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CHAPTER 14

Grief and Bereavement

ROBERT O. HANSSON, BERT HAYSLIP JR., and MARGARET S. STROEBE

THE NATURE OF GRIEF

It is often the case that grief and bereavement accompany the aging process via

the increasing likelihood of the deaths of friends, parents, a spouse, and ulti-

mately oneself. Irrespective of the veracity of this presumed association, its un-

critical acceptance may have the unfortunate consequence of desensitizing others

to the impact of the loss of valued relationships on older adults (Kastenbaum,

1978). It is for this reason that understanding the role that grief and adjustment to

bereavement play in the lives of older persons is so critically important.

Irrespective of age, the experience of grief is best understood to include two com-

ponents: an emotional reaction to losing a close attachment relationship and a need to

cope with “secondary stressors” resulting from the death, for example, disrupted fi-

nances, threats to family security, or having to assume new responsibilities for family

and household maintenance (M. S. Stroebe & Schut, 1999). As most grieving persons

can attest, this reflects the distinction between the private and the public experience

of the loss of a loved one, which in many respects do not parallel one another.

Understandably, then, the symptomatology of grief can be complex. It involves a

broad mix of potentially disruptive emotions (e.g., depression, anxiety, loneliness,

and guilt), physiologic-somatic symptoms, disrupted functions (e.g., disturbances

in sleeping patterns and cognitive functioning, changes in self-regulation, immune

functioning), a diminished capacity to cope, increased vulnerability to illness and

disease, and increased mortality rates (Shuchter & Zisook, 1993; W. Stroebe &

Stroebe, 1987). In this respect, the distinction between what would be character-

ized as “normal” grieving and “pathological” grieving hinges on the extent to

which the loss of a valued relationship interferes with the older person’s everyday

functioning, work performance, relationships with others, emotional and cognitive

status, and health. Consider the following case example of pathological grief.

Case Study

Debra, a 62-year-old female, learned that her 37-year-old adult son had been

killed by a bus while biking. She had not seen him in some years, and theirs had

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Table 14.1

Death Rates by Age (All Causes): United States 2000

Deaths per

Age (Years) 100,000

All ages 854

55–64 992

65–74 2,399

75–84 5,666

85 and older 15,524

Source: Health, United States, 2003

(Special Excerpt: Trend

Tables on 65 and Older Population), by the U.S. Department

of Health and Human Services, 2003, Washington, DC: Cen-

ters for Disease Control and Prevention, National Center for

Health Statistics.

been a characteristically conflicted and distant relationship, about which she felt

quite guilty; she indicated that she felt she had somehow “failed” him as a

mother. Debra reacted to her son’s death dramatically: Shortly after his funeral,

she began to have difficulty in her work as a computer programmer, missing work

more often than not, withdrawing from friends and coworkers, and making more

mistakes than normal. Moreover, she had a great deal of difficulty talking about

her son’s death and her relationship to him. Within a month of his death, she quit

her job and stayed at home, spending a great deal of time by herself, not eating

well, and having difficulties functioning on a daily basis. Eventually, and at the

urging of her husband, she sought professional help and developed an interest in

gardening. Ultimately, after 2 years, she returned to work. At present, she seems

to have put his death into perspective and is moving on with life.

Especially among older adults, despite the fact that for such persons the expe-

rience of loss becomes increasingly normative in nature, individual grief reac-

tions may vary in their intensity and duration. Most bereaved persons, however,

are eventually able to adapt, returning to preloss baseline with respect to such in-

dicators as depression and physical symptoms. Some, however, experience a more

complicated grief experience, perhaps in response to the traumatic circumstances

of the death (Prigerson & Jacobs, 2001), the implications of concurrent life stres-

sors, or individual vulnerabilities.

It will not go unnoticed by gerontologists or geriatricians that this symptom

picture overlaps considerably with the experience of older persons generally as

they attempt to deal with normative, age-related life transitions or with life stres-

sors characteristic of old age. Concerns thus arise with respect to distinguishing

between the consequences of bereavement and the consequences of aging-related

problems more generally; any needed interventions would likely parallel, in part,

those provided in response to other, serious life stressors.

Table 14.1 provides some perspective on the experience of loss throughout the

life span. It summarizes current patterns of death rates by age for the United

States. It is clear from this table that old age is a time in which bereavements may

become more frequent; older adults may thus face an accumulation of grief expe-

riences, compounding the consequences for emotional and practical coping and

Grief and Bereavement 369

for the stability of support networks. Conjugal bereavements, in particular, rise in

incidence with age; among community living elders, 20% of those age 65 to 74,

39% of those age 75 to 84, and 63% of those age 85+ have become widowed (Fed-

eral Interagency Forum on Aging-Related Statistics, 2004). In addition to the

death of one’s spouse, the deaths of siblings and lifelong friends can have espe-

cially heavy impact.

The causes of death also change with old age. In early life, they are more likely

to involve traumatic circumstances such as accidents, homicide, suicide, cancers,

and acute illnesses. In mid- and late life, however, the emphasis tends to shift to-

ward chronic illness such as heart disease, respiratory and vascular diseases, and

influenza or pneumonia (U.S. Department of Health and Human Services, 2002).

This pattern of changing causes of death across the life span suggests at least two

important implications for the experience of bereavement. First, bereavements of

older persons less frequently involve a traumatic death. Second, conjugal bereave-

ments among older persons are more likely to have previously involved the bur-

den of a prolonged care-giving experience, a circumstance that will have elicited

coping and adaptation efforts prior to the death itself.

RESEARCH ON AGING AND BEREAVEMENT

Early empirical research on bereavement treated age as one of many potential risk

variables for poor outcome. These studies were cross-sectional and often found

younger bereaved persons to have experienced greater distress from the death

(Archer, 1999; Parkes, 2001; C. Sanders, 1989). Post hoc explanations of such data

were readily available (e.g., that the death of an older spouse is less unexpected),

and researchers moved on to other issues (Hansson & Stroebe, in press).

The early research, then, was not formulated from a gerontological perspective:

• It did not recognize that age, per se, is an imperfect predictor of mental or

physical status, of vulnerability to stressful life events, or of competence to

adapt.

• It did not recognize the potential variability within older populations with

respect to their vulnerability to the consequences of loss, the likely nature

and course of their grief reaction, their coping resources and resiliency.

• It did not reflect an appreciation of the nature of late-life development.

• It did not consider the various contexts of aging as they might interface with

the contexts of the death of a loved one (Hansson & Stroebe, in press).

In addition, much of the early research suffered a variety of methodological

shortcomings:

• Most studies were cross-sectional, precluding consideration of long-term

outcomes or of generational influences.

• Prebereavement baseline assessments were typically unavailable.

• Cause of death was often not considered.

• Men, ethnic populations, institutionalized elderly, and nonconjugal be-

reavements (e.g., by siblings or grandparents) were often undersampled.

• Appropriate control groups of nonbereaving younger and older persons

were often not included.

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• Little consideration was given to issues of the validity of assessment among

older populations.

• Assessed outcomes were often limited to snapshots of current physical and

mental health status, precluding examination of important dynamics such

as coping and the emergence of social support, examination of the differen-

tial trajectories over time of the various classes of outcome variables, or mor-

tality patterns.

• The possibility that relationships between age and any aspect of the be-

reavement reaction might be nonlinear (e.g., that middle-aged persons

would be more or less affected than either younger or older persons) was

typically not considered (Hansson & Stroebe, in press).

Subsequently, researchers began to explore aging and bereavement from more

complex, gerontological perspectives. The important epidemiological studies are

now longitudinal in nature and guided by a richer base of life span developmen-

tal theory. The focus is now on more complex questions, such as the following:

• How might the configuration of bereavement symptoms change or become

more complex in old age?

• Might the nature of bereavement symptoms reflect a greater physical com-

ponent in late life?

• What might be the implications of residual, unresolved symptomatology for

subsequent processes of disablement in late life?

• Might research from the area of aging and emotion explain earlier findings

of lower intensity grief among older persons?

• To what extent might the contexts of aging in general (e.g., reduced eco-

nomic status, smaller social networks) operate as risk or protective factors

in the bereavements of older persons?

• Might an increased incidence of bereavements in late life result in a cumula-

tive bereavement effect?

• How does the bereavement experience vary across older persons, and what

are the sources of such variability (e.g., person, social, and cultural factors)?

• How might adaptations to previous losses (successful or unsuccessful) af-

fect vulnerability?

• What forms of intervention may be appropriate for older bereaved persons;

how might standard interventions need to be adapted for older persons; and

how should we think about goals for (and evaluation of) intervention?

OUTCOME STUDIES ON AGING AND BEREAVEMENT

ETEROGENEITY OF THE

EREAVEMENT

ESPONSE

An important and pervasive finding in contemporary outcome studies of older

bereaved persons concerns the heterogeneity of their reactions, consistent with the

fact that between-person variability is greater among older persons than among

younger and middle-aged persons (Nelson & Dannefer, 1992). Each older person

enters a bereavement experience with a unique mix of mental and physical abili-

ties, coping resources, and adaptive reserves. It is thus consistent that researchers

have found older persons to have diverse reactions to the loss of a loved one. In

one longitudinal study of elderly widowed persons, Lund, Caserta, and Dimond

Grief and Bereavement 371

(1993) found that some respondents experienced severe distress, as might be ex-

pected. Others, however, appeared able to meet this challenge, to learn the skills

needed to cope, and to find a way to adjust to the loss. In addition, these re-

searchers found considerable within-respondent variability of experience. That

is, an older widowed person might cope well in some areas of her life but do

poorly in others.

Bonanno, Wortman, and Nesse (2004) illustrated the issue of diversity of re-

sponse from a different perspective. They found it possible to classify a sample of

elderly widowed persons into five distinct bereavement patterns with respect to

experienced depression. One group (termed “resilient”) experienced relatively

little preloss depression, and their depressive symptoms remained low for 18

months after the death. A “common grief pattern” group saw a loss-related spike

in depressive symptoms, but these declined over the 18 months postloss. A

“chronic grief” pattern involved a postloss increase in depression, which then re-

mained high for the 18 months. A “depressed-improved” pattern involved per-

sons with high predeath depression, which then declined over the 18 months. A

“chronic depressed” pattern involved high preloss symptoms that remained high

during all follow-up assessments.

ESILIENCE IN THE

ESPONSE TO

EREAVEMENT

Another important finding is that many older bereaved adults exhibit consider-

able resilience. Lund, Caserta, and Dimond (1989, 1993) reported that over 80% of

their conjugally bereaved elderly respondents were successfully coping with the

consequences of their loss, were managing their health and their relationships

with some success, and felt reasonable life satisfaction. Many respondents re-

ported that this was an adaptive process and that they had successfully learned

new skills needed for their changed lives. A study by Fry (1998) echoed these

findings; most of her elderly bereaved respondents reported that they had experi-

enced some success in adapting to the death and its emotional and practical con-

sequences, resulting in increased feelings of personal control and autonomy. In

this respect, a great deal of recent attention has been devoted to the study of re-

silience among older men (see, e.g., Carr, 2006; Moore & Stratton, 2002; Wolff &

Wortman, 2006), underscoring the importance of identifying those older individ-

uals who are able to assimilate the loss of a spouse, child, friend, parent, or

grandchild into their identities as individuals, parents, husbands/wives, or adult

children.

ONTEXTUAL

SSUES IN

ATE

-L

IFE

EREAVEMENT

A number of contextual parameters influence the experience of bereavement in

old age. Losing a spouse of many years can be especially disorganizing for older

persons, as it disrupts lifelong social roles, affects income, support systems, and

social opportunities, and may signal increasing dependency on support systems

that may not fill one’s needs (Lopata, 1993, 1996). In addition, elderly bereaved

persons are more likely to be women and to live alone. They are unlikely to re-

marry, and because many are childless, they have diminished access to needed

support (O’Bryant & Hansson, 1994). Simply because of their age, they are likely

to have experienced a greater number of deaths of their loved ones. And in the

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case of the death of a younger family member, their grief may not be viewed with

as much concern as that of younger grieving family members. The elderly may be

viewed instead as a “secondary griever,” their symptoms may be misattributed to

age, and their grief “disenfranchised” (Moss & Moss, 1989). As we explore later in

this chapter, because of their advanced age, they will more likely experience the

death of a child or grandchild, with potentially devastating consequences (Fry,

1997; Hayslip & White, in press; Moss & Moss, 1994).

ONSEQUENCES OF

EREAVEMENT AMONG

LDER

DULTS

A number of longitudinal studies of older bereaved persons have now appeared.

These studies vary in their focus and duration. It would appear, however, that

older adults experience a mix of physical, emotional, cognitive, and social conse-

quences similar to those found among younger bereaved. The course of the grief

reaction also appears similar to that of younger persons. Acknowledging individ-

ual variations, the pattern reflects an elevation of symptoms in the first months

postloss, and then gradually diminishing symptoms as the individual finds some

success in adaptation.

This pattern was nicely illustrated in a study of recently widowed elderly per-

sons and matched controls (Gallagher-Thompson, Futterman, Farberow, Thomp-

son, & Peterson, 1993; Thompson, Gallagher-Thompson, Futterman, Gilewski, &

Peterson, 1991). Respondents in this study were assessed over a period of 30

months postloss with respect to indicators of depression, grief-specific distress,

mental health symptoms, and mortality risk. In the first 2 months postloss, the

bereaved experienced increased levels of general and grief-specific psychological

distress and physical illness. By 12 months postloss, the bereaved group no longer

differed significantly from controls on measures of psychopathology, depression,

or physical complaints. Scores on emotional symptoms more specific to grief,

however, continued to be higher among the bereaved throughout the course of the

30-month study.

Researchers have also provided insights regarding the consequences of be-

reavement for interpersonal functioning among older persons. Lopata’s (1996)

studies of elderly American widows, for example, identified loneliness as a com-

mon and highly distressing consequence. The loss of a long-time spouse often sig-

nifies the loss of one’s core emotional ties, shared experiences and worldviews,

patterns of behavior, and validation of self as someone to be unconditionally

loved. Lopata’s respondents reported not only emotional loneliness (for a specific

person), but also a broader social loneliness. Such findings have been widely

replicated, for example, in studies by Lund et al. (1993) and van Baarsen, van

Duijn, Smit, Snijders, and Knipscheer (2001–2002).

Longitudinal studies have also provided considerable insight into the physical

health consequences of bereavement for older persons. Here, however, we provide

the reader of such research with a cautionary note: Many of these studies failed to

consider the importance of prebereavement health status (Murrell, Himmelfarb,

& Phifer, 1988). This presents a serious problem for the interpretation of health

findings in bereavement research because so many adults age 65 and older suffer

from a chronic and progressive disease process, such as arthritis, diabetes, can-

cer, stroke, hypertension, heart disease, vision loss, and physical disability (Fed-

eral Interagency Forum on Aging-Related Statistics, 2004). Such conditions are

Grief and Bereavement 373

known in the health literature to render one more vulnerable to subsequent phys-

iological events, but might also be considered a “coping deficit,” with implica-

tions for one’s potential to cope and adapt to subsequent illness or life stress. In

this context, it is instructive that a longitudinal study of older bereaved persons

by Murrell et al. (1988) found that bereavement contributed little unique variance

to health status after controlling for predeath health status. This issue, then, sug-

gests one important way that the bereavement experience of older persons differs

from that of most younger persons. But the effect may be twofold; older bereaved

persons will likely have been in poorer health, reflecting age-related factors, but

they may also have been experiencing elevated health symptoms owing to the

stress of caregiving for the spouse who died.

Bereavement in late life also appears to influence normal functioning impor-

tant to survival. One example is nutrition. Rosenbloom and Whittington (1993)

found that elderly widows (compared to matched married controls) reported ele-

vated loneliness and poorer appetite at mealtimes. They were more likely to con-

sume unhealthy snacks, had generally lower overall nutrition, were less likely to

take nutritional supplements, and experienced more unintended weight loss.

Scores on a measure of grief resolution significantly predicted meal quality and

enjoyment and weight loss.

A broader array of physical disruptions can undermine stability and adaptive

coping on the part of elderly bereaved persons. Disruptions of sleep and social

(and circadian) rhythm stability also appear important. L. F. Brown et al. (1996)

found bereavement-related depression to predict increased problems with sleep

and rhythm patterns and in adjusting to the loss. It is consistent, then, that wid-

owhood is a significant predictor of first entry to a nursing home (Wolinsky &

Johnson, 1992).

The experience of pain may similarly be affected. Bradbeer, Helme, Yong,

Kendig, and Gibson (2003) found that widowed elderly adults were 3 times more

likely to indicate significant (severe and activity-limiting) pain, compared to non-

widowed controls. In a path analysis, they demonstrated that the relationship be-

tween widowed status and experienced pain was mediated by bereavement-

related mood status (widowhood alone accounted for only 1% of the variance in

experienced pain, but a path model reflecting widowhood → mood disturbance

→ pain accounted for 17% of the variance in pain).

Finally, studies have also examined the potential for excess mortality among

older bereaved persons. Two general patterns seem to emerge from these analy-

ses. Older bereaved persons appear somewhat less at risk for death due to the

stress of bereavement than younger persons (M. S. Stroebe & Stroebe, 1993). It

also appears that causes of death among the bereaved who are very old reflect the

causes in the broader very old population in general, suggesting that after ac-

counting for age-related physical decline, little variance remains to be accounted

for by the stress of bereavement (Bowling, 1994).

Many of the longitudinal bereavement studies on older persons have used de-

pression as a core indicator of adjustment. It is worth noting, however, that re-

liance on depression in research can be problematic among older populations.

One reason is the issue of medical comorbidity (Blazer, 2003). That is, patients

with chronic pain, heart disease, stroke, or diabetes typically report elevated de-

pression regardless of marital status. On the other hand, depression can also ex-

acerbate medical problems (e.g., heart disease, weight loss, and osteoporosis),

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and it is associated with increased use of medical services (Blazer, 2003). Another

reason is the difficulty inherent in interpreting depression scores among the el-

derly (Gatz & Fiske, 2003). Depressive symptoms among the elderly may differ

from those seen in younger populations; confusion may arise in attributing cer-

tain symptoms either to depression or to physical disorders; cognitive decline

may undermine reliability of assessment protocols; and persons with major de-

pression are less likely to live into very old age (Gatz & Fiske, 2003). That said, in

these studies bereavement has been a consistent predictor of depression (Har-

wood, 2001; Parkes, 1997; Rosenzweig, Prigerson, Miller, & Reynolds, 1997). It is

also a concern that among older persons, untreated depression is an important

risk factor for suicide (Szanto et al., 2002). Widowed men (age 60 and over) are at

particular risk; they are 3 times more likely than married men to commit suicide

(Li, 1995).

ISSUES OF CONTEXT AND TRANSITION

IN LATE-LIFE BEREAVEMENT

Bereavement does not occur in a vacuum. Contextual factors can increase or de-

crease risk with respect to adaptation. In this section, we describe a number of

these factors.

RANSITIONS FROM

AREGIVING

Causes of death in old age generally involve chronic conditions or disease process.

Bereavements have the potential to become more complex because they involve a

transition from a stressful period of caregiving. For some elderly bereaved per-

sons, dealing with both caregiver stress and subsequent bereavement may result

in an accumulation of stress that may compound any negative consequences. For

many others, however, coping with one’s care-giving responsibilities may enhance

coping skills and sense of personal mastery. Consistent with this reasoning, Wells

and Kendig (1997) found that older widowed persons who had previously been

spouse caregivers experienced less depression than either married-current care-

givers or widows who had not previously engaged in caregiving. Wolff and Wort-

man (2006) note that among resilient widows and widowers, the death of a spouse

represents the end of a chronic stressor rather the beginning of a series of difficult

bereavement-related adjustments.

The burden of caregiving can be extensive, however, and can have lasting con-

sequences for some older persons. This was illustrated in a study by Robinson-

Whelen, Tata, and MacCallum (2001) that compared depressive symptoms among

elderly caregivers over a 3-year period postbereavement to matched control

groups of continuing caregivers and noncaregivers. At prebereavement assess-

ment, both caregiver groups were experiencing more depression than noncare-

giving controls, and this pattern continued to be observed out to 3 years postloss.

Similarly, at prebereavement assessment, perceived stress was highest among the

caregiver-bereaved group. Over the period of the study, perceived stress among

the caregiver-bereaved eventually dropped to levels reported by continuing care-

givers, but for both caregiver groups remained higher than among controls for the

remainder of the study.

Grief and Bereavement 375

Schulz et al. (2001) examined these relationships more directly. Their study

classified older, recently widowed persons on the basis of the extent to which

their caregiving involved strain (reflecting their patient’s health, disability, or

need for assistance with activities of daily living prior to the death), and on the

basis of rated caregiver strain. The caregiver-strained group was found to experi-

ence higher depressive symptoms at prebereavement assessment and throughout

the study. Caregiver-strained respondents at predeath assessment also reported

more risky health behaviors (e.g., forgetting medications and doctor’s appoint-

ments). After the death, however, problematic health behavior diminished to the

level of the nonstrained group, perhaps reflecting a relief from the demanding re-

sponsibilities of caregiving and the infusion of assistance from family.

A number of specific issues arise in the context of the transition from caregiv-

ing to bereavement. As in the broader care-giving burden literature, there is evi-

dence of diminished personal control and social isolation, in addition to

emotional distress (Ferrario, Cardillo, Vicario, Balzarini, & Zotti, 2004). Caregiv-

ing for some kinds of patients (e.g., terminal cancer patients) can also involve

traumatic exposure, witnessing a loved one in extreme pain who may become de-

hydrated, unable to eat, and confused and may choke or vomit. Such experiences

are particularly common among spouse caregivers and appear to have an effect on

subsequent depression and adjustment above and beyond the effects of caregiver

burden (Prigerson et al., 2003).

The transition from care-giving bereavement also appears particularly difficult

when the patient is cognitively impaired. As we discuss further later in the chap-

ter, caregiving for Alzheimer’s patients, for example, demands more time, often

requiring the caregiver to withdraw from other social and employment responsi-

bilities. The disease is chronic and unpredictable, further increasing stress. It

eventually involves not only the provision of complete personal care, but also a

deep sadness and degree of uncertainty, each of which is associated with care-

giver outcomes (Marwit & Meuser, 2002).

ONCURRENT

TRESSORS

Old age is a time when stressful life events tend to cluster. A bereavement may be

accompanied by problems with health, economic disruption, and mandated

change of residence (and having to leave old friends). But small events (e.g., fam-

ily conflicts, pain, things in the house not working) can also accumulate and con-

tribute significant distress over and above the effects of larger events such as

bereavement (Murdoch, Guarnaccia, Hayslip, & McKibbin, 1998).

OPING

ESOURCES

As at any age, older adults vary with respect to the personal and social coping re-

sources on which they can draw in dealing with a bereavement. A study by Gass

(1987) found that such resources (e.g., social support, religious beliefs, prior

health, and financial security) can influence an older person’s appraisal of

threats associated with the death and appear to enhance both physical and psy-

chological outcomes. In this context, it is a concern that the percentage of surviv-

ing spouses living in poverty rises significantly in the 1st year after the loss of

a spouse (Hungerford, 2001), especially among women (Zick & Smith, 1991).