Suicide in Late Life
Article Outline
- Abstract
- Background
- Risk Factors for Suicide
- Identification and Assessment of Older Adults at Risk
- Depression
- Summing Up: Key Risk Areas for Assessment and the Plan of Care
- Resources
- References
- Biography
- Copyright
Late-life suicide is a persistent threat and a reality from which no one emerges unscathed. Family members and significant others feel guilty and inconsequential. Assisted living residence staff is demoralized. The residents feel frightened and confused. Although constituting only 13% of the population in the United States, older adults accounted for 18% of suicide deaths in the later 1990s. There is at present a national strategy for suicide prevention among youth under 19 years and adults aged 65 years and older. The assisted living community that fosters independence and self-determination can be, simultaneously, an environment in which the warning signs of suicidal ideation and self-destruction can be missed. This article discusses risk factors of suicide, the association of depression with suicide, basic screening tools, and supportive actions.
Ethel Mitty
Sandi Flores
Although older adults constitute at present only 13% of the U.S. population, adults aged 65 years or older accounted for 18% of suicide deaths in 1998.1 Among all age groups, the suicide rate is highest among white males 75 years and older. Given the graying of America, it is predicted that the suicide rate among those older than 65 years will reach 35% by 2030. A national strategy for suicide prevention holds that prevention of suicide among older adults is a top priority.2 Given the assisted living (AL) philosophy that promotes independence and self-determination, together with the association of depression and multiple medical conditions common among AL residents, the failure to recognize individuals at risk for late-life suicide is realistic and supported by the facts. This article provides information about the risk factors for suicide, describes the basics of screening, and suggests crisis intervention steps. It includes definitions of some terms related to suicidal ideation and behavior, theories of suicide, a profile of the older adult at risk, and some preventative measures. Antidepressant therapy is discussed. The act of rational suicide, a decision made by an individual with full mental competence and with presumably sufficient reason to end his or her life (sometimes with assistance from others—euthanasia and/or physician-assisted suicide [PAS]) is not discussed in this article.
Background
Suicidal ideation can be active thoughts of taking one's own life, or it can be passive, that is, feeling hopeless, that life is not worth living, wishing for death. Coping with multiple losses and feeling that life is no longer meaningful in the face of covert suggestions that suicide by an older person is not as bad as a younger person committing suicide is somewhat like adding salt to the proverbial wound. Hence, the expression: old age is not for sissies.
The oldest-old (i.e., >80 years) are more likely to describe having or expressing suicidal ideation in comparison to younger older adults (i.e., 65–80 years) and to younger adults.3 Not surprisingly, suicide is associated with depression (87% of cases), psychiatric illness, dementia, and taking tranquilizer or anxiolytic medications.3 Epidemiological studies indicate that 20% of older adults who committed suicide saw their primary care provider in the previous 24 hours; 41% in the previous week; and 75% in the previous month.4 Suicidal ideation is associated with depression and anxiety but less likely associated with alcohol use.5 In comparison, suicidal ideation is least associated with African Americans and more associated with Asians.5 There is no reported study to date about increased risk of suicide with a diagnosis of dementia or delirium. Overall, suffering with 3 or more significant illnesses presents an increased risk of suicide.6
Attempted suicide is less common among older adults compared with younger adults and adolescents.3 Older adult men and women are more likely to use a gun to commit suicide than younger adults.7 What are the AL state regulations or facility policies with regard to gun ownership by an AL resident?
Women attempt suicide much less frequently than men and are less successful at it. Given that women have multiple roles (and multitask), they likely have a bigger repertoire and greater adaptive flexibility compared with men. Research data indicate that the more children a woman has had, the less likely the risk of suicide.8 Nevertheless, suicide attempts among older adults are more successfully completed, resulting in death. This is attributed to reduced likelihood of rescue because of having given fewer “hints” as well as social isolation,5 reduced physiological reserve, and a greater resolve to die; therefore the individual takes the time to have a good plan and use more lethal means.
The notion of “passive suicide” involves covert or overt actions that can shorten life, such as refusing food or fluid, refusing to take medications or follow a treatment regimen, and taking deliberate actions that could exacerbate a chronic condition (e.g., a person with chronic obstructive pulmonary disease persisting in smoking).8
Nurses engaged in psychiatric or mental health nursing view suicide in terms of primary, secondary, and tertiary prevention.8 Primary prevention (or just “prevention”) is the dissemination of information and public education about suicide risk factors, myths, and resources. Secondary prevention (or “intervention”) is implemented when suicide risk or tendencies are evident (via assessment) and referral for appropriate care is warranted. Tertiary prevention (or “postvention”) are measures to help those who have been affected by an attempted or successful suicide, for example, AL residents in the community. There are also interventions designed to help the older adult who made an unsuccessful suicide attempt and who is no longer suicidal but needs various kinds of ongoing support.
Myths about Suicide
One of the most pervasive myths about suicide is that it happens without warning.8 This myth tends to be supported by two other myths, both of which can place an older adult at peril: the first, that it will be obvious when a person is contemplating suicide; the second, that a person who talks about it is not serious about it. It is a myth, also, that talking about suicide either encourages it or, at the very least, satisfies a narcissistic need to manipulate others.
Theories of Suicide
There are 3 conceptual models of suicide, each of which is a framework for understanding suicide risk of an older adult: sociological, biological, and psychological.8 Sociological theories draw on population or cohort group data and examine economic, geographic (e.g., urban vs. rural), network, and cultural influences on the acceptance and likelihood of suicide. Biological theories examine evidence that might associate a particular illness or physical condition, medication, or risk for developing clinical depression with suicidal ideation or attempt.
Psychological theories concentrate on mental health history, personality or character traits, coping mechanisms, and the common threads that appear to be present in many individuals who are at risk for suicide. Holkup and colleagues8 provide an encompassing review of these aspects with a considerable body of research evidence in support of the theoretical framework. Personality or character traits generally persist and are stable throughout the lifetime. Studies conducted during the 1990s reported that suicide is associated with the need to be in control and to act autonomously, with pride, rigidity, an openness to experience, pessimism, obsessiveness, hypochondria, and proneness to feelings of despair as the inevitability and evidence of aging can no longer be denied.9
The mental health history of the older adult and, in reflection and recall, the role models and events that shaped this individual as a young person and an adult, could have shaped his or her ways of knowing and adapting to the world. Depression is almost always associated with loss of some kind—physical ability, appearance, social role, death of others, domicile, financial security. Older adults suffering with clinical depression feel as if their world has narrowed; their choices are fewer; their interests and preferences are no longer attainable. They are feeling overwhelming sadness. Depressive symptoms, perceived poor health status, impaired quality of sleep, and absence of someone to confide in are additional predictors of late-life suicide.10 Nurses need to know how to administer a depression assessment instrument and interpret the findings. These data contribute to an assessment of suicide risk.
Common themes of suicide include the pressing need to solve or end a situation (including intolerable mental pain), feeling hopeless, and feeling unable and without resources to make things better. The more that is known about the older adult's personal strengths and capacities, history of coping with stress, and ability for insight into his or her problems, the greater the likelihood of an effective life-saving (and life-altering) plan.
Risk Factors for Suicide
Risk factors for late-life suicide are categorized as demographic, mental health, physical well-being, and social functioning.3 Demographic factors were noted earlier. However, there is some evidence that a couple living together but unmarried sets up a potential for suicide in both parties. Garand and colleagues,3 in their extensive review of the literature, reported that older adults at risk for or having been successful in a suicide act, suffer(ed) from major depression or some kind of affective illness. Psychosis, personality disorders, and delusional disorders were not associated with late-life suicide to any great extent, nor was substance and alcohol abuse (compared with younger adult suicides).
The data are inconclusive with regard to the influence of physical illness and functional impairment on suicide risk. Clearly, there is a burden of illness, but its action as an independent risk factor has not been established. Affective or mood disorders are more likely to influence the burden of illness and propensity to suicide than physical well-being and functionality. Social isolation, lack of a network or social supports, and loneliness are implicated in suicide risk and successful suicide.11 Family discord rather than financial problems is predictive of older adult suicide. A new resident in an AL community who feels that the decision was made without his or her full agreement or who is feeling abandoned by the family is an older adult at risk.
Warning signs of suicide risk are categorized as verbal, behavioral, contextual, or situational and as symptom clusters.8 Verbalization about wanting to end it all or expressions of despair are easier to identify than behavioral clues. These can include giving away possessions and money, hoarding medications, poor hygiene, disinterest in food or eating, and diminished well-being. Relocation, whether agreed to and welcomed or not; loss of a spouse, partner, close friend, or child; and being diagnosed with a rapidly progressing terminal illness are situationally invoked stressors that can have profound repercussions. A resident who at one time was social and talkative but is now quiet and self-isolating, is a resident who needs attention.
The symptoms (or “syndromatic” clues) related to suicide risk are particularly important. Many older adults tend not to seek psychological or mental health services because they think it is a sign of weakness, a stigma. Depression is often masked by somatization—an excessive expression of physical complaints. Drawing on significant research by others, Holkup and colleagues8 described these syndromatic clues as depression with an overlay of anxiety; dependency accompanied with guilt; rigidity alternating with impulsivity; and a seemingly complete recovery from severe depression almost overnight.
A variety of studies conducted in the 1990s identified internal and external “protective factors” that are part of an older adult's armamentarium as he or she ages.8 Internal factors are resources an individual has drawn upon throughout the life span and that have proven efficacy in times of stress as well as time of peacefulness and growth. These include the ability to analyze, understand, and benefit from experience; use knowledge; accept help; feel that there is purpose and meaningfulness in one's life; and know that one has mastered adversity. The community in which the older adult resides is the repository of external resources. This includes the AL residence itself as well as local religious institutions or affiliations, a supportive and thoughtful network (family, friends), and a health care provider who is available and caring.
Identification and Assessment of Older Adults at Risk
On admission, and at least annually, the resident should be assessed (i.e., screened) if for suicide risk. For the new admission, questions should be asked about individuals' current concerns, things that make them feel stressed, recent losses, and feelings and changes that might suggest depression (e.g., weight and appetite changes, sleep pattern changes, transient or vague physical complaints). Listen to the language of feeling helpless or hopeless, that life has no meaning any more. Similar questions can be asked annually.
Similar to the 1-item depression assessment question—“Are you feeling sad?”— older adults who say they have “lost interest in things” or who just seem down can be asked specific questions: “Have you been feeling so sad lately that you were thinking about death or dying?” “Have you had thoughts that life is not worth living?” “Have you been thinking about harming yourself?”3 (p. 64). Rather than assume in advance that residents will be annoyed or humiliated by the question(s), asking the question might finally allow the resident to express the pain and hopelessness they are feeling. An additional question, “How would you kill yourself if you decided to do it?” can provide some insight into whether it is best to hospitalize the person or institute one-on-one companionship and observation.
The SLAP interview protocol can be used when a person has expressed suicidal ideation.12 The focus of this interview is to try to figure out the lethality of the person's plan; has the person really thought through what he or she is going to do?
S = the specificity of the plan with regard to time, place, other details. Which plan speaks to increased risk of a successful suicide?
L = the lethality of means. Which means are least/most likely to be harmful?
A = availability of the means. Which means is most accessible given the environment?
P = what is the proximity to rescuers or foilers? Which plan is most likely to be obstructed?
Depression
Depression is an extremely complex phenomenon, as is suicidal ideation or attempt. The fact that there is sadness because of a profound loss or illness, or even the statement “I don't want to live” does not automatically have to generate one-on-one observation, medication, or hospitalization. Depression is a mood disturbance that ranges from mild to extreme, of short or long duration. The diagnosis of depression is based on specific criteria described in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Screening tools can identify residents at risk because they have symptoms that suggest clinical depression, but the context of the findings need to be evaluated (e.g., Are there recent losses? Is there a life-altering diagnosis?). The treatment of depression focuses, in part, on rapid reduction of suicide risk.13
Depression Assessment
The 30-item Geriatric Depression Scale (GDS) has been used extensively with older adults and is considered one of the best screening tools for older adults who are healthy or ill, mild to moderately cognitively impaired, and in community, acute, and long-term care settings.14 The 15-item short form GDS is just as effective and differentiates depressed from nondepressed older adults. All items require a yes or no response. Although the GDS is not a tool to assess for suicidal risk, any score indicating significant depression should require an intensive risk assessment for suicide.
The 21-item Beck Depression Inventory (BDI) posited a set of 3 negative conditions associated with major depression: thoughts about the world, the self, and the future.15 The BDI, revised twice, contains a specific item about suicidal thoughts or wishes: “(1) I don't have thoughts of killing myself; (2) I have thoughts about killing myself but would not carry them out; (3) I would like to kill myself; (4) I would kill myself if I had the chance” (http://www.ibogaine.desk.nl/graphics/363961c_23.pdf). Unpublished data indicate that those who scored 2 or higher on this item were more likely to commit suicide than those who scored less than 2. Findings like these are not to be taken at face value as absolutely predictive of high suicide risk. Rather, as with the GDS, they point to the necessity for skilled clinicians to intervene.
As with all self-report inventories and questionnaires, the GDS and BDI scores can be high or low because they are dependent on the person completing the survey or assessment. The presence of pain or fatigue or confusion at the time the individual completes the instrument can artificially distort the score.
Alzheimer's Disease/Dementias, Depression, and Suicide Risk
The onset of loss of cognitive competence (or “abilities”) is frequently associated with a concomitant awareness of this deficit, this inevitable loss. It is not at all surprising, then, that depression would be a comorbidity. Yet apathy in the face of dementia is a different phenomenon; it implies limited awareness of the cognitive and functional changes. The risk of suicide for those with mild-moderate dementia must be considered if there is evidence of significant depression. Even in the absence of clinical depression, patients' awareness of their cognitive and functional changes coupled with their retained ability to do something about it (characterized as an absence of apathy) constitute a major risk for a suicidal act.16
Antidepressant Medication Therapy
Recent changes in the Centers for Medicare and Medicaid Services (CMS) guidelines to nursing home surveyors about the use of antidepressants in nursing home residents prompted an outpouring of concerned statements that depression is underdiagnosed and undertreated, concern about abrupt cessation or tapering of antidepressant medications, lack of knowledge about the standard of care for antidepressant use, and the potential of a survey deficiency related to the number of residents with symptoms of depression but for whom no antidepressant medication was prescribed (nor any mental health intervention available, let alone ordered). AL quality of care should not be immune from these concerns.
It is suggested that nonpharmacologic approaches should be tried, albeit for a short period, before starting medication therapy. These approaches can be effective for older adults with intermittent symptoms of depression. However, antidepressant therapy might be needed long term for some older adults who can only be comfortable at the same dosage that gained a therapeutic response to their symptoms. Hence, tapering must be done cautiously and with reference to the original need or justification for the medication.
Summing Up: Key Risk Areas for Assessment and the Plan of Care
The Nurses' Global Assessment for Suicide Risk (NGASR) might be helpful in collecting and assessing information about an older adult's suicidal ideation and suicide risk.17 It has not been validated using controlled research design, however. Key features to look for that might require further assessment include the following:
The notion of “selective prevention” is instituted before a suicidal crisis. As part of intake and ongoing assessment—including conversation with the older adult—this approach reduces or eliminates the known factors that place the individual at risk. In the presence of a realistic plan and available means to accomplish a lethal suicide, hospitalization is necessary. However, it should not be recommended to avoid suicide; there is no guarantee of that. Rather, hospitalization is recommended because immediate treatment of the underlying psychological issues is more available. In the absence of immediate means or a plan, a support system should be activated that calls on available family support, such as being present or by paying for one-on-one companionship and observation. It bears mention that the presence of a family member might not be salutary.
In the AL community—typically, one nurse and many residents—attention is given to the obvious physical threats to well-being. Psychosocial needs are not attended to; suicidal ideation may go unnoticed. Although some residents may make an overt significant attempt to kill themselves, others are more “quiet”; they may simply stop eating, refuse treatment, underreport not feeling well, and so on. These self-destructive behaviors in nursing home residents have been associated with residents' feeling that they have nothing to look forward to, nowhere to go, and no one to be with. States are increasing staff training requirements; however, the focus tends to be on activities of daily living, medication assistance, and other supportive skills. Staff are likely to be unaware of distinct warning signs, such as a resident giving away his or her belongings or a resident expressing a sense of relief or resolution. Medication aides know how to assist with or administer an antidepressant medication correctly but lack knowledge about the therapeutic range of the drug and think that a resident is “safe” because he or she has been on the medication for a few days.
Although the resident has the right to refuse antidepressant medication (or any drug or treatment), even in the presence of significant clinical depression, there is no sense of urgency on the resident's behalf; in many cases, staff fail to notify the physician, RN, or nurse practitioner. Denial of a diagnosis of depression is not uncommon; it may be associated with shame or is not given the attention it warrants: “He'll get over it; this is around the time his wife died.” The privacy so valued in ALs by all the stakeholders is the very thing that “protects” the resident from being observed, thus preventing or delaying the diagnosis from being made and increasing isolation.
“Strange, when you come to think of it, that of all the countless folks who have lived before our time on this planet not one is known in history as having died of laughter.” Sir Max Beerbohm (1872–1956).
Resources
References
- Deaths: final data for 2001. Nat Vital Stat Rep. 2003;52:1–115
- . National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: U.S. Department of Health and Human Services; 1999;
- Suicide in older adults: nursing assessment of suicide risk. Issues Ment Health Nurs. 2006;27:355–370Downloaded at Mt. Sinai School of Medicine, Levy Library. Available at http://dx.doi.org/10.1080/01612840600569633. Cited Jan. 10, 2008
- . Facts about suicide on older adults. www.apa.org/ppo/issues/oldersuicidefact.htmlCited Jan. 10, 2008
- Suicidal and death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Am J Geriatr Psychiatry. 2002;10:417–427
- . The effect of hospitalization with medical illness on the suicide risk in the oldest-old: a population-based register study. J Am Geriatr Soc. 2005;53:771–776
- Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry. 2002;10:407–416
- . Evidence-based protocol (Elderly suicide—secondary prevention). J Gerontol Nurs. 2003;6–17June
- . Suicide. In: Capezutti EA, Siegler EL, Mezey MD editor. The encyclopedia of elder care. 2nd ed. New York: Springer Publishing Company; 2008;p. 755–758
- Risk factors for late-life suicide: A prospective community-based study. Am J Geriatr Psychiatry. 2002;10:398–406
- . Predictors of suicide in the older elderly. Gerontologist. 2003;49:398–406
- SLAP. Available at www.ssw.u.mich.edu/simulation/rubo-asssessmentScales.pdf. Cited Jan. 29, 2008.
- . Depression. In: Capezutti L, Zwicker D, Mezey M, et al. editor. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York: Springer Publishing Company; 2008;p. 57–82
- . Try This: The Geriatric Depression Scale (GDS). 2007;# 4. Available at www.hartfordign.org. Cited Jan. 29, 2008
- . www.http://en.wikipedia.org/wiki/Beck_Depression_InventoryCited Jan. 22, 2008
- Letter to the editor. Am J Geriatr Psychiatry. 2002;10:484–485
- . The Nurses' Global Assessment of Suicide Risk (NGASR): developing a tool for clinical practice. J Psychiatr Ment Health Nurs. 2004;11:393–400
ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, and Consultant in Long Term Care at the Hartford Institute for Geriatric Nursing, College of Nursing, New York University.
SANDI FLORES, RN, C, was the founder of the American Assisted Living Nurses Association and is currently the education director of Community Education LLC (www.communityed.com).
PII: S0197-4572(08)00075-X
doi:10.1016/j.gerinurse.2008.02.009
© 2008 Mosby, Inc. All rights reserved.
