- 2 Downloads
Thanatology, literally stated, is the study of death, although Kastenbaum (1993) considered it as the study of life with death left in (p. 76). More broadly, it is the interdisciplinary, systematic, and scholarly study of attitudes toward dying, death, loss, grief, bereavement, life-threatening behavior, traumatic death, suicide, euthanasia, physician-assisted death, and the associated anthropological, developmental, historical, ethical, legal, philosophical, educational, psychological, scientific, sociological, spiritual, and theoretical elements (Fonseca and Testoni 2012; Chapple et al. 2017; Doka et al. 2016; Wittkowski et al. 2015). As a discipline, the field of thanatology is noteworthy in that it is both academic and applied (Chapple et al. 2017).
Overview of Thanatology
The fields of gerontology and thanatology are presumed to have overlap, often due to the perception of reduced time until death (Depaola et al. 2003), and increased likelihood of having more loss experiences the longer one lives. The relevance of thanatology within gerontology, however, encompasses a number of important experiences including potentially significant life transitions for older adults. The focus of this entry is on how the study of death, dying, and loss (thanatology) can inform our understanding of the human experience of being an older adult.
Older adults experience a number of social and interpersonal losses including spouses, friends, children, and even community members. Along with these social losses, there is often a loss of roles within the family and community, especially if the older adult lives in an assisted living, graduated care, or nursing home environment (see de Vries and Johnson 2002 on the notion of the “oldest-old” individuals at risk of outliving their family members). Assessment of attitudes toward death among older adults can be important and there are benefits in initiating clinical discussions with older patients around perceptions of and a wish for death (Bonnewyn et al. 2016). Thanatology broadens the conversation in the global context of increased life span by focusing on the philosophical and existential questions of life satisfaction, attitudes toward death, the embracing of finitude, and the recognition that, in a cure-based medical system, there is much that is not known about age differences with respect to attitudes toward dying and death (Baars 2017; Jose et al. 2018; Krause 2018; Krause et al. 2018).
Historically, death was considered to be a lack of responsiveness, or an absence of (externally) observable biological functioning (heartbeat, respiration, pupillary constrictions), followed by rigor-mortis (stiffness), bloating, or signs of decomposition. The Harvard Criteria of brain death shifted classification to encompass internal biological functions which require technology to measure. These include brain activity/waves (detected via electroencephalogram (EEG)), transcranial Doppler and nuclear scintigraphy, and digital subtraction angiography. Imaging studies are sometimes used in addition to clinical assessments (Rizvi et al. 2018). The notion of brain death is not without controversy. Ethicists exploring the notion of total brain death have frequently concluded that the death of the brain results in the loss of humanity (Smith 2014; Lee 2016; Wittenmyer 2019), but more recent conceptual definitions of death include total brain failure, in which even those who are severely impaired are believed to continue to interact with their environment and may experience the instinct to survive (Zamperetti and Bellome 2009; Austriaco 2016). Further, there are implications for rigorous criteria for brain death within the realm of organ donation and procurement (Symons and Chua 2018). In most countries, certificates of cause of death provide a legal record including the cause of death, which might be important for insurance purposes. Secondly, they are a source of mortality statistics that are important in medical research. Causes of death are classified and grouped by the International Classification of Diseases. The medical certificate of cause of death recommended by the World Health Organization identifies the disease or condition directly leading to the death as well as any antecedent causes and other contributing conditions.
History of Thanatology
Earlier societies viewed death as a communal, not individual or private, experience. Further, there was a cultural component in how death, and activities of mourning were ritualized, as not only a means of memorializing the deceased but as a notional form of control over events with misunderstood causes (weather, disease, natural disasters, etc.). One of the seminal researchers who explored the study of response to death was Phillipe Aries (1914–1984). Aries (1975) attempted to study Western societal attitude shifts in how we conceptualize death and identified four primary psychological themes: (1) an awareness of the individual (I am an entity distinct from you, and vice versa); (2) defense of a given society against nature (acts of God/gods); (3) a belief in some form of an afterlife (we continue to exist in some form or fashion); and (4) a belief in the existence of evil. Currently, many Western societies are considered to be “death denying,” meaning they attempt to minimize focus on, or avoid any overt discussion of death. It is important to note that Aries’s research was limited in scope and did not explore Eastern beliefs, philosophies, or practices regarding dying, death, or bereavement.
Herman Feifel is arguably the first scholar of modern (twentieth century) Western thanatology, while Edwin S. Shneidman was the first scholar of modern suicidology. In 1949, Shneidman discovered hundreds of suicide notes in the vaults of the Los Angeles County Coroner’s office and, together with Norman Farberow, began the first empirical studies in suicidology (Leenaars 2010). This work led to the establishment of the Los Angeles Suicide Prevention Center and the training of nonprofessional volunteers to provide crisis intervention to suicidal individuals. In the 1960s, Shneidman established the American Association of Suicidology and established the first peer-reviewed journal in suicidology, Suicide and Life-Threatening Behavior.
Trained in behavioral psychology and psychoanalysis, Feifel convened a symposium at the 1956 meeting of the American Psychological Association in Chicago, Illinois, USA: “The Concept of Death and its Relation to Behavior” (Lamers 2012), and in 1959, Feifel published an edited book based on the symposium. Feifel’s work helped to spearhead what became known as the Death Awareness Movement which led, in turn, to the establishment of two organizations: the Association for Death Education and Counseling (ADEC) and the International Work Group on Death, Dying and Bereavement, in the mid-1970s. Feifel and Shneidman were members of both organizations.
There was a dearth of publications focusing on death-related topics in the 1950s, and although not the first, one important publication in 1959 was The Meaning of Death, edited by Feifel and published by McGraw-Hill. In the preface, Feifel noted that little attention was given to the consideration of death in scholarly literature prior to the book’s publication. The volume brought together writings by psychologists, philosophers, theologians, and scientists including Shneidman, Farberow, Jung, Tillich, Kaufman, Kastenbaum, and Wahl – thus emphasizing the interdisciplinary nature of the (then) emerging discipline of thanatology.
In 1977, New Meanings of Death was published, also edited by Feifel who described the collection not as one that included all areas of thanatology, but provided readers with clinical and empirical research findings, conceptual frameworks, options for public policy and professional best practices in death, dying, and bereavement, written for a general audience (pp. xiii–xiv). A few authors from the first volume made a second appearance (Feifel, Kastenbaum, Shneidman) and were joined by others whose names would soon be established in the discipline such as Jaffe, Kalish, Leviton, Lifton, Weisman, and Saunders. With this volume, Feifel propelled thanatological publishing forward and demonstrated the ways in which thanatology had been established as a professional discipline.
Stillion and Attig (2014) offer a comprehensive and fascinating Chronology of Developments in the Movement (pp. xix–xxvii), and their volume offers an extensive and detailed review of complex multidisciplinary and cross-disciplinary roots of thanatology. Corr et al. (2019) outline the history of thanatology in a variety of contexts.
Key Research in Thanatology
Research on Grief and Mourning
Grief is considered the physiological and psychological response to having been bereaved. The acute phase of grief is often relatively short (approximately 6 weeks to 6 months, although this is highly variable depending on cultural and personal factors, and the mode of death), and may include intense, disorganizing episodes of overwhelming sadness or distress, coupled with physiological sensations of breathlessness, nausea, chest pains or constriction, or vertigo, etc. According to the World Health Organization (2018), prolonged (chronic) grief disorder (PGD) occurs in response to the loss of a close relationship and extends beyond the initial acute period of 6 months and exceeds or surpasses that which is considered to be culturally “normative” for that individual. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) added a diagnosis of persistent complex bereavement disorder (PCBD), although the criteria remain controversial (Malgaroli et al. 2018). Additionally, in a long-term comparison of the symptomatology criteria for PCBD from the DSM-V versus the PGD from the ICD-11, PGD symptoms were better at differentiating between diagnoses, and provided clearer and more clinically comprehensive information with regard to psychopathology (Bonanno and Malgaroli 2019).
Chronic grief has no definitive end point, and may include less intense, but lingering and intermittent feelings of sadness, guilt, remorse, depression, and/or anxiety (particularly in cases of prolonged/complicated grief disorder) (Prigerson et al. 2008; Kim and Lyu 2018), coupled with stress-related physiological symptoms (high-blood pressure, weight changes, sleep disorders, changes in immunoglobulin levels, etc.). Some researchers found that higher levels of intense or acute grief beyond the initial period post-death was a predictor for increased likelihood of later diagnosis of complicated grief syndrome (Bonanno et al. 2002, 2007). Further, meta-analysis indicates that up to 1 out of every 10 adults will or has experienced prolonged/chronic grief (Lundorff et al. 2017).
In thanatology, we refer to bereavement as the factual condition of having lost someone/thing significant, which may include a change in role, or status, e.g., widow/ers have lost their spouses, an orphan its parents, and so forth. Distinct from bereavement, the term mourning refers to social and culturally patterned expressions of being in a state of loss or bereavement, e.g., wearing specific colors or tokens to show you are mourning, singing/reciting particular songs or prayers
Several areas within thanatology that are particularly germane to gerontology include losses that are “typical” for older adults due to life transitions, and aging friends and family members. The loss of numerous significant relationships and roles in quick succession (meaning another loss is experienced prior to processing the previous loss) can lead to bereavement overload (Kastenbaum 1969), in which the individual is unable to adequately process and cope with successive losses due to already overtaxed physiological and psychological resources. Increasingly older adults will have experienced the death of parents, spouses, aged siblings and friends, and even children or grandchildren. Thus, the longer the individual survives, the likelier they are to experience the deaths of loved ones, and this is not without impact. D’Epinay et al. (2003) drew on data collected as part of the Swiss Interdisciplinary Longitudinal Study on the Oldest Old with an eye to the impact the death of a friend or relative had on octogenarians and found that while the death of a close relative was associated with depression, the death of a relative or friend was correlated to the older adult’s sense of isolation. Additionally, individuals who experience multiple losses may benefit from interventions which allow them to disentangle the specific losses and process each accordingly (Neimeyer 2016).
Kubler-Ross (1969) posited five stages of dying (denial, anger, bargaining, depression, and acceptance) and these were later used to describe stages of grief. Corr (2015) and Parkes (2013) have provided critical commentary exploring how these stage theories have been misinterpreted (applied to grieving instead of dying) and misapplied, with even educated health care providers using them as prescriptive, instead of descriptive. Stage theories are by nature intuitive and easily substantiated through ecological fallacy, thus resistant to change.
Numerous theories of grief have arisen since Kubler-Ross’s stages of dying. More robust theories include Stroebe and Schut’s (1999) dual process model (DPM), in which the individual vacillates between loss-orientated thoughts and behaviors which focus on the grief and the relationship with the deceased, and those which are restoration-oriented and focus on adaptation to life without the deceased. Rubin (1999) proposed a two-track model; Track I accounts for Functioning (psychological and tasks of daily life), and Track II accounts for Relationship (memories, perceived quality of the relationship, etc.). Rando (1984, 1995) proposed a Six “R” model: (1) Recognize the loss; (2) React to the separation; (3) Remember and reexperience; (4) Relinquish attachment/assumptions; (5) Readjust to the world; and (6) Reinvest in living. Stroebe and Schut (2016) recently recommended expansion of the original DPM to account for bereavement overload.
Neimeyer (2001, 2019) offered a meaning making model, in which individuals learn to develop a meaningful life, post-loss, including how the griever needs to redefine their sense of self, and engages with the world in the absence of the deceased. Worden (2018) has merged much of the recent research and current models and posits that our experience of grief has several mediators: attachment; factors around the death itself; kinship; personal history of the griever; personality variables; social factors; and concurrent stresses/ors. Further, Worden explains that in order to work through (not cure!) grief, there are specific tasks which account for healthy processing: (1) We need to accept the reality of the loss itself; (2) Afford ourselves opportunities to experience and process the pain of the loss; (3) Learn to adjust to the world post-loss, without the deceased; and (4) To find meaningful ways to connect with the deceased while finding or establishing a new life without them.
Research on Non-death Loss and Shifts in Social Support
Transitions to assisted living or graduated/nursing care facilities often limit access to previously available social networks, and this can be considered a non-death loss. Loneliness and perceived lack of social support are implicated as predictors of higher mortality, and increased depression, anxiety, and illness in numerous studies, across industrialized nations (Paúl 2014; Bellamy et al. 2014; Litwin and Shiovitz-Ezra 2006). Bellamy et al. (2014) suggest that a health-promoting palliative care approach to developing bereavement support through family and established community networks can be more effective than professional bereavement services for older adults. New research suggests that some of the anxiety experienced post-nursing home transition (as measured by the Geriatric Anxiety Inventory) is not unique to the current environmental factors but rather preexisting psychological and social factors unique to the individuals (Creighton et al. 2019). Additionally, mortality rates are much higher in older individuals in psychiatric care for disorders comorbid to dementia (Golüke et al. 2019).
A lack of social supports may compound instances of bereavement overload and exacerbate grief symptoms. Additionally, due to a lack of social connectedness for those living in care-providing facilities, older individuals may feel disenfranchised. Doka (2002; see also Corr et al. 2019) described grievers who are not socially supported as being disenfranchised, although current attitudes in thanatology (Doka included) articulate the grievers as being marginalized, not that the grief itself is disenfranchised. Although social connectedness can help, it might not be enough. Utz et al. (2014) suggest that social support for bereaved older adults is most effective if it is easily accessed and the bereaved person has an opportunity for self-expression about their grief.
Secondary losses are those which are distal to the loss of the individual who died. For example, if a child loses their mother, they have also lost their cook, playmate, tutor, and so forth. Additionally, the loss of additional income may lead to altered living arrangements, wherein the child losses their home, neighborhood, school district, and friends. For older adults, secondary losses may be especially pronounced. Loss of one’s home and independence often follow loss of a spouse or adult child-caretaker, in addition to the loss of the social role of “spouse” or “parent.” Similarly, the loss of one’s identity in a relationship role may be considered a secondary, yet significant, loss. Finally, changes in living situations for the older adult can result in the loss of friends and result in deep loneliness. Liu et al. (2019) found that the loss of friends among Chinese immigrants in Chicago, although associated with an increased sense of loneliness, also impacted quality of life, particularly among the “old-old” (age 70–79). Van Humbeeck et al. (2016) investigated how nurses and caregivers in Flemish nursing homes assisted residents with grief support. They found that grief care for nursing home residents is characterized by a tension between the need for professional boundaries and the need to be with the resident but also completing caregiving tasks. Recommendations included that nursing homes develop a grief care policy that includes some focus on the non-death and cumulative losses of residents, helping residents to develop reflective practices and self-care for the staff.
Grief, and the health problems that may be compounded by grief, may further exacerbate diminishing mental status. Memory, mood, and desire to socialize may all decrease, leading to further social isolation from friends and family. Additionally, adherence to medical protocols may be compromised by those who are grieving numerous losses. Difficulty in temperament (mood swings, aggressive outbursts) and diminished capacity for self-care may lead to pharmacological intervention, which dulls or inhibits the pain or distress caused by grief. Use of medications may prevent the individual from employing the cognitive processes imperative to processing the grief, leading to a protracted or arrested grief resolution. Decreasing cognitive ability may also impact one’s ability to comprehend new information, such as death notification.
Research on Cognitive Decline and Death Comprehension
Death comprehension is the term used to describe one’s ability to recognize the reality, irreversibility/finality, and universality of death. Koocher (1973) mapped a child’s ability to comprehend death onto Piaget’s stages of cognitive development. Older adults with cognitive decline often have full comprehension of death when told about the death of another, but may not remember the death from one day to the next. Many families and caregivers struggle with how to approach this complication in death notification and subsequent grieving, and sometimes tell the person repeatedly. In the absence of the cognitive capacity to process the previous notification, however, the grief is experienced as new and “fresh” with each retelling. Gruetzner et al. (2012) found that patterns of response by older adults with dementia include “self-threat,” or worries about who will care for them now; “substitution,” or inability to remember the one who died, and substituting with a relative who died previously; and “metaphone,” or substitution of the deceased with an object.
Recent research has found that individuals with dementia attempt to stay “on-topic” in conversation and attempt to elicit help from their conversation partners – indicating that they are open to guidance from the other person (Hall et al. 2018). Yet because of the emotional nature of discussions about the deceased, approaches used by some are to either deflect the individual’s attention when asked about the deceased e.g., “Oh, those are pretty flowers Aunt Sarah sent.”, or to prevaricate/lie, e.g., “Dad went to work. He’ll be by later.” Neither approach provides resolution or opportunity to process the grief, however, the former is often more palatable for family and friends, and the latter is often more compassionate for the older adult with diminished memory. Gruetzner et al. (2012) suggest that individuals with dementia should be told of the deaths of loved ones in most circumstances, but that interventions may be needed to address the confusion that might result. Families must try to be prepared that the older adult with dementia may not respond to a death notification in ways they would have in the past.
Watanabe and Suwa (2017) found that individuals with dementia experience a different mourning process than those without dementia. The ability to remember and store the fact of a spouse’s death differs across the stage of dementia and the individual circumstances and shifts with the progression of dementia and changing circumstances. Current scholar-practitioner models support reminders of the death notification as long as the person can be “prompted” to remember having been told, but to discontinue repeated reminders once the individual can no longer recall having been previously told. The key is that if there is any carryover recollection, some grief work or processing may occur, but if there is no recollection, and the individual asks questions such as “when did it happen,” upon finding out it was in the past they may not only feel the grief as a new event, but may feel betrayed by the person sharing, and react out of fear or anger. More research is needed in this area.
Research on Attitudes Toward Death
There is a dearth of research on attitudes toward death among older adults. Wittkowski (2016) notes the decades of thanatological research on the fear of death as well as the dearth of research on coping with or accepting one’s own mortality. In a review of the empirical research on attitudes toward death, Wittkowski determined that there was a need to operationalize a multidimensional approach (p. 323). The study explored relationships between coping strategies and attitudes toward death and dying among German adults between the ages of 18 and 93. Among the older age group, participants older than 65 showed a positive association between fear of another’s death and a cluster of positive coping strategies, whereas negative coping strategies were correlated with a fear of one’s own dying and death (p. 330). A study of Japanese middle and older aged adults demonstrated that death anxiety, or fear of death, stabilized in older adults, and did not increase over time (Tange et al. 2016).
Fortuin et al. (2017) examined the notion of meaning in the context of awareness of mortality among older adults. They identified three thanatological cultural niches, specifically a canonical, utilitarian, and expressive niche. The canonical cultural niche consists of those cultural values associated with religion and religious authority in which older adults adhere to a belief in a soul and afterlife and embrace the notion of dying as a community and family event. The utilitarian cultural niche is based on rational and utilitarian reasoning and linked with increased medicalization and secularization in a society in which dying is under the purview of medical professionals. The expressive cultural niche includes those based on nondogmatic expressions of spirituality and includes alternative healing and meditation practices. In their study (n = 85), the researchers found that the expressive niche was embraced most by participants who sought meaning in the face of death. Additionally, studies within terror management theory explore protective factors against death anxiety, even in the presence of imminent death due to age, including the increased use of various coping mechanisms in the presence of reminders of one’s mortality (Maxfield and Bevan 2019).
Research on Suicide Among Older Adults
Bereavement overload from multiple successive losses, numerous secondary losses, a reduction in agency and self-advocacy, and an increase in rates of depression are all risk factors for aging adults. Additionally, the absence of social support, an increased knowledge or awareness of their own mortality, and limited access to mental health resources are risk factors for suicide ideation and attempts within an aging population. The emergent relevance of suicidology (the scientific study of suicidal behavior, ideation, and death by suicide) to gerontology has recently emerged as an area of concern within the field of thanatology as global suicide rates are highest, and increasing, for individuals age 70 and above. According to the World Health Organization (WHO 2016), suicide rates are lowest in persons under age 15 and highest in those aged 70 years and older for both men and women in almost all parts of the world, with some regional differences. Older women in low- and middle-income countries have much higher suicide rates than older women in high-income countries. Income level has also been identified as a unique predictor for increased risk of suicide in older adults (Choi et al. 2019). According to the Institute for Health Metrics and Evaluation, in 1990, the global suicide rate (per 100,000) for adults age 70 and up was 38.71, for adults age 59–69 was 22.68, and, for comparison, the age-standardized rate was 15.43. In 2017, the suicide rate for adults age 70 and up dropped to 27.45 whereas for adults age 59–69, the rate dropped to 16.17, and the age-standardized rate was 9.98. A newer area of research within thanatology/suicidology is a movement to use “postvention” efforts as prevention strategies, raising awareness of risk factors (e.g., isolation, bereavement overload, loss of a close relationship due to suicide), and bolstering protective factors (e.g., social support, intervention for depression, etc.). Further, newer research has indicated that suicide ideation estimates for older adults are under-assessed, as they often occur in conjunction with depression. Correcting for survey bias, research has found that passive suicide ideation in individuals over 50 years of age is much higher than previously reported (Dong et al. 2019).
Death Education and Thanatology
Another sub-domain within thanatology is death education. For over 40 years courses on dying, death and loss have been part of the curricula for many colleges and universities around the world. Death education is also delivered to the general public and professional audiences, and includes topics such as suicide prevention, advance directives, coping with grief and loss, rituals, religious perspectives, social and cultural perspectives, and more.
With respect to gerontology, death education is important for professional and non(para)-professional caregivers since a caregiver’s own death anxiety can impact the care given to the dying person. Mejia et al. (2018) studied how death concerns and ageist attitudes impact a psychology trainee’s willingness to work with older adults. They found that death anxiety and salience of death-related thoughts were positively correlated with each other and positively associated with negative behaviors towards older adults. They concluded that death education can help students become more comfortable with their own mortality and can reduce negative behaviors towards older adults. Aday and Shahan (1995) conducted a 7-week educational program on death and dying with older adults in a nursing home setting that was positively regarded by the participants and resulted in a further reduction of already low levels of death anxiety.
Future Directions of Research in Thanatology
Future research could be most beneficial for older adults if focused on practical applications (Bellamy et al. 2014; Tang and Chow 2017; Nam 2017; Brodbeck et al. 2019) such as how to provide opportunities for grief work for those who have experienced multiple losses and have reduced social networks, and possible cognitive decline (Neimeyer 2001, 2016). Grief is experienced before, during, and after a death, and older adults are shown to benefit from interventions which include acknowledgement of the loss, meaning-making, strategies for emotional self-regulation (coping strategies), and opportunities to share memories (Meichsner et al. 2020).
Additional research is needed to understand the implications for comfort and/or palliative care at the end of life for older adults (with or without dementia) to ensure adequate support and comfort during the dying process (Miranda et al. 2020). Further, more research is needed to help families facilitate difficult conversations with older loved ones who are terminally ill (Tang 2019) – and any research must account for social variation and incorporate the type of cultural humility that precludes a “one-size-fits-most” approach. Parallel to understanding and supporting families and their dying older loved ones, more research is needed to explore differences between medical care providers’ and patients’ attitudes toward death; one example is a study done in Thailand, exploring the differences between nurses and their patients (Manjavong et al. 2019).
Finally, designing and implementing educational programs or training on best practices in bereavement support, end-of-life care and dementia for those who work as caregivers for older adults could supplant the need for therapeutic intervention, and reduce physiological consequences of both acute and unresolved chronic grief, not only for the caregivers but for the older adults (Faronbi et al. 2019; Bull et al. 2016; Kemper-Koebrugge et al. 2019; Holtslander et al. 2016; Van Humbeeck et al. 2016). Additional research should explore if any of the current models on grief and grief work are more or less suited to older adults who have experienced different life transitions than those previously studied.
Dying, death, and bereavement are areas which continue to be underappreciated and understudied in older populations. The understanding of how we approach grief and the study thereof is imperative to improving quality of life for older adults. Recognizing the extant primary and secondary losses, relational and otherwise, experienced by older adults should drive efforts to increase research, and inform public health policy in caring for those who are most vulnerable to bereavement overload.
- Aries P (1975) Western attitudes toward death from the Middle Ages to the present (trans: Patricia M. Ranum). Johns Hopkins University Press. https://doi.org/10.1177/089124167500400209
- Bellamy G, Gott M, Waterworth S, McLean C, Kerse N (2014) “But I do believe you’ve got to accept that that’s what life’s about”: older adults living in New Zealand talk about their experiences of loss and bereavement support. Health Soc Care Community 22(1):96–103. https://doi.org/10.1111/hsc.12069CrossRefGoogle Scholar
- Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J, Carr D, Nesse RM (2002) Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J Pers Soc Psychol 83(5):1150–1164. https://doi.org/10.1037/0022-3518.104.22.1680
- Bonanno GA, Neria Y, Mancini A, Coifman KG, Litz B, Insel B (2007) Is there more to complicated grief than depression and posttraumatic stress disorder? a test of incremental validity. J Abnorm Psychol 116(2):342–351. https://doi.org/10.1037/0021-843X.116.2.342
- Bonanno GA, Malgaroli M (2019) Trajectories of grief: comparing symptoms from the dsm-5 and icd-11 diagnoses. Depress Anxiety. Advance online publication. https://doi.org/10.1002/da.22902
- Brodbeck J, Berger T, Biesold N, Rockstroh F, Znoj HJ (2019) Evaluation of a guided internet-based self-help intervention for older adults after spousal bereavement or separation/divorce: a randomised controlled trial. J Affect Disord 252:440–449. https://doi.org/10.1016/j.jad.2019.04.008CrossRefGoogle Scholar
- Choi JW, Kim TH, Shin J, Han E (2019) Poverty and suicide risk in older adults: a retrospective longitudinal cohort study. Int J Geriatr Psychiatry. Advance online publication. https://doi.org/10.1002/gps.5166
- Corr C, Corr D, Doka K (2018/2019) Death & dying: life and living (8th ed). Cengage Learning. ISBN-10: 1337563897Google Scholar
- de Vries B, Johnson CL (2002) The death of a friend in later life. In: Settersten RA, Owens TJ (eds) Advances in life course research: new frontiers in socialization, vol 7. JAI Press, Oxford, UK, pp 299–324. ISBN-10: 1-111-34313-6Google Scholar
- Doka KJ (ed) (2002) Disenfranchised grief: new directions, challenges, and strategies for practice. Research Press Pub. ISBN-13: 978-0878224272; ISBN-10: 9780878224272Google Scholar
- Dong L, Kalesnikava VA, Gonzalez R, Mezuk B (2019) Beyond depression: estimating 12-months prevalence of passive suicidal ideation in mid- and late-life in the health and retirement study. Am J Geriatr Psychiatry. Advance online publication. https://doi.org/10.1016/j.jagp.2019.06.015
- Feifel H (1956) Older persons look at death. Geriatrics 11:127–130. PMID: 13294464Google Scholar
- Golüke NMS, Geerlings MI, Vorst IE, Vaartjes IH, Jonghe A, Bots ML, Koek HL (2019) Risk factors of mortality in older patients with dementia in psychiatric care. Int J Geriatr Psychiatry. Advance online publication. https://doi.org/10.1002/gps.5232
- Holtslander L, Duggleby W, Teucher U, Cooper D, Bally JMG, Solar J, Steeves M (2016) Developing and pilot-testing a finding balance intervention for older adult bereaved family caregivers: a randomized feasibility trial. Eur J Oncol Nurs 21:66–74. https://doi.org/10.1016/j.ejon.2016.01.003CrossRefGoogle Scholar
- Jose S, George N, Dante G (2018) Life satisfaction as a predictor of death anxiety among the elderly people. Indian J Health Wellbeing 9(6):829–832. Retrieved from http://www.i-scholar.in/index.php/ijhw/article/view/181091Google Scholar
- Kastenbaum R (1969) Death and bereavement in later life. In: Kutscher AH (ed) Death and bereavement. Charles C Thomas, Springfield, pp 28–54. ISBN-10: 1135690014 ISBN-13: 978-1135690014Google Scholar
- Kubler-Ross E (1969) On death and dying. The Macmillan Company, New York. ISBN 10: 0026050609Google Scholar
- Leenaars AA (2010) Lives and deaths: biographical notes on selections from the works of Edwin S Shneidman. Suicide Life-Threat 40(5):476–491. https://doi.org/10.1521/suli.2010.40.5.476
- Liu J, Mao W, Guo M, Xu L, Chi I, Dong X (2019) Loss of friends and psychological well-being of older Chinese immigrants. Aging Mental Health. Online first. https://doi.org/10.1080/13607863.2019.1693967
- Lundorff M, Holmgren H, Zachariae R, Farver-Vestergaard I, O’Connor M (2017). Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. J Affect Disorders 212:138–149. https://doi.org/10.1016/j.jad.2017.01.030
- Manjavong M, Srinonprasert V, Limpawattana P, Chindaprasirt J, Pairojkul S, Kuichanuan T, Kaiyakit S, Juntararuangtong T, Yongrattanakit K, Pimporm J, Thongkoo J (2019) Comparison of Thai older patients’ wishes and nurses’ perceptions regarding end-of-life care. Nurs Ethics 26(7–8):2006–2015. https://doi.org/10.1177/0969733019826410CrossRefGoogle Scholar
- Maxfield M, Bevan AL (2019) Aging and coping with mortality: understanding attitudes about aging and age-related differences in coping with death. In: Routledge C, Vess M (eds) Handbook of terror management theory. Elsevier Academic, pp 391–415. https://doi.org/10.1016/B978-0-12-811844-3.00017-2
- Meichsner F, O’Connor M, Skritskaya N, Shear MK (2020) Grief before and after bereavement in the elderly: an approach to care. Am J Geriatr Psychiatry. Advance online publication. https://doi.org/10.1016/j.jagp.2019.12.010
- Miranda R, van der Steen JT, Smets T, Van den Noortgate N, Deliens L, Payne S, Kylänen M, Szczerbińska K, Gambassi G, Van den Block L (2020) Comfort and clinical events at the end of life of nursing home residents with and without dementia: the six-country epidemiological pace study. Int J Geriatr Psychiatry. Advance online publication. https://doi.org/10.1002/gps.5290
- Neimeyer RA (ed) (2001) Meaning reconstruction & the experience of loss. American Psychological Association, Washington, DC. ISBN: 978-1-55798-742-6Google Scholar
- Neimeyer RA (2016) Disentangling multiple loss. In: Neimeyer RA (ed) Series in death, dying, and bereavement. Techniques of grief therapy: assessment and intervention. Routledge/Taylor & Francis Group, pp 153–156. ISBN-10: 1138905933Google Scholar
- Paúl C (2014) Loneliness and health in later life. In: Pachana NA, Laidlaw K (eds) The Oxford handbook of clinical geropsychology. Oxford University Press, New York, pp 381–394. https://doi.org/10.1093/oxfordhb/9780199663170.001.0001CrossRefGoogle Scholar
- Prigerson HG, Vanderwerker LC, Maciejewski PK (2008) A case for inclusion of prolonged grief disorder in DSM-V. In: Stroebe MS, Hansson RO, Schut H, Stroebe W (eds) Handbook of bereavement research and practice: advances in theory and intervention. American Psychological Association, Washington, DC, pp 165–186. https://doi.org/10.1037/14498-008CrossRefGoogle Scholar
- Rando T (1984) Grief, dying, and death: clinical interventions for caregivers. Research Press, Champaign. ISBN-10: 0878222324Google Scholar
- Rando T (1995) Grieving: how to go on living when someone you love dies. Lexington Books, Lanham. ISBN 9780553352696Google Scholar
- Stillion JM, Attig T (eds) (2014) Death, dying, and bereavement: Contemporary perspectives, institutions, and practices. Springer Publishing Company. ISBN-13: 978-0826171412; ISBN-10: 0826171419Google Scholar
- World Health Organization (2016) Global health observatory data. Retrieved from https://www.who.int/gho/mental_health/suicide_rates/en/
- World Health Organization (2018) International classification of diseases for mortality and morbidity statistics (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en