Late-life bereavement and complicated grief: a proposed comprehensive framework

Prolonged grief disorder prevalence in adults 65 years and over: a systematic review

BACKGROUND

Prolonged grief disorder (PGD) is a recently recognised mental health disorder with an estimated prevalence of 10% in the bereaved adult population. This review aims to appraise and summarise evidence relating to PGD in older adults (≥65 years), a growing population group, most likely to experience bereavement and often assumed to cope well.

METHOD

Literature from Medline, PsycINFO, CINAHL, Cochrane Library and Web of Science was searched. Epidemiological and non-epidemiological studies including data on frequency of PGD in older adults bereaved by mainly natural causes were included and a descriptive analysis undertaken.

RESULTS

From 2059 records, three epidemiological and six non-epidemiological studies were included. Most studies had good internal but not external validity. Conditional prevalence for PGD ranged between 3.2% and 48.8%. Heterogeneity in sample characteristics and study methodology contributed to this variability resulting in a descriptive analysis. The prevalence rate of 9.1% by Kersting et al was the best available estimate for PGD in older adults for western countries. The small number of epidemiological studies and the use of varying PGD-constructs which did not match International Classification of Diseases 11th Revision and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria were the main limiting factors.

CONCLUSION

This first review on PGD prevalence in older adults suggests that, despite studies' methodological short comings, a similar proportion of older adults experience PGD as the general bereaved adult population (1:10). With older adults forming the largest subgroup among the bereaved, health and social care systems need to adapt their provision of care to address the specific needs of older adults.

When goodbyes matter: The conditional relationship between final conversations and symptoms of depression

An online survey of 528 people who lost someone close to them in the last 5 years was used to test associations between having final conversations (FCs) and depression. The direct effect was nonsignificant, but there were two significant moderation effects. Time since bereavement moderated the FC-depression relationship; there was a negative relationship between FCs and depression shortly following bereavement, but no relationship after more time had passed. The age of the deceased also moderated this relationship; there was a negative relationship between FCs and depression when the deceased was older, but no relationship when the deceased was younger.

Group-based compassion-focused therapy for prolonged grief symptoms in adults - Results from a randomized controlled trial

Prolonged grief disorder is a debilitating condition, which affects approximately one out of ten who lose a loved one. While existing meta-analyses have synthesized evidence regarding the overall effect of psychological interventions for pathological grief across different types of psychotherapy, it remains clinically relevant to explore whether specific types of psychological interventions are efficacious in the treatment of grief. The present study investigated the efficacy of group-based Compassion-Focused Therapy (CFT) for adults who had lost a spouse or a parent, and who reported clinically relevant levels of prolonged grief symptoms (PGS) at 11 months post-loss. A total of 82 participants were randomized to the CFT group (n = 42) or the waitlist control (n = 40). Time × group interactions showed no statistically significant effects of the intervention on the primary outcome PGS at post-intervention or 6-month follow-up. Likewise, no statistically significant effects were found for any of the secondary outcomes or process variables, with the exception of posttraumatic stress symptoms and self-reassurance. Taken together, in the present study group-based CFT did not emerge as an efficacious treatment for PGS. Possible explanations include that CFT may not target core maintaining processes in PGS and that the group-based, 8-week operationalization of CFT may be less than optimal.

Effectiveness of late-life depression interventions on functional limitations: A systematic review

Depression is one of the most prevalent mental disorders in older adults and leads to considerable decreases in health, well-being, and impaired functioning. Intervention studies have focused on the effects on symptomatic recovery, and most do not include functional recovery as an outcome. Reduction of functional limitations as a treatment goal in old-age psychiatry aligns with the values of older persons. The objective of this review was therefore to evaluate the effectiveness of late-life depression interventions on functional limitations. This systematic review identified 15 randomized controlled trials in which the effectiveness of different interventions on functional limitations was evaluated in patients with late-life depression. The interventions were categorized into four categories: psychological interventions, drug treatment, physical exercise, and collaborative care. Multicomponent and collaborative-care interventions appear to be the most promising for improvement of functional limitations, particularly in primary care and community-dwelling populations of older persons with symptoms of depression. There is, however, a lack of evidence regarding studies in specialized mental health care.

The past as a resource for the bereaved: nostalgia predicts declines in distress

Nostalgia, a sentimental longing for one's past, can serve as a resource for individuals coping with discomforting experiences. The experience of bereavement poses psychological and physical risks. In a longitudinal study, we examined whether dispositional nostalgia predicted reductions in distress associated with the death of a loved one. Undergraduate students (N = 133) provided information regarding their loss (time elapsed since loss, expectedness) and levels of initial grief, nostalgia, and distress (hyperarousal, intrusion, avoidance) at three time points over a one-month period (Times 2 and 3 occurred one week and one month after the initial session, respectively). Individuals experiencing higher nostalgia reported a decrease in intrusive thoughts across time, whereas those experiencing lower nostalgia reported no change in intrusive thoughts across time. Hyperarousal (physical symptoms, negative feelings) decreased across time among individuals with higher initial grief who experienced greater nostalgia, but increased across time among those with higher initial grief who experienced lesser nostalgia. No changes occurred in avoidance. Nostalgia can palliate bereavement.

Sadness and Worry in Older Adults: Differentiating Psychiatric Illness from Normative Distress

Older adults experience greater emotional well-being in late life. However, older adults may be vulnerable to certain physiologic risk factors, including less physiologic resilience to prolonged stress. Depression and anxiety can be difficult to diagnose in late life owing to differences in self-reported symptoms from younger adults and unclear distinctions between normative and non-normative emotional experiences. We discuss age differences in the presentations of depression and anxiety, and normative and non-normative late life developmental trajectories around bereavement and grief, social isolation and loneliness, and thoughts of death and suicide. We provide recommendations for clinicians for assessing and diagnosing older adults.

Older Adults' Conduct of Everyday Life After Bereavement by Suicide: A Qualitative Study

Background

The loss of a loved one to suicide can be a devastating experience that can have negative long-term effects on the social life and physical and mental health of the bereaved person. Worldwide, an estimated 237 million older adults have experienced suicide bereavement. As assumed in critical psychology, “the conduct of everyday life” reflects the social self-understanding by which people actively organize their lives based on their personal concerns, negotiation with co-participants in various action contexts, and their life interests. Bereaved people may change their social self-understanding as they adjust to their new roles and relationships in everyday life. The aim of this study was to investigate how older adults bereaved by suicide conducted their everyday life during the first 5 years after the loss of a loved one.

Methods

This was a semi-structured qualitative interview study carried out by a research team consisting of co-researchers (older adults aged ≥60 years and bereaved by suicide), professionals, and researchers. The team conducted 15 semi-structured interviews with 20 older adults bereaved by suicide. The interviews were audio-recorded and verbatim transcribed. The participants’ mean age was 67.6 (range 61–79) years at the time of the loss. Data were thematically analyzed through a “conduct of everyday life” theoretical perspective.

Results

We constructed a central theme, “the broken notion of late-life living” in that late-life would no longer be as the participants had imagined. They struggled with their understanding of themselves and other people in social communities when they pursued their concerns adjusting to their broken notions of late-life living. We construed three primary concerns: (1) seeking meaning in the suicide, (2) keeping the memory of the deceased alive, and (3) regaining life despite the loss.

Conclusion

The participants’ bereavement process was influenced by their stage in life. They perceived themselves as having reduced possibilities to restore their life project and limited time to re-orient their life. Age-related factors influenced their possibilities to pursue their concerns in order to adjust to their new life conditions.

Inventory of complicated grief: Factor structure among middle-aged and older bereaved parents

This study examines the psychometric properties and factorial structure of the Hebrew version of Prigerson's Inventory of Complicated Grief (ICG), on 116 middle-aged and older Israeli bereaved parents. Analysis revealed a three-factor structure: emotional distress, yearning for the dead and social-emotional detachment. A high percentage of explained variance and sound internal consistency were found for the entire scale and for all factors, as well as adequate convergent and construct validity. These findings suggest that the Hebrew version of the ICG questionnaire is reliable, valid and appropriate for evaluation of grief in later life.

Older Adults Bereaved by Suicide: A Systematic Literature Search Identifying Zero Studies

The objective of the present study was to identify empirical studies of older adults (≥60) bereaved by the loss of a significant other to suicide. A systematic literature search in CINAHL, Embase, Medline, PsycINFO, and SCOPUS was conducted. The inclusion criteria were empirical studies investigating people bereaved by suicide at age ≥60 published in English or a Nordic language. Although a total of 12,871 references were identified, after screening, no articles fulfilled the inclusion criteria. The study led to the conclusion that there is a lack of research on older adults bereaved by suicide. With the aim of tailoring evidence-based interventions to this group, future research should investigate whether they have particular experiences, psychosocial responses and needs, and help-seeking strategies.

Are older men more vulnerable to depression than women after losing their spouse? Evidence from three German old-age cohorts (AgeDifferent.de platform)

BACKGROUND

Old age is accompanied by a higher risk of losing a spouse. This study aims to longitudinally investigate the effect of widowhood on depression severity with a special focus on sex differences. We examine depression before and after widowhood in men and women separately to investigate which sex is at greater risk after losing a spouse.

METHODS

Data came from the AgeDifferent.de platform, which includes three pooled old age cohort studies. In order to examine factors associated with depression over time, we applied a linear hybrid mixed-effects regression model for the overall sample and analysed additional separate models for men and women.

RESULTS

Of 2470 respondents (mean age at baseline 79.2 (SD 3.64) years), 1256 were men. In total, 209 men and 332 women experienced spousal bereavement after baseline. In general, both sexes showed higher depression severity after widowhood. However, there were significant sex differences. Widowed men were more prone to subsequent depression than widowed women. In terms of depression severity, widowed men differed significantly compared to non-widowed men; however, this was not the case for women.

LIMITATION

We harmonized three cohort studies which used different measurement scales for depression and different recruitment procedures.

CONCLUSION

Our study showed that although both genders suffer from losing a spouse, men are more prone to subsequently develop depressive symptoms. Raising the awareness among practitioners for sex-specific differences as well as developing tailored interventions for both widowed men and women should be considered.

Primary Care for the Elderly Bereaved: Recommendations for Medical Education

The aim of this study was to explore the current practices of primary care physicians (PCPs) in providing bereavement care to elderly patients, with implications for medical education. A total of 63 PCPs answered a brief online survey about their typical practices, barriers, comfort level with bereavement, and confidence in their ability to diagnose prolonged grief disorder (PGD). They were recruited through an online newsletter and contacts of one of the authors. The results found that two-thirds of the PCPs do not routinely screen their elderly patients for recent losses, nor do they refer to mental health clinicians when loss is identified. Barriers included not learning of the deaths in patients' lives and lack of time during clinic visits. Those PCPs who had experienced their own losses were significantly more comfortable in speaking to patients about recent losses and more confident in their ability to diagnose PGD. We recommend bereavement education be incorporated into the medical school curriculum from the outset, utilizing the psychological principle of graded exposure to bereaved individuals.

The Impact of Complicated Grief on Diurnal Cortisol Levels Two Years After Loss: A Population-Based Study

OBJECTIVE

Few studies have focused on the effect of complicated grief-unresolved and prolonged grief-on the neuroendocrine systems. The present study examined the association of complicated grief and normal grief with the diurnal cortisol patterns in a large population-based study.

METHODS

This study was set in the Rotterdam Study and comprised 2084 persons aged older than 55 years (mean [SD] age, 64.9 [5.5] years). Participants were assessed with the Complicated Grief Inventory and classified into no grief (n = 1922), normal grief (n = 131), or complicated grief (n = 31) if they experienced the loss in the past 2 years. Saliva samples were collected to measure cortisol levels. Morning cortisol and summary measures (area under the curve and the slope) were studied to account for the diurnal pattern of cortisol. Persons with depressive disorders were excluded, and analyses were additionally adjusted for depressive symptoms.

RESULTS

Compared to normal grievers, participants with complicated grief showed lower levels of morning cortisol (11.26 vs 15.51 nmol/L; difference, -4.24; 95% confidence interval [CI] = -7.87 to -0.62; p = .022), and lower levels of overall diurnal cortisol (6.89 vs 8.98 nmol/L; difference, -2.09; 95% CI = -3.81 to -0.37; p = .017). No difference was observed in slope between both groups. Participants with complicated grief also showed lower levels of morning cortisol than the nongrievers (11.26 vs 14.71; difference, -3.46; 95% CI = -6.78 to -0.13; p = .042). In contrast, cortisol secretion patterns did not differ between persons with normal grief and nongrieving controls.

CONCLUSIONS

Participants with complicated grief showed low levels of morning cortisol and low overall diurnal cortisol levels characteristic for a chronic stress reaction.

Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis

BACKGROUND

Prolonged grief disorder (PGD) is a bereavement-specific syndrome expected to be included in the forthcoming ICD-11. Defining the prevalence of PGD will have important nosological, clinical, and therapeutic implications. The present systematic review and meta-analysis aimed to estimate the prevalence rate of PGD in the adult bereaved population, identify possible moderators, and explore methodological quality of studies in this area.

METHODS

A systematic literature search was conducted in PubMed, PsycINFO, Embase, Web of Science, and CINAHL. Studies with non-psychiatric, adult populations exposed to non-violent bereavement were included and subjected to meta-analytic evaluation.

RESULTS

Fourteen eligible studies were identified. Meta-analysis revealed a pooled prevalence of PGD of 9.8% (95% CI 6.8-14.0). Moderation analyses showed higher mean age to be associated with higher prevalence of PGD. Study quality was characterized by low risk of internal validity bias but high risk of external validity bias.

LIMITATIONS

The available studies are methodologically heterogeneous. Among the limitations are that only half the studies used registry-based probability sampling methods (50.0%) and few studies analyzed non-responders (14.3%).

CONCLUSIONS

This first systematic review and meta-analysis of the prevalence of PGD suggests that one out of ten bereaved adults is at risk for PGD. To allocate economic and professional resources most effectively, this result underscores the importance of identifying and offer treatment to those bereaved individuals in greatest need. Due to heterogeneity and limited representativeness, the findings should be interpreted cautiously and additional high-quality epidemiological research using population-based designs is needed.

The suffering in silence of older parents whose child died of cancer: A qualitative study

As life expectancy grows, the death of an adult child becomes a highly prevalent problem for older adults. The present study is based on nine interviews and explores the experience of parents (≥70 years) outliving an adult child. The bereaved parents described some silencing processes constraining their expression of grief. When an adult dies, the social support system nearly automatically directs its care towards the bereaved nuclear family. Parental grief at old age is therefore often not recognized and/or acknowledged. Health care providers should be sensitive to the silent grief of older parents both in geriatric and oncology care settings.

Late-Life Bereavement

Healthy aging is critical for the elderly to be independent and enjoy at least a satisfactory quality of life. However, late-life bereavement threatens healthy aging, as it may lead to adverse health effects. Using data from the Health and Retirement Survey, this study investigates the relationship between weight—specifically, body mass index (BMI)—and the loss of a parent, sibling, or spouse at an older age. It is the first attempt to investigate this relationship among the elderly population in the United States and makes the following notable contributions to the literature: (a) use of a large longitudinal dataset, (b) estimation of the effects of a familial death on a person’s BMI, and (c) investigation of the consequences of the bereavement for older people. Our results suggest that losing a family member at an older age results in a decrease in BMI.

Bereavement-related depression in the older adult population: a distinct disorder?

BACKGROUND

Bereavement is a phenomenon that shares many symptoms with depression, and that a great number of older adults experience following the loss of a close relative. The objectives of the present study were to (1) determine whether the symptoms of depression reported by bereaved individuals differ from those with non-bereavement minor/major depression (NBRD), (2) assess whether BRD is as persistent during a one year follow-up as compared to NBRD, and (3) identify factors and consequences associated with BRD.

METHODS

The data used for this study came from the Longitudinal Study ESA (Study Health of Elders), conducted between 2005 and 2008, using a representative sample (n=2811) of community-dwelling older adults, aged 65 and over. To test our hypothesis, an exploratory latent class analysis and multivariate logistic regression were used.

RESULTS

BRD prevalence among older adults suffering from depression was 39%. BRD individuals report all symptoms of depression, but in lower probabilities, and BRD is as persistent as MDD over 12 months, suggesting that it does not differ from NBRD. The principal factors associated with BRD were widowhood and lower level of education. Individuals with BRD are less likely to consult medical services and be dispensed an antidepressant, compared to NBRD.

LIMITATIONS

We have to be cautious when generalizing our findings to individuals with major depression alone, since our results included both minor and major depressions in the same group.

CONCLUSION

No evidence was found that BRD differed from non BRD in terms of depressive symptoms and persistence. The bereavement exclusion criterion in the DSM-IV should be reconsidered.