In the course of a lifetime, one of the most stressful events encountered is the loss of a loved one through death. Almost no person makes it through his or her life without having to cope with such a loss. As this is such a universal experience, bereavement, as well as the grief response to it may be looked upon by both medical and lay people as a very ‘normal’ and expected emotion. In fact, research shows that for the majority of people, grief after a significant personal loss may last from about two to six months, and requires no treatment (Friedman, 2012). Nevertheless, it can be a period of intense suffering for some people as well as a risk factor in developing mental as well as physical health problems.
Unlike their younger counterparts, the older adult population encounter bereavement much more frequently in terms of family members, and thus may be impacted more so; spousal bereavement is most frequent with about 45% of women and 15% of men older than 65 years becoming widowed (Stroebe, Hanson, Schut & Stroebe, 2007). Family caregivers and spouses in particular are at risk for a variety of health issues including increased incidence of depression, decreased immune system response, sleep issues as well as increased mortality (Burton, Haly & Small, 2005). How is our health system addressing the issue of bereavement in the elderly? Are we examining the condition as the possible risk factor for mental illness that it can be? How do we distinguish between normal and more complicated grief – and what is the fine line that sets it apart from a disabling mental illness? This report will aim to address the aforementioned issues, as well as examine current and recommended possible treatment strategies.
Bereavement can be defined as the situation or state of having recently lost a relative, close friend or a significant person through death (Stahl & Schulz, 2014; Stroebe, Schut & Stroebe, 2007). Although bereavement can occur at any age, it is most common in later life and is characterized by adverse physical and psychological declines, intense suffering, as well as a higher risk of mortality (Stahl & Schulz, 2014). These responses to bereavement are described as grief – or the emotional, psychological and physical manifestations to the situation of loss.
Generally, this ubiquitous human experience results in an expected or normal response which has been documented as a process of ‘stages’, most notably by psychiatrist Elisabeth Kubler-Ross in 1969 when she introduced what became known as the “five stages of grief.” In her book, “On Death and Dying”, Dr. Kubler-Ross first explored the now-famous five stages: denial and isolation, anger, bargaining, depression and acceptance. But not every person experiences and deals with the loss of a loved one in the same way – and with the elderly, symptoms of grief may be confounded or discounted as simply signs of ‘getting older’, and even more concerning, any actual existing mental illness symptomology that does need treatment, may be overlooked.
Commonly, a client who has just lost a loved one would present to his or her physician with symptoms that are akin to mild depression, (i.e. sadness, insomnia, tearfulness), (Friedman, 2012). Using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), a practitioner would look at these symptoms as grief-related and not diagnose clinical depression, if the symptoms are relatively mild and have lasted less than six months. It has been documented that 10-20% of bereaved people do not get over grief that easily and may go on to develop a condition known as ‘complicated grief’ (Friedman, 2012). Complicated grief (CG) is defined as a deviation from the normal (cultural and societal) grief experience in either duration, intensity or both and is marked by more intense emotionality or possibly even an inhibited or delayed-onset response (Stroebe, Schut & Stroebe, 2007). Symptoms include an intense and persistent longing for the lost loved one, a sense of anger and disbelief about the death and a disturbing preoccupation with the deceased.
For most, grief does resolve on its own and the vast majority of bereaved elders are indeed seen by primary care practitioners. It is critical that such practitioners be skilled at distinguishing between uncomplicated and complicated grief, and major clinical depression; major depression requires treatment whereas uncomplicated grief is a normal response to loss. But the condition and symptoms of complicated grief may be a pre-cursor to possible clinical depression and needs to be monitored. Currently, our medical system is based on the disease model, therefore, treatment for any condition – especially for elders, is primarily reactive in its approach. Thus, the health care system has dealt with bereavement, and death in general in a ‘pro re nata’ (PRN) or ‘take as needed’, after-the-fact and restorative way.
For example, the current DSM-V has now included “Persistent Complex Bereavement Disorder” under their ‘Conditions for Future Study’ component of the manual. The three proposed criteria one would have to meet include at least twelve months of experiencing one of four symptoms after the loss (yearning, intense sorrow and emotional pain, preoccupation with the deceased, preoccupation with circumstances of death) as well as meeting six out of twelve more specific sub-criteria symptoms. Associated features include hallucinations, somatic complaints, and experiencing the deceased person’s symptoms. They report a prevalence rate of the proposed Persistent Complex Bereavement Disorder between 2.4 – 4% and more so in females than in males. One end note and very pertinent statistic is its affiliated or comorbid disorders: they include major depressive disorder, PTSD and substance use disorders.
These said ‘comorbid’ conditions that go along with complicated grief are the very conditions that are least screened for in the older population. Assumptions fueled by ageist attitudes seem to be at the root of this screening deficiency by primary care and health care practitioners, and can also be carried by the bereaved client’s own family members. Substance use may be written off as ‘cognitive and mobility issues’ or simple ‘forgetfulness’. Depression may be also assumed to be an ’expected’ emotional state of aging. These are the challenges that new government programs and policies put forth by health care governing bodies are hopefully addressing which will be examined further.
Treatments, Support Strategies and Recommendations
A review of literature in the British Journal of General Practice reveals GP’s and nurses view bereavement care as an important part of their work, but one for which they have received limited training. In primary care, bereavement care-provisions vary: some practices are more structured and include protocols such as home visits, telephone consultation and/or condolence letters; others are reactive in their approach and wait for the bereaved client to be in need. The latter approach is described as coming from fear of medicalising a traumatic, yet normal life event (Nagraj & Barclay, 2011). Luckily, we are beginning to see programs in Ontario that are dedicated to creating a more preferable, proactive and preventative approach to the growing need of supports for the older population – including their bereavement needs.
In 2009, for example, the Ministry of Health and Long Term Care (MOHLTC) released a discussion paper entitled “Every Door Is The Right Door” which is currently being used as a template for discussion, insight and strategies for a seniors’ framework for mental health and addictions. Included are recommendations for community based care, collaboration across all sectors to deliver a social model of care, recovery-based approach that involves the client and family in system planning, implementation and evaluation. One inclusion in this document asserts to “Act Early”, and describes methods and benefits of prevention (of mental health concerns) and of early identification and intervention.
The MOHLTC also released a document in 2011 called “Advancing High Value Palliative Care in Ontario” which recommends a comprehensive, person-centred and integrated circle of care – not only for the individual with chronic disease, but for their caregivers before, during and after the loss.
Other resources include the Canadian Mental Health Association (CMHA) which has services for seniors including programs and service supports for at-risk adults and those living with addiction, mental health and concurrent disorders. They have documented most occurring mental health disorders in older adults as being depression, suicide, anxiety disorders, dementia, delusional disorders, delirium, psychotic disorder and concurrent disorders.
Ultimately, screening and risk assessment by primary care practitioners are invaluable in early detection of mental illness and treatment, specifically for depression and possible substance use due to bereavement. If such screening were done across the board with the elderly population, and was to indicate existing issues, all measures should and can be taken with all the available community, medical and societal supports given to any person of a younger demographic. Individual, person-specific health care is the strived goal.
“There is not a typical response to loss, as there is no typical loss. Our grieving is as individual as our lives.” – Elisabeth Kubler-Ross
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