Chapter 4: Aging, Death, and Bereavement

Intro

Introduction

It is predicted that, by the year 2020, more than 15% of the population will be more than 65 years of age. In fact, the fastest-growing segment of the population is what has been referred to as the “old–old,” people more than 85 years of age. In Britain, the medical care of the elderly is commonly referred to as “old age medicine.” In the United States, such a descriptor for this group of citizens is avoided. Rather, the care of aging patients is called geriatrics; the study of aging is termed gerontology; and the patients themselves are most commonly referred to as senior or mature citizens. Whatever the terminology, the care of the steadily growing elderly population has become an important branch of medicine.

Although death is an unfortunate reality at any age, most deaths occur in the elderly population. Because of this, a discussion of death and grief, or bereavement, is included in this chapter.

Old Age: 65 Years and Older

How can one identify the point at which a middle-aged person becomes a senior citizen? The Federal Government defines this milestone as age 65. At about this age, individuals become eligible to collect Federal pension (Social Security) and health insurance (Medicare) (see Chapter 27) benefits, which are funded by monies accrued throughout one’s working life by a combination of employee, employer, and government contributions. The benefits continue until death of the contributor and may, for his spouse and dependents, even continue beyond his death. Because it is the recognized age of retirement from work, 65 years is considered by many to be the transition point where middle age ends and old age begins.

The losses of aging

Americans tend to place a high value on work and independence and on youth and physical beauty (see Chapter 20). Therefore, retired, aging people may be perceived as less valuable. Unfortunately, the loss of social status associated with this perception is only one of the losses the elderly face. They must also deal with loss by death of spouses, family members, and friends; they must confront the inevitable declines in their own health and strength.

Although the losses and changes associated with aging can contribute to the development of depression (see below and Chapter 13) in some people, most elderly people adjust well to these changes and continue to learn, and to contribute to and enjoy life. On the positive side, freedom from the responsibilities of work and childrearing allow older people to pursue interests and education that they did not have time for when they were younger.

Erikson described old age as the stage of ego integrity versus despair; a time when a person either has satisfaction and pride in her past accomplishments or feels that she has wasted her life. It is reassuring for younger people to learn that most elderly people achieve ego integrity in the last years of life.

Independence versus care by others

Many people believe that, invariably, the elderly will ultimately have to be cared for by others. In fact, this is not true. Although aging people in certain cultural groups are typically cared for by relatives (see Chapter 20), less than one-fourth of the American elderly are cared for by younger family members, and fewer than that spend their last years in long-term care facilities like nursing homes (see Chapter 27). In fact, most elderly Americans live independently and care for themselves. Newer options, such as assisted living, in which people live in complexes consisting of private rooms or apartments and receive help with meals, shopping, and housework, allow elderly Americans to remain relatively independent for longer periods of time.

Nursing homes provide inpatient, long-term care for about 5% of the elderly population. This care, often costing more than $1,000 per week, is not covered by Medicare. Therefore, a serious illness or injury that requires long-term inpatient care can effectively pauperize an elderly patient. Federal and State agencies are currently addressing ways of helping the elderly pay for long-term care in nursing homes and assisted living services.

Cognitive function in the elderly

The idea that elderly people invariably have significant cognitive impairment is another pervasive but unsupported stereotype. Although some memory and learning problems may occur in normal aging, they generally do not interfere with the person’s ability to function independently. Dementia, which has been referred to by the now outmoded term “senility,” is a relatively uncommon disorder, occurring in <10% of the total elderly population (see Chapter 18).

The prevalence of dementia does, however, increase with age, and some degree of cognitive impairment is present in up to half of the population over the age of 85. Innovative pharmacological treatments such as the acetylcholinesterase inhibitors and drugs that block the neurotoxic action of glutamate (see Chapter 19) for the most common type of dementia, Alzheimer’s disease, promise that, in the future, these cognitive changes can be prevented or treated effectively.

Longevity

In the United States, the average life expectancy at birth is currently about 77 years. The average life expectancy for men is about 75 years, and for women, it is about 80 years although these figures vary by gender and ethnicity (Fig. 4-1). Although demographic differences in life expectancy have been decreasing over the past few years (African-American men in particular are living longer), they still extend to more than 10 years between white women and African-American men. Longer life expectancy in Hispanic Americans has been attributed to the fact that individuals who immigrate to the United States are among the healthiest from their native countries [Stobbe, 2010]. While women tend to live longer than men, this advantage comes with a burden. Elderly women are more likely than elderly men to have disabling health problems.

Figure 4-1.

Figure 4-1

Life expectancy (in years) at birth in the United States by sex and ethnic group in 2005–2006.
(Data from National Center for Health Statistics, 2008–2009.)

Research in gerontology suggests that longevity is associated primarily with a family history of longevity. It is also associated with continued physical and occupational activity, work satisfaction, advanced education, and, as discussed in Chapter 3, the presence of social support systems such as marriage.

Physical and neurological changes in aging

It has been said that aging is not for cowards. Physical strength and health gradually decline, and cardiovascular, renal, pulmonary, gastrointestinal, musculoskeletal, and immune functions are ultimately compromised. It is ironic that about the only thing that increases with aging is the ratio of body fat to muscle mass.

Neurological changes that occur in normal aging include decreased cerebral blood flow and decreased brain weight. Amyloid plaques and neurofibrillary tangles may also appear, although to a lesser extent in normally aging brains than in brains of patients with Alzheimer’s disease (see Chapter 18). Despite these brain changes, which can be accompanied by mild reductions in memory and learning speed, intelligence (in the absence of dementia or other brain disease; see Chapter 10) remains approximately the same throughout life.

Neurotransmitter availability in the brain decreases with age. This decrease occurs via several mechanisms. First, secretion of the major behavioral neurotransmitters diminishes. Also, concentration of monoamine oxidase increases, leading to the accelerated breakdown of some of these neurotransmitters. Finally, neurotransmitter receptors may be less responsive in the aging brain. The clinical consequences of these changes in neurotransmitter availability in the elderly can include increased likelihood of psychiatric symptoms (Table 4-1) and of negative side effects associated with psychopharmacological treatment.

Table 4.1 Neurochemical Changes in the Aging Brain

Neurochemical Change with Aging Possible Psychiatric Result
Norepinephrine Decrease Depression
Dopamine Decrease Depression
?-Aminobutyric acid (GABA) Decrease Anxiety
Acetylcholine Decrease Dementia
Monoamine oxidase Increase Psychiatric symptoms

Psychosocial changes in aging

The common physical health problems associated with aging not only are uncomfortable, but they can have serious emotional and social consequences. For example, the embarrassing problem of reduced bladder control seen in some aging patients can impair one’s ability to leave home. Age-associated losses in muscle strength and in sensory functions like vision and hearing can further decrease social opportunities and increase social isolation, well-known contributors to the occurrence of depressive symptoms in people of any age.

Another, often undetected, serious social problem associated with aging is the abuse of cognitively or physically impaired elderly people by their caretakers (see Chapter 22).

Psychopathology in the elderly

Depression in the elderly is commonly characterized by memory loss and cognitive problems. These symptoms can mimic and thus be misdiagnosed as dementia. This misdiagnosed disorder, known as pseudodementia (see Chapter 18), must be identified because depression can increase suicide risk. Also, in contrast to dementia, pseudodementia is highly responsive to treatment.

Suicide resulting from social loss, physical illness, or depression is more common in the elderly than in the general population. Anxiety and fearfulness also are more common in the elderly, who must deal with the realistic possibility of developing a serious illness or of falling and breaking a bone. In addition, daytime confusion resulting from unidentified alcohol- or benzodiazepine-related abuse (see Chapter 23) as well as sleep disorders (see Chapter 7) can exacerbate anxiety and depression in the elderly. Sometimes, depression or medical illness leading to delirium (see Chapter 18) in the elderly can be accompanied by delusions, often of the persecutory type. These delusions include the belief that a spouse is unfaithful or that a caregiver is stealing money or household objects.

Although common, depression and anxiety are neither inevitable, nor are they normal in the elderly.

With medical and pharmacological interventions and practical suggestions for self-care, the primary care physician can aggressively and successfully treat these disorders. Unfortunately, because Medicare currently does not completely cover outpatient prescription drug costs (see Chapter 27), elderly patients without sufficient resources may be unable to use some of the newer and often more expensive pharmacological agents (see Chapter 19). Supportive psychotherapy (e.g., cognitive therapy; see Chapter 11) and electroconvulsive therapy (ECT) (see Chapter 19) can also help relieve depression in the elderly. The latter is particularly useful for seriously depressed elderly patients who are intolerant of or who do not respond to other treatments.

Dying, Death, and Bereavement

The losses of youth usually revolve around jobs and relationships. In contrast, the most significant loss facing the elderly is loss of life itself. Confronting the end of life requires that a person separate from friends, family, and possessions. This painful task requires that one pass through a variety of psychological stages. Ideally, the last of these stages includes acceptance.

Stages of dying

Some researchers have studied the psychology of dying. Although there is no one typical way of dying, the physician, Elizabeth Kübler-Ross, described the process of dying and loss as a sequence of five stages: denial, anger, bargaining, depression, and acceptance. She noted that some people who anticipate their own or a loved one’s death go through only two or three of the stages, whereas others go through the stages simultaneously or in a different order. Most commonly, however, people experience the stages in the following sequence:

  • In the first stage, denial, the patient unconsciously cannot accept the diagnosis and refuses to believe that she is dying. She may make statements like “the laboratory made an error” or “that must be someone else’s diagnosis.” This stage generally resolves within a few hours or, at most, days.
  • The stage that follows is characterized by anger, often directed at the physician and hospital staff. Verbal confrontations initiated by the patient such as “you should have done more tests,” are common. Physicians must learn not to take such comments personally; instead, they should try to understand the fear and anxiety in the patients that provoke the outbursts.
  • After the anger stage is resolved, the patient frequently tries to strike a bargain with God or some higher being. This stage of bargaining is characterized by statements like “I will give half of my money to charity if I can get rid of this disease” in an unconscious effort to “undo” (a defense mechanism, see Chapter 8) this negative life event.
  • The stage of depression, including preoccupation with death and emotional detachment, follows. In this stage, the patient feels distant from others and seems sad and hopeless. In a normal grief reaction, depression is short-lasting and is quickly followed by acceptance. In a complicated grief reaction, the patient may get “stuck” in this stage and not advance to the final stage, acceptance.
  • In the acceptance stage, the patient deals calmly with her fate and is able to use and even enjoy her remaining time with friends and family.

It is of interest that the stages of dying can also occur with other life losses such as the loss of a body part through amputation or mastectomy or, for younger people, a natural or induced abortion.

Bereavement (normal grief) versus complicated bereavement (abnormal grief/depression)

It is normal to feel great sadness after the loss of a loved one or in anticipation of one’s own death. This normal reaction, also called bereavement, like the stages of dying, can occur with life losses other than death. Although most grief reactions after a severe life loss are considered normal, others are extreme enough to be considered abnormal. For example, both normal grief and complicated grief are characterized initially by shock and even denial that the event has actually occurred. However, although denial tends to last up to a few hours in normal grief, the denial of abnormal grief may persist over days or weeks. Both normal grief and abnormal grief include sadness, crying, and other expressions of sorrow, particularly in the early stages. In normal grief, these expressions gradually subside over a 1- to 2-year period. However, they commonly and normally recur on holidays or special occasions, a phenomenon called the anniversary reaction. In contrast, in abnormal or complicated grief, the characteristics of bereavement persist and may even intensify over time. It is important to rule out depression even in terminally ill patients because its successful treatment can make the last weeks of life rewarding for the patient and the family.

Case 4.1

The Patient

A 72-year-old diabetic patient whose wife died 8 months ago appears unkempt and unshaven. He reports that he cries frequently during the day when he thinks about his wife and has recurrent nightmares about the circumstances of her death. Although previously gregarious, he states that he now prefers to be alone and has no interest in interacting with friends and family. There is no evidence of a thought disorder or suicidal ideation. Physical examination, although essentially normal, reveals that the patient’s blood sugar, formerly well controlled, is elevated and he has lost 15 lb (6.8 kg) since his checkup the previous year. He explains that he has forgotten to give himself his daily insulin injection a few times in the last few weeks and has little appetite for food.

Comment

This patient demonstrates a complicated grief reaction. He is showing signs of depression (e.g., poor grooming, significant weight loss, social withdrawal, and lack of self-care; see Chapter 13). Although forgetting to take his insulin could indicate the development of dementia, it is better explained as another symptom of depression (pseudodementia).

Management

For this patient, the best first recommendation of the physician is antidepressant medication coupled with frequent, scheduled visits and regular phone conversations with the doctor. If the patient does not respond to or has significant side effects from the medication, another option for this elderly man is ECT (see Chapter 19). The patient’s difficulties with appetite, sleep, and self-care will improve as his mood improves

Cultural differences are notable in normal grief reactions. In some cultures, the bereaved are expected to outwardly express their distress with verbalizations and actions. In others, such displays are discouraged (see Chapter 20). No matter what the culture, the characteristics of normal grief can sometimes mimic those of mental illness. For example, illusions (e.g., misperceptions that the deceased person is physically present) are seen in normal grief reactions. In contrast, the presence of frank delusions, such as a belief that the dead person is controlling one’s thoughts, or hallucinations, such as hearing the dead person talking, suggests an abnormal grief reaction. See Table 12-4 for further clarification of these terms. Comparisons between normal and abnormal grief reactions are shown in Table 4-2.

Table 4.2 Comparison Between Bereavement and Complicated Bereavement

Bereavement (Normal Grief Reaction) Complicated Bereavement (Abnormal Grief Reaction/Depression)
Minor weight loss (;5 lb [2.26 kg]) Significant weight loss (;5% of body weight)
Minor sleep disturbances (e.g., some difficulty falling asleep) Significant sleep disturbances (e.g., repeated nighttime awakenings and early morning awakenings)
Some guilty feelings Intense feelings of guilt and worthlessness
Illusions (see Chapter 12) Hallucinations or delusions (see Chapter 12)
Attempts to return to work and to social activities Resumes few, if any, work or social activities
Cries and expresses sadness Considers or attempts suicide
Severe symptoms resolve in ;2 months Severe symptoms persist for ;2 months
Moderate symptoms subside in ;1 year Moderate symptoms persist for ;1 year
Treatment includes increased contact with the physician, supportive psychotherapy, grief peer support groups, and sleep agents, for example zolpidem (Ambien) for transient problems with sleep Treatment includes antidepressants, antipsychotics, or electroconvulsive therapy and professional psychotherapy

The role of physicians in dying and death

Physicians play an important role for the dying patient and bereaved family. First, it is up to the physician to make the dying patient (and, with the patient’s permission, the family) completely aware of the diagnosis and prognosis (see Chapter 24). Next, the doctor can provide reassurance to the patient and family that their intense responses to the news are to be expected. The doctor also can be an important resource for the dying patient and for the family before and after the death.

Physicians have the training to make the distinction between normal and abnormal grief reactions. They also have the training and tools to support the patient or family member experiencing the former, and to aggressively treat the person experiencing the latter. On a practical note, doctors need to medically follow bereaved family members because the risk of morbidity and mortality is increased for close relatives (especially widowed men) in the first year of bereavement (see Chapter 25).

Physicians often feel a sense of failure when they cannot prevent the death of their patients. Doctors who recognize this reaction can resist the emotional detachment it can lead to, ultimately making them even more effective in guiding the patient and family through this most important of all of life’s transitions.