Journal of Gerontological Nursing

Grief Responses of Senior and Elderly Widows: Practice Implications

Marge Hegge, RN, EdD; Cheryl Fischer, RN, MS

Abstract

TABLE 1

RESEARCH FINDINGS: DEMOGRAPHIC

TABLE 2

FINDINGS OF RESEARCH QUESTIONS

TABLE 3

SUPPORT NETWORKS FOR WIDOWS OLDER THAN AGE 65

TABLE 4

COPING STRATEGIES OF WIDOWS OLDER THAN AGE 65

TABLE 5

DIFFERENCES IN GRIEF RESPONSES OF WIDOWS OLDER THAN AGE 60

TABLE 6

NURSING ASSESSMENTS FOR WIDOWS OLDER THAN AGE 60

TABLE 7

ASSESSMENT FACTORS FOUND TO BE HELPFUL IN WORKING WITH SENIOR AND ELDERLY WIDOWS…

Does the grief process change with advancing years? This research project was designed to describe grief responses among community-dwelling senior (i.e., age 60 to 74) and elderly (i.e., age 75 to 90) widows. In this study, widow was defined as a man or woman who had recently lost a life partner. The specific aim was to determine how death of a life partner compounds the simultaneous cumulative losses of aging so nursing approaches can be modified to meet the unique needs of grieving senior and elderly widows.

The literature is inconsistent about the impact of age on grieving. Earlier studies indicated older widows adjust better than younger widows (Carey, 1977; Morgan, 1976). Hey man and Gianturco (1973) found that widowhood in old age is easier because there are more role models. Yet, a more recent study of widowed women found that loss in later years is not accepted so easily and that sadness remains longer than generally assumed (Sable, 1991).

Table

TABLE 1RESEARCH FINDINGS: DEMOGRAPHIC

TABLE 1

RESEARCH FINDINGS: DEMOGRAPHIC

Many factors influence grief resolution. Religious beliefs, emotional stability, social activities, and previous grief experiences were found to ease grief (Gass & Chang, 1989). The quality of the marriage was pivotal to grief resolution. Dependent spouses and those with ambivalent feelings or unfinished business had more difficulty adjusting. Widows experiencing other simultaneous losses also had greater difficulty (Gass & Chang, 1989).

METHODOLOGY

This qualitative study differentiated the grief responses of 22 senior widows (age 60 to 74) with a recent loss from those of 17 elderly widows (age 75 to 90) to determine how death of a life partner compounds the simultaneous cumulative losses of aging. The study sought to answer five research questions:

* What are the most frequent problems of elderly individuals who have lost life partners?

* What are their most troubling problems?

* What coping strategies are used?

* What support systems are used?

* What adjustments are made in personal goals?

Instrument

A structured tool was developed by Hegge (1991) from the work of Parkes (1970, 1975) and Caplan (1974). The interview tool was critiqued by a panel of experts consisting of five nursing faculty, four of whom were affiliated with Dakota Plains Gerontology Education Center and a pharmacy professor with expertise in gerontology. This established the content validity of the tool. After revisions, the interview tool was pilot tested on two widows older than age 60, and instructions were refined for clarity and readability. This established the face validity of the tool. Reliability was not established because the tool consisted of open-ended questions eliciting qualitative data. The Institutional Review Board reviewed the research methodology and approved the data collection procedures as protective of rights of human rights.

Sample

Volunteers were obtained from churches, senior citizen centers, and hospice programs in small cities and rural settings in a rural state in the midwestern United States. Table 1 describes the characteristics of the sample. Criteria for inclusion in the study were:

* Experiencing the loss of a spouse within the past 4 years (an arbitrary time period).

* Living independently in own home.

* Being older than age 60.

* Being cognitively functional.

After completing written informed consent forms, 22 senior widows (age 60 to 74) with a recent loss and 17 elderly widows (age 75 to 90) agreed to be interviewed at their convenience in their own homes. The distinction between senior and elderly individuals corresponds to the age 75 cut-off point used in the demographic census designation.

The interview questions were open-ended, eliciting narrative responses regarding the length of marriage, months since the death, and nature of the death experience. Widows were asked to describe their relationships with their spouses, the meaning of the death to them, their usual coping strategies, and their effectiveness in coping with their loss. They were asked to describe their primary problems as widows, their most troubling problems, and changes in their lives since the death experience.

Interviews were audiotaperecorded, transcribed verbatim, and analyzed for patterns. Responses were coded using concept analysis. Themes emerged from the narrative data. Responses of each group were coded for recurrent themes and compared for similarities and differences (Table 2). Subthemes emerged on second and third analyses. The themes corresponded closely to the questions on the tool, although new categories emerged.

FINDINGS

The Work of Grieving

The findings of this study reinforce those of grief literature (Caplan, 1974; Hegge, 1991; Parkes, 1970, 1975). The work of grieving was found to follow an erratic cycle with peaks and valleys, spurts, and relapses through four major phases of grief resolution.

Widows in both groups progressed through phases of grief as they adjusted to the loss of a life partner (Figure) (Caplan, 1974; Hegge, 1991; Parkes, 1970, 1975). While the literature suggests sequences and time frames for these phases, the real experience of grieving was not so orderly or predictable. Phases overlapped and regression to previous phases was common. Forward progress was erratic because the peaks and valleys propelled widows between phases, gradually moving them toward acceptance.

The first phase, numb shock, was marked by reactions of denial or disbelief characterized by insomnia, nausea, stupor, restlessness, withdrawal, and aimless activity. The second phase, emotional turmoil, began when the reality of the loss became apparent. The widows experienced alarm or panic reactions. Anger, guilt, pining for the lost spouse, and mood swings were common during this stage. The third phase was characterized by disorganization, despair, regret, and self-doubt as the enormity of the loss was realized fully. Situational depression often impeded the ability to imagine the future or see any purpose in life (Rando, 1993). Dependency on others and difficulty making decisions were experienced. Loneliness was a hallmark of this phase. The final phase of acceptance emerged gradually. Widows began to reorganize life by developing new identities, new ties to others, or new roles. Self-confidence developed as the challenges of life were met alone. Some widows progressed more rapidly to acceptance, while others remained in earlier phases for many years.

Table

TABLE 2FINDINGS OF RESEARCH QUESTIONS

TABLE 2

FINDINGS OF RESEARCH QUESTIONS

Figure. The grieving cycle. From Hegge (1991).

Figure. The grieving cycle. From Hegge (1991).

Table

TABLE 3SUPPORT NETWORKS FOR WIDOWS OLDER THAN AGE 65

TABLE 3

SUPPORT NETWORKS FOR WIDOWS OLDER THAN AGE 65

Similarities in Responses of All Widows

Senior and elderly widows (N = 39) experienced many similar physical and psychosocial symptoms (Table 2). Emotional responses were similar, both immediately and over time. Most widows were in the acceptance phase by the end of the first year.

Manner of death was similar in both age groups, with 27% of the senior deaths and 24% of the elderly deaths being sudden and unexpected. While the senior widows had experienced two suicides, there were none reported in the elderly group. Seventy-three percent of the senior widows and 76% of the elderly widows had lost spouses through expected deaths. Seven (41%) of the elderly widows had placed their spouses in long-term care, while only one of the senior widows had done so. A high percentage of widows in both studies had been caregivers for their spouses (senior = 64%; elderly = 71%). Both groups expressed relief that the suffering was over and that their caregiving responsibilities were concluded. In some cases, energy levels were restored after the spouse had died and the caregiving was complete. Caregivers in both groups reported anticipatory grieving moved them into the acceptance phase sooner. According to Shearer and Davidhizar (1994):

Anticipation does not decrease or increase the amount of emotion generated by the loss, yet it can help work through feelings in advance and resolve unfinished business before the separation actually occurs" (p. 62).

Loneliness in an empty house was the most frequent problem for all widows (senior = 55%; elderly = 60%). Both groups experienced social awkwardness as singles in coupled groups. They reported feeling like a fifth wheel at social gatherings. Both groups experienced lack of a confidant to validate their decisions, with 23% of senior widows and 18% of elderly widows finding this problematic. Elderly widows already may have adjusted to solo decision-making because of their spouses' Alzheimer's disease or nursing home placement. Nine percent of senior widows and 12% of elderly widows worried about finances. Home management was more of a worry for the elderly widows (24%) than for the senior widows (9%).

The most troubling problems for senior widows were financial or legal issues (23%) and being lonely in an empty house (23%). The most troubling problem for 60% of elderly widows was being lonely in an empty house. Sleeping or eating disruptions and home management followed, with 24% of elderly widows experiencing these troubling problems. The elderly widows were more troubled by physical decline (18%) than the senior widows (4.5%). Fear of dependence was equally troubling for both groups (senior = 14%; elderly = 18%).

Coping strategies were similar in both groups. Senior and elderly widows reported the daily times they would have spent with their spouses as the most difficult. Mealtimes, evenings, and bedtime were more painful because they faced familiar situations alone, staring at the empty chair or empty bed. These daily disruptions interfered with normal patterns of eating and sleeping, causing nutritional and energy deficits, subsequently affecting susceptibility to illness. Twenty-seven percent of senior widows and 70% of elderly widows reported they adjusted by coping the best they could. Reliance on others was more prevalent in the elderly widows. Faith in God was a strategy used by one third of each group. Keeping busy to distract themselves from painful grief was more prevalent in the elderly widow group, with 30% (versus 9% of the senior widow group) using this strategy. Empathy toward others and ability to ask for help were common coping strategies.

Solace was found in memories of married life. Pictures and keepsakes that encouraged memories were prized possessions often shared during interviews. Both senior and elderly widows reported having vivid dreams or sensing the presence of the dead spouse. These visions were pleasant because they reminisced over happy memories. Twenty-three widows (59%) reported sensing the presence of their dead spouses in their homes. This shadowing phenomenon was more common with the elderly widows (70%) than the senior widows (50%). They reported hearing their spouses cough, speak, laugh, or walk into a room. One widow reported seeing a vision of her husband standing in the doorway asking for his clothing. Others sensed the presence of their spouses so strongly they would find themselves talking with them. Most of these events occurred in the evening. On occasion, widows were assisted in decision-making by these visions. Widows were not troubled by these perceptions but were reluctant to share them with their families because they feared their families' reactions. Fifty percent of the senior widows and 41% of the elderly widows reported dreams of their dead partners which were more reassuring than troubling. Sometimes these dreams were reminiscent of happy times together, while other times they conveyed messages about life decisions.

Table

TABLE 4COPING STRATEGIES OF WIDOWS OLDER THAN AGE 65

TABLE 4

COPING STRATEGIES OF WIDOWS OLDER THAN AGE 65

Table

TABLE 5DIFFERENCES IN GRIEF RESPONSES OF WIDOWS OLDER THAN AGE 60

TABLE 5

DIFFERENCES IN GRIEF RESPONSES OF WIDOWS OLDER THAN AGE 60

Table

TABLE 6NURSING ASSESSMENTS FOR WIDOWS OLDER THAN AGE 60

TABLE 6

NURSING ASSESSMENTS FOR WIDOWS OLDER THAN AGE 60

Support networks played an important role in the grieving process regardless of age (Table 3). Widows moved more smoothly through the phases of grieving if family, church, neighbor, or friend support systems were readily available to them. This supports the findings of Caserta and Lund (1992). Emotional and social losses after a death demanded new or sharper coping skills to accomplish the tasks of grieving. These findings supported work of Anderson and Dimond (1995) and Gass and Chang (1989) (Table 4). During initial grief both groups relied on their children, relatives, and friends. Neighbors, clergy, and other widows were supportive more for senior widows.

Personal goals were viewed in terms of living each day as it comes (senior = 18%; elderly = 70%) and hoping to maintain independence in their own homes as long as possible (senior = 64%; elderly = 76%).

Differences Between Senior and Elderly Widows

Table 5 summarizes the differences between senior and elderly widows in this study. Elderly widows moved more smoothly and rapidly through the grieving process, perhaps because so many had been caregivers (71%) and had time for anticipatory grieving. The peaks and valleys of grieving phases were less intense in the elderly widow group. The types of relationships prior to the loss of a spouse varied from positive teams to abusive marriages. Eighteen percent of senior widows reported abusive marriages, while none were reported in the elderly widow group. The senior widows reported more positive partnerships (68%) than the elderly widows (24%). The elderly widows older than age 75 reported 76% of their relationships had been deteriorating as a result of ill health, with four of those because of Alzheimer's disease. No instances of Alzheimer's disease were reported in the senior widow group. Elderly widows reported more deaths of institutionalized spouses (41%). The situation of watching their spouses slowly deteriorate may have hastened the grieving process for the elderly widows. Senior caregivers were more likely to miss this role, feeling useless because their caregiving responsibilities had ended.

There was a difference in support networks. In the senior widows, children were the main support system in the initial phase of grief, but friends became more important in later phases. Senior widows were reluctant to become dependent on their children for too long because their independence may be jeopardized. The elderly widows reported their children were their main support throughout all grieving phases. This may result from lost membership in the network of married couples. Reliance on children could result from loss of older friends because of illness, institutionalization, or death. Mobility limitations may have contributed to reliance on family for meeting their basic needs (e.g., transportation).

Elderly widows were more likely to have experienced multiple recent losses. Many stated they had outlived their contemporaries. Several had lost all siblings, becoming the last remaining family member of their generation. The cumulative losses of aging coupled with losses of family and friends left these elderly widows feeling isolated, vulnerable, and old. One elderly widow summed it up, "My world has disappeared. There's no one left who has lived this life with me. No one shares my memories."

Help received from bereavement support groups differed in the two groups. In the senior widow group, 13 attended bereavement support groups, but only 3 reported positive results. The remaining 10 cited overemphasis on the trauma of death as being an impediment to their gaining help. All 6 elderly widows who attended grief support groups reported positive results.

Elderly widows were more focused on their own death than the senior widows. They looked forward to a reunion with their loved ones in the afterlife and were less afraid to face their own deaths. Senior widows were more likely to reconnect with life and re-establish identities as single individuals.

Table

TABLE 7ASSESSMENT FACTORS FOUND TO BE HELPFUL IN WORKING WITH SENIOR AND ELDERLY WIDOWS

TABLE 7

ASSESSMENT FACTORS FOUND TO BE HELPFUL IN WORKING WITH SENIOR AND ELDERLY WIDOWS

NURSING ASSESSMENTS OF WIDOWS OLDER THAN AGE 60

Nurses should assess each individual who has lost a life partner for strengths, weaknesses, risk factors, and coping strategies. Responses to spousal loss vary greatly regardless of age. Table 6 summarizes nursing assessments for widows older than age 60. Verbalization of grief reactions is important for both age groups as they progress through the phases of grief. Expression of feelings associated with loss (e.g., anger, guilt, shock, sadness) is healthy. Widows may be selective in sharing their grief. Both senior and elderly widows may be reluctant to express feelings and need encouragement from a caring listening presence. (Anderson & Dimond, 1995).

The ability to make decisions may be impeded during the phases of grief until new identities and confidence emerge. No major life decisions should be made within the first year because this is a time of turbulent transition that could affect rational decision-making. Independence should be promoted as long as health permits. Nutrition and sleeping disruptions may interact with disorientation to cause accident-prone tendencies. Safety precautions should be taken during this vulnerable phase. Depression, anxiety, confusion, and preoccupation with death may lead to false labels of dementia, so clinical assessments should be performed to ascertain the extent and duration of these symptoms.

Choices of coping strategies and resources rest with each widow. Widows may need assistance to maximize their coping capacities. Previous successful coping strategies can be reviewed to determine their applicability in the current loss. Preferred coping styles may differ from need for solitude to yearning for company. Some widows find comfort in keeping busy and relying on family or friends for support in difficult times. Others find comfort in more solitary activities such as meditation, prayer, and reflection on memories (Moneyham & Scott, 1995).

Support systems such as friends, neighbors, or clergy should be identified and discussed with each widow. They not only provide functional help but also involve widows in social activities and relationships essential to re-establishing their identity as a single individual. Proximity, quality, and effectiveness of family and relatives should be assessed periodically. Support groups of other widows can be a source of coping strategies during bereavement but should be monitored carefully for their relevance. To ensure appropriate group activities, an assessment should be conducted of each group to determine the kind of help needed so programming can be planned accordingly. For example, widows who need assistance with financial and legal issues or household management may be referred to appropriate experts in these areas.

NURSING ASSESSMENTS FOR SENIOR WIDOWS

Table 7 summarizes nursing assessments for senior widows. The findings of this study provide the following rationale for tailoring assessments to senior widows specifically. While nurses can begin with a general assessment and modify it based on individual responses, these general factors should be considered. Senior widows rely on their children in earlier phases of grieving but switch to friends in later phases. While some senior widows seek escape from the painful act of grieving through work, others find their productivity hampered through pointless activities. Other senior widows may become overdependent on support systems.

Desire for new life goals and skills should be ignited so the widows begin to establish a new identity apart from the role of grieving widow. Senior widows should be encouraged to turn from introspection to external interests. New socialization should be encouraged. Matching creative interests with community groups can be a way of networking with others. Relationships with children, grandchildren, and other family members are important social networks that should be encouraged. Neighborhood activities such as organized community events can promote a sense of belonging. Volunteer work is a way of refocusing on the needs of others. If a grieving widow can express caring for another individual, a sense of being needed emerges. This is the beginning of re-engagement with the living world. Volunteer senior companion programs provide a structured way for senior widows to visit homebound elderly individuals regularly. Hospital volunteer programs and foster grandparent programs where senior widows provide companionship for institutionalized children or adults can provide fulfillment. Pets may be another way of meeting attachment and affection needs when other individuals are not readily available.

NURSING ASSESSMENTS FOR ELDERLY WIDOWS

Table 7 also summarizes nursing assessments appropriate for widows who are older than age 75. While there is no clear age cut-off for different responses, this study found patterns prevalent in the elderly widow group that bear monitoring in the assessment process. Elderly widows should be assessed specifically for family support systems, need for grief support groups, nutritional deficits, accident-prone tendencies, confusion or disorientation, and preoccupation with their own deaths. Elderly widows look to their children as their main support for decision-making throughout all grieving phases. If children are distant either geographically or emotionally, other support mechanisms should be developed. Grief support groups should be considered because they can be very effective for elderly widows. Elderly widows are more likely to focus on their own deaths after the loss of a spouse. They may need counseling to work through their own fears or to put their business in order for their own deaths.

Elderly widows who live independendy need frequent surveillance from family, neighbors, or other support systems to ensure their wellbeing and to promote patterns of emotional healing. Frequent telephone calls from distant family can be helpful. Regular telephone calls at expected times give elderly widows something to look forward to and a concrete demonstration of love. Programs, such as lifeline, encourage autonomy. Lifeline programs provide assurance and encourage automony through telephone devices worn at all times for instant assistance. The program provides daily calls to assure equipment function and individual safety.

Elderly widows are at greater risk for nutrient deficits and diminished nutritional status (Rosenbloom & Whittington, 1993). Regular nutritional assessment is needed to assure maintenance of healthy intake. Meals on Wheels or senior congregate dining may assist in the provision of nutritious meals. External dining also involves elderly widows in social interactions necessary to reestablish their identities through networking.

Extreme stress and disrupted sleep patterns may cause decreased alertness or distraction, which can be dangerous. These behaviors carry increased risk for accidents. Disorientation and confusion related to nutritional and sleep deprivation can lead to labels of dementia. Nurses should be alert to the possibility for mislabeling temporary grief reactions as dementia because the consequences for institutionalization and chemical restraints are serious.

Assistance with potential problems of elderly widows (e.g., accident prevention, home maintenance, financial or legal matters) may be needed. Because elderly widows are at increased risk for injury during acute stress, methods of accident prevention should be taught.

Those elderly widows who are deteriorating physically may need alternate living arrangements for proper care. Referrals to social service or other agencies may relieve daily stresses. Home care, homemaker services, or other support care may be needed to maintain the elderly widows in their own homes as long as possible until appropriate long-term care arrangements can be made. Their readiness for institutional life should be ascertained before decisions are made.

Elderly widows who have outlived their contemporaries and family need a listening presence when they reminisce about the past. They need someone with whom to share their memories. Elderly widows are at risk for isolation and depression, and they may feel they have outlived their usefulness. Therefore, they may need more structured support systems to monitor their functional and emotional status.

CONCLUSIONS

Newly widowed individuals in both age groups were resilient, relying on their faith and families to help them through the painful work of grieving. They were concerned about maintaining their independence while re-establishing their identities. Their courage and adaptability can inspire others experiencing the loss of a life partner.

Gerontological nurses can tailor their interventions to the particular phase of grieving and its unique manifestations in the individual. Sensitivity to the widow's cumulative losses and fear of dependence must be maintained throughout the therapeutic relationship.

REFERENCES

  • Anderson, K., & Dimond, M. (1995). The experience of bereavement in older adults. Journal of Advanced Nursing, 22(1), 308315.
  • Caplan, G. (1974). Support systems and community mental health: Lectures on concept development. New York: Behavioral Publications.
  • Carey, R. (1977). The widowed: A year later. Journal of Counseling Psychology, 24(2), 125-131.
  • Caserta, M., & Lund, D. (1992). Bereavement stress and coping among older adults. Expectations versus the actual experience. Omega, 25(1), 33-45.
  • Gass, K., & Chang, A. (1989). Appraisals of bereavement, coping, resources and psychosocial health dysfunction in widows and widowers. Nursing Research, 38(1), 36-38.
  • Hegge, M. (1991). Coping strategies of newly widowed elderly. Midwest Alliance in Nursing Journal, 2(1), 8-16.
  • Heyman, D., & Gianturco, D. (1973). Long term adaptation by the elderly in bereavement. Journal of Gerontology, 28, 259-362.
  • Moneyham, L., & Scott, C. (1995). Anticipatory coping in the elderly. Journal of Gerontological Nursing, 21(7), 23-28.
  • Morgan, L. A. (1976). A reexamination of widowhood and morale. Journal of Gerontology, 31, 687-695.
  • Parkes, CM. (1970). The first year of bereavement - A longitudinal study of the reaction of London widows to the death of their husbands. Psychiatry, 33, 444-467.
  • Parkes, CM. (1975). Determinants of outcome following bereavement. Omega, 6(4), 303-323.
  • Rando, T. (1993). The increasing prevalence of complicated mourning. Omega, 26(1), 43-59.
  • Rosenbloom, C, & Whittington, F. The effects of bereavement on eating behaviors and nutrient intakes of elderly widowed persons. Journal of Gerontology, 48(A), S223-S229.
  • Sable, P. (1991). Attachment, loss of spouse, and grief in elderly adults. Omega, 23(2), 129-138.
  • Shearer, R., & Davidhizar, R. (1994). It can never be the way it was. Home Healthcare Nurse, 12(4), 60-65.

TABLE 1

RESEARCH FINDINGS: DEMOGRAPHIC

TABLE 2

FINDINGS OF RESEARCH QUESTIONS

TABLE 3

SUPPORT NETWORKS FOR WIDOWS OLDER THAN AGE 65

TABLE 4

COPING STRATEGIES OF WIDOWS OLDER THAN AGE 65

TABLE 5

DIFFERENCES IN GRIEF RESPONSES OF WIDOWS OLDER THAN AGE 60

TABLE 6

NURSING ASSESSMENTS FOR WIDOWS OLDER THAN AGE 60

TABLE 7

ASSESSMENT FACTORS FOUND TO BE HELPFUL IN WORKING WITH SENIOR AND ELDERLY WIDOWS

10.3928/0098-9134-20000201-12

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