Grief

Older Adult

"Season of loss" Many non-death losses that are a part of aging.

Stages of Grief: John Bowlby

*1. Numbness/Protest* Feeling of shock *2. Disequilibrium* Profound urge to recover what has been lost *3. Disorganization/despair* ADL's become increasingly disorganized and behavior is restless and aimless. *4. Reorganization* Accepts or becomes resigned to the loss. Observed in all individual who have experienced loss.

Adaptive versus Non-Adaptive

*Crucial difference is loss of self-esteem* Marked feelings of worthlessness indicative of depression May ultimately devolve into depression

Outcome Measures

-Acknowledges awareness of loss -Expresses feelings about loss -Verbalizes own position in grief process -Recognizes appropriateness of associated feelings and behaviors

Interventions

-Assess stage of grief -Assist w talking about loss; (when/how loss happened) -Listen!! -Help Identify/express feelings -Expect anger, guilt, fears that one could not carry on alone -Provide adequate time for client's grief -Provide continuing support -Identify pathological defenses and strategies being used. -Identify behaviors that tend to mask the pain of loss -Encourage relationship review through journaling. (positive and negative aspects) -Encourage normal nutrition status -Caution use of substances to allay painful feelings -Promote exercise regimen congruent with age and physical status -Discuss sleep patterns and recommend sleep hygiene measures -Administer medications as ordered; review side effects

Complicated Grieving Risk Factors

-Lack of social support -Denial of loss -Interference with functioning -Little or no reduction of intensity of grief -Predisposition to anxiety/inadequacy -Frequency of major life events

Factors Influencing outcomes

-Person was highly dependent on lost object -Lost relationship was a highly ambivalent one -Experienced lots of recent losses; grief tends to be cumulative -Age of lost object if a person -Unstable health of survivor Perception of responsibility for loss

Depression

-Self-Esteem is disturbed *-NO ANGER* -PERSISTENT dysphoria (all bad days) -Anhedonia (no experience of pleasure) -No response to social interaction and support -PERSISTANT hopelessness -GENERALIZED guilt -Depression IS NOT RELATED to a specific experience -Chronic physical complaints

Normal Grief

-Self-esteem -Openly expresses anger -Mixture good/bad days -Accepts comfort and support -Maintains feelings of hope -May express guilt over some ascots of the loss -Relates feeling of depression to the specific loss experienced -May express transient physical symptoms

John Bowlby's stages of grief may be expressed as early as

6 months of age

Delayed or Inhibited

Absence of grief when it would normally be expected. Grief response is then triggered later (often years) with the experience of a subsequent loss.

Stage of Grief: Kubler-Ross The individual is ready to die and may become quiet and withdrawn as they disengage from their environment.

Acceptance

-Realize death is final and affects everyone including themselves. -Peer relationships and school performance may be impacted.

Age 10-13

-Start to understand finality of death. -Associate death with old age/illness -Withdrawal and clinging behaviors are common

Age 6-9

-Believe death is reversible -Concerned with own safety -Need reassurance -Regressive behaviors -Changes in eating and sleeping

Ages 3-5

Stage of Grief: Kubler-Ross How can he think about a vacation when I am dying. Includes other related affects of sadness, guilt, shame, hopelessness and helplessness.

Anger

Stage of Grief: Kubler-Ross If only I could ... If only I had ...... Trying to make a deal for a second chance or more time.

Bargaining

-Feelings of loss and separation. -Become quiet, lose weight and sleep less.

Birth-2

Chronic or Prolonged

Care must be taken when making this determination because the length of the grief response depends on the individual.

Stage of Grief: Kubler-Ross This can't be happening to me, There must be some mistake, My test results were mixed up with someone else May serve as a source of protection against the psychological pain of reality.

Denial

Stages of grief: Kubler-Ross

Denial Anger Bargaining Depression Acceptance

Stage of Grief: Kubler-Ross Mourns for that which has been or will be lost. Individual may withdraw or socially isolate themselves.

Depression

Distorted/exaggerated

Individual is dysfunctional in management of daily living.

Grieving Process

Initiated by loss Mourning + Grief

Mourning

Psychological process of adaptation to loss

Forms of Loss

Significant other Illness or debilitating conditions Developmental/maturational change or situations (growing up) Inability to meet self-expectations or those of others Decrease in self-esteem Personal possessions

Grief response facilitated positively:

Significant other are supportive There is an opportunity to prepare for the loss

Grief

Subjective states that accompany mourning; the emotions of the mourning process. Syndrome with a predictable course and expected resolution

Anticipatory grieving

The experiencing of feelings associated with normal grief response before the loss actually occurs Can be positive or negative May serve defensive purposes

When Frank's wife of 34 years dies, he is very stoic, handles all the funeral arrangements, doesn't cry or appear sad, and comforts all of the other family members in their grief. Two years later, when Frank's best friend dies, Frank has sleep disturbances, difficulty concentrating, loss of weight, and difficulty performing on his job. This is an example of which of the following maladaptive responses to loss? a. Delayed grieving b. Distorted grieving c. Prolonged grieving d. Exaggerated grieving

a. Delayed grieving

Which of the following is a correct statement when attempting to distinguish normal grief from clinical depression? a. In clinical depression, anhedonia is prevalent. b. In normal grieving, the person has generalized feelings of guilt. c. The person who is clinically depressed relates feelings of depression to a specific loss. d. In normal grieving, there is a persistent state of dysphoria.

a. In clinical depression, anhedonia is prevalent.

Which of the following is thought to facilitate the grief process? a. The ability to grieve in anticipation of the loss b. The ability to grieve alone without interference from others c. Having recently grieved for another loss d. Taking personal responsibility for the loss

a. The ability to grieve in anticipation of the loss

A major difference between normal and maladaptive grieving has been identified by which of the following? a. There are no feelings of depression in normal grieving. b. There is no loss of self-esteem in normal grieving. c. Normal grieving lasts no longer than 1 year. d. In normal grief, the person does not show anger toward the loss.

b. There is no loss of self-esteem in normal grieving.

Which grief reaction can the nurse anticipate in a 10-year-old child? a. Statements that the deceased person will soon return. b. Regressive behaviors, such as loss of bladder control. c. A preoccupation with the loss. d. Thinking that they may have done something to cause the death.

c. A preoccupation with the loss.

Which of the following is not true regarding grieving by an adolescent? a. Adolescents may not show their true feelings about the death. b. Adolescents tend to have an immortal attitude. c. Adolescents do not perceive death as inevitable. d. Adolescents may exhibit acting out behaviors as part of their grief.

c. Adolescents do not perceive death as inevitable.

Nancy, who is dying of cancer, says to the nurse, "I just want to see my new grandbaby. If only God will let me live until she is born. Then I'll be ready to go." This is an example of which of Kübler-Ross's stages of grief? a. Denial b. Anger c. Bargaining d. Acceptance

c. Bargaining

Gloria, a recent widow, states, "I'm going to have to learn to pay all the bills. Hank always did that. I don't know if I can handle all of that." This is an example of which of the tasks described by Worden? a. Task I: Accepting the reality of the loss b. Task II: Processing the pain of grief c. Task III: Adjusting to a world without the lost entity d. Task IV: Finding an enduring connection with the lost entity in the midst of embarking on a new life

c. Task III: Adjusting to a world without the lost entity

Engel identifies which of the following as successful resolution of the grief process? a. When the bereaved person can talk about the loss without crying b. When the bereaved person no longer talks about the lost entity c. When the bereaved person puts all remembrances of the loss out of sight d. When the bereaved person can discuss both positive and negative aspects about the lost entity

d. When the bereaved person can discuss both positive and negative aspects about the lost entity

Which of the following is most likely to initiate a grief response in an individual? a. Death of the pet dog b. Being told by her doctor that she has begun menopause c. Failing an exam d. A only e. All of the above

e. All of the above

Loss

the experience of separation from something of personal importance anything that is perceived as a loss by the one describing it

Length of grieving process depends on

the individual

Acute Phase of grieving

~6-8 weeks Longer in Older Adults Traditional belief = 6mo-1 year