1. Running head: A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 1
A Concept Analysis of Grief in the Elderly as They Transition
From Independent Living to Assisted Care
Pam Davis, RN, BSN
November 24, 2013

2. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 2
A Concept Analysis of Grief in the Elderly as They Transition
From Independent Living to Assisted Care
Background
In the last three years I have watched my father, a brilliant man with a near genius IQ,
spiral downward as his health has declined resulting in a need to transition from independent
living to assisted care. His declining health has forced me to become involved in an intimate
way with a man that I have spent much of my life wanting to avoid due to his volatile temper and
eclectic behavior. Spending time with him over these past few years however has given me the
opportunity to come to know a man I never knew, a man whom I’ve concluded has spent his
entire life running from the demon of mental illness and more recently, something else. That
something, I suspect, is related to the changes that aging is bestowing upon him, occurring so
rapidly he must feel he is on a runaway train.
During this time of transition I have witnessed anger relayed through phone calls
demanding his car back or wanting to go back home. I have seen the animal fear in his eyes as
he attempts to remember how to navigate the path down to the dining hall and back, and the
despondence of a blank stare into nowhere. I have watched him struggle both mentally and
physically with the loss of a leg due to PAD, and the inevitable loss of a second due to the
severity of the disease. I have witnessed this swing from denial through anger, depression, and
finally resignation as he spoke “no more, next time just let me go”.
Like a voyeur witnessing a horror so disturbing yet unable to turn away, I have wondered
if this “something” is not grief related; grief at the loss of what he could once do, grief at having
to be at the mercy of someone else to meet needs he has previously done on his own, grief at
having to resign to others decisions that were once his, and grief at the remembrances of

3. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 3
yesterday’s long past. I’ve come to question if grieving these losses is common in the elderly
and if so, how they grieve these changes.
It is assumed that grief is a universal occurrence that is booth inevitable and necessary, an
active, non-linear process in which individuals work through their grief within a reasonable
period of time otherwise assumed to be pathological (Hewson, 1997). As individuals age,
changes in physical and mental health often result in the loss of independence, and as is common
in the United States due to cultural norms and the socioeconomic environment, a need for
institutionalized care. Going into this analysis as a nurse and the daughter of an elderly parent,
my assumption is that the elderly do grieve as they traverse the losses of aging and in analyzing
this concept, assistance can be offered in helping them to grieve effectively, maintaining the
highest level of independence possible. This being said, for the purposes of this concept
analysis, grief will be defined in the context of the elderly as they transition through the changes
of aging from independence to the need for assisted care.
Definitions
The word grief has both an Old French and a Latin background. It can mean a wrong that
has taken place towards something or someone as in “wrong, grievance, injustice, misfortune,
calamity” or it can mean “mental pain, sorrow, pain, afflict, burden or oppress” (Etymology,
n.d.). Merium-webster defines grief as a deep distress or cause of suffering, or can mean an
unfortunate mishap, trouble or annoyance (Merriam, n.d.).
Freud was one of the first to develop studies and theory based on a psychoanalytic view
of grief defining grief as the result of an internal struggle that is internally painful in which an
individual has lost a love object (Wortman, 2001). Bowlby and Kubler-Ross were instrumental
in developing theories on the stages of grief in which grief is defined as a struggle between the

4. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 4
opposites of activated attachment and the reality of the loss (Wortman, 2001). Tudiver
summarizes grief as a “normal emotional and physical process that accompanies the experience
of acute loss”. (Tudiver, 1986) The American Psychological Classification diagnostic criteria
defines grief as a reaction to a loss, and is considered pathological if not dealt with effectively
(DSM - IV, n.d.). Coyle and Ferrell define grief as a subjective emotional response to a loss that
is cognitive, spiritual, social, physical and philosophical in nature (Coyle, 2006). For purposes of
this paper, the definition of grief will be the subjective reaction to the personal loss of
independence related to aging that affects the elderly mentally, physically and spiritually.
Antecedents
Before grief can occur, a loss must happen. Loss encompasses the absence of things or
purposes, persons or potentials, abilities, wherewithal or assets (Coyle, 2006). In the elderly, the
antecedents of grief can include the loss of a loved one, typically referred to as bereavement, or
relationship including a beloved pet or social support (Coyle, 2006). The loss of health, a change
in lifestyle including a move from home to assistant living or the requirement of assisted care
within the home can initiate the grief process as well as a change in financial status (Tudiver,
1986). The grief process is commonly expressed through mourning; the cultural and social
expression of grief which is the external response to the loss and subsequent assimilation of the
loss into the individual’s life. (Coyle, 2006)
Defining Characteristics
Grief is considered to have four critical components that present themselves in the form
of manifestations indicating the grief process; affective, behavioral, cognitive and physiologic
(Hanson, 2013, Howarth, 2011, and Coyle 2006) (see TABLE 1). These indicators are highly

5. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 5
individualized and can appear individually or together; not every elderly person experiencing
grief will exhibit all symptoms.
Grief is an affective or emotional expression of an experienced loss. Individuals work
through the loss typically beginning with denial, disbelieving that they are in need of assisted
care or prepared for this lifestyle change. Avalon and Green found that many elderly saw
continued care facilities as “places of death” (Aylon, 2012). Progression through periods of
anxiety worrying about the effects of the loss of independence will have on their life concludes
with possible relief that the stress of managing day to day activities that had become difficult are
no longer there.
Grief is a behavioral response to the loss of independence in which the elderly cry, beg,
and become easily agitated or irritable, fiercely fighting this loss of independence. They revert to
childlike behavior, attempt to bargain with family stating they will “do better”, or withdraw,
closing off thoughts of the changes the loss has brought to their life. Often the elderly see a move
to a continued care with ambivalence, denying the need for the move, frequently stating their
children wanted them to make the move (Aylon, 2012).
Grief is expressed cognitively in memory loss, or difficulty concentrating. Some may be
preoccupied with their old life requesting to go back home and talking about how well they
managed their lives or minimize the difficulties they were experiencing on their own. They may
feel hopeless as if they will not find any new friends or be able to make independent choices
again. If grieving effectively they will eventually come accept to accept their new lifestyle
assimilating into a “new normal”.

6. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 6
Loss of appetite resulting in weight loss, difficulty sleeping and somatic complaints can
be physiologic expressions of grief as the elderly work through the affective and cognitive
manifestations of grief in relation to the loss of independence they are experiencing.
TABLE 1: Manifestations of Grief
Affective Behavioral Cognitive Physiologic
Anger
Loneliness
Despair
Relief
Anxiety
Guilt
Crying
Agitation
Withdraw
Fatigue
Memory Loss
Difficulty
Concentrating
Preoccupation with or
idealization of the
deceased
Hopelessness
Helplessness
Acceptance
Adjustment
Finding Meaning in
the loss
Loss of appetite
Insomnia
Weight Loss
Headaches
Somatic complaints
Dizziness
Increased susceptibility to
illness
Consequences
The end goal of the grief process is resolution. As the elderly assimilate into a lifestyle
that now includes assistance with daily activities of living, the critical attributes of grief should
fade or minimize. Shippee found that an active community that encourages autonomy was
essential for the elderly to transition through the grief process of moving into an assisted living
lifestyle (Shippee, 2012). Grief is considered to be normal if the individual works through the
loss experience and moves forward eventually reconciling the loss (Howarth, 2011).

7. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 7
Complicated grief on the other hand is typically noted when the loss is traumatic causing
the individual to have difficulty moving through the grief process. These individuals have
overwhelming symptoms of depression and have difficulty talking about the loss. Complicated
grief is considered pathologic and may require intensive intervention as these individuals
frequently become suicidal (Howarth, 2011).
Application to Nursing
Model Case
Mrs. McDonald, an active 90 year old who had until recently been living independently
and driving herself around town, has newly been moved into an assisted living facility by her
family due to a recent fall that resulted in a hip fracture. They felt that Mrs. McDonald could no
longer care for herself and required closer observation. Upon moving in, her family set up her
apartment in a manner that closely resembled the lay out of her home utilizing her personal
belongings. Initially, Mrs. McDonald would call her children several times a day asking them to
bring her car back to her and wanting to know when she could go back home. She lost 5 pounds
after several weeks which was attributed to her failing to go down for meals stating that she was
not hungry. After a visit with her children, Mrs. McDonald would begin to cry when they went
to leave. Her family was concerned, but after approximately three months they noted that Mrs.
McDonald seemed to enjoy meal times, lingering to visit with friends and frequently participated
in social activities. She began to tell them that the move had been a good one and she enjoyed
not having to be responsible for paying the bills, cooking or cleaning any longer. Mrs.
McDonald had successfully traveled the grief process as she began to accept her loss of
independence and assimilated into the assisted care facility.

8. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 8
Contrary Case
Thirty-four year old Mr. Randal’s family has recently moved him into a nursing home
facility after he suffered a motorcycle accident leaving him with limited mobility due to a
traumatic brain injury. He does not respond to verbal commands or interact socially making
minimal eye contact and, due to his lack of appetite, a feeding tube was placed. He is easily
agitated when spoken to or during activities of daily living. The staff have come to expect
inappropriate verbal comments from him upon interaction or physical stimulation. Mr. Randal is
not experiencing grief, his behavior is due to the brain injury he suffered.
Borderline Case
Mrs. Krammer, a 78 year old female, has been placed in an assisted living facility after
suffering a hemorrhagic stroke. She cries easily, alternates between sleeping a lot and insomnia.
She has difficulty with social interactions and frequently states she wishes she had just died.
Mrs. Krammer’s behavior is difficult to judge. Her symptoms could be grief related to the loss
of her independence after the change in health status she has experienced, requiring her to need
assisted care, or her behavior could be a result of the brain injury she sustained due to the stroke.
In all likelihood, Mrs. Krammer is probably experiencing both.
Summary
Grief for anyone experiencing a loss is a highly individualized experience. It has been
noted in the elderly as they transition from independent living to the need for assisted care. The
loss of independence is difficult to navigate for them, and they frequently do not initially
perceive it to be necessary. The non-linear grief process evidences itself in the elderly through
cognitive, behavioral, affective and physiologic indicators. Successfully maneuvering through
grief subsequent to the loss of independence requiring assisted care will lead to resolution and

9. A CONCEPT ANALYSIS OF GRIEF IN THE ELDERLY AS THEY 9
assimilation of the loss into their new lifestyle. Understanding the concept of grief in relation to
the loss of independence in the elderly permits healthcare providers the opportunity to assist
them in successfully finding resolution of the loss and through the grief process.

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