Consider first the situation prior to a bereavement in old age.

1. What was the nature and status of the relationship at this time?

This question should be answered structurally and substantively, e.g. ‘He was her older brother; she relied on him for advice and support more than on any other person, including her husband’, or ‘She was his second wife; he had expected her to look after him – actually, to wait on him hand and foot! – and suddenly he had to be the caring person.’ It is useful to explore affective and pragmatic dimensions of the relationship. Was the survivor or the deceased heavily dependent on the other person? Had the relationship been in serious trouble? If so, was this characterized by silent co-existence or stormy disputes? Did the deceased provide most of the couple’s link to society? Had the survivor organized his or her life around taking care of the deceased?

An elderly person’s response to the death of an adult child or grandchild is too often underestimated². There can be a deep interiorization of grief after the first shock of the loss, followed by an intensified life review. Researchers have documented a ‘double pain’: their own loss of a grandchild and their anguish over their adult children’s grief³. There is also often a disenfranchised grief situation⁴. Grandparents can be subject to interpersonal signals that they are not fully entitled to mourn the loss. The extent to which grandparents might become isolated in their grief is influenced by their pre-bereavement status in the family. Counselling interventions could include resolving issues that generated intra-family tension prior to the loss. Instead of labelling the problem as ‘depression’ in the elder, one might instead discover a dysfunctional family pattern that is affecting all the members.

2. How was the prospect of bereavement integrated into the life scenario?

Bereavement in later life most often involves the loss of a sibling or spouse. It is not unusual for elderly people to have floating expectations regarding the loss of people they have known for much of their lives. These cohort peers are at significant risk for death because of their advancing age and accumulated vulnerabilities. Therefore, it will be a sad but not surprising day when their lives come to an end. On the other hand, they have always been around, so it is easy to assume that they will continue to go on and on. A recently bereaved elder might alternate between the more logical and the more habituated-wishful view. Psychologically, the death has been both anticipated and not anticipated.

Anticipatory grief is often a more complex response than usually assumed. Anticipatory grief is similar in many respects to the grief that is experienced after a death⁴. There are affective, cognitive and somatic components, e.g. sadness, obsession, exhaustion etc. It has often been suggested that anticipatory grief helps the survivor to cope with the loss – paid for in advance. Early studies suggested that sudden death has a much more disturbing impact than expected death⁵. More recent studies have taken more variables into account and suggest that anticipatory grief does not always cushion the survivor’s stress when the loss does occur¹. Potential caregivers would do well, then, to observe the particulars of the situation carefully, rather than assume that expectation is necessarily ameliorative. (Many elders have told me how they still feel helpless and miserable because they could not do anything to palliate the suffering prior to an expected death.)

Not all deaths are clearly expectable. Fatal accidents (especially falls and motor vehicle) are far more common among people 65 and older than in any other age group. Nevertheless, there is a greater probability the death will have been expectable, if not necessarily expected. Not only does an increasing proportion of deaths occur in old age, but modern health care has lengthened the interval between development of a life-threatening condition and the day of death. The four leading causes of death for elderly people in the USA (heart disease, malignant neoplasms, cerebrovascular disease and respiratory conditions) all involve a long period of living with progressive life- threatening conditions and, therefore, opportunity for both prolonged stress and adaptation to the prospect of death for the patient and significant others.

Physicians and other caregivers have the opportunity to strengthen the survivor’s ability to cope with grief by sensitive response to the situation as it exists prior to death. Offering accurate information, suggesting other options and improving the lines of communication within the family are among the ways in which one can help to shape the anticipatory grief period into a source of strength rather than intensified anxiety. The age differential between most caregivers and the elderly bereaved people they are trying to help sometimes interferes with communications, e.g. when elders are patronized and their ability to cope with bad news is underestimated. There is also an underappreciated connection between quality of terminal care and grief recovery. A hospice physician reports that, ‘The pain relief we achieve for an old man in his last weeks of life helps his wife to be more of her normal self when he really needs her – and a widow with fewer regrets and nightmares later.’

3. What was the survivor’s own health status prior to the bereavement?

This is a particularly useful question to ask with respect to the older bereaved person⁶. The spouse was most frequently the principal family caregiver in the 40 hospices studied by Mor et al.⁷