7 Old age psychiatry7.9 Bereavement and adjustment disorders
7.9 Bereavement and adjustment disorders in later life
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Written by Resident Doctor Committee · Published
Grief and the losses that provoke it
Bereavement is loss through death, grief is the response, and mourning is its culturally shaped expression.
Grief also follows losses of health, home, independence or role.
Normal grief comes in waves of yearning, sadness or anger. It has no fixed timetable.
Bowlby and Parkes described phases from numbness and searching to reorganisation, but people need not pass through them in order.
Telling grief from depression
In later-life bereavement, depression is marked by loss of self-esteem.
Feature | Normal grief | Depression |
|---|---|---|
Mood | Waves linked to reminders, with pleasure possible between them | Pervasive, with marked loss of pleasure |
Self-esteem | Preserved | Worthlessness |
Guilt | About the death or particular actions | Beyond the death, global or delusional |
Thoughts of death | Wish to join the deceased | Death wishes from self-loathing |
Sleep and appetite change is common in normal grief, so it does not separate grief from depression.
A wish for reunion still needs assessment of intent and plans.
Bereavement neither establishes nor excludes an ICD-11 depressive episode; symptoms must exceed the expected grief response and meet the episode requirements.
Experiences of the deceased
Transient perception of the deceased (sensing, hearing or seeing them) is part of normal grief and is often comforting.
In Rees's 1971 study of 293 widowed people, 46.7% had such experiences, most often a sense of presence, and many had told no one.
Broader psychotic symptoms, commands, cognitive change or altered arousal need fuller assessment for delirium, depression, medicines, sensory loss or Lewy body disease.
Prolonged grief disorder
Feature | ICD-11 (International Classification of Diseases, 11th revision) |
|---|---|
Time since death | At least 6 months |
Core symptom | Persistent, pervasive longing or preoccupation with intense emotional pain |
Other symptoms | Such as guilt, anger, denial or numbness |
ICD-11 requires that the grief clearly exceeds cultural expectations and causes significant impairment.
Prolonged grief centres on yearning for the deceased, whereas post-traumatic stress disorder centres on fear of the traumatic event. The two can coexist.
Complicated grief treatment, a grief-focused psychotherapy, gave response in 70.5% of older adults against 32.0% with interpersonal psychotherapy, a number needed to treat of about 3.
Citalopram did not improve grief symptoms compared with placebo, but helped depressive symptoms when added to grief treatment.
Adjustment disorder
Feature | ICD-11 |
|---|---|
Onset | Usually within 1 month of the stressor |
Resolution | Usually within 6 months after the stressor and its consequences end |
ICD-11 defines it by preoccupation with the stressor and failure to adapt.
Normal grief does not meet the diagnosis.
Later-life stressors include moving into care, loss of driving, illness, disability and dependence. Self-harm risk can be serious.
Benzodiazepines
Hypnotics and benzodiazepines do not treat grief, and in older people they risk falls, confusion and dependence.
Benzodiazepine dependence in community-dwelling older adults is associated with depression, panic disorder, suicidal ideation, mild cognitive impairment and female sex, not with the medical conditions the drugs are prescribed for.
Course and risk
Most bereaved people develop no disorder, and grief that returns around anniversaries does not mean relapse.
A Danish study found self-harm and suicide rose soon after bereavement, but not around anniversaries at population level.
Parkes found mortality 40% above expected in the first six months among 4,486 widowers aged 55 or over.
Bereavement can unmask dementia that a partner had compensated for, and new confusion needs medical assessment for delirium.
Suicidal intent, failure to maintain food or fluids, weight loss, delirium, psychosis or escalating substance use need prompt assessment.