Loss and Bereavement in the Elderly

Donald P. Bartlett

Marlon Russell

Koenigsberg Jeffrey

M. Moll

CLINICAL PEARLS

Normal grief does not unfold in a series of predictable stages. It is a set of common reactions (e.g., shock, denial, and sadness) that vary in intensity and gradually diminish over time.
Complicated grief is a syndrome characterized by delayed or incomplete adaptation to loss.
Symptoms of complicated grief or major depressive disorder lasting beyond 6 months, or suicidal thinking at any time, indicates a need for mental health evaluation and treatment.
Gradually shifting to palliative care enables consideration of anticipatory grief issues for both patients and families.
A bereavement register enables tracking of patients and families for proactive case management to overcome isolation in elderly bereaved.
Writing a letter of condolence can be a simple yet powerful act that comforts the family and provides a bridge to bereavement care.
Grief is universal, yet the experience is always idiosyncratic.
Help the bereaved by listening well, gently probing for more, and accepting their experience.

INTRODUCTION

The prevalence of bereavement increases with age, making it a significant challenge for older adults whose health and adaptive capacities may already be compromised.¹ Family physicians and general internists often provide care for multiple generations of a family over long periods, developing a rapport that is valuable at times of loss. They are in a unique position to identify the bereaved, track the course of their experiences, screen for complications, and provide support throughout the process.

Bereavement is a significant health risk for many patients.¹,² Within 5 years of the death of a spouse, mortality
from ischemic heart disease increases between 20% and 35%.² Grief reactions are also associated with high-risk health behaviors, development of high blood pressure,² and increased use of alcohol and tobacco.¹ Unresolved grief is related to an increase in the incidence of anxiety and depressive disorders, which in turn negatively affect the course of many chronic diseases.² There is also a related increased risk of suicide attempts in the bereaved.¹ These health risks increase the burden on an already overtaxed health care system and on individual providers. After the loss of a spouse, there is an increased rate of clinic visits by widowed persons.¹ Furthermore, studies of bereavement in the elderly have found that normal grief symptoms can persist up to 4 years after the death of a spouse.²

This chapter briefly reviews guidelines for the identification and management of bereavement in the primary care office. Although the focus is on helping spouses and families through the grieving process, we also address the challenge of assisting dying patients with managing their own anticipatory grief.

Terminology

Interpretation of guidelines and relevant research requires consistent terminology. The terms loss, bereavement, mourning, and grief are often used interchangeably, with some confusion. We present the following definitions as common ground for discussions on the assessment and treatment of grief reactions.³, ⁴, ⁵

Loss: The permanent separation from and deprivation of something or someone of value and attachment. The loss may be physical (tangible) or psychosocial (symbolic). Some examples of loss include death of a loved one, loss of a beloved object (e.g., house burning down), loss of functioning or independence (e.g., decreased mobility or amputation), or a significant change in one’s life (e.g., entry into a nursing home).

Bereavement: The period after a loss during which mourning occurs and grief is experienced.

Mourning: The culturally defined process by which people adapt to loss. “Mourning refers to the social expression of grief … and it includes rituals and behaviors that are specific to each culture and religion”⁶ (page 130). For example, in Navajo culture the public rituals of mourning occur for only 4 days.⁴

Normal Grief: The unique personal response to separation and loss. The grief response includes psychological, behavioral, social, and physical reactions including shock, disbelief, overwhelming sadness, anxiety, poor sleep and eating patterns, fatigue, headache, and social withdrawal. Types of grief⁴,⁶ include:

Anticipatory Grief: A grief reaction that occurs in anticipation of an impending loss. This includes anger, guilt, anxiety, irritability, sadness, feelings of loss, and/or a decreased ability to perform usual tasks.⁴

Acute Grief: Grief occurring at the time of death or in the first few days/weeks after death. It may include denial, intense crying spells, panic attacks, derealization (a sense of unreality), emotional numbness, and a variety of somatic symptoms that can seem exaggerated or frightening to family and friends.

Chronic Phase of Normal Grief: Refers to intense grief that subsides during the first year and may then return as temporary waves or pangs of grief at certain times, such as the anniversary of the spouse’s death, birthdays, or specific reminders. This exacerbation of grief is episodic, and grief reactions diminish in frequency and intensity with time.⁶

Complicated Grief: A syndrome characterized by delayed or incomplete adaptation to loss.¹ Complicated grief occurs when symptoms do not resolve over time and/or increase in intensity.

NORMAL GRIEF

Misdiagnosis of grief reactions often occurs because intense symptoms of grief are seen as indicators of depression or dementia. Accurate differential diagnosis requires a clear model of normal grief and algorithms to distinguish normal grief from complicated grief and depression.

Initially, normal grief was described as occurring in stages.⁷ The classic Kubler-Ross stages included denial, anger, bargaining, depression, and acceptance. Bowlby theory of attachment⁷ postulated the following series of stages: Shock and numbness, yearning and searching (i.e., separation anxiety and denial of the reality of the loss), disorganization (i.e., depression, despair, or difficulty planning for the future), and reorganization and positive readjustment. Research now indicates that grief does not unfold in so orderly a manner¹ but often comes in unpredictable waves, with some stages or reactions being more prominent than others.⁸ Practitioners who are preoccupied with a rigid stage model often misdiagnose normal grief as complicated grief or depression. Unfortunately, patients who are aware of the stage model often feel they are not grieving “the right way” if their reactions vary. A clinically useful way to view normal grief is as a set of common reactions that vary in intensity but diminish over time. The commonly observed reactions¹,⁴,⁷ are as follows:

Sadness: Overwhelming sadness is of course the central feature of grief. Surviving family and friends may be unable to talk about the deceased without crying. Initially, some weepiness may be constantly present. In normal grief, the frequency and intensity of crying gradually diminishes.

Shock: Symptoms of shock include disorientation, emotional numbness, cognitive slowing, and fluctuating dissociation. This is more common in acute grief immediately following death but may recur after an
intense trigger (e.g., autopsy results). Persistence beyond 6 months is an indication of complicated grief.¹

Denial: Some patients may refuse to talk about their relative’s death, may resist bequeathing the deceased’s possessions, or may leave intact previous plans involving the deceased. Others may avoid objects or situations related to the deceased or may avoid talking about them altogether. These behaviors can be an initial adaptive reaction to protect the self from pain of loss and fear of the future. However, normal grieving eventually entails a gradual acceptance of the loss and a growing accommodation to new roles and situational demands.

Separation Distress: Episodic intense yearning for the deceased and thoughts about the deceased are characteristics of separation distress. However, after 6 months most bereaved patients exhibit less frequent and less intense symptoms of separation distress.¹

Anger: Anger is a common reaction to stress. Hostility may be directed toward the deceased, health care providers, family, and others. When present, this largely resolves within 6 months.

Guilt: Commonly, surviving family members experience pangs of guilt that they did not do enough for the deceased. They may feel that they should have been more alert to signs of deterioration or acted more assertively to seek emergency medical care. Temporary expressions of guilt are normal and gradually subside over time.

Acceptance and Adaptation: Normal grief is characterized by the episodic expression of the symptoms described in the preceding text, which gradually diminish over time and show marked improvement by 6 months. Some reactions may last 2 years or more but the overall course is one of less intense grief and increasing functional ability. The adapting patient shows increasing self-confidence, trust in others, acceptance of the loss, expressed belief that life is still meaningful, and a willingness to accept new life roles.¹

Differential Diagnosis of Normal Grief and Depression

A patient’s history of a recent major loss may predispose the physician to not consider medical comorbidities that may be contributing to the patient’s current depressive symptoms. It is important to rule out the existence of undiagnosed medical conditions that may present with depressive symptoms. This workup should include a thorough medical history and physical examination, review of prescribed and over-the-counter medications for side effects and polypharmacy, screening for substance abuse or herbal treatments that may impact mood, Mini-Mental State Examination, thyroid panel, complete blood count, basic chemistry panel, vitamin B₁₂ and folate levels, and serum drug levels (if the patient is taking medications such as theophylline or digitalis). Toxicology screen and an electrocardiogram may also be indicated. A more complete discussion and table of medical differential diagnosis of depressive symptoms in the elderly are given in Table 17.5.

Having ruled out medical comorbidities, the clinical challenge is to distinguish normal grief from clinical depression. The presentation of normal grief and depression usually begin to diverge between 3 and 6 months after the loss. Periyakoil and Hallenbeck⁹ outline the following differential indicators for normal grief and depression:

Temporal Variation: Grief diminishes over time and is experienced in waves triggered by memories or cues that remind the person of his or her deceased partner. Depression is often defined by a persistent sadness or dysphoria that can become chronic without treatment.

Negative Self-image: Grieving patients present a relatively normal self-image. Depressed patients often show a pervasive sense of worthlessness.

Anhedonia: The ability to experience pleasure and enjoy special moments with family is still present in patients who are grieving. Depressed patients often show an inability to experience pleasure.

Hopelessness: Whereas depressed patients often present with a marked sense of hopelessness, the grieving patient shows a capacity to think about and anticipate the future.

Response to Support: Patients who are grieving may withdraw temporarily, but at other times they will seek or appreciate social support to help them through the grieving process. Depressed individuals are more likely to persistently withdraw from social contact and derive little solace from it.

Preoccupation with Death: Grieving patients may show some occasional preoccupation with death and may express a desire to be with the deceased. However, these patients do not experience the persistent and active suicidal ideation or intent that can be present in clinical depression.

COMPLICATED GRIEF

Some bereaved patients seem to “get stuck.” For these patients the more intense symptoms of normal grief (e.g., denial, sadness, and numbness) do not diminish over time. Prigerson and Jacob’s extensive research on bereavement reactions has identified complicated grief as a syndrome distinct from normal grief and depression.¹ The diagnostic criteria for complicated grief¹ are given in Table 6.1.

Complicated grief produces greater functional impairment than normal grief¹ but is not as severe as depression. Complicated grief is also associated with adverse health outcomes if untreated (including high blood pressure, ulcerative colitis, suicidal ideation, cancer, and cardiac events).¹ The careful differential diagnosis of complicated grief and depression is important because treatment of
complicated grief differs from that of depression (discussed in the subsequent text).¹

TABLE 6.1 PROPOSED DIAGNOSTIC CRITERIA FOR COMPLICATED GRIEF

Person must meet all four criteria

Criterion A

Person has experienced the death of a significant other and response involves three of the four following symptoms, experienced at least daily or to a marked degree:

Intrusive thoughts about the deceased
Yearning for the deceased
Searching for the deceased
Excessive loneliness since the death

Criterion B

In response to the death, four of the eight following symptoms experienced at least daily or to a marked degree:

Purposelessness or feelings of futility about the future
Subjective sense of numbness, detachment, or absence of emotional responsiveness
Difficulty acknowledging the death (e.g., disbelief)
Feeling that life is empty or meaningless
Feeling that part of oneself has died
Shattered worldview (e.g., lost sense of security, trust, or control)
Assumption of symptoms or harmful behaviors of, or related to, the deceased person
Excessive irritability, bitterness, or anger related to the death

Criterion C

The disturbance (symptoms listed in the preceding text) endures for at least 6 months

Criterion D

The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

Reprinted with permission, Prigerson HG, Jacobs SC. Perspectives on care at the close of life. Caring for bereaved patients: “All the doctors just suddenly go”. JAMA. 2001;286(11):1369-1376.

Complicated grief, normal grief, and depression share some core symptoms (e.g., sadness, guilt, and appetite and sleep disturbance). In fact, during the first few weeks or months, normal grief and/or complicated grief may be indistinguishable from depression.⁹ One should begin careful monitoring for complicated grief and/or depression by approximately 6 months.¹ Compared to normal grief, the distinguishing feature of complicated grief is a preoccupation with the deceased that does not diminish over time (see Table 6.2). This may include intrusive thoughts about the deceased, yearning and searching for the deceased, or assuming certain behaviors or mannerisms of the deceased. Complicated grief does not include the persistent vegetative signs that characterize major depression.

The presence of suicidal ideation should prompt an immediate psychiatric referral at any point in the course.

BEREAVEMENT CARE

Presented in the subsequent text are guidelines for bereavement care.³,⁸,¹⁰ To enhance clinical relevance, the guidelines are presented in an approximate sequence of care as patients are followed from anticipatory grief to acute grief, and through bereavement to resolution.

Gradually Shift to Palliative Care

Introduce palliative care concepts and interventions long before exhausting curative care regimens. This gradual introduction of a second focus on reducing suffering and improving quality of life is responsive to patient and family needs throughout the course of illness and avoids an abrupt, stressful shift at a later date.¹¹,¹²

Patients vary in their receptiveness to medical information and decision making. Check how much the patient wants to know (e.g., “Some of my patients like to know the full details about their condition, they read up on it and ask many questions; some of my patients do not want much detail, they just want to know about the treatment plan. What about you?”). Check who else should be included in education and decision making (e.g., “Is there anyone else who should be involved in these discussions?”). Recheck these points from time to time—over the course of a terminal illness, patients often vary in their desire for information and comfort in including family members in the discussions.

TABLE 6.2 DIFFERENTIAL DIAGNOSIS^a

	Normal Grief	Complicated Grief	Depression
Overview	The grief response includes psychological, behavioral, social, and physical reactions that may come in waves of sadness, shock, disbelief, anxiety, anger, guilt, irritability, and feelings of loss Gradually, unevenly, these diminish with time The capacity to think about and anticipate the future gradually returns	What begins as normal grief fails to resolve Grief symptoms plateau or worsen with time Denial may persist—there is continued difficulty acknowledging the death The bereaved may continue to feel purposeless; their future seems futile They may continue to feel numb, detached, and emotionally unresponsive They may be very irritable, bitter, or angry about the death	In major depression, intense sadness is persistent rather than fluctuating, as in normal grief Depression is also characterized by persistent vegetative signs that are not as prominent as those in complicated grief
Temporal	Intense symptoms of acute grief begin to subside after a few weeks and gradually (but unevenly) diminish over a year or two By 6 mo, there is marked improvement Temporary intense waves of grief may be triggered by special days or other reminders The overall course is one of less intense grief and improved functioning	Bereaved patients “get stuck” The intense symptoms of normal grief do not diminish over time; functioning fails to improve Sometimes symptoms and functioning actually worsen over time	Depressive symptoms are more continuous and persistent Symptoms such as negative mood and social withdrawal are present most days
Social	Patients who are grieving may withdraw temporarily, but at other times they will seek or appreciate social support to help them through the grieving process The ability to enjoy everyday pleasures and special moments with family gradually returns Certain pleasures may be accompanied by guilt (i.e., “I should not be enjoying myself—my husband died”), but this decreases with time	Individuals continue to be preoccupied and have difficulty with extended socialization and enjoyment of everyday activities Pervasive feelings of loneliness and isolation are present.	Depressed individuals are more likely to persistently withdraw from social contact and derive little solace from it Well-meaning attempts to break one’s routine with some pleasurable activity may be met with apathy or aggravation and are rarely helpful in lifting the spirits Depressed patients often show an inability to experience pleasure (anhedonia)
Cognitive	There is an initial preoccupation with the death, including images and thoughts of what could have or should have been done, but this lessens with time Recollection of pleasant memories gradually returns The ability to discuss the deceased without overwhelming emotion gradually improves	Preoccupation with the deceased persists unabated, with yearning, searching, and intrusive thoughts about the deceased A shattered view of self and environment continues, including the feeling that life is empty or meaningless and that part of oneself has died, or a lost sense of security, trust, or control	Depressed patients often show a pervasive sense of worthlessness and/or hopelessness, which is often associated with persistent and active suicidal ideation or intent The risk of suicide is highest in the depressed elderly
Functional impairment	Individuals may initially show decreased ability to perform usual tasks. In the very old, slowed reaction times and decreased ability to adjust to new situations complicate this, as does frailty or cognitive impairment The adapting patient shows increasing self-confidence, trust in others, acceptance of the loss, expressed belief that life is still meaningful, and a willingness to accept new life roles	Complicated grief produces greater functional impairment than normal grief, but does not rise to the severity of depression	Depression includes clinically significant impairment in social, occupational, or other important areas of functioning
^aDifferential diagnosis of medical conditions is covered in Table 17.5.
Portions adapted from Prigerson HG, Jacobs SC. Perspectives on care at the close of life. Caring for bereaved patients: “All the doctors just suddenly go”. JAMA. 2001;286(11):1369-1376, and Periyakoil VS, Hallenbeck J. Identifying and managing preparatory grief and depression at the end of life. Am Fam Physician. 2002;65(5):883-890.

Establish a Bereavement Register

A bereavement register enables tracking of patients who are receiving palliative care or approaching the end of life and identifying families currently in bereavement.² If the practice already maintains a death register, this can be expanded to create a bereavement register for spouses and family members of recently deceased patients.¹³ Many grieving geriatric patients, especially those with little family and social support, tend to suffer in silence until worsening emotional or health problems bring them to the physician’s office. The bereavement register can be a prompt for assertive bereavement care and result in proactively reaching out to bereaved patients.²

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