Grace Denny
Introduction
Contributing Factors
Despite much attention given to suicide in adolescents and young
adults, older adults actually have the highest rate of suicide in the US
compared to other age groups. This high rate of suicide comes despite
the fact that a majority of older adults who complete suicide
communicate a wish to die to a family member or health professional
in the year prior to their death. Biases towards the elderly may
contribute to a lack of identification of older adults at risk for suicide.
For example, some may expect older adults to think and talk about
dying so suicidal ideation is dismissed as typical of older adults and
not taken seriously (Worchel & Gearing, 2010). Additionally, suicide may be seen
as more acceptable in the elderly, “as peaceful terminations of long,
complete lives” (Cohler & Jenuwine, 1995, p. 201) and thus it is given less attention
than suicide in other age groups.
While are many risk factors that can contribute to suicide in older adults, it is
important to be aware of the significant contributing factors so that suicide risk can be
assessed and prevented. The model below is a model of the Interpersonal Theory of
Suicide applied to later life.
Some Facts:
•In 2012 the elderly (ages 65+) made up 13.75% of the population
and accounted for 16.37% of all suicides in the US
•Older adults have more completed suicides and fewer attempts than
other age groups. For all age groups the rate of completed suicide to
attempt is 1:100-200, for adults age 65+ the same ratio is 1:4.
•White men over age 85 are at the greatest risk for all race-gender-age
groups. Their suicide rate is 50.67 per 100,000. This is 2.5 times the
rate for men of all ages.
(American Association of Suicidology, 2014)
•Rates may be underestimated by 40% due to “silent suicides” such as
overdose, self-starvation or dehydration, and “accidents” (AAMFT, 2014).
(Van Orden & Conwell, 2011)
Adverse Childhood Experiences
Personality Characteristics
In one study those who completed suicide
or had serious suicide attempts had
elevated rates of adverse childhood
experiences (such as sexual abuse or high
parental control) compared to a control
group
High neuroticism
(Beautrais, 2002)
Low openness to experience (preference for the
routine and familiar, a constricted range of
intellectual interests, and blunted affective and
hedonic responses)
Introverted style with low development of
support networks
Difficulty accepting help, self-sufficient
Having role transitions out of sync with
one’s cohort may cause more psychological
distress
Mood Disorders, Depression
A majority of older adults who complete suicide have a current
psychiatric disorder. Depression plays a very large role in older adult
suicide. 54-87% of older adults who complete suicide were suffering
from major depression (Van Orden & Conwell, 2011). The next most common
psychiatric illness found in older adult suicide is bipolar I and II (Beautrais,
2002).
•The presence of some physical illnesses are linked with increased
risk of suicide in older adults, however researchers think that it is
more a result of depression resulting from the illness (de Souza Minayo & Cavalcante,
(Conwell, 2007; Cohler & Jenuwine, 1995)
Social Disconnectedness
The meaning of suicide may differ
according to age or cohort (i.e. a person
receiving the Alzheimer’s diagnosis now
versus 10 years ago may have a different
meaning based on new knowledge about
the disease)
Living alone
Men and women may experience aging
differently due to differences in career
trajectories and retirement, though this is
changing.
Low social support
Loss of a spouse
Loneliness
Mental Illness in Older Adult Suicide
No Psychiatric
Disorder
12%
Other
Psychiatric
Disorders
17%
(Van Orden & Conwell, 2011)
References
Additional Concerns in Health Care
Despite these biases and difficulties with assessing suicide in older
adults, there is a great opportunity for health care providers to
intervene and identify those at risk for suicide.
•About 75% of older adults who complete suicide saw their
primary care provider within 30 days of completing suicide. 25%50% saw their primary care provider within their last week of life
•Suicide risk among recently hospitalized older adults remains
high from discharge to two years (Duberstein & Heisel, 2006).
•Older adults in long-term care facilities have high rates of
suicide, despite residents having limited access to means of
suicide. They may have greater risk factors including low social
support, depression, and cognitive impairment (Mezuk, Prescott, Tardiff, Vlahov, &
Galea, 2008).
Check for free ASIST offerings at your Community Mental Health
center for professionals and community members.
Protective Factors
Physical illness, perceived poor
health, pain, fear of prolonged
illness
Bereavement, complicated or
traumatic grief
Financial difficulties
Extroversion, open to new
experiences
Major changes in social roles
Biases about suicide and depression in older adults lead to less
vigorous treatment. Studies have shown that physicians do not
treat suicidal ideation in older adults to the same extent they
would in younger patients. Additionally, it has been found that
older adults are referred for psychiatric consultation less than
younger patients, and are assessed less for psychiatric history and
suicidal ideation (Worchel & Gearing, 2010).
Applied Suicide Intervention Skills Training (ASIST)
Other Risk Factors
Functional Impairment
Major
Depression
71%
Efforts to decrease the rate of suicide in older adults will not be able to bring
the rate down to zero, but should “do whatever must be done to decrease the
number of people who believe that suicide is their only option” (Duberstein &
Heisel, 2006). There are several areas that efforts can focus. Prevention
focuses on normal life behaviors that might lead to suicide. Intervention
focuses on persons who currently have thoughts of suicide. Postvention is a
way of dealing with those who are affected by suicide loss.
(Van Orden & Conwell, 2011)
(Cohler & Jenuwine, 1995)
Legal difficulties
Biases & Difficulty Assessing
There are several factors that complicate assessing for suicide in
older adults:
•Passive statements about dying such as “I have nothing to look
forward to” are not interpreted as suicidal, as people assume that
elderly are naturally contemplating death and dying.
•Higher intent to die leads this population to take precautions
against being discovered.
•Symptoms of depression can overlap with physical illnesses
common in this age group. Additionally, older adults tend to have
greater somatic complaints and minimize psychological distress.
Interpersonal Discord
2010).
•Some studies have found that depression with psychotic features is
also a common suicide risk (Finkel & Rosman, 1995).
Solutions
Prevention
Prevention efforts can be aimed at reducing access to means of persons
completing suicide and changing broad patterns in society. Literature also
suggests that with older adults, emphasis should be placed on improving
quality of life. Examples include:
Prevention Examples
Quality of Life
Telephone services – twice weekly calls,
and anytime as needed to clients at risk for
poor physical and mental health resulted in
significantly fewer suicides (Conwell, 2007).
Enhanced independent living
Universal Prevention – gun violence
prevention results in fewer firearm suicides
for persons aged 55 and older (Conwell, 2007).
Change attitudes about aging (Duberstein & Heisel,
2006).
Sensitivity to morale and well-being in later
life
Opportunities for psychotherapy and
psychological intervention for
depressed older adults
Loneliness
Sensitivity to morale and well-being in
later life
Appreciation for factors that influence
client’s worldview
(Cohler & Jenuwine, 1995)
Increase rates of mental health literacy and
health-promoting behaviors (Duberstein & Heisel,
2006).
(Conwell, 2007; Finkel & Rosman, 1995).
Rigid
Culture/Life events
Systemic Issues
Positive social support networks
(i.e. children)
Engaged in activities (hobbies,
organizations)
Religious commitment
Beautrais, A. (2002). A case control study of suicide and attempted suicide in older
adults. Suicide and Life Threatening Behavior, 32(1), pp. 1-9.
American Association of Marriage and Family Therapy. (2014). AAMFT Topic: Suicide in Center for Suicide Prevention. (2014). Plus 65: At the end of the day. Retrieved from
the Elderly. Retrieved from
http://suicideinfo.ca/LinkClick.aspx?fileticket=cmFwRL4DMJw=.
http://www.aamft.org/iMIS15/AAMFT/Content/Consumer_Updates/Suicide_in_t
Cohler, B. J., & Jenuwine, M. J. (1995). Suicide, life course, and life story. International
he_Elderly.aspx
Psychogeriatrics, 7(2), pp. 199-219.
American Association of Suicidology. (2014). Elderly Suicide Fact Sheet Based on 2012
Conwell, Y. (2007). Suicide in older adults: Management and Prevention. Psychiatric
Data. Retrieved from
Times, 24(1), pp. 9-15.
http://www.suicidology.org/Portals/14/docs/Resources/FactSheets/Elderly2012.
pdf.
de Souza Minayo, M. C., & Cavalcante, F. G. (2010). Suicide in elderly people: A
literature review. Rev Saude Publica, 44(4), pp. 1-7.
Duberstein, P., & Heisel, M. J. (2006). Suicide in older adults: How do we detect risk
and what can we do about it? Psychiatric Times, 23(13), pp. 46-54.
Finkel, S. I., & Rosman, M. (1995). Six elderly suicides in a 1-year period in a rural
midwestern community. International Psychogeriatrics, 7(2), pp. 221-230.
Having a knowledge of the high rate of suicide in older adults as well as
contributing factors is important for professionals working with older adults.
Based on the influence of depression on suicide, all health care providers,
particularly primary care providers should be able to screen for depression in
older adults. Additionally, treatment for depression should be accessible and
culturally competent for older generations. Furthermore, services that increase
social support in late life is important to not only improve quality of life and
health, but to decrease the risk of negative events such as suicide.
Professionals working with the aging population may want to use the
interpersonal theory to identify risk factors.
Finally, professionals should be aware of their own biases and systemic
failings that may contribute to the high rate of suicide in older adults. Talk of
death and depression in older adults should be taken seriously. Additionally,
efforts should be made to minimize risk in Long-Term Care facilities and other
programs through improving staff turnover rates, reducing risk factors, and
improving quality of life of clients.
Helpful Screenings
•9-item Physician’s Health Questionnaire (PHQ-9)
•15-item Geriatric Depression Scale-Short Form (GDS-S)
•5-item Brief Symptom Rating scale
•Geriatric Suicide Ideation scale
•Coping Orientations to Problems Experienced scale
•Reasons for Living inventory
Perceived meaning in life, life
satisfaction
Adaptive coping, lack of
hopelessness
(Worchel & Gearing, 2010; American Association of Suicidology, 2014; de Souza Minayo & Cavalcante, 2010)
Implications for Professionals
(Living Works, 2014)
If you or someone you know needs help:
•National Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255)
•Veterans Crisis Line: 1-800-273-8255, press 1, www.veteranscrisisline.net
•Friendship Line (Institute on Aging): 800-971-0016,
email: friendshipline@ioaging.org
Living Works. (2014). ASIST Particiapnt Workbook. Canada.
Mezuk, B., Prescott, M. R., Tardiff, K., Vlahov, D. & Galea, S. (2008). Suicide in older
adults in long-term care: 1990-2005. JAGS, 56(11), pp. 2107-2111.
Van Orden, K., & Conwell, Y. (2011). Suicides in late life. Current Psychiatry Reports,
13(3), pp. 234-241.
Worchel, D., & Gearing, R. E. (2010). Suicidal Assessment and Treatment: Empirical and
Evidence-Based Practices. Springer Publishing Company: New York, NY.
Acknowledgments
Thank you to the GVSU School of Social Work, specifically Dr. Robin SmithColton, Dr. Diane Green-Smith, and Dr. Lihua Huang. Additional thanks to
those who contributed to the Art and Science of Aging Conference, and Su
Hood from the Kent County Suicide Prevention Coalition.