Supporting the Bereaved in the COVID-19 Era: A Scoping Review of Interventions.

People whose family member(s) friend(s) have died from COVID-19 or other causes have been deeply affected by the physical and social restrictions imposed during the pandemic. These limitations have affected end-of-life care and support for the bereaved. The purpose of this review is to identify: the published studies of evaluated programs about interventions for people who have experienced bereavement during the COVID-19 pandemic, and to develop recommendations for researchers and policy makers. Using scoping review methodology, a literature review was undertaken for articles published from January 1, 2020 through February 28, 2023 to identify interventions shown to be beneficial to people who have experienced the death of loved ones during the COVID-19 pandemic. The search yielded 1588 articles of which three studies met the criteria of utilizing a pre and post-test design with only one of these, a randomized controlled trial. The interventions included in this review demonstrate preliminary efficacy.

Changing Funerals and Their Effects on Bereavement Grief in Japan.

Bereavement is an extremely personal feeling, but Japanese society tends to disapprove of displays of negative personal emotion or weakness. For ages, mourning rituals like funerals provided an exception where social permission was given to sharing grief and seeking support. However, the form and significance of Japanese funerals have changed rapidly over the past generation, and especially since the advent of COVID-19 restrictions on assembly and travel. This paper overviews the trajectory of changes and continuities in mourning rituals in Japan, looking at their psychological and social impacts. It goes on to summarize recent Japanese research showing that appropriate funerals are not merely of psychological and social benefit, but may have an important role in reducing or supporting grief that might otherwise require medical and social work intervention.

Evaluations of Funerals and Health Trajectories in the Second Year After Bereavement-The Ongoing Japan National Survey.

Our nationwide postal survey analyzing 190 responses from Japanese bereaved who had responded a year earlier found that funeral dissatisfaction rose during the second year after the funeral. Controverting previous research advocating participation in funeral planning, elderly bereaved spouses forced to decide about and/or pay for the funeral showed elevated grief as much as 2 years later. While not reaching levels diagnosed as prolonged, traumatic, or complicated grief, nevertheless one out of three of our bereaved sample showed continuing daily symptoms of grief from 14 to 24 months after their bereavement, with continued or increasing use of tranquillizers or antidepressants. The medical and pharmaceutical costs incurred by mourners more than a year after bereavement warrant further research into what factors improve or exacerbate the health of grieving bereaved, not limited to a single year after the bereavement.

Identifying bereaved grievers with greatest medical or social service needs in Japan.

OBJECTIVE: Severe grief adversely affects the health of bereaved families, potentially burdening medical and community health services. Interventions for effective community health maintenance must identify the people likely to face severe effects of bereavement. The present study identified characteristics of mourners who experience severe grief within a year of bereavement to confirm whether this grief increased their reliance on Japanese medical and social services. DESIGN: We conducted a nationwide postal survey of Japanese bereaved within the previous year, to compare those reporting daily or overwhelming 'heavy' grief to those with less heavy grief, in terms of demographic and socioeconomic details, daily work and non-work activity, frequency of medical and social service use. SETTING/PARTICIPANTS: In 2019, with the support of the Ministry of Education and the All Japan Funeral Co-Operation, we distributed approximately 5500 questionnaires to Japanese who had presided at funerals within the past year for anonymous return. By January of 2020, we received 1078 complete voluntary responses from bereaved Japanese. RESULTS: Half of the 'heavy grief' group (n=143) reported adverse effects on health and daily life, including needs for pharmacological, medical or welfare support. Losses of husbands or children were particularly connected to severe grief; 'unexpected' death from cancer caused the greatest shock. Employment (even part-time) buffered against severe grief; grief was greater for the unemployed and substantially worse for those who lost significant income at the same time as they lost loved ones. CONCLUSION: These findings suggest that prior counselling should reduce the shock of bereavement and economic loss, which increases subsequent medical dependence. Medical professionals and community health workers can use the above factors to target in advance the family members in greatest danger of heavy grief, to intervene lest grief adversely affect their physical and psychological health after bereavement.

Mourners' Dissatisfaction with Funerals May Influence Their Subsequent Medical/Welfare Expenses-A Nationwide Survey in Japan.

Japan's super-aged mortality rate bereaves millions of people annually, threatening the mental health of the bereaved population. Previous research suggests that participation in satisfying funeral rituals can protect or improve the health of a bereaved population-but pandemic restrictions threaten traditional funeral assemblies. To determine how bereaved mourners' mental health-and consequent dependence upon medical, pharmaceutical, or social services-are affected by funerals and the aspects of funerals most likely to cause satisfaction or dissatisfaction, we conducted an anonymous nationwide survey across Japan. In total, 1078 bereaved Japanese responded; we analyzed their responses by comparing the 106 citing funeral dissatisfaction with the 972 citing no dissatisfaction. The cohort showing greatest satisfaction with funerals tended to be older widows or parents who lost children; they showed greater grief but spent less on medical, pharmaceutical, or social services thereafter than the dissatisfied. Conversely, mourners with the greatest dissatisfaction toward their interactions with funeral directors and Buddhist priests tended to spend more on medical, pharmaceutical, or social services after bereavement. We conclude that training or education to improve priests' and funeral directors' interactions may reduce dissatisfaction with funerals, potentially reducing subsequent costs of medical, pharmaceutical, or social services for the rapidly growing population of bereaved Japanese.

How Grief, Funerals, and Poverty Affect Bereaved Health, Productivity, and Medical Dependence in Japan.

Grief has been shown to weaken bereaved persons' health, but measurements of their lost time and medical expense remain rare. Funerals traditionally managed and assuaged grief through ritual expression, approval, and social support. Research suggests that satisfying funeral participation reduces grief, while poverty exacerbates it. We hypothesized that: (1) psycho-physical symptoms of grief, (2) abbreviation/dissatisfaction in the funeral, and (3) poverty, correlate with decreased productivity and increased medical and social services use. We collected data from 165 mourning families about their grief, funerals, and subsequent medical conditions. (1) Deeper grief after bereavement in Japan correlated with more physical problems, more down time, and more medical dependency. (2) Low satisfaction with funerals correlated with higher hospital, pharmacy, and counseling costs. (3) Low income families lost more time, while declining incomes showed increased pharmaceutical costs. This suggests that satisfying funerals and income safeguards may reduce costs of low productivity and increased public services dependency.

11C-PiB PET can underestimate brain amyloid-ß burden when cotton wool plaques are numerous.

Individuals with familial Alzheimer's disease due to PSEN1 mutations develop high cortical fibrillar amyloid-ß load but often have lower cortical 11C-Pittsburgh compound B (PiB) retention than Individuals with sporadic Alzheimer's disease. We hypothesized this is influenced by limited interactions of Pittsburgh compound B with cotton wool plaques, an amyloid-ß plaque type common in familial Alzheimer's disease but rare in sporadic Alzheimer's disease. Histological sections of frontal and temporal cortex, caudate nucleus and cerebellum were obtained from 14 cases with sporadic Alzheimer's disease, 12 cases with familial Alzheimer's disease due to PSEN1 mutations, two relatives of a PSEN1 mutation carrier but without genotype information and three non-Alzheimer's disease cases. Sections were processed immunohistochemically using amyloid-ß-targeting antibodies and the fluorescent amyloid stains cyano-PiB and X-34. Plaque load was quantified by percentage area analysis. Frozen homogenates from the same brain regions from five sporadic Alzheimer's disease and three familial Alzheimer's disease cases were analysed for 3H-PiB in vitro binding and concentrations of amyloid-ß1-40 and amyloid-ß1-42. Nine sporadic Alzheimer's disease, three familial Alzheimer's disease and three non-Alzheimer's disease participants had 11C-PiB PET with standardized uptake value ratios calculated using the cerebellum as the reference region. Cotton wool plaques were present in the neocortex of all familial Alzheimer's disease cases and one sporadic Alzheimer's disease case, in the caudate nucleus from four familial Alzheimer's disease cases, but not in the cerebellum. Cotton wool plaques immunolabelled robustly with 4G8 and amyloid-ß42 antibodies but weakly with amyloid-ß40 and amyloid-ßN3pE antibodies and had only background cyano-PiB fluorescence despite labelling with X-34. Relative to amyloid-ß plaque load, cyano-Pittsburgh compound B plaque load was similar in sporadic Alzheimer's disease while in familial Alzheimer's disease it was lower in the neocortex and the caudate nucleus. In both regions, insoluble amyloid-ß1-42 and amyloid-ß1-40 concentrations were similar in familial Alzheimer's disease and sporadic Alzheimer's disease groups, while 3H-PiB binding was lower in the familial Alzheimer's disease than the sporadic Alzheimer's disease group. Higher amyloid-ß1-42 concentration associated with higher 3H-PiB binding in sporadic Alzheimer's disease but not familial Alzheimer's disease. 11C-PiB retention correlated with region-matched post-mortem amyloid-ß plaque load; however, familial Alzheimer's disease cases with abundant cotton wool plaques had lower 11C-PiB retention than sporadic Alzheimer's disease cases with similar amyloid-ß plaque loads. PiB has limited ability to detect amyloid-ß aggregates in cotton wool plaques and may underestimate total amyloid-ß plaque burden in brain regions with abundant cotton wool plaques.

Efficacy of group-based multi-component psycho-education for caregivers of people with dementia: A randomized controlled study.

AIM: The aim of this study was to examine the ability of a group-based multi-component psycho-educational intervention (GMC-PEI) to reduce depression, and improve caregiving appraisals, coping skills of informal caregivers and the condition of people with dementia. METHODS: In this randomized controlled and blinded trial, we enrolled 54 informal caregivers of people with dementia visiting the Japan National Center of Geriatrics and Gerontology, and divided them into GMC-PEI and control groups. The intervention group received a 12-week GMC-PEI program that included six 2-h structured sessions to enhance their knowledge of dementia, caregiving skills and coping skills. The control group received leaflets containing information about dementia. We evaluated caregivers' depression, caregiving time, subjective burden, caregiving appraisal and care coping skills. We also evaluated people with dementia at baseline and 12 weeks, and reassessed 20 participants from the intervention group at 24 and 48 weeks. RESULTS: The GMC-PEI significantly improved depression, positive appraisals of fulfillment in caregiving, affection for care recipients, self-growth and coping skills, such as seeking formal support. Depression, fulfillment and affection for people with dementia showed a peak improvement at 24 weeks; formal support-seeking showed a linear improvement throughout the 48-week follow-up period. CONCLUSIONS: The group-based multi-component psycho-educational intervention reduced depression, improved self-appraisal and enhanced coping skills in caregivers. However, emotional enhancements dissipated sooner than support-seeking skills, suggesting that caregivers should be reviewed every 12-24 weeks. Geriatr Gerontol Int 2021; 21: 561-567.

Unexplored Costs of Bereavement Grief in Japan: Patterns of Increased Use of Medical, Pharmaceutical, and Financial Services.

Bereaved families may experience psychological and physical problems increasing their reliance on medical, pharmaceutical, and financial/legal services. Our Japan-wide survey (n = 1078) researched bereaved who showed increased reliance on medical, pharmaceutical, and financial/legal services. Increased use was most evident in the '50's age bracket, and for unemployed widows; it corresponded less with low annual income than with high income declining significantly after bereavement. Increased users showed higher psychological and physical symptoms of grief, and reported their decline in physical health seriously influencing their work and lives, suggesting "presenteeism"-reduced productivity for those continuing to work. Increased users spent 2.7 times more for medical and pharmaceutical services than those reporting continual use, portending 4 to 10 times more Japanese government expense for this group, half of whom considered their own out-of-pocket expenses a financial burden. These findings warrant further research on cost-effectiveness of interventions to reduce declining health of the bereaved.

Listening to Sutra-Chanting Reduces Bereavement Stress in Japan.

Buddhist Chaplains chanting sutras after the Great East Japan Earthquake in 2011 often encountered survivors who felt that hearing sutra chanting itself ameliorated their bereavement grief. This research is the first experimental examination of the effects of sutra chanting on listeners' bereavement stress. Prior research demonstrates that sudden pet loss causes bereavement stress in students and that physiological stress can be noninvasively measured by salivary alpha-amylase. We asked Japanese college students to raise pet goldfish until they developed an attachment to them, then confiscated the fish, and told the students that they had to be killed. To compare the bereavement stress of groups listening and not listening to sutra chanting, we used psychological and salivary analyses. Perceived Stress Scale (PSS), Multidimensional Empathy Scale (MES), and State half of the State Trait Anxiety Inventory (STAI) psychological scales showed no statistically significant differences between sutra and control groups, but salivary analyses indicated measurable stress reduction in the sutra-listening group only. This pilot study tentatively confirmed the hypothesis that listening to Buddhist sutra chanting reduces Japanese bereavement stress. Further research is needed both to verify these stress-reduction effects and to determine whether such effects are primarily musical or cultural/spiritual.

Influence of apolipoprotein-E genotype on brain amyloid load and longitudinal trajectories.

To characterize the influence of apolipoprotein-E (APOE) genotype on cerebral Aß load and longitudinal Aß trajectories, [11C]Pittsburgh compound-B (PiB) positron emission tomography (PET) imaging was used to assess amyloid load in a clinically heterogeneous cohort of 428 elderly participants with known APOE genotype. Serial [11C]PiB data and a repeated measures model were used to model amyloid trajectories in a subset of 235 participants classified on the basis of APOE genotype. We found that APOE-ε4 was associated with increased Aß burden and an earlier age of onset of Aß positivity, whereas APOE-ε2 appeared to have modest protective effects against Aß. APOE class did not predict rates of Aß accumulation. The present study suggests that APOE modifies Alzheimer's disease risk through a direct influence on amyloidogenic processes, which manifests as an earlier age of onset of Aß positivity, although it is likely that other genetic, environmental, and lifestyle factors are important.

Development of a Japanese Version of the Daily Record of Severity of Problems for Diagnosing Premenstrual Syndrome.

Background: Premenstrual syndrome (PMS) causes physical and mental symptoms in women during the luteal phase of the menstruation cycle. To confirm the relationship between symptoms and the menstruation cycle, daily symptom records are essential for diagnosing PMS. The daily record of severity of problems (DRSP) is currently the most validated tool for tracking symptoms to confirm and scale the severity of PMS, but there has been no validated Japanese version of this instrument. We developed a Japanese version of the DRSP and assessed its psychometric properties. Methods: A Japanese version of the DRSP was developed following the translation guidelines of the latest Patient-Reported Outcomes Consortium. We conducted a computational psychometric study among 119 women, all of whom completed the Japanese version of the DRSP, the Center for Epidemiologic Studies Depression Scale (CES-D), the Premenstrual Dysphoric Disorder (PMDD) scale, and a Numerical Rating Scale (NRS) for general health status. Each was filled out twice, 2 weeks apart, so that one set was completed in the luteal phase. Results: The Japanese version of the DRSP was developed with translation and cultural adaptation. The internal consistency coefficient for the total score was 0.93. The DRSP in the luteal phase correlated highly with the CES-D, PMDD scale, and NRS for general health status. Conclusions: Our Japanese version of the DRSP, developed as a PMS/PMDD diagnostic tool, was shown to provide substantial validity and reliability to rate premenstrual symptoms for Japanese women.

[Overcoming Fear of Death in Home Caregiving].

This study aimed to clarify the factors for reducing the burden of caregivers caring for terminal patients. We conducted semi-structured interviews with bereaved caregivers, seeking those who had felt neither fear nor anxiety during caregiving; their responses were analyzed using the Steps for Coding and Theorization. The one caregiver who showed neither fear nor anxiety(1)believed in an afterlife,(2)sought a physician who would respect her belief,(3)sought respect for her medical decisions, and(4)found distance to the clinic to be a critical factor. Our findings suggest that doctors' respect for caregivers' beliefs may be an important factor in reducing caregiver burden at the end of life.

Timing and facilitation of advanced directives in Japan.

OBJECTIVES: This study aimed to reveal Japanese elders' perspective on optimal timing and method of receiving unified guidance about advance directives (AD). METHODS: We convened 202 elders (average age 66) to learn about end-of-life at Kyoto University. They listened to a presentation and viewed two videos on advance care planning and AD; then 167 completed detailed questionnaires about unified timing and methods of providing such information. RESULTS: A majority of Japanese elders (79%) agreed with unified guidance in combination with the issue of health insurance cards at age 65 or 75. The most preferred method for receiving information was video presentation. CONCLUSIONS: Japanese elders appear to welcome the idea of receiving information about AD when they are issued health insurance cards at age 65 or 75. Use of video materials holds great promise for educating elderly Japanese about their choices on AD.

Impact of partial volume correction on the regional correspondence between in vivo [C-11]PiB PET and postmortem measures of Aß load.

The positron emission tomography (PET) radiotracer Pittsburgh Compound B ([C-11]PiB) demonstrates a high affinity for fibrillary amyloid-beta (Aß) aggregates. However, [C-11]PiB's in vivo sensitivity and specificity is an ongoing area of investigation in correlation studies with postmortem measures of Aß pathology. One potential confound in PET-to-postmortem correlation studies is the limited spatial resolution of PET and resulting partial volume effects (PVEs). In this work, we evaluated the impact of three partial volume correction (PVC) techniques - the Meltzer, the modified Müller-Gärtner, and the Region-Based Voxel-Wise - on correlations between region-matched in vivo [C-11]PiB standardized uptake value ratios (SUVRs) and postmortem measures of Aß pathology in a unique cohort of nine subjects. Postmortem Aß pathology was assessed histologically as percent area coverage of 6-CN-PiB positive and Aß immunoreactive (4G8 antibody) deposits. The application of all three PVC techniques resulted in minimally reduced PET-to-postmortem correlations relative to no PVC. However, correlations to both 6-CN-PiB and 4G8 percent area across all PVC techniques and no PVC were statistically significant at p < 0.01, suggesting that PVC is of minimal importance in understanding the relationship between Aß PET and neuropathologically assessed Aß. Thus, the utility of PVC in Aß PET imaging should continue to be examined on an application-specific basis.

Image-Based 2D Re-Projection for Attenuation Substitution in PET Neuroimaging.

PURPOSE: In dual modality positron emission tomography (PET)/magnetic resonance imaging (MRI), attenuation correction (AC) methods are continually improving. Although a new AC can sometimes be generated from existing MR data, its application requires a new reconstruction. We evaluate an approximate 2D projection method that allows offline image-based reprocessing. PROCEDURE: 2-Deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) brain scans were acquired (Siemens HR+) for six subjects. Attenuation data were obtained using the scanner's transmission source (SAC). Additional scanning was performed on a Siemens mMR including production of a Dixon-based MR AC (MRAC). The MRAC was imported to the HR+ and the PET data were reconstructed twice: once using native SAC (ground truth); once using the imported MRAC (imperfect AC). The re-projection method was implemented as follows. The MRAC PET was forward projected to approximately reproduce attenuation-corrected sinograms. The SAC and MRAC images were forward projected and converted to attenuation-correction factors (ACFs). The MRAC ACFs were removed from the MRAC PET sinograms by division; the SAC ACFs were applied by multiplication. The regenerated sinograms were reconstructed by filtered back projection to produce images (SUBAC PET) in which SAC has been substituted for MRAC. Ideally SUBAC PET should match SAC PET. Via coregistered T1 images, FreeSurfer (FS; MGH, Boston) was used to define a set of cortical gray matter regions of interest. Regional activity concentrations were extracted for SAC PET, MRAC PET, and SUBAC PET. RESULTS: SUBAC PET showed substantially smaller root mean square error than MRAC PET with averaged values of 1.5 % versus 8.1 %. CONCLUSIONS: Re-projection is a viable image-based method for the application of an alternate attenuation correction in neuroimaging.

What Behavioral and Psychological Symptoms of Dementia Affect Caregiver Burnout?

OBJECTIVES: Patients' irritability and aggression have been linked to caregiver depression, but the behaviors that most burden caregivers are not yet definitively identified. This study examines the connection between behavioral and psychological symptoms of dementia (BPSD) and the burnout of caregivers caring for home-dwelling elders with dementia symptoms in Japan. METHODS: 80 Japanese rural and urban family caregivers completed detailed questionnaires about their experiences in caring for demented family members. We statistically analyzed the results for correlations between types of dementia, Pines Burnout, and Caregiver Distress. RESULTS: BPSD symptom severity significantly correlated with caregiver distress. The dementia symptoms most strongly correlated with caregiver burnout were: aggression, irritability, abnormal motor behavior, and hallucinations. CONCLUSIONS: Among the commonest symptoms, apathy, anxiety, and depression did not seriously aggravate caregiver burnout. Caregivers displayed higher burnout facing agitation/aggression, irritability, aberrant motor behavior, and hallucinations. Caregivers' reported distress was surprisingly dissimilar to their burnout scores; patients' delusions and anxiety led to higher distress reporting but not to burnout. CLINICAL IMPLICATIONS: Advance diagnosis of BPSD symptoms should be helpful to support nurses and caregivers of dementia patients. Particular support should be considered for caregivers and nurses of patients expressing aggression, irritability, abnormal motor behavior, and hallucination.

Bereavement life review improves spiritual well-being and ameliorates depression among American caregivers.

OBJECTIVE: The aim of our study was to investigate the utility of bereavement life review (BLR) to elevate spiritual well-being and alleviate depression among Hawaiian-American caregivers, and to identify changes that occur when caring for their loved ones up to the time of death. METHOD: Bereavement life review therapy was provided for 20 bereaved Hawaiian Americans. In the first session, subjects reviewed memories of the deceased with a therapist, who recorded their narratives and collected them into a personal history book. During the second session, subjects discussed the contents of this book. Caregivers completed the Functional Assessment Chronic Illness Therapy-Spiritual (FACIT-Sp) questionnaire and the Beck Depression Inventory, Second Edition (BDI-II) pre- and post-intervention. Subjects also described changes in their views that occurred during the caring process in response to questions. RESULTS: FACIT-Sp scores significantly increased from 34.1 ± 9.63 to 36.3 ± 10.6 (t = -2.6, p < 0.05, and BDI scores significantly decreased from 11.7 ± 7.7 to 8.8 ± 7.0 (t = 2.27, p < 0.05). Five categories were chosen from the narratives on changes that had occurred during caregiving and due to the deceased death: "Learning from practical caring experience," "Positive understanding of patients," "Recognition of appreciation," "Self-change or growth," and "Obtaining a philosophy." SIGNIFICANCE OF RESULTS: These findings show the applicability of bereavement life review therapy for Hawaiian families, including efficacy for spiritual well-being and depression. The comments of the caregivers also indicate the potential of the therapy for identifying the positive aspects of caring for terminally ill patients.