From Loss to Loneliness: The Effects of Prolonged Grief in Elderly

Introduction: COVID-19 high death tolls have brought about many bereavements all over the world. In this brief report, we aim to describe the effects of traumatic end-of-life experiences causing prolonged grief and loneliness as mediators for psychiatric disorders in the elderly. Case: The patient was a 60-year-old woman with chronic sleep disturbance since her only daughter suddenly passed away after several days of being isolated in the hospital during the COVID-19 pandemic and being hastily buried with the COVID-19 protocols. The patient yearned for her daughter but at the same time also avoided all memories of her daughter. She felt anxious most of the day which escalated to panic attacks requiring visits to the emergency room. Various examinations were carried out with normal results, except for blood pressure. She was diagnosed with prolonged grief, generalized anxiety, post-traumatic stress disorder, and hypertension. Treatments included SSRI, benzodiazepine, antihypertensive medicine, and psychotherapy. Improvements were significant within 9 months of therapy. Discussion: Traumatic end-of-life events may precipitate prolonged grief and loneliness. Bereavement is the most common cause of loneliness in the elderly. Untreated prolonged grief and loneliness generate a loss of sense of self and purpose and are associated with low-grade peripheral inflammation and poor health. The combination of pharmacotherapy and psychotherapy is the most effective treatment which improves the patient’s outcome significantly. Conclusion: Traumatic end-of-life experiences are associated with prolonged grief disorder, poor physical and mental health outcomes, hence the right holistic approach is necessary to improve patient outcomes.

Keywords: Prolonged Grief, Loneliness

Introduction

The coronavirus disease (COVID-19) has become a public health emergency and global pandemic since 2019. It has claimed almost 7 million lives worldwide[1]. Death rates from other life-threatening illnesses also proportionally increased, partly attributed to limited access to health services and postponed treatment during the pandemic. Unsurprisingly, the pandemic high death tolls have brought about many bereavement that profoundly affected survivors, families, and friends. [2,3]. Moreover, the traumatic end-of-life experiences, isolation, disruption of social and economic support, and being unable to visit or say goodbye to loved ones have been associated with dysfunctional or prolonged grief, more intense loneliness, and other psychiatric disorders, especially in the elderly population. [4,5]. The perceived lack of funeral ritual, profound sadness, and anxiety regarding the future and pandemic situation, loneliness, and sleeping problems were some of the extents of day-to-day effects of loss during the pandemic.[6].

The elderly are at greater risk of grieving due to multiple losses of their loved ones.[7], with the most devastating is the loss of a child[8]. Grief is the emotional response to a loss. For some, it is difficult to adjust to bereavement over time, moreover in the elderly, their grieving persists daily for years as prolonged grief.[9]Prolonged grief is associated with poor physical and mental health outcomes. Loneliness which has risen during the pandemic is another significant factor in grieving.[2]. In this report, we aim to describe the effects of COVID-19 traumatic end-of-life experiences causing prolonged grief and loneliness as mediators for psychiatric disorders in the elderly.

Case

The patient was a 60-year-old woman who came to the psychiatric clinic with a referral from a cardiologist. She came with the chief complaint of difficulty sleeping from 1.5 years ago, which was the peak of the COVID-19 pandemic when her only daughter suddenly passed away after being isolated for several days at the hospital due to untreated complications of diabetes. Without a chance to say her last goodbye, her daughter was hastily buried with COVID-19 protocols. Since then, the patient remained in anguish, miserable, and anxious.

The patient had a hard time accepting her daughter’s death. She was very close to her daughter who always accompanied and helped her daily to take care of her bedridden husband and the house. Her daughter was a hard worker but had economic crises during the pandemic. She regretted how her daughter’s life ended so tragically, leaving 2 children to live on their own. She unconsciously reexperienced her childhood memory, when at the age of 8, she left her parents in a small village to live with her uncle in a big remote city. Due to several practical reasons, her mother never visited her, eliciting lonely feelings underneath ever since.

The patient tried hard to avoid the memory of her daughter by doing extra activities from morning to evening. She always sought noisy places surrounded by people and avoided solitude, but in the night, she became increasingly restless and fearful.

What disturbed her most was her anxiety. She worried much about her orphaned grandchildren’s future. Her anxiety persisted throughout the day as if something bad was always ready to happen. She described her feeling as if her life was on the edge of something dangerous. Her mind often felt full and restless. Her chest sometimes felt heavy, followed by difficulty breathing as if she was choked, and then could barely move her limbs.

Those symptoms got worse to the point that she twice visited the emergency room (ER) with the presumption of having heart attacks. Various examinations were carried out. She had hypertension stage II but had been well-treated with antihypertensive medicines. The following tests included physical examination, routine blood test, cardiac markers, chest X-ray, and cardiac catheterization, were within normal limits. She was also treated for a suspected gastroesophageal reflux disease (GERD) but to no avail. Her symptoms persisted over time.

The cardiologist then referred the patient to see a psychiatrist. After thorough examinations, the patient was diagnosed with generalized anxiety disorder, post-traumatic stress disorder, and prolonged grief disorder. Hamilton Anxiety Rating Scale (HAM-A) scored 31 (severe anxiety) and the Inventory of Complicated Grief (ICG) scored 46 (cut-off point is 25). She was treated with sertraline 25 mg once daily, clobazam 5 mg twice daily, and continued her antihypertensive medicines. She was taught to practice relaxation and sleep hygiene. Complicated Grief Treatment (CGT), integrated with dynamic and existential psychotherapy (logotherapy), was conducted on a weekly and then monthly basis. In the third month, she became symptom-free, HAM-A score decreased to 7 (minimal anxiety) and ICG score decreased to 14, since then clobazam was no longer prescribed. She continued taking sertraline for the following 6 months before it was finally tapered off. The cardiologist also reported that the patient needed fewer medicines to control her blood pressure.

Discussions

Prolonged Grief, Loneliness, and Related Health Outcomes

The patient lost her daughter all a sudden during the pandemic, more than a year ago, without a proper farewell. She had been grieving ever since. COVID-19 restrictions made many families mourn without a body and could not hold proper funerals, making it challenging to achieve emotional closure. It is reasonable that people find it difficult to adaptively overcome the loss, hence they develop pathological reactions and pain, as in dysfunctional grief.[2]

Dysfunctional or complicated or prolonged grief results from transition failure from

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