January/February 2021

Mental Health: The Emotional Toll of the Pandemic
By Kathy Hardy
Today’s Geriatric Medicine
Vol. 14 No. 1 P. 26

How Older Adults Are Grieving

The enormity of losses experienced in the time since the COVID-19 pandemic hit have tested even the strongest of people. This is nowhere more evident than in older adults, who may be suffering through the loss of family members as they’re experiencing the emotional impact of self-quarantine and the lack of interaction with friends and family.

COVID deaths are hitting older adults disproportionately, according to Katherine Supiano, PhD, LCSW, APHSW-C, an associate professor at the University of Utah College of Nursing in Salt Lake City who attributes this to changes in medical care caused by the need for isolation in the care of patients with COVID-19.

“The lack of palliative and hospice care in both hospitals and nursing homes during this time leaves people without the type of care they’ve come to expect,” she says. “Medical staff is being as hands-on as they can, but it’s still not the hand of a family member comforting someone suffering from COVID. Hospice and palliative care also prepare the family for death.”

Supiano is also director of “Caring Connections: A Hope and Comfort in Grief Program.” Part of the College of Nursing, the program offers support and resources to individuals dealing with various types of grief. Her research promotes greater understanding of loss, grief, and bereavement as well as of methods to facilitate constructive grief. Her primary focus is developing, evaluating, manualizing, and disseminating effective psychotherapy interventions to treat and ultimately prevent complicated grief—a chronic grief that can be disabling. It’s also referred to as prolonged grief disorder (PGD).

Grief is a how people adapt to loss, and a natural response to bereavement, says Joseph S. Goveas, MD, a specialist in geriatric psychiatry at the department of psychiatry and behavioral medicine at the Medical College of Wisconsin in Milwaukee. In some cases, however, acute grief can evolve into PGD. This is where the effects of a pandemic can influence the grieving process.

“COVID is not changing the criteria for prolonged grief disorder,” Goveas says. “We’re just anticipating that certain factors of COVID could derail the grieving process, leading to more prolonged grief disorder.”

Risk factors, he says, are characteristics of the bereavement experience that can disrupt the healing process and increase the likelihood that someone will developing PGD. They make it more difficult to get over a loss. Examples of risk factors, in relation to the bereaved person, include previous depression or anxiety, a history of insecure attachment, and instances of previous trauma or loss.

“Risk factors related to the relationship to the deceased include an especially close identity-defining relationship, such as a romantic partner or being a parent to the deceased,” Goveas says.

Goveas points to additional factors related to loss during the pandemic that could further increase PGD risk, including the circumstances of deaths. The deaths occur quickly and without warning. Family members are dying alone due to visitation restrictions. Then there’s the context of the death, with restrictions on funerals and death-related rituals. Finally, he notes, there are the consequences of the death, such as being alone, fear of contamination, having to care for sick family members, and dealing with financial concerns.

Goveas adds that the typical feelings of guilt that are often seen following a death, such as the thought that one could have done more to prevent the outcome, are heightened when people grieve during COVID-19.

“The end-of-life experiences for these individuals are much different with COVID-19,” he says. “There are mostly just health care workers around them, wearing lots of [personal protective equipment]. You can’t see their faces. They might be holding the patient’s hand but are wearing gloves, so there is no warmth from the human hand. Family members feel a sense of guilt or regret, thinking they could have done something more.”

There is also “survivor’s guilt,” Goveas adds, particularly among older adults. “There is the unease or discomfort of the living, wondering why they were spared,” he says.

Older adults are also grieving the loss of cultural and faith-based practices that take place following death. With the need to remain socially distant and the restrictions on the number of people who can gather within closed areas, many funerals are being held virtually via Zoom or other streaming avenues.

“Families feel tremendous guilt that they cannot be together to provide comfort to each other and share their loss,” Supiano says. “This impacts their grief. They have an expectation of how they will honor someone when they die, and if it doesn’t go the way they imagine, that’s hard.”

In addition, traditional rituals that bring mourners support and social context are being disrupted, being replaced with more abbreviated ceremonies, often held virtually rather than in person.

“Practices such as washing of the body, kissing of the deceased, and open casket viewing are not permitted in certain situations,” Goveas says. “Private viewings are often not possible, and when allowed, are only made possible for immediate family members. If there is any in-person funeral, mourners must refrain from hugging or touching one another. The feeling among those grieving is that they are not able to give the deceased a proper goodbye.”

There’s always been grief associated with death, and with that, methods of preventing unnecessary suffering, mitigation, and support for grief as well as treatment for more complicated grief. The circumstances of loss due to COVID-19 have left professionals to find nuanced methods for helping older adults come to terms with their feelings at this difficult time.

“You will always have guilt associated with grief,” Supiano says, “but we need to do things a little differently now to address this grief. Now, we need to emphasize to mourners that they’ve done the best they can for the deceased given the circumstances of what needs to be done with quarantines and physical distancing in place.”

To mitigate the adverse consequences of COVID-19 grief, Goveas suggests educating laypeople about grief and the milestones that those acutely grieving pass through before adapting to loss, as well as ways the pandemic might affect grief.

“We can promote awareness of derailers, which are the thoughts, feelings, and behaviors that can slow the grieving process,” he says.

Supiano recommends that mourners become involved in grief support groups or form compassionate friendships. Within these groups, members can receive affirmation that they did the best they could for their deceased family members given the requirements of life during a viral pandemic.

In addition to mourning for the loss of life, there’s grief related to the loss of life as it was. Supiano says the absence of normalcy brings a sense of loss to older adults, even those who have not been affected directly by COVID-19.

“The loss of a regular routine is disruptive for older adults,” she says. “For example, the cessation of programs like Meals on Wheels means the loss of that regular social interaction. Meals on Wheels volunteers don’t just bring food to the older adults. They also provide conversation and regular interaction with the people they visit. They check up on those they deliver meals to.”

Supiano says this is a vital time in elder care. When considering the “what next” aspect of COVID-related grief in older adults, she refers to a conversation she had with her husband, a marathon runner who knows the importance of pace and endurance. “My husband always says, ‘It’s not a sprint, it’s a marathon.’ But even with a marathon, you know there’s an end. The end of COVID’s effects on our lives is something less certain.”

— Kathy Hardy is a freelance writer based in Pottstown, Pennsylvania.