners was identified.

Prolonged grief disorder in Chinese Shidu parents who have lost their only child

Background: China has the largest population of '"loss-of-only-child' parents, that are also known as Shidu parents in Chinese society; however, little is known about their unresolved grief. Objective: This is the first study to examine the grief symptoms, prevalence, comorbidity and potential predictors of prolonged grief disorder (PGD) in such parents, taking into consideration that the new PGD diagnostic criteria ICD-11 will soon be implemented in China. Methods: 149 Shidu parents completed assessments of PGD (PG-13), PTSD (PCL-C), depression (CES-D) and general psychiatric morbidity (GHQ-12) via in-person interviews. Results: Of the 149 Shidu parents, 22.2% met the PGD criteria, with a mean of 7.59 years post-loss, and 62.4% experienced daily longing or yearning. Regression analysis indicated that fewer years since loss, subjective perception of poor economic situation, female gender and more hospital visits were prominent risk factors for the development of PGD. Older age of the parents at the time of child loss was also associated with PGD. Parents with PGD had higher comorbidity of PTSD or depression compared with those without PGD. Conclusions: There is a high prevalence of PGD and a high rate of comorbidity between PGD and PTSD or depression in Shidu parents in China, which highlights the need of timely developing effective assessments and interventions to prevent PGD in this population, particularly in female, recently bereaved, low-income and aged parents who lost their only child.

Trajectories of cognitive decline by widowhood status among Korean older adults

OBJECTIVES

Given the limited evidence regarding the longitudinal impact of widowhood on cognitive function in later life, the present study aimed to investigate the longitudinal effect of widowhood status on cognitive change among Korean older adults.

METHODS

The study sample was drawn from a nationally representative data set, the Korean Longitudinal Study of Ageing (KLoSA); it consisted of 3,660 Korean adults aged 60 and over who were married at baseline. Our dependent variable, cognitive function, was measured by the Korean version of the Mini-Mental State Examination (K-MMSE). Widowhood status was measured with the combination of widowhood status and duration. Growth curve models were constructed using five waves of the KLoSA (2006-2014) to examine the longitudinal trajectories of cognitive changes.

RESULTS

In the unadjusted model, widowed older adults had significantly lower cognitive function than their nonwidowed counterparts regardless of widowhood duration. Adjusting for covariates, results from the growth curve models showed that widowed older adults with widowhood duration 4 to 6 years had a significantly steeper decline in cognitive function than nonwidowed older adults (P < 0.05).

CONCLUSIONS

These findings suggest that widowhood is detrimental for late-life cognitive function. Further research is required to understand the mechanisms underlying this relationship. Policy and practice implications are discussed according to the cultural context.

Grief: A Brief History of Research on How Body, Mind, and Brain Adapt

OBJECTIVE

Using an integrative view of psychology, neuroscience, immunology, and psychophysiology, the present review of literature curates the findings that have had an impact on the field of bereavement research and shaped its development.

METHODS

Beginning with pivotal systematic descriptions of medical and psychological responses to the death of a loved one by Lindemann in the mid-1940s, this selective review integrates findings in bereavement research from studies that investigate medical outcomes after loss, their psychological predictors, and biopsychosocial mechanisms.

RESULTS

Morbidity and mortality after the death of a loved one have long been a topic of research. Early researchers characterized somatic and psychological symptoms and studied immune cell changes in bereaved samples. More recent research has repeatedly demonstrated increased rates of morbidity and mortality in bereaved samples, as compared with married controls, in large epidemiological studies. Recent developments also include the development of criteria for prolonged grief disorder (also termed complicated grief). Newer methods, including neuroimaging, have observed that the greatest impact of the death of a loved one is in those who have the most severe psychological grief reactions. Research addressing the mechanisms tying bereavement to medical outcomes is relatively scarce, but differences in rumination, in inflammation, and in cortisol dysregulation between those who adapt well and those who do not have been offered with some evidence.

CONCLUSIONS

Recommendations to propel the field forward include longitudinal studies to understand differences between acute reactions and later adaptation, comparing samples with grief disorders from those with more typical responses, and integrating responses in brain, mind, and body.