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

The matter of grief, loss and bereavement in families of those living and dying in residential aged care setting: A systematic review

The grief, loss and bereavement needs of the families of those living and dying in residential aged care setting is not very well understood. This systematic review examines grief, loss, and bereavement experience of, and interventions relating to, family caregivers of those entering, living and dying in residential aged care. Out of 2023 papers that were identified, 35 met the inclusion criteria which included (n=28) qualitative and (n=7) quantitative intervention studies. The qualitative findings indicated quality of care provided to the resident at the end of their life, and after death care influenced family caregivers' grief reactions. The intervention studies revealed that educational interventions have the potential to lead to some benefits in the context of grief loss and bereavement outcomes. Recognizing the emotional experiences and support needs of families and carers may enhance the understanding of the ageing, caring, dying, grieving pathway for older people and their families.

Suicide After Partner's Death in the Elderly Population: Results From a Nationwide Cohort Study in Italy

OBJECTIVE

This study aims to investigate the effect of partner loss on suicide mortality for surviving partners in the elderly Italian population and to explore differences according to sex and time elapsed since the loss.

DESIGN

This was a historical cohort study.

SETTING

All Italian residents registered by the 15th Italian Population Census (9 October 2011) were linked to emigration records and death certificates for 2012-2017 to track migration, vital status, and cause of death.

PARTICIPANTS

5,068,414 individuals living as a couple, as registered in the census, and aged ≥69 years on January 1, 2012.

MEASUREMENTS

Mortality rate ratios (MRR) estimated through Poisson regression models were used to compare suicide mortality at age ≥75 years between subjects who experienced partner loss and those who did not.

RESULTS

Among people who experienced partner loss, there were 383 suicide deaths in men and 90 in women. Suicide mortality was higher in older men and women who experienced the loss compared to those who did not, and the impact of the spouse loss on mortality was stronger in men (age-adjusted MRR=2.83) than in women (1.41). Among men the excess risk was particularly high during the first year following the loss; in women, no substantial differences in the excess risk were observed over the follow-up period.

CONCLUSION

Study findings provide evidence of the sex differences in the impact of spouse loss based on data from a large national cohort and reinforce the need for monitoring suicide risk in recently widowed older people.

Grief, Social Support, Spirituality, and Depressive Symptoms Among Older Adults in Assisted Living in Kansas

PURPOSE

The purpose of this study was to explore the roles of grief, social support, as well as spirituality on the depressive symptoms of older adults in assisted living in Kansas. This study tested three hypotheses: a high level of grief will be related to a high level of depressive symptoms; high levels of social support (family, friends, and significant persons) will be associated with a low level of depressive symptoms; and high levels of spiritual experience and coping will be associated with a low level of depressive symptoms.

METHODS

This study recruited 316 older adult residents aged 65 or over from seven assisted living facilities in Kansas. This cross-sectional survey was done by face-to-face interviews using the purposive sampling method. Hierarchical multiple regression was used to test the three sets of variables in relation to depressive symptoms: socio-demographics, social support factors, and spiritual factors.

RESULTS

Participants' mean age was 82.6 years, ranging from 65 to 102; 70.9% were female. Married participants consisted of 18.7%, and over 64% were widowed. Hierarchical multivariate regression results indicated that a high level of grief was significantly related to a high level of depressive symptoms. On the other hand, high levels of social support from friends and spiritual coping were significantly associated with a low level of depressive symptoms.

DISCUSSION AND CONCLUSION

Assisted living facilities may consider developing appropriate bereavement, social support, and spiritual intervention programs, which will alleviate the depression issues of older adult residents after the COVID-19 pandemic.

Relation between resilience and personality traits: The role of hopelessness and age

Resilience refers to the process by which individuals use the ability to cope with challenges to successfully adapt to adverse situations, inclining towards the future and hope. The main aim of this study was to analyze the relation between resilience, personality traits, and hopelessness. Furthermore, we conducted comparisons between two age groups: young and older adults. The sample comprised 439 Spanish participants (66.7% women; M = 43.73, SD = 26.41; age range = 18-98 years). The Connor-Davidson Resilience Scale, NEO-Five Factor Inventory, and Beck Hopelessness Scale were used to measure the main study variables. The results revealed a negative relation between resilience and neuroticism, and a positive association with the other personality traits. Additionally, levels of resilience were found to be negatively related to hopelessness. The group of older adults showed significantly lower resilience levels than the young adults, although age was not a significant predictor of resilience. Neuroticism, extraversion, openness, and hopelessness were the only predictors of resilience for the current study. This work contributes to the study of resilience and related factors, by attempting to understand the role of resilience and resistance to risk and how individuals tackle challenges over time, with important implications for mental health.

Patients' experiences and expectations of the General Practitioner's role during bereavement care after losing a loved one: A qualitative study

General practitioners (GPs) are well positioned to support patients during their grieving process. This study investigated patients' experiences and expectations of their GP's role during bereavement care after losing a loved one. Semi-structured interviews (N = 14) were conducted to gain a deeper insight with the aim to improve the quality of primary bereavement care. Results showed a role for GPs in the assessment of and response to patients' needs. Patients had limited expectations of their GP but did appreciate it when their GP showed concern about their loss. It is recommended that GPs discuss bereavement care during patient encounters.

Risk, Resilience, and the Two-Track Model of Dementia Grief Among Spouses of People Living With Cognitive Decline

Pre-death grief in the context of dementia caregiving is a significant risk factor for depression, burden, anxiety, and adjustment difficulties. The Two-Track Model of Dementia Grief (TTM-DG) provides a bifocal perspective addressing the nature of the emotional attachment to a loved one living with cognitive impairment, along with a medico-psychiatric perspective associated with stress, trauma, and change in life. The aims of the present study were to empirically validate the components of the model as to identify salutary and risk factors for maladaptive grief responses. Participants were 62 spouses of people living with cognitive impairment, and a control group of 32 spouses. All completed a battery of self-report questionnaires. Structural Equation Modeling yielded six variables consistent with the TTM-DG: partner's behavioral disorders; caregiver's burden; social support; physical health; attachment anxiety; and dementia grief as an outcome measure. Additional findings addressed participants at risk for grief difficulties. The findings provide empirical support for the utility of the TTM-DG in the identification of risk factors associated with maladaptive responses and pre-death grief following a spousal cognitive decline. The TTM-DG can assist in the formulation of evidence-based evaluations and interventions to assist spouses caring for their loved ones living with dementia.

The Effectiveness of Integrated Group Therapy on Prolonged Grief Disorder of Bereaved People from COVID-19 Randomized Controlled Trial

This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study's conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention (p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.

Loss and Grief in the Context of Dementia Caregiving

As a universal human reaction to perceived and/or actual loss, grief is becoming increasingly pervasive at all levels of society. Among the broad spectrum of loss experiences, those associated with dementia are perhaps of the most complex. The shift toward considering loss and grief within the context of dementia caregiving is promising. However, pre-loss grief is understudied, and interventions are lacking. Only few studies have evaluated the effectiveness of pre-loss psychosocial grief interventions for dementia caregivers. Preliminary findings from an ongoing clinical trial testing the effects of an 8-week, group-based online video intervention with dementia caregivers indicate that compared to precoronavirus disease 2019 pandemic, the experience of loss and separation was exacerbated by loss of control and severe physical contact restrictions in long-term care facilities. Finding effective grief interventions that can be translated into clinical and community-based environments is necessary to alleviate dementia caregivers' emotional distress and improve their quality of life. [Journal of Psychosocial Nursing and Mental Health Services, 60(10), 7-10.].

A Scoping Review of Interventions for Spousal Bereavement in Older Adults

The loss of a spouse is a common and natural life event for older adults. Nearly one of four older bereaved spouses experience prolonged grief, impaired function or chronic depression. Mechanisms underlying these and other long-term health risks are not well understood. We conducted a scoping literature review to examine the interventions and outcomes that have been studied for late-life spousal bereavement to date. We identified 22 studies of group and individual-level interventions with most studies concerning grief processes within the first year. Nearly all studies evaluated emotional and psychological symptoms of loss and a small number evaluated the restoration of adaptive functioning. Four interventions addressed the treatment of complicated grief or grief with major depressive disorder. Qualitative studies explored themes of spirituality and mindfulness. There were 17 controlled studies, including 13 randomized controlled trials. Findings were eclectic, with evidence supporting mindfulness techniques in a group format for emotional and life satisfaction outcomes; an individual, function-based therapy addressing sleep to improve emotion and function; an individual, writing-based emotional expression therapy for short-term improvement in emotion and function; nortriptyline for the treatment of bereavement-related major depressive disorder; a group-based, complicated grief therapy for this condition; an internet-based CBT intervention for prolonged grief; and pharmacotherapy for cardiovascular changes during bereavement. These findings highlight the small literature of methodologically strong intervention studies addressing spousal bereavement in older adults and the need for greater exploration of relevant biological, social, cognitive and behavioral factors to improve short and long term health outcomes.

Review of Grief Therapies for Older Adults

Purpose of Review

The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic.

Findings

The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic.

Summary

Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

Patient Portals to Support Palliative and End-of-Life Care: Scoping Review

BACKGROUND

Although patient portals are widely used for health promotion, little is known about the use of palliative care and end-of-life (PCEOL) portal tools available for patients and caregivers.

OBJECTIVE

This study aims to identify and assess the user perspectives of PCEOL portal tools available to patients and caregivers described and evaluated in the literature.

METHODS

We performed a scoping review of the academic literature directed by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) extension for Scoping Review and searched three databases. Sources were included if they reported the development or testing of a feature, resource, tool, or intervention; focused on at least one PCEOL domain defined by the National Coalition for Hospice and Palliative Care; targeted adults with serious illness or caregivers; and were offered via a patient portal tethered to an electronic medical record. We independently screened the titles and abstracts (n=796) for eligibility. Full-text (84/796, 10.6%) sources were reviewed. We abstracted descriptions of the portal tool name, content, targeted population, and reported user acceptability for each tool from included sources (n=19).

RESULTS

In total, 19 articles describing 12 tools were included, addressing the following PCEOL domains: ethical or legal (n=5), physical (n=5), and psychological or psychiatric (n=2). No tools for bereavement or hospice care were identified. Studies have reported high acceptability of tools among users; however, few sources commented on usability among older adults.

CONCLUSIONS

PCEOL patient portal tools are understudied. As medical care increasingly moves toward virtual platforms, future research should investigate the usability and acceptability of PCEOL patient portal resources and evaluate their impact on health outcomes.

Traumatised, angry, abandoned but some empowered: a national survey of experiences of family caregivers bereaved by motor neurone disease

Background

There are few illnesses as disruptive as motor neurone disease, a fatal neurodegenerative condition, where diagnosis introduces a clinical narrative of inevitable decline through progressive immobilisation into death. Recent evidence suggests that bereaved motor neurone disease family caregivers are more likely to be at moderate or high risk of complicated grief.

Methods

Qualitative data from an anonymous national survey of bereaved motor neurone disease caregivers (n = 393) was examined through thematic analysis to explore the experiences of people who are at low, moderate, and high risk of complicated grief. Up to 40% responded to three open-ended questions: How caregivers viewed their coping strategies; the advice they had for others and what had been positive about their experience.

Results

Ten themes informed the narratives of illness and loss. All three groups shared similar experiences but differed in their capacity to address them. The low-risk group seemed to recognise the uncertainty of life and that meaning needed to be created by them. For the moderate-risk group, while motor neurone disease was a major disruption, they could with support, regroup and plan in different ways. The high-risk group did not have many resources, external or internal. They felt let down when professionals did not have answers and could not see or did not know how to change their ways of responding to this unwanted situation.

Conclusion

The differences in these three profiles and their narratives of loss should alert health and community service providers to identify and address the caregivers' support needs early and throughout the caregiving journey. Motor Neurone Disease Associations are involved throughout the illness journey and need to invest in a continuum of care incorporating end-of-life care and bereavement support. Community grief literacy and enhancement of social networks are keys to improved support from families and friends that can enable the focus to be on feelings of empowerment rather than abandonment.

Health Education as a Means of Addressing Death in the Elderly

Education for death is an emerging field of study in which health education research and proposals are increasingly being made with the aim of acquiring knowledge and skills to promote positive attitudes towards health and preparation for the end of life. The aim of this study is to find out what experience older people have had with death education and the importance they give to health education. A qualitative methodological design was selected using a semi-structured interview. The survey consisted of interviews with 28 participants from the city of Granada (Spain) aged 61 to 78. This qualitative-descriptive study is based on an analysis of older people's experience of education and preparation for death throughout their lives. The results show that, in most cases, the only information received was in childhood and always from a religious perspective. Death and health are closely related, so working on death education helps to improve the quality of life of elderly people. Health education offers ways of coping with the end of life through the transmission of values and practices that make it possible to anticipate and resolve situations of instability or anxiety. Facing death naturally and as just another part of life will help to make healthy ageing possible, through educational proposals related to the integral health of elderly people.

"It's Always Been a Second Class Cancer": An Exploration of the Experiences and Journeys of Bereaved Family Carers of People with Sarcoma

Sarcomas are a group of rare and aggressive cancers, which develop in bones and connective tissue throughout the body. Sarcomas account for only 1-2% of all cancers worldwide; however, mortality rates for sarcoma are high with approximately two in four sarcoma patients dying following a diagnosis. Delays in diagnosis, poor management of symptoms, patients' high symptom loads and high carer burden are all associated with carer distress, which may lead to complications after bereavement. The experience of having a family member referred for palliative care is also distressing for carers, with the realisation that their family member is dying. This study aimed to explore the experiences of bereaved family carers of people diagnosed with sarcoma. A qualitative descriptive design using a social constructionist framework was adopted. Interviews were conducted with sixteen participants, and thematic analysis was used to identify patterns in the data. Four overarching themes emerged: beginning the journey; moving through treatment; transitioning to palliative care; and experiencing bereavement. The narratives were coherent and potent, and people reflected on their journeys. Interventions and supports for bereaved carers could include opportunities for counselling to support reflections, supports for developing a narrative such as writing therapy, and preparation for the death of the family member.

Caregivers' Grief in Acquired Non-death Interpersonal Loss (NoDIL): A Process Based Model With Implications for Theory, Research, and Intervention

The number of family members caring and caregiving for a loved one undergoing physical and mental changes continues to increase dramatically. For many, this ongoing experience not only involves the “burden of caregiving” but also the “burden of grief” as their loved-one’s newfound medical condition can result in the loss of the person they previously knew. Dramatic cognitive, behavioral, and personality changes, often leave caregivers bereft of the significant relationship they shared with the affected person prior to the illness or injury. This results in what we term conditions of acquired “non-death interpersonal loss” (NoDIL). Current approaches to these losses use an amalgam of models drawn from both death and non-death loss. Despite their utility, these frameworks have not adequately addressed the unique processes occurring in the interpersonal sphere where the grieving caregiver needs to reach some modus vivendi regarding the triad of “who the person was,” “who they are now,” and “who they will yet become.” In this paper we propose a process-based model which addresses cognitive-emotional-behavioral challenges caregivers meet in the face of their new reality. These require a revision of the interpersonal schemas and the relationships that takes into account the ongoing interactions with the affected family member. The model and its utility to identify adaptive and maladaptive responses to NoDIL is elaborated upon with clinical material obtained from caregivers of people diagnosed with major neuro-cognitive disorder and pediatric traumatic brain injury. The article concludes with implications for theory, research and clinical intervention.

Top Ten Tips Palliative Care Clinicians Should Know About Bereavement and Grief

Palliative care (PC) focuses on caring for the whole person, from birth to death, while managing symptoms and helping to navigate medical complexities. Care does not stop at the time of death, however, as assisting patients, families, and fellow clinicians through grief and bereavement is within PC's purview. Unfortunately, many clinicians feel unprepared to deal with these topics. In this article, PC and hospice clinicians define and explain bereavement, distinguish normative grief from pathological grief, offer psychometrically sound scales to screen and follow those suffering from grief, and discuss the interaction between grief and bereavement and the physical and mental health of those who are left behind after the death of a loved one.