Grief can be described as the instinctive but natural response to the death of a loved. For a majority of people who experience loss of a loved, adaptation often takes place. However, grief often persists for some groups of people, especially the elderly, and this can be severe to the extent that it impacts normal body functioning as well as the quality of life (Perng & Renz, 2018). This condition is popularly referred to as complicated grief. Compared to other populations, older adults have to deal with more cumulative effects of multiple losses.
Additionally, the elderly may have limited resources as well as outlets for coping with the loss of the loved ones, but still be under greater pressure to move on (Perng and Renz 2018). Hashim, Eng, Tohit & Wahab (2013) opine that loss and grief among the elderly are of great concern to primary care as it can bring about psychological illnesses such as depression. The current paper seeks to examine the current nursing practice as far as identifying and managing loss and grief in the elderly is concerned.
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The number of people that die in the US alone on an annual basis is approximately 2.5 million people. This means that exposure to grief is something that cannot be avoided. The death of a loved one is acknowledged as one of the most distressing, traumatic and intense events a person can ever experience in their lifetime. Acute grief is often accompanied by a variety of strong emotions such as disbelief, shock, intense separation distress, sadness, and longing. Individuals who have lost their loved ones may become preoccupied with memories, thoughts, and images of the people they have lost. Simon (2013) points out that there is no single way of grieving, and that most people are usually able to navigate through loss and grief without clinical intervention successfully. He adds that unlike normal grief, complicated grief is characterized by a complicated process adapting to and accepting the finality of the loss. Symptoms that indicate complicated grief include self-blame, intrusive pre-occupation with the circumstances that resulted in the loss, intense longing, and avoidance of previously shared activities. The negative outcomes that are linked to complicated grief include functional impairment, reduced quality of life, sleep disturbance, high-risk behaviors, cancer and even increased suicide ideation. As a result, it is very important to screen individuals who have lost loved ones for complicated grief and to carry out safety risk assessments among those whose screening results are positive ( Simon, 2013).
Shear (2015) reports that currently, there is no consensus about the criteria as well as a formal name for complicated grief. Based on extensive literature review, a proposal was drafted by The Working Group on the Classification of Disorders Specifically Associated with Stress. The proposal sought to incorporate a diagnosis by the name “prolonged grief disorder” in the International Classification of Diseases, 11th Revision. Accompanying this proposal was consensus guidelines which according to Shear (2015) are still going through field testing. The working group for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was presented with two proposals which resulted in the incorporation of the category "persistent complex bereavement disorder” in the DSM-5, but as a condition that needs further research (Shear, 2015).
As part of the standard diagnostic evaluation for complicated grief among the elderly, questions regarding essential losses have to be incorporated. The presence of behaviors and thoughts that point to complicated grief should be examined using a clinical interview (Solomon, 2015). It is worth noting that while intense grief is not pathologic, it is essential to identify the complicating behaviors and thoughts that make it difficult to adapt to the loss. At times, patients feel ashamed about their persistent grief, a fact that makes it essential for primary caregivers to ask direct questions but emphatically and sensitively (Shear, 2015). The Inventory of Complicated Grief and the Brief Grief Questionnaire have stood out as the most popular self-report questionnaires that clinicians can utilize to screen for complicated grief. The standard procedure also calls for screening of medical and psychiatric conditions during the evaluation process given how common coexisting conditions occur (Shear, 2015).
Shear (2015) points out that at the moment, professional guidelines for the treatment and management of complicated grief do not exist. However, randomized controlled trials have shown that psychotherapy and pharmacotherapy are some of the approaches that can be used in the management of complicated grief. Shear (2015) states that psychotherapy is often used as a first-line treatment. She adds that the most widely studied psychotherapy treatment for complicated grief is a short-term approach known as "complicated grief treatment." The objectives of this treatment include to pinpoint and find solutions to complications of grief and to make it possible for people to adapt to loss. Under pharmacotherapy, antidepressants remain the most commonly utilized medication. There remain many areas of uncertainty as far as the diagnosis and management of complicated grief are concerned. There is inadequate data on the risk factors for complicated grief, and there is a need for consensus as far as diagnostic criteria are concerned. Data on how effective approaches such as pharmacotherapy are also limited (Simon, 2013). However, scholars continue to examine current best practices to identify those that best work with the elderly population.
Shear et al. (2014) conducted a randomized clinical trial to examine the treatment of complicated grief in the elderly. They point out that the condition is very much prevalent among the elderly individuals, and that despite it being a debilitating condition, very few full-scale randomized clinical trial specifically focusing on the elderly individuals have been conducted. In this study, the researchers enrolled 151 people aged 60 years and older. The participants were recruited starting from January 2008 to August 2013. The researchers report that during the last eight months of recruitment, the minimum age was lowered to 50 years. The participants were then randomized to receive complicated grief treatment (CGT) or grief-focused interpersonal psychotherapy (IPT). In their findings, Shear et al. (2014) report that both the treatments resulted in significant improvements in complicated grief symptoms. However, they are quick to report that the response rate for CGT was higher than that for IPT by over two times. They conclude that the response rates for treatment of complicated grief were clinically and statistically significant to a greater extent for CG symptoms compared to a treatment of depression that has been proven. They add that the findings from the study point to the need for primary care practitioners to separate complicated grief from depression. Shear et al. (2014) add that given the constantly increasing population of elderly individuals, the prevalence of bereavement among this population will keep increasing. This will also be accompanied by an increase in the marked psychological and physical impact of grief, hence the need for clinicians to develop an understanding of how to manage and treat complicated grief among the elderly.
In another study, Harting and Viola (2015) examine the therapeutic benefits of online grief support communities. They point out that these communities have become quite popular over the past few years, thanks to the increased utilization of the internet. According to Harting and Viola (2015), many Facebook pages and websites specifically seek to bring together individuals who have been bereaved, and that it is important for healthcare professionals to look into the therapeutic benefits that virtual communities present as far as the management of grief is concerned. After examining 185 grief support networks, Harting and Viola (2015) report that most of the people who joined the networks reported less psychological distress after joining the groups and that the psychosocial benefits did increase over time.
A look at the studies examining current practices in the management and treatment of loss and grief among the elderly reveals that there is a significant and rapidly growing body of research into the management of grief and loss, especially among elderly individuals (Simon, 2013). However, a significant number of clinicians, even those in specialty psychiatric settings, are not fully aware of the evidence that is available on grief management. This is especially due to the absence of evidence-based treatment guidelines. Available data offers some level of guidance for diagnosis, early support for antidepressant use as well as a psychotherapeutic intervention (Simon, 2013). More studies are being done, and these will go a great length in optimizing treatment, especially for the elderly individuals.
In conclusion, complicated grief is very much prevalent among elderly individuals. The negative outcomes that are linked to complicated grief include functional impairment, reduced quality of life, sleep disturbance, high-risk behaviors, cancer and even increased suicide ideation. As a result, it is very important to screen individuals who have lost loved ones for complicated grief and to carry out safety risk assessments among those whose screening results are positive. Currently, there is no consensus about the criteria as well as a formal name for complicated grief. Additionally, professional guidelines for the treatment and management of complicated grief do not exist. However, randomized controlled trials have shown that psychotherapy and pharmacotherapy are some of the approaches that can be used in the management of complicated grief. More studies are being done, and these will go a great length in optimizing treatment, especially for the elderly individuals.
References
Hartig, J., & Viola, J. (2016). Online Grief Support Communities: Therapeutic Benefits of Membership. OMEGA-Journal of Death and Dying , 73 (1), 29-41.
Hashim, S. M., Eng, T. C., Tohit, N., & Wahab, S. (2013). Bereavement in the elderly: the role of primary care. Mental health in family medicine , 10 (3), 159.
Perng, A., & Renz, S. (2018). Identifying and Treating Complicated Grief in Older Adults. The Journal for Nurse Practitioners , 14 (4), 289-295.
Shear, M. K. (2015). Complicated grief. New England Journal of Medicine , 372 (2), 153-160.
Shear, M. K., Wang, Y., Skritskaya, N., Duan, N., Mauro, C., & Ghesquiere, A. (2014). Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry , 71 (11), 1287-1295.
Simon, N. M. (2013). Treating complicated grief. Jama , 310 (4), 416-423.
