Journal of Gerontological Nursing

Multiple Losses in Older Adults

Jean E Garrett, EdD, MSN, BSN, RN

Abstract

Most aging persons have accommodated grief in their experiences of life. Even persons who have, however, may experience a profound grief when losses are numerous and occur within a short period of time.

Aging brings the lifetime enemy of death into a different perspective. Fear of the death event is often abated while fear of the process of dying and the losses that inevitably occur in later life emerge as dominant concerns. Loss, a prevalent theme in the life of an aging person, is frequently interpreted as an assault on personal integrity, which evokes far more fear than death itself.

Aging persons experience personal, social, and economic losses, which are seen as mini or partial deaths.1 The most damaging and significant losses, however, are "people" losses. The loss of parents, siblings, friends, spouse and others are significant, can diminish the number of meaningful relationships, and gradually isolate the older person. The older a person becomes, the more alone he/she may feel, since people in their 80s and 90s usually find themselves in an unfamiliar world with few cohorts. For some, it eventually depletes their will to live, especially if they feel all alone, while others recoil from each loss and manage to resume their life with determination and resistance.

The losses also may be sudden and frequent. "Bereavement overload" is a phenomenon described by Kastenbaum2 as an overwhelming grief precipitated by the occurrence of multiple losses with little allowance for separate grieving time. Following the death of their husbands, elderly widows are especially vulnerable to bereavement overload since often they are forced to make many adjustments, such as a change in residence and friends, reduction in income, loss of transportation, and loss of social identity. The emotional crisis imposed by numerous losses and changes can result in mental confusion, disorientation, and withdrawal. The highly stressed individual may feel that everyone and everything meaningful to him has been taken away, and the pervasive sense of loneliness and helplessness may threaten his own survival, perhaps even leave him suicidal.1

The intrinsic ability of some individuals to deal with an extreme amount of grief is often astonishing and difficult to define. The older person's ability to cope with loss is dependent upon many factors which vary with each individual . It is apparent that some of the influences upon a person's ability to cope with grief are age , the number of losses encountered within a short time span, pasl experience with Joss and previous methods of coping, the existence and use of a support system, the ability to maintain a sense of control over some of the factors relevant to the loss, the prior existence of a positive relationship with the deceased person, the griever's state of health, and the griever's belief in a power greater than oneself.4

Grief Characteristics of Older Adults

A study of whether there are differences between the grief experience of older adults and that of younger adults has not been adequately conducted and has, therefore, been tentatively addressed. An early effort to investigate the question was initiated by Stern, Williams and Prados.5 Their study revealed several grief reactions in a group of older persons that seemed to indicate a difference from that of younger subjects. A summary of the findings showed that in older adults there were:

* A relative paucity of guií (they tended to identify with the deceased rather than feel guilt towards him).

* A tendency to replace emotional grief reactions with somatic equivalents.

* A distortion of the image of the deceased into an unreal glorification.

* A proclivity towards self-isolation and hostility…

Most aging persons have accommodated grief in their experiences of life. Even persons who have, however, may experience a profound grief when losses are numerous and occur within a short period of time.

Aging brings the lifetime enemy of death into a different perspective. Fear of the death event is often abated while fear of the process of dying and the losses that inevitably occur in later life emerge as dominant concerns. Loss, a prevalent theme in the life of an aging person, is frequently interpreted as an assault on personal integrity, which evokes far more fear than death itself.

Aging persons experience personal, social, and economic losses, which are seen as mini or partial deaths.1 The most damaging and significant losses, however, are "people" losses. The loss of parents, siblings, friends, spouse and others are significant, can diminish the number of meaningful relationships, and gradually isolate the older person. The older a person becomes, the more alone he/she may feel, since people in their 80s and 90s usually find themselves in an unfamiliar world with few cohorts. For some, it eventually depletes their will to live, especially if they feel all alone, while others recoil from each loss and manage to resume their life with determination and resistance.

The losses also may be sudden and frequent. "Bereavement overload" is a phenomenon described by Kastenbaum2 as an overwhelming grief precipitated by the occurrence of multiple losses with little allowance for separate grieving time. Following the death of their husbands, elderly widows are especially vulnerable to bereavement overload since often they are forced to make many adjustments, such as a change in residence and friends, reduction in income, loss of transportation, and loss of social identity. The emotional crisis imposed by numerous losses and changes can result in mental confusion, disorientation, and withdrawal. The highly stressed individual may feel that everyone and everything meaningful to him has been taken away, and the pervasive sense of loneliness and helplessness may threaten his own survival, perhaps even leave him suicidal.1

The intrinsic ability of some individuals to deal with an extreme amount of grief is often astonishing and difficult to define. The older person's ability to cope with loss is dependent upon many factors which vary with each individual . It is apparent that some of the influences upon a person's ability to cope with grief are age , the number of losses encountered within a short time span, pasl experience with Joss and previous methods of coping, the existence and use of a support system, the ability to maintain a sense of control over some of the factors relevant to the loss, the prior existence of a positive relationship with the deceased person, the griever's state of health, and the griever's belief in a power greater than oneself.4

Grief Characteristics of Older Adults

A study of whether there are differences between the grief experience of older adults and that of younger adults has not been adequately conducted and has, therefore, been tentatively addressed. An early effort to investigate the question was initiated by Stern, Williams and Prados.5 Their study revealed several grief reactions in a group of older persons that seemed to indicate a difference from that of younger subjects. A summary of the findings showed that in older adults there were:

* A relative paucity of guií (they tended to identify with the deceased rather than feel guilt towards him).

* A tendency to replace emotional grief reactions with somatic equivalents.

* A distortion of the image of the deceased into an unreal glorification.

* A proclivity towards self-isolation and hostility towards the rest of the family or friends.

A tendency of older adults to somaticize their grief was supported by Burnside3 and Grämlich.6 The older findings in the Stern, Williams and Prados5 study (lack of guilt feelings, image distortion, and self-isolation) have not been substantiated as necessarily unique characteristics of the elderly, but seem to have some applicability to their grief reactions.

Styles of Grief

Each person has a unique style of mourning which can range from silent grief and suicide to a demonstrable outpouring of feelings and tears. The time required to grieve is also part of the individual style. Persons in mourning experience a varying course of feelings and behaviors. Older people tend to follow their previous patterns of managing grief that have evolved over many years and from numerous losses.

Immediately following the loss of a significant other, some behaviors of an individual may appear rather bizarre. Widowed persons have reported grieving activities during a time which they called a "crazy period" that consisted of unusual behavior for them. Examples of such behaviors were: wearing their dead spouse's clothing, carrying around an item thai belonged to their spouse, sleeping on the spouse's side of the bed and making graveside visits to "talk things out" with him/her. Adherence to old patterns of life seemed to be a resistance to the change of everything at one time; the loss of a loved one could not be prevented, but everything in the "old" life did not have to be relinquished at one time. The old practices seemed to maintain a feeling of security during the transition to the new state of being single.7

These "strange" behaviors are not usually regarded as pathological responses to grief as long as they are carried out for a limited period of time and are not disruptive io health or welfare. If the unusual behaviors become exaggerated, prolonged, or disruptive to relationships, then referral to a mental healthcare worker is necessary. Other abnormal changes are: complete emotional and/or social withdrawal, threats to health or welfare (such as refusal to eat or take medications), insomnia, depression, a dramatic alteration of personality or suicidal tendencies.8 A close friend or family member can compare grieving behavior to prior behavior and identify persistent, inappropriate behavior in a griever. Supportive care by friends and family members is usually sufficient to assist most older adults through times of loss and grief. Especially difficult situations are those in which the older person has neither family nor friends, because persons without sufficient support systems face the greatest risk to abnormal reactions of grief.9

Resolution of Grief

Timetables are inappropriate when applied to grief responses in older adults since they mislead family or observers in expecting an older person to manifest specific characteristics of grief resolution at designated time intervals. There are other indicators that mourning has been completed and that grief has been accommodated. Several signs have been derived from the suggestions of others and from personal observations that are more helpful determinants than specific time allotments. They are regarded as indicators of progress in grief for adults of all ages, but are not all-inclusive.8,10

1. The person can recall the deceased loved one with both positive and negative memories. The recollection of the deceased immediately after death is frequently overly positive and somewhat idealized.8 After a period of time, the survivor recalls a more balanced image of the loved one, who can be remembered as having many likeable qualities, but not as perfect, since there are also some disagreeable characteristics.

2. After a varying period of time, a person who has experienced a loss can reach out to other persons who are acutely grieving and comfort them. During the immediate time following the loss of a loved one, an individual is often preoccupied with personal loss and the effects of the loss upon later life.

It takes a period of time, which is different with each person, to work through grief and during which it is difficult to be sensitive to the grief of another. In faci, a person may be competitive in expressing their feelings and the intensity of their pain. When a person can listen compassionately to the expression of pain by another individual, personal grief usually has been reconciled.

3. Reinvestment in new relationships, development of new interests, or revival of old friendships and interests are also indicators that an effective degree of grief resolution probably has occurred. Kastenbaum8 refers to this state of adjustment as "reconstruction," and Silverman" describes it as "accommodation." This point in the resolution of grief does not imply replacement or substitution for a deceased loved one, since it is fully acknowledged that human beings can never be replaced. At this time of reintegration, survivors explore new alternatives, meet new people, and, in general, are described as going on with life, which indicates a reinvestment in life after completion of the business of mourning. "You cannot establish satisfactory relationships until you have established some kind of equilibrium, have quieted somewhat your anxiety, adjusted to your grief, and emerged as a person who has something to offer to others. 12

Grief that is not resolved becomes residual or chronic. Grief often becomes chronic in older people because they may not be able to reinvest in new relationships.6,13 Chronic grief is often difficult to identify in older adults since the losses for which they grieve may have occurred several years previously and caregivers search for recent explanations. The grief accumulated from previous losses may be silent in that some individuals may not show overt signs of grieving, but appear sad. preoccupied, and withdrawn, while others may grieve more conspicuously through continuous weeping, talking about their losses, and expressing feelings of loneliness.3 The latter behavior may be frustrating to friends and caregivers, since the grieving person repetitively laments losses and dwells on his/her own misery; all focus on the present has been lost, and there is no vision for the future.

Suicide

Suicide usually does not have a single identifiable "cause," but seems to be a desperate act to escape from a series of adverse, dehumanizing changes and losses experienced by the elderly. Old age is a time when persons are less able to adjust to change and stress, yet it is the time when stress has its greatest impact. The reaction of some elderly individuals to multiple losses with which they are unable to cope is suicide. During most of this century, the average suicide rate across all age groups and both sexes has remained within a range of 9 to 13 per 100,000 population.14-15 Miller16 found that males and females over the age of 60 years comprised 18.5% of the country's population, but accounted for 23% of all the suicides. Aging white males are especially at risk and appear to have the highest rate of suicide of any age, race, or sex, since their overall rate is three to four times the national average.14-16,17

Older persons who committed suicide had some of these common characteristics: male, white, Prostestant, over the age of 60, unmarried, in poor health, lacked organizational affiliations, retired or unemployed with diminished income level, and felt all alone.14,16 Suicide may be the option for persons with a terminal illness who can no longer endure the pain, indignity, and partial deaths that result from a debilitating condition. Generally, Wenz18 warned that an older person with a negative view of himself, the world, and the future should be further assessed for suicidal intentions.

Once a decision has been made, the suicidal intentions of elderly males are usually irrevocable; their planning is infallible, with little chance for rescue; their clues are not readily recognized (not many people take an 80- year-old man seriously when he threatens to "end it all" ): and their selection of a method is quite lethal.14,16,18 Very few guidelines have been developed for the immediate prevention of geriatric suicide, but crisis intervention techniques were proposed by Osgood.14

Coping Strategies

Many coping strategies have been reported by older adults themselves who have overcome the disabling effects of grief.7,19 Some of the methods of managing the multiple losses of old age are applicable to persons at risk of suicide as well as to others who struggle with cumulative loss.

1. Helping Others - Avoidance of self-centeredness can be best maintained by helping others who have greater needs; the distraction from preoccupation with one's own loss helps restore self-esteem and a sense of worthiness.

2. Making New Friends - Befriending other people and developing friends across all age groups can be beneficial in broadening the support network, as well as in gaining a new perspective of experiences from diverse age groups. Also, friends do not seem to "all die at once" and ongoing relationships can be maintained. Having even one friend helps an older person feel worthy of being someone's friend.

3. Joining Groups - Groups that offer opportunities for pursuit of interests in hobbies, religious activities, recreational activities, etc, can provide companionship and encouragement for lonely people. Support groups are invaluable sources of information and emotional reassurance for individuals who have experienced loss. The Widowed Persons' Services is an excellent example of a well-organized, effective support group.

4. Setting Goals - Developing goals, planning projects, and noting daily progress toward fulfillment can reaffirm a sense of achievement, as well as ensure an investment in the future.

5. Maintaining Independence - Keeping healthy, active, current in knowledge and skills enables an older person to make decisions and maintain control over his/her own life.

6. Adopting a Pet - Ffets frequently provide companionship and foster a sense of being needed since they give unconditional love and are oblivious to wrinkles and disability.

7. Maintaining a Sense of Humor - Understanding the funny side of human behavior, including their own, and not taking trivial events too seriously, enables many elders to maintain a stability in their perception and management of problems.

8. Sustaining Family Ties - Maintaining an active interest in family affairs helps ensure a place as a participant rather than an observer in family activities; this includes both the sharing of grief and the joy encountered in normal family life. Protection of elder family members from these occurrences only deprives them of a sense of belonging to the family and denies them some validity as a human being.

9. Avoiding Isolation and S elfPity - Seeking nurturance and support from friends and family helps combat sadness and loneliness. It is a positive strategy to accept help when needed and helps provide a bridge to renewed self-confidence. Assistance can be reciprocated when the helper needs someone to lean on; the older person will benefit from giving rather than always being the recipient.

Summary

Adjustment to loss is a challenge in the process of aging. Whether or not aged individuals react differently to grief than younger persons has not been definitely determined, but there is some indication that there is a variation. Resolution of grief is not achieved in the sense that it is ever finished or completed, but seems instead to be integrated into the life of a survivor who remembers, although is no longer prostrated by the event. Most aging persons have accommodated grief in their experiences of life, but a few have not. Even persons who have coped with past losses may experience a profound grief reaction when losses are numerous and occur within a short period of time. Sometimes suicide is perceived as the only alternative for older men who have not resolved grief. Some of the most efficacious methods of coping with loss have originated with elderly persons who have successfully dealt with loss; they provide insight and positive measures for action for older people who struggle with the depressing and sometimes overwhelming effects of loss.

Members of the health professions, family members, other caregivers and friends can provide assistance to grieving individuals. The alliance of all of these resources can better support older individuals in this later task in life -adjustment to multiple losses.

References

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10.3928/0098-9134-19870801-08

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