Abstract
Objective: To examine the effect of Accelerated Resolution Therapy (ART) on the quality of life (QOL) of older adults with complicated grief (CG) over time.
Design: Subanalysis of a randomized controlled trial.
Setting/Subject: Older adult, former caregivers were recruited from a large hospice in the southeastern United States to be treated with ART for CG.
Measurement: The CDC Health-Related Quality of Life (HRQOL) Healthy Days Module was administered pre-, post-, and eight weeks after therapy.
Results: The subsample consisted of 27 older adults. A multilevel model indicated a statistically significant, negative difference of 8.21 (improvement) in QOL scores for each period of data collection (β = −8.21, t = 4.02, p < 0.001). Both the intervention (11%, p = 0.013) and time (7.8%, growth curve p = 0.014) contributed significantly.
Conclusion: There was a significant large effect of ART on CG. This study supports concurrent improved patient-related outcome—QOL.
Keywords: accelerated resolution therapy, caregivers, complicated grief, older adults, quality of life
Introduction
Complicated grief (CG) is a persistent (greater than six months), intense grief that includes continued yearning, longing, sadness, maladaptive thoughts, and dysfunctional behaviors.1,2 CG negatively affects mental and physical health quality-of-life (QOL) domains3,4 and independently predicts depression and anxiety.4–6
The death of a care recipient, most often a spouse or life partner, is a top source of stress.7 CG compounds this stress, affecting sleep and the disruption of the normal functioning of the central nervous, immune, cardiovascular, neuroendocrine, and gastrointestinal systems, all contributing to poor QOL for the survivor.7,8 Left untreated, comorbidities and impairments may develop or worsen, impeding the ability to recover.9 First noted in the 1970s,10 measuring QOL has increased in frequency.11 QOL includes physical, mental/psychological, social, and environmental domains,12 which suggests that an individual's QOL may be impacted by CG.
Older adult former caregivers may need outside assistance with CG as they may be at increased risk due to diminishing social and emotional support, poorer physical health, and experiencing multiple deaths as well as other significant losses.13 There is a paucity of literature regarding the relationship between CG on QOL. This study addresses this gap by examining longitudinal QOL data for older adults with CG receiving Accelerated Resolution Therapy (ART).
Methods
Study design
This was a designed subanalysis of QOL data from the randomized wait list-controlled trial (randomized controlled trial [RCT]) “Accelerated Resolution Therapy for Treatment of Complicated Grief in Senior Adults” (R21AG056584) described elsewhere.14 The study received University of South Florida Institutional Review Board approval.
Participants and eligibility criteria
Inclusion criteria for the parent study were: age ≥60 years; previous primary caregiver of immediate family member who died after hospice enrollment and at least 12 months before study; current symptoms indicative of proposed diagnostic criteria for CG disorder15 or psychological trauma16; denial of suicidal ideation or intent, and no evidence of psychotic behavior.14 Exclusion criteria were: currently engaged in another psychotherapy, ART, or eye movement therapy; and have major psychiatric disorder or current substance abuse dependence treatment anticipated to interfere with therapy.14 No additional criteria were applied for this subanalysis.
Intervention
Eligible participants received up to four weekly individual sessions of ART at the hospice center. ART is an evidence-based psychotherapy for mental health issues that includes the core components of trauma-focused therapy. With hand movements and guided imagery, the therapist assists the participant in rescripting traumatic events and images.17–19 See Supplementary Appendix SA1 for more details on ART. Participants were randomly assigned to receive ART immediately (n = 20) and or four weeks after enrollment (wait list n = 7).
Instruments
Participants completed a demographic survey and Charlson Comorbidity Index at enrollment. The CDC HRQOL was completed at enrollment, post-wait list, post-ART, and at eight-week follow-up as a measure of perceived physical and mental health.20
The CDC HRQOL-14 is in the public domain, has good psychometric properties,21–23 and is used to assess changes in health-related QOL in response to treatment.24 This subanalysis used the 4-item Healthy Days Module of the CDC HRQOL.
Statistical analyses
Demographic and clinical characteristics were summarized with descriptive statistics and bivariate analyses. Fifty-four participants participated in the parent study. A missing value analysis for the Healthy Days Module was conducted and resulted in retaining a sample of 27 who provided a QOL score for baseline, end of treatment, and eight weeks after completion of therapy. When completers versus noncompleters were analyzed, there were no statistically significant differences in salient variables such as age and baseline CG.
Due to a lack of variability, questions 2–4 were used as aggregate scores. A multilevel linear model was fitted to the data to test for a significant effect of the intervention and a significant difference in QOL over time. After sensitivity analyses, one participant with extreme scores was removed from the final model.
Results
Sample
The majority of the sample was female (85.2%, n = 23), White (96.3%, n = 26), and had a mean age of 66 years (standard deviation ±6.60). On average, there was improvement in the total QOL scores from baseline (38.85 ± 26.20) to the end of treatment (26.92 ± 22.91) with a relative stability of the scores at eight weeks post-completion of therapy (21.26 ± 23.71). There was a statistically significant difference in employment between the intervention and wait list groups (χ2 = 11.493, df = 4, p < 0.05) with the immediate ART group having the majority (15, 78.9%) of retired participants. Employment was not, however, a significant predictor of QOL. No other statistically significant differences were found (Tables 1 and 2).
Table 1.
Demographic Characteristics Comparing Groups with Test Statistics
| Variable | All participants, N = 27 |
Immediate treatment group, n = 20 |
Wait list control group, n = 7 |
Test statistic |
|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | ||
| Age | 66.1 ± 6.60 | 67.0 ± 6.95 | 63.6 ± 5.13 | t = 1.173, df = 25 |
| n (%) | n (%) | n (%) | ||
| Biological sex | χ2 = 0.002, df = 1 | |||
| Male | 4 (14.8) | 3 (15.0) | 1 (14.3) | |
| Female | 23 (85.2) | 17 (85.0) | 6 (85.7) | |
| Marital status | χ2 = 5.390, df = 3 | |||
| Married/partnered | 5 (18.5) | 2 (10.0) | 3 (42.9) | |
| Divorced | 5 (18.5) | 3 (15.0) | 2 (28.6) | |
| Widowed | 16 (59.3) | 14 (70.0) | 2 (28.6) | |
| Single/never married | 1 (3.7) | 1 (5.0) | — | |
| Annual income | χ2 = 3.318, df = 3 | |||
| Less than $25,000 | 11 (40.7) | 10 (50.0) | 1 (14.3) | |
| $25,001–$49,999 | 9 (33.3) | 5 (25.0) | 4 (57.1) | |
| $50,000–$74,999 | 4 (14.8) | 3 (15.0) | 1 (14.3) | |
| $75,000 or greater | 3 (11.1) | 2 (10.0) | 1 (14.3) | |
| Educational level | χ2 = 0.902, df = 4 | |||
| ≤High school | 5 (18.5) | 3 (15.0) | 2 (28.6) | |
| Some college/tech | 7 (25.9) | 5 (25.0) | 2 (28.6) | |
| Associate degree | 4 (14.8) | 3 (15.0) | 1 (14.3) | |
| Bachelor's degree | 5 (18.5) | 4 (20.0) | 1 (14.3) | |
| Graduate degree | 6 (22.2) | 5 (25.0) | 1 (14.3) | |
| Race | χ2 = 0.363, df = 1 | |||
| White | 26 (96.3) | 19 (95.0) | 7 (100.0) | |
| Other | 1 (3.7) | 1 (5.0) | — | |
| Hispanic ethnicity—yes | 3 (11.1) | 3 (15.0) | — | χ2 = 1.181, df = 1 |
| Employment | Missing n = 1 | Missing n = 1 | χ2 = 11.493, df = 4* | |
| Full time | 3 (11.5) | 1 (5.3) | 2 (28.6) | |
| Part time | 2 (7.7) | 1 (5.3) | 1 (14.3) | |
| Retired | 16 (61.5) | 15 (78.9) | 1 (14.3) | |
| Disabled | 4 (15.4) | 1 (5.3) | 3 (42.9) | |
| Other | 1 (3.8) | 1 (5.3) | — |
Percentages may not add up to 100% due to rounding/missing data.
*p < 0.05; all other test statistics are nonsignificant.
SD, standard deviation.
Table 2.
Clinical Characteristics Comparing Groups with Test Statistics
| Variable |
All participants, mean ± SD or n (%) |
Immediate treatment group, mean ± SD or n (%) |
Wait list control group mean ± SD or n (%) |
Test statistic |
|---|---|---|---|---|
| N = 27 | n = 20 | n = 7 | ||
| No. of comorbidities | 1.22 ± 1.42 | 1.45 ± 1.54 | 0.57 ± 0.79 | t = 1.434, df = 25 |
| Hospitalizationsa | χ2 = 6.432, df = 3 | |||
| None | 20 (74.1) | 16 (80.0) | 4 (57.1) | |
| One | 1 (3.7) | 1 (5.0) | — | |
| Two | 2 (7.4) | 2 (10.0) | — | |
| ≥Three | 4 (14.8) | 1 (5.0) | 3 (42.9) | |
| Physician/provider visitsa | χ2 = 4.021, df = 3 | |||
| None | 1 (3.7) | 1 (5.0) | — | |
| One | 1 (3.7) | — | 1 (14.3) | |
| Two | 2 (2.4) | 1 (5.0) | 1 (14.3) | |
| ≥Three | 23 (85.2) | 18 (90.0) | 5 (71.4) | |
| Deceased's diagnosis | Missing n = 11 | Missing n = 9 | Missing n = 2 | χ2 = 7.941, df = 6 |
| Cancer | 7 (25.9) | 6 (30.0) | 1 (14.3) | |
| Dementia/Alzheimer's | 3 (11.1) | 1 (5.0) | 2 (28.6) | |
| Liver ± kidney failure | 2 (7.4) | 1 (5.0) | 1 (14.3) | |
| Respiratory | 2 (7.4) | 2 (10.0) | — | |
| Brain stem injury | 1 (3.7) | 1 (5.0) | — | |
| Stroke | 1 (3.7) | — | 1 (14.3) | |
| Quality-of-life scoresb | ||||
| Baseline | 38.85 ± 26.20 | 32.80 ± 21.94 | 56.14 ± 31.29 | t = 2.169, df = 25 |
| End of treatment | 26.92 ± 22.91 | 26.16 ± 24.74 | 29.00 ± 18.55 | t = 0.275, df = 24 |
| Eight weeks post-completion | 21.26 ± 23.71 | 21.40 ± 24.01 | 20.86 ± 24.70 | t = 0.051, df = 25 |
Percentages may not add up to 100% due to rounding/missing data. All test statistics are nonsignificant.
Number of times since death of care recipient.
Aggregate scores for questions 2–4 of CDC HRQOL-14, Healthy Days Measure. Lower scores indicate better quality of life.
Multilevel model
There was a statistically significant change in QOL over time (β = −8.21, t = 4.02, p < 0.001); for each period of data collection there was an 8.21 negative difference (improvement) in QOL scores. There were statistically significant differences for total and within-persons variance indicating that other predictors would help to explain differences in QOL. Time was entered first into the model and explained 7.8% of the variance in QOL. The slope of the growth curve for aggregate QOL scores over time was statistically significant (p = 0.014), indicating QOL improved over time. Intervention group (i.e., immediate and wait list) was then added and was a statistically significant predictor (p = 0.013) explaining 11.0% of the variance. Given the size of this sample, it was not possible to test a potential interaction between time and group.
Discussion
This study examined QOL data over time for older adults with CG receiving ART. QOL scores improved significantly over time from baseline to eight weeks post-completion. Given that these participants were at least 12 months post-death without improvement in CG prior suggests that any improvements were not a function of time, but rather an effect of ART. Both time and intervention contributed to the model suggesting that ART had a positive effect on participants' QOL.
ART has been successfully used in numerous studies to treat trauma-based conditions, such as post-traumatic stress disorder (PTSD) and sexual assault.25–28 While multiple studies have examined associations between CG and poorer QOL in military service members and veterans,29 bereaved caregivers,4,6,30,31 and general population of older adults,3 only one previous study tested the effect of ART on QOL (measured by the Short Form 36) finding an improvement in participants with PTSD.26
In a recent review of the literature of CG,13 only 1 out of 32 studies examined QOL32; however, it did not include a treatment intervention. While the literature is scant in this area it underscores the importance of this study in filling the gap. While clear treatment guidelines for CG are lacking33 there are currently other treatment options. For example, CG Treatment34 is the most widely implemented evidence-based therapy33,35,36; however, no QOL studies were found with Cognitive Grief Treatment (CGT). CGT is a 16-week cognitive behavioral therapy that combines psychoeducation and dual processing for imaging and conversation revisiting,36,37 whereas ART, a four-week mind–body therapy, utilizes visualization, reimaging, and rescripting.
To date, Buck et al. is the first study to examine ART to treat CG and this subanalysis presents the data for QOL in this RCT. Results suggest that ART may improve QOL as well as CG in bereaved family caregivers. Whether reducing CG is the mechanism through which ART improves QOL needs further examination. Results suggests ART, given in four brief sessions for CG with similar results14 to the more expensive, intensive 16-week CG treatment, can potentially improve QOL in a shorter period of time as well. The lack of studies examining CG and QOL calls for further research, including exploration of QOL domains.
Limitations
Limitations of the parent study are described elsewhere.14 For this subanalysis, limitations included the small sample size. While the CDC HRQOL is a well-established instrument with significant psychometric work, it was designed for epidemiological populations studies for health surveillance and identifying disparities among subpopulations.20,38 In this study, it was used for a sample of former family caregivers completing hospice counseling. Missing data were expected and addressed with the analytic plan. However, ultimately half the sample was eliminated due to missing values. This may have been a function of confusion and burden as participants had multiple instruments to complete at each study visit. Second, the CDC HRQOL was used more frequently as intended (weekly during ART vs. monthly) in this study. These weekly, paper-based instruments offered a response option, “I don't know,” not presented for the original telephone surveys. These may have all contributed to incongruities and missing values.
Conclusion
Former family caregivers with CG who received ART reported improved QOL over the study period. This study provides preliminary data supporting further research on the effect of treatment on CG and QOL.
Acknowledgment
The authors would like to thank colleague Dr. Kevin Kip, coprincipal investigator.
Appendix A1. Accelerated Resolution Therapy Intervention Components
Imaginal exposure: The therapist elicits physiological reactions associated with recall (auditory or visual) of the traumatic/distressing experience of the death of their family or friend.
Left-to-right eye movements: As reactions emerge, the person is instructed to focus on specific body-centric reactions while tracking the clinician's hand as it oscillates left to right, a short distance from the eyes.
Imagery rescripting: After two full courses of processing (reducing), all physiological reactions induced by imaginal exposure, imagery rescripting, broadly defined as working directly with imagery to change meanings and ameliorate distress, are used. In this component, the person imagines a positive way to recall their experience(s). Emphasis is on “replacing” negative images with positive images. This is based on the process of memory reconsolidation, which allows for “adding” of positive material to the recall of negative, highly emotional past experiences.
Authors' Contributions
All authors contributed to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafted the work or revised it critically for important intellectual content; and reviewed the final article before submitting for publication.
Funding Information
This work was supported by the National Institute on Aging of the National Institutes of Health under award number R21AG056584.
Author Disclosure Statement
The authors have nothing to disclose.
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