Mananaging Grief And Bereavement In Older Adults

This information on grief and bereavement is for health and mental health professionals including:

psychologists
psychiatrists
psychotherapists
physicians
psychiatric nurses
clinical social workers

This information is for reference only. Always consider the needs of individual patients and available resources.

Prevelance
Cultural Factors
Risk Factors and Symptoms
Diagnosis
Management

Prevelance

Loss of a spouse is common in late life. About 800,000 older Americans are widowed each year.
At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement.

(Mental Health: Report of the Surgeon General, SAMHSA, 1999)

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Cultural Factors

Elders’ expressions of grief are often shaped by their cultural values and beliefs.

(Lewis ID, McBride M. Anticipatory grief and chronicity: Elders and families in racial/ethnic minority groups. Geriatr Nurs. 2004 Jan-Feb;25(1):44-7.)

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Risk Factors and Symptoms

Risk factors for grief and bereavement

Risk factors for complicated grief

Excessive dependency on the person who died
History of depression or anxiety
Sudden death of a loved one

Risk factors associated with grief and bereavement

Anxiety or panic.40 percent of people who lose a spouse experience generalized anxiety or panic syndromes in the first year. (Jacobs S, Prigerson H. Psychotherapy of traumatic grief: A review of evidence for psychotherapeutic treatments. Death Stud. 2000 Sep; 24(6): 479-95.)
Complicated grief.oughly 15 percent of people who have lost a loved one might be susceptible to “complicated grief,” a condition more severe than the average loss-related life transition, depression, and anxiety. “Complicated grief is marked by broad changes in all personal relationships, a sense of meaninglessness, a prolonged yearning or searching for the deceased, and a sense of rupture in personal beliefs.” (Szanto, K, Prigerson, H, Houck, P, et al., Suicidal ideation in elderly bereaved: The role of complicated grief. Suicide Life Threat Behav. 1997 Summer; 27(2): 194-207)
Death.In the first six months after a loss, mortality among surviving spouses increases 40 to 70 percent compared with the general population. (Parkes, CM. Bereavement dissected--a re-examination of the basic components influencing the reaction to loss. Isr J Psychiatry Relat Sci. 2001; 38(3-4): 150-6.)

Symptoms of grief and bereavement

Depression (with possible suicidal ideation)
Anxiety
Substance abuse
Symptoms of “complicated” grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the loss. (Prigerson HG, Frank E, Kasl SV, et al. Complicated grief and bereavement-related depression as distinct disorders: Preliminary empirical validation in elderly bereaved spouses. Am J Psychiatry. 1995 Jan; 152(1):22-30)

Other potential causes of symptoms

Alcohol or substance abuse
Bipolar illness
Stressful situation (e.g., traumatic incident, major life transition such as retirement)
Coexisting illness (e.g., diabetes, stroke, cancer)

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Diagnosis

DSM-IV diagnostic criteria

Grief may lead to post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and adjustment disorder (AD).

A definitive diagnosis of bereavement-related depression and anxiety is based on the following criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV):

Bereavement Symptoms

This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal," although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups. The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss.

However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. These include:

Guilt about things other than actions taken or not taken by the survivor at the time of the death;
Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person;
Morbid preoccupation with worthlessness;
Marked psychomotor retardation;
Prolonged and marked functional impairment; and
Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.

A diagnosis of “complicated grief” may be included in the DSM-V. (Prigerson HG, Bierhals AJ, Kasl SV, et al. Complicated grief as a disorder distinct from bereavement-related depression and anxiety: A replication study. Am J Psychiatry. 1996 Nov; 153(11):1484-1486; Lichtenthal WG, Cruess DG, Prigerson HG. A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clin Psychol Rev 2004 Oct; 24(6): 637-662).

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.

Other Scales

Grief Measurement Scale (to distinguish between bereavement-related depression and anxiety and complicated grief).
Inventory of Complicated Grief (ICG). (Prigerson, HG, Maciejewski, PJ, Reynolds, CF 3rd, et al. Inventory of Complicated Grief: A scale to measure maladaptive symptoms of loss. Psychiatry Res. 1995 Nov 29;59(1-2):65-79.)
The Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) Scale. (Priger, HG, Cherlin, E, Chen, JH, et al. The Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) Scale: A measure for assessing caregiver exposure to distress in terminal care. (Am J Geriatr Psychiatry 2003 May-Jun;11(3):309-319)

More specialized assessments

Some patients also require evaluation for:

Medical problems
Psychological issues
Substance abuse

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Management

Care for suicidal patients

Refer patients who present safety risks to themselves or others to a hospital emergency department. (See Latham AE, Prigerson HG. Suicidality and bereavement: Complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide Life Threat Behav. 2004 Winter;34(4):350-62)

Medication

See “The Pharmacologic Management of Major Depression in the Primary Care Setting”,Department of Veterans Affairs
http://www.vapbm.org/guidelines/depressionguidelines_1.pdf

Anti-depressant drugs

Commonly Prescribed Antidepressant Drugs:

Type:	Examples:
SSRI: selective serotonin reuptake inhibitor	Zoloft (sertraline), Prozac (fluoxetine), Paxil (paroxetine), Celexa (citalopram); Lexapro (escitalopram)
SNRI: serotonin and norepinephrine reuptake inhibitor	Effexor (venlafaxine); Cymbalta (duloxetine)
NaSSA: noradrenaline and selective serotonin antidepressant	Remeron (mirtazapine)
NDM = norepinephrine and dopamine modulator	Wellbutrin (bupropion)
MAOI: Monoamine oxidase inhibitor	Nardil (phenelzine)
TCA: Tricyclic antidepressant	Pamelor (nortriptyline); Norpamine (desipramine)

The choice of an antidepressant is based on several considerations, including the patient s age, coexisting medical and psychiatric illnesses, prior response to medications, possible drug interactions, side effects that are to be avoided, or side effects that may be helpful.

Other medications

Paroxetine and nortriptyline have been shown to be effective in managing traumatic grief symptoms. (See Zygmont M, Prigerson HG, Houck PR, et al. A post hoc comparison of paroxetine and nortriptyline for symptoms of traumatic grief. J Clin Psych 1998 May; 59(5):241-245.)

General information about acute treatment

Medications are usually started at low doses that may not be effective, and are gradually increased to effective levels.
Most side effects to anti-depressant drugs occur in the first few weeks of treatment, but are usually tolerated. If the patient develops intolerable side effects (defined by the patient) he or she should immediately contact his or her doctor.
Highest quality care would include 3 visits with the provider in the first 3 months of treatment.
Patients may not notice a change in symptoms during the first 2 to 6 weeks of medication treatment and the dose of the medication is usually gradually increased.
Patients who do not respond to an anti-depressant by 8 weeks, and are taking maximum daily doses, may require a switch to a different medication, addition of an adjuvant medication, and/or referral to a mood disorders specialist.
Patients who respond to medication treatment should continue to take anti-depressants for at least 12 months after symptoms resolve if this is their first depressive episode.
Patients who have experienced two or more depressive episodes should continue to take anti-depressants for a longer time period.

Lack of a response to anti-depressant medication may be due to:

Lack of understanding as to how to correctly take the medication
Non-compliance (may be due to intolerable side effects)
Inadequate dosing
Inadequate duration of therapy
One-third of patients who are treated with any given anti-depressant will simply not respond to that medication. Sometimes several medication trials are necessary.

Psychotherapy

Immediately refer patients to a psychiatrist if they are bereaved and depressed and have any of the following conditions:

Severe anxiety or agitation
Anorexia with weight loss
Significant psychomotor agitation or retardation
Psychosis: especially somatic delusions (believing one has cancer or a terminal illness when none exists); auditory hallucinations (hearing voices that say derogatory things or tell the patient to kill himself or herself)
Suicidal or homicidal thinking

Consider referring patients to a psychiatrist if they are bereaved and depressed and have any of the following disorders:

Substance abuse or excessive alcohol intake
Post-traumatic stress disorder
History of childhood abuse or neglect
Obsessive compulsive disorders or personality disorders

Grief therapy

Recent research suggests that instead of striving for closure, the goal of grief therapy should be to help the bereaved person maintain a lasting bond with the deceased person through memory, consideration of how his or her perspective might be applied to current situations, and carrying on an internal dialogue with him or her. Asking the patient to bring in photos of happy times with the deceased can be helpful. This facilitates a focus on positive recollections of the relationship.

Psychologist Donald Meichenbaum notes that right after the death, the person who is grieving may be helped by symptom-management strategies that include relaxation skills and thought stopping. (APA's Ad Hoc Committee on End-of-Life Issues and published in Professional Psychology: Research and Practice [Vol. 34, No. 6] in December 2004.)

Techniques from cognitive-behavioral therapy can also help grieving individuals to restructure their assumptions about themselves and the world. (Matthews LT, Marwit SJ. Complicated grief and the trend toward cognitive-behavioral therapy. Death Stud 2004 Nov; 28(9):849-863.)

Adapted from:

Brigham and Women’s Hospital. Depression. A guide to diagnosis and treatment. Boston (MA): Brigham and Women's Hospital; 2001.
Excellus/Identification and Treatment of Major Depression in Primary Care
APA’s Ad Hoc Committee on End-of-Life Issues and published in Professional Psychology: Research and Practice (Vol. 34, No. 6) in December 2004.
Karen Kersting, A new approach to complicated grief, Monitor on Psychology, Volume 35, No. 10 November 2004
Kent H, McDowell J. Sudden bereavement in acute care settings. Nurs Stand. 2004 Oct 20-26;19(6):38-42.
Gamino LA, Sewell KW. Meaning constructs as predictors of bereavement adjustment: A report from the Scott & White Grief Study. Death Stud. 2004 Jun;28(5):397-421