Introduction
The phenomenon of grief, as a mental experience, can be influenced by factors such as the loss of loved ones, loss of independence, illness, relationship breakups, and retirement, which can be considered as antecedents of grief. These antecedents can lead to anxiety and depression and loss of emotional and financial support, which are considered as the consequences of grief. Although no study has directly addresses the antecedents and consequences of grief in the elderly, some findings regarding the antecedents and consequences of grief can be extracted from the literature. In most of the studies, the death of a spouse or loved ones was identified as an antecedent of grief, and feelings of loneliness, guilt, anxiety, loss of emotional intimacy, inability to pay bills, financial dependence on relatives, bot having companionship, social isolation, loss of social support, loss of emotional support, self-improvement, learning new skills, finding meaning in life, volunteering in schools and charity organizations, and creating new activities have been reported as consequences of grief. Since grief is related to a cultural context and the effort to comprehensively identify this phenomenon is strongly influenced by the socio-cultural factors, qualitative studies are needed. Therefore, this is the first qualitative study that examines the antecedents and consequences of grief among the elderly residing in Tehran, Iran.

Methods & Materials
This qualitative study was conducted using the conventional content analysis method. The participants were 16 older men and women, aged 60-85, who were selected from among the residents of Tehran dwelling in parks or visiting two elderly day care centers (Yas and Arman Pouyan), using a purposive sampling method. They underwent semi-structured interviews. The interviews began with the question: “Have you ever lost someone or something important to you?” Followed by questions such as “How did it happen?” and “How did you feel after this event?”. The interview continued with probing questions such as “Could you please explain this more?” and “Please describe one of them.” After the initial responses, statements and questions were used to delve deeper into the participants’ experiences. The interviews lasted for 60-90 minutes. We used Lindgeren et al. (2020)’s method for qualitative data analysis. Additionally, to ensure the accuracy and reliability of the data, Guba and Lincoln’s criteria, including credibility, dependability, transferability, and confirmability, were used.

Results
In this study, four categories of grief antecedents were identified: Loss of loved ones, loss of health, retirement, and regret for a life not lived. Also, three categories of grief consequences were extracted: Resilience, health-related problems, and socio-economic problems (Table 1).



Antecedents
- Loss of loved ones: The experience of losing family members and friends, divorce, and the migration of loved ones during old age causes the person to miss out on deep and lasting emotional interactions and to experience unpleasant emotions.
- Loss of health: The decline in physical health (gradual decrease in strength and energy) and mental health due to life pressures and difficulties are important antecedents of grief in the elderly.
- Retirement: The end of a continuous period of employment can have a negative impact on an individual. It can affect the occupational identity of the people, especially those whose jobs hold great importance or social status. Some older people may lose their sense of self-worth with retirement and find themselves caught in a repetitive, purposeless, and unchanging life. Additionally, they may lose their most important social interactions and may have a feeling of being invisible.
- Regret for a life not lived: The pain of missed opportunities in life and the loss of youth are common unpleasant feelings that people may experience in old age. 

Consequences
- Resilience: It refers to the ability to cope with difficult situations and be strong. The person gains a new perspective on oneself, takes on new roles and learning new skills necessary for changing life, engages in new positive activities, and pray more for adapting to losses.
- Health-related problems: Grief can have psychological and physical consequences, such as feelings of sadness, depression, and the experience of physical problems or disorders in older adults.
- Socio-economic problems: The experience of grief leads to the loss of meaningful relationships. Sometimes, the individual may not be respected by society. The older women who have lost their husbands are often unable to pay bills, feel like a burden to family, and worry about their living costs.

Conclusion
The antecedents of grief in Iranian older adults are loss of loved ones, loss of health, retirement, and regret for a life not lived. Its consequences are resilience, health-related problems, and socio-economic problems. Exploring the experiences of older adults suffering from grief and recognizing its antecedents and consequences can help better understand this phenomenon and provide the necessary help for them. Timely diagnosis of these individuals leads to developing effective interventions and improving their living conditions and health. The results of this study can be helpful for professionals in the elderly care centers, including counselors, psychologists, psychiatrists, social workers, and geriatric nurses.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Health and Rehabilitation Sciences, Tehran, Iran (Code: IR.USWR.REC.1400.258). 

Funding
This article was extracted from the doctoral thesis of Roya Marsa at the Department of Counseling, Faculty of Behavioral Sciences, University of Social Health and Rehabilitation Sciences. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors' contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the elderly daycare centers of Yas and Arman Pouya and all seniors who participated in this research for their cooperation.

References

1. WHO. Ageing and health. Geneva: WHO; 2024. [Link]
2. Bonanno GA, Wortman CB, Nesse RM. Prospective patterns of resilience and maladjustment during widowhood. Psychology and Aging. 2004; 19(2):260-71. [DOI:10.1037/0882-7974.19.2.260] [PMID]
3. Scrutton S. Bereavement and grief: Supporting older people through loss. Florida: CRC Press; 1995. [Link]
4. Smaeili M, Ghaseminia F. [Factors facilitating the meaning crisis in the elderly: A qualitative study (Persian)]. Journal of Caspian Health and Aging. 2018; 3(1):43-50. [DOI:10.22088/cjhaa.3.1.43]
5. Cowles KV, Rodgers BL. The concept of grief: A foundation for nursing research and practice. Research in Nursing & Health. 1991; 14(2):119-27. [DOI:10.1002/nur.4770140206] [PMID]
6. Corr CA. Enhancing the concept of disenfranchised grief. OMEGA - Journal of Death and Dying. 1999; 38(1):1-20. [DOI:10.2190/LD26-42A6-1EAV-3MDN]
7. Boland R, Verdin ML,  Ruiz P. Sadock’s synopsis of psychiatry: Behavioral sciences [F. Rezaee, Hodavandkhani F, Jamshidian P, Esfandzad AH, Persian trans.]. Tehran: Arjmand pub; 2015. [Link]
8. Bailley SE, Dunham K, Kral MJ. Factor structure of the Grief Experience Questionnaire (GEQ). Death Studies. 2000; 24(8):721-38. [DOI:10.1080/074811800750036596] [PMID]
9. Corr CA. Bereavement, grief, and mourning in death-related literature for children. OMEGA - Journal of Death and Dying. 2004; 48(4):337-63. [DOI:10.2190/0RUK-J18N-9400-BHAV]
10. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. International Journal of Surgery. 2014; 12(12):1495-9. [DOI:10.1016/j.ijsu.2014.07.013] [PMID]
11. Katz S, Florian V. A comprehensive theoretical model of psychological reaction to loss. International Journal of Psychiatry in Medicine. 1986-1987; 16(4):325-45. [DOI:10.2190/YGRX-AA2B-XUY5-F7DL] [PMID]
12. Rafii M, Skandari H, Borjali A, Farokhi N. [Investigation on experienced losses in the life story of young people living in Tehran: A phenomenological study (Persian)]. Counseling Culture and Psycotherapy. 2019; 10(37):63-98. [Link]
13. Lekalakala-Mokgele E. Death and dying: Elderly persons’ experiences of grief over the loss of family members. South African Family Practice. 2018; 60(5):151-4. [DOI:10.4102/safp.v60i5.4924]
14. Bourgeois-Guérin V, Millette V, Lachance J. Communication and silence surrounding the experience of bereavement of older adults living in seniors’ residences. Journal of Humanistic Psychology. 2021. [DOI:10.1177/0022167821995352]
15. Manyedi ME, Koen M, Greeff M. Experiences of widowhood and beliefs about the mourning process of the Batswana people. Health SA Gesondheid. 2003; 8(4):69-87. [DOI:10.4102/hsag.v8i4.146]
16. Holm AL, Severinsson E, Berland AK. The meaning of bereavement following spousal loss: A qualitative study of the experiences of older adults. Sage Open. 2019; 9(4). [DOI:10.1177/2158244019894273]
17. Motsoeneng M, Modise MA. Grieving widows’ lived experiences in a rural South African setting. Journal of Psychology in Africa. 2020; 30(3):264-7. [DOI:10.1080/14330237.2020.1767935]
18. Costello J, Kendrick K. Grief and older people: The making or breaking of emotional bonds following partner loss in later life. Journal of Advanced Nursing. 2000; 32(6):1374-82. [DOI:10.1046/j.1365-2648.2000.01625.x] [PMID]
19. Malkinson R, Bar-Tur L. Long term bereavement processes of older parents: The three phases of grief. OMEGA-Journal of Death and Dying. 2005; 50(2):103-29. [DOI:10.2190/W346-UP8T-RER6-BBD1]
20. Wilson SC, Supiano KP. Experiences of veterans’ widows following conjugal bereavement: A qualitative analysis. Journal of Women & Aging. 2011; 23(1):77-93. [DOI:10.1080/08952841.2011.540479] [PMID]
21. Rodgers LS. Meaning of bereavement among older African American widows. Geriatric Nursing. 2004; 25(1):10-6. [DOI:10.1016/j.gerinurse.2003.11.012] [PMID]
22. Marsa R, Bahmani B, Ebadi A, Azkhosh M, Delbari A. [Grief in the elderly: A concept analysis (Persian)]. Iranian Journal of Ageing. 2024; 19 (3):362-81. [DOI:10.32598/sija.2024.2390.4]
23. Eisenbruch M. Cross-cultural aspects of bereavement. I: A conceptual framework for comparative analysis. Culture, Medicine and Psychiatry . 1984; 8:283–309. [Link]
24. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004; 24(2):105-12. [DOI:10.1016/j.nedt.2003.10.001] [PMID]
25. Bakhtiyari F, Foroughan M, Fakhrzadeh H, Nazari N, Najafi B, Alizadeh M, et al. [Validation of the persian version of Abbreviated Mental Test (AMT) in elderly residents of Kahrizak charity foundation (Persian)]. Iranian Journal of Diabetes and Metabolism. 2014; 13(6):487-94. [Link]
26. Lindgren B-M, Lundman B, Graneheim UH. Abstraction and interpretation during the qualitative content analysis process. International Journal of Nursing Studies. 2020; 108:103632. [DOI:10.1016/j.ijnurstu.2020.103632] [PMID]
27. Naef R, Ward R, Mahrer-Imhof R, Grande G. Characteristics of the bereavement experience of older persons after spousal loss: An integrative review. International Journal of Nursing Studies. 2013; 50(8):1108-21. [DOI:10.1016/j.ijnurstu.2012.11.026] [PMID]
28. Safa A, Adib-Hajbaghery M, Rezaei M, Araban M. The meaning of losing a child in older adults: A qualitative study. BMC Geriatrics. 2021; 21(1):652. [DOI:10.1186/s12877-021-02609-9] [PMID]
29. Tourjeman K, Doron I, Cohen M. Losing a grandchild: The mourning experience of grandparents in Israel. Death studies. 2015; 39(8):491-9. [DOI:10.1080/07481187.2014.970298] [PMID]
30. Oskui P, Farahbakhsh K, Moradi O. [Persistence in mourning: A phenomenological study of the experience of abnormal mourning after the death of a family member (Persian)]. Knowledge & Research in Applied Psychology. 2022; 22(4):28-42. [Link]
31. Cain BS. Divorce among elderly women: A growing social phenomenon. Social Casework. 1988; 69(9):563-8. [DOI:10.1177/104438948806900905]
32. Pilkington FB. Grieving a loss: The lived experience for elders residing in an institution. Nursing Science Quarterly. 2005; 18(3):233-42. [DOI:10.1177/0894318405277525] [PMID]
33. Zarghami H, Mahmoudian H. [Children s out-migration and loneliness feeling in rural older parents (Persian)]. Quarterly Journal of Health Psychlogy. 2017; 5(19):103-22. [Link]
34. Dark L, Balandin S, Clemson L. Communicating about loss: Experiences of older Australian adults with cerebral palsy and complex communication needs. Communication Disorders Quarterly. 2011; 32(3):176-89. [DOI:10.1177/1525740109353936]
35. Bedaso TS, Han B. Work after retirement affects elderly mental health and behaviors in Addis Ababa. Health Psychology Open. 2021; 8(1):2055102921996189. [DOI:10.1177/2055102921996189] [PMID]
36. Midanik LT, Soghikian K, Ransom LJ, Tekawa IS. The effect of retirement on mental health and health behaviors: The Kaiser Permanente Retirement Study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 1995; 50(1):S59-61. [DOI:10.1093/geronb/50B.1.S59] [PMID]
37. Abdulkadir A, Rasaq AO, Gafar I. Psychological effects of retirement of retirees: Implications for counselling. Cypriot Journal of Educational Sciences. 2018; 13(1):15-22. [Link]
38. Ng SM, Leng L, Wang Q. Active interest mentorship for soon-to-retire people: A self-sustaining retirement preparation program. Journal of Applied Gerontology. 2019; 38(3):344-64.[DOI:10.1177/0733464816687448] [PMID]
39. Alavi Z, Alipour F, Rafiey H. [Psychosocial issues of retirement in Iran: A qualitative study (Persian)]. Iranian Journal of Ageing. 2021; 15(4):396-409. [DOI:10.32598/sija.15.4.2879.1]
40. Holland JM, Thompson KL, Rozalski V, Lichtenthal WG. Bereavement-related regret trajectories among widowed older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2014; 69(1):40-7. [DOI:10.1093/geronb/gbt050] [PMID]
41. Newall NE, Chipperfield JG, Daniels LM, Hladkyj S, Perry RP. Regret in later life: Exploring relationships between regret frequency, secondary interpretive control beliefs, and health in older individuals. International Journal of Aging & Human Development. 2009; 68(4):261-88. [DOI:10.2190/AG.68.4.a] [PMID]
42. Zhang H, Shan W, Jiang A. The meaning of life and health experience for the Chinese elderly with chronic illness: A qualitative study from positive health philosophy. International Journal of Nursing Practice. 2014; 20(5):530-9. [DOI:10.1111/ijn.12198] [PMID]
43. Stern K, Williams GM, Prados M. Grief reactions in later life. American Journal of Psychiatry. 1951; 108(4):289-94. [DOI:10.1176/ajp.108.4.289] [PMID]
44. Sadeghmoghadam L, Foroughan M, Mohammadi Shahboulaghi F, Ahmadi F, Farhadi A, Nazari S, et al. Lost dignity: Predominant experience of old age by the elderly. Journal of Research and Health. 2019; 9(5):381-6. [DOI:10.29252/jrh.9.5.381]
45. Fry P. Spousal loss in late life: A 1-year follow-up of perceived changes in life meaning and psychosocial functioning following bereavement. Journal of Personal & Interpersonal Loss. 1998; 3(4):369-91. [DOI:10.1080/10811449808409711]