Canadian Coalition for Seniors’ Mental Health
www.ccsmh.ca
Suicide Assessment & Prevention
for Older Adults:
Life Saving Tools for
Health Care Providers
Funded by the Public Health Agency of Canada
Adapted from a presentation by Dr. Marnin J. Heisel, Project Lead, Suicide Prevention
in Older Adults Committee, Canadian Coalition for Seniors’ Mental Health
Contact Information
Canadian Coalition for Seniors’ Mental Health
Address:
c/o Baycrest
3560 Bathurst Street
Room 311, West Wing, Old Hospital
Toronto, Ontario, M6A 2E1
Phone:
416-785-2500 ext. 6331
Fax:
416-785-2492
Web:
www.ccsmh.ca
Contributors
Dr. Martha Donnelly, MD (Project Lead)
Head of the Division of Geriatric Psychiatry
Department of Psychiatry
University of British Columbia
Ian Ross, MSc
Executive Director
Crisis Intervention and Suicide Prevention Centre
of British Columbia
Dr. Marnin J. Heisel, PhD, C. Psych. (Project Lead and
DVD Content Expert)
Assistant Professor
Departments of Psychiatry and Epidemiology & Biostatistics
Schulich School of Medicine and Dentistry
The University of Western Ontario
Joan Seabrook, MEd, SO
Educational Consultant
Survivor Chair, Canadian Association for Suicide
Prevention
Dr. Sharon Moore, RN, MEd, PhD, C. Psych. (Project Lead)
Associate Professor
Centre for Nursing & Health Studies
Athabasca University, Alberta
Charlene Foster, BA
Trainer and Volunteer Coordinator
London and District Distress Centre, Ontario
Diane Yackel, MA, FT
Executive Director
Centre for Suicide Prevention, Alberta
Sherri Helsdingen, BA
Project Manager
Canadian Coalition for Seniors’ Mental Health
Kimberley Wilson, MSW, BASc
Executive Director
Canadian Coalition for Seniors’ Mental Health
Learning Objectives
By the end of this workshop, you will be able to:
 Demonstrate a basic understanding of the epidemiology of late life
suicide;
 Be aware of the risk factors for suicide, as well as protective
factors;
 Identify suicide warning signs;
 Initiate life-saving conversations about depression and suicide risk
using key questions to assess for suicide risk;
 Be familiar with late-life suicide risk assessment and clinical
intervention strategies;
 Integrate components of the CCSMH Late Life Suicide Prevention
Toolkit into clinical care.
Epidemiologic Considerations
 The World Health Organization estimates that approximately One
Million lives are lost to suicide worldwide every year.
 Suicide is a leading cause of preventable death that accounts for
more deaths annually than homicide and war combined.
 Every death by suicide leaves at least 6 survivors.
 Suicide is a leading cause of preventable morbidity and mortality
worldwide.
World Health Organization (WHO) Data
The Epidemiology of Late Life Suicide
 Older adults have high rates of suicide worldwide, including in
Canada and the U.S.
 There are currently over 4.3 million Canadians aged 65 years and
older.
 1 out of every 7 Canadians is a senior citizen. In 2006, seniors
accounted for a record high of 13.7% of the total population.
 Between 2006 and 2026, the number of seniors is projected to
increase from 4.3 million to 8.0 million. Their share of the
population is expected to increase from 13.2% to 21.2%.
 “Baby boomers” have high rates of suicide.
Reality: Seniors (by age sub-groups)
as % of the Total Population
Canada, 1921-2041
25
65-74
75-84
85+
Percentage
20
15
10
5
0
1921
1931
1941
1951
1961
1971
1981
Year
1991
2001
2011
2021
2031
2041
Mortality Statistics
 Demographic risk factors include sex (Male), age (Older), and
ethnicity (Caucasian/White).
 In 2004, 427 Canadians 65+ died by suicide, including 319 men
and 108 women.
 Men between 85 and 89 years of age had a suicide rate
(26.8/100,000) that more than doubled the national average of
approximately 13/100,000.
 Suicide mortality data underestimate “true” suicide rates, and do
so differentially.
2004 StatsCan Suicide Rates (per 100,000)
30
25
20
Male
Female
Total
15
10
5
0
65-69 70-74 75-79 80-84 85-89
90+
Mortality Statistics
 The ratio of suicidal behaviour to deaths for older adults
is between 1-4:1, while that for adolescents is as high as
200-300:1
 Many older adults may end their lives by refusing food
and / or needed medications; however, these deaths are
typically not officially deemed suicides.
 Means of suicide differ by age, gender, and location.
 Detection of suicide risk in older adults is crucial;
interventions can then follow.
Suicide Prevention Among Older Adults
 Barriers exist to effective risk detection and intervention.
 Until recently, one such barrier was the absence of practice
guidelines for suicide risk assessment and interventions for older
adults.
 CCSMH recently released 4 federally funded (Public Health
Agency of Canada) National Guidelines for the care of mental
health issues affecting older adults:
• Assessment and Prevention of Suicide
• Delirium
• Depression
• Mood and Behavioural Problems in Long-term Care Homes
All are available free of charge online at www.ccsmh.ca
CCSMH Late Life Suicide Prevention Toolkit
 CCSMH National Guidelines for Seniors’ Mental Health:
The Assessment of Suicide Risk and Prevention of
Suicide
 Clinician pocket-card - Suicide: Assessment & Prevention
for Older Adults
 DVD - Suicide Assessment & Prevention for Older
Adults: Life Saving Tools for Health Care Providers
Suicide Assessment & Prevention
for Older Adults: Warning Signs
Q:
What are the warning signs that
someone is at risk for suicide?
Suicide Assessment & Prevention
for Older Adults: Warning Signs
Remember “IS PATH WARM?”
– I
Ideation
– S
Substance Use
– P
Purposelessness
– A
Anxiety/Agitation
– T
Trapped
– H
Hopelessness/Helplessness
– W
Withdrawal
– A
Anger
– R
Recklessness
– M
Mood Changes
From the American Association of Suicidology (AAS) website (www.suicidology.org).
Suicide Assessment & Prevention
for Older Adults: Risk Factors
Q:
What are the risk factors
for suicide?
Suicide Assessment & Prevention
for Older Adults: Risk Factors
1. Suicidal Ideation and / or Behaviour
 Prior suicidal behaviour (including suicide attempt), prior self-harm
behaviour, previous expression of suicide ideation
 Feels tired of living and/or wishes to die
 Thinks about suicide, has suicidal wishes and / or desires
 Has a suicide plan / note
2. Family History
 Family history of suicide, suicide ideation, mental illness
Suicide Assessment & Prevention
for Older Adults: Risk Factors
3. Mental Illness (can include)
 Any mental disorder, co-morbidity
 Major depressive disorder
 Any mood disorder
 Psychotic disorder
 Substance misuse disorder / addictions
4. Personality Factors
 Personality disorders
 Emotional instability
 Rigid personality
 Poor coping skills, introversion
Suicide Assessment & Prevention
for Older Adults: Risk Factors
5. Medical Illness
 Pain, chronic illness
 Sensory impairment
 Perceived or anticipated / feared illness
6. Negative Life Events and Transitions
 Family discord, separation, death or other losses
 Financial or legal difficulties
 Employment/retirement difficulties
 Relocation stresses
7. Functional Impairment
 Loss of independence
 Problems with activities of daily living
Suicide Assessment & Prevention
for Older Adults: Resiliency Factors
Q:
What are some of the resiliency
(protective) factors?
Suicide Assessment & Prevention
for Older Adults: Resiliency Factors
1. Sense of meaning and purpose in life.
2. Sense of hope.
3. Sense of optimism.
4. Religious (or spiritual) practice.
5. Active social networks and support from family and friends.
6. Good health care practices.
7. Positive help-seeking behaviours.
8. Engagement in activities of personal interest.
Suicide Assessment & Prevention
for Older Adults: Assessment Process
Q:
How do I tell if someone is at
risk of suicide?
Suicide Assessment & Prevention
for Older Adults: Assessment Process
1.
Establish rapport and assess for suicide risk in a sensitive and
respectful fashion.
2.
Respect the dignity of older adults. Acknowledge their
experiences and validate their feelings.
3.
Assess for suicide risk factors.
4.
Assess for psychological resiliency.
5.
Assess for suicide warning signs IS PATH WARM.
Suicide Assessment & Prevention
for Older Adults: Assessment Process
6.
Where appropriate, access collateral information
(medical chart, family members, other providers).
7.
Be mindful of ambivalent wishes to live and to die.
8.
Develop a risk management/action plan.
9.
Seek consultation and/or assistance if you do not have
specialized training in mental health or in suicide prevention.
Suicide Assessment & Prevention
for Older Adults: Key Questions
Q:
What questions do I ask?
Suicide Assessment & Prevention
for Older Adults: Key Questions
1. Ask about their feelings
 Do you feel tired of living?
 Have you been thinking about harming yourself and/or
ending your life?
 Have you been thinking about suicide?
Suicide Assessment & Prevention
for Older Adults: Key Questions
2. Ask about a suicide plan
 Have you thought of specific ways of hurting yourself or ending
your life?
 Have you made any specific plans or preparations (giving away
possessions, tying up 'loose ends')?
 Have you asked someone to help you end your life or join you in
death?
 Do you have access to lethal means like a gun or other
implements?
 Have you collected pills in order to take an overdose?
 Have you started to put a suicide plan into action?
Suicide Assessment & Prevention
for Older Adults: Key Questions
3. Ask about their reasons to live
 What has kept you from harming yourself?
 Who or what makes life so worth living that you would not
harm yourself?
What other questions could you ask?…
Suicide Assessment & Prevention
for Older Adults
Q:
What are some strategies for
intervening and managing risk?
Suicide Assessment & Prevention
for Older Adults: Risk Management
RISK MANAGEMENT STRATEGIES:
Help the older adult connect with a team of supports:
 other medical and/or mental health care providers,
 social service providers, clergy, family members, friends,
and/or other community members.
Suicide Assessment & Prevention
for Older Adults: Risk Management
Immediate Risk Management
1. Do not leave the person alone until you have arranged for the
involvement of another appropriate care provider or source of
protection.
2. Establish an immediate safety plan that includes:
 family support
 homecare support
 24-hour (or in-home) care providers
 police intervention (if needed)
Suicide Assessment & Prevention
for Older Adults: Risk Management
Immediate Risk Management (Cont.):
3. Consider care needs:
 emergency services
 telephone and / or in-person crisis / distress / support services
 mental health services
 medical services
 social service providers, community supports
4. Ensure that follow-up care is arranged.
5. Where possible, restrict access to lethal means.
Suicide Assessment & Prevention
for Older Adults: Risk Management
Ongoing Risk Management
1. Address underlying issues:
 medical illness
 mental health problems
 social problems, concerns, transitions
 environmental factors
2. Continually re-assess suicide risk, resiliency, and warning signs.
3. Continue to build and sustain the therapeutic relationship.
4. Look for ways to foster hope and enhance a sense of meaning in
life.
Suicide Assessment & Prevention
for Older Adults: Risk Management
Ongoing Risk Management (Cont.)
5. Develop a safety plan that includes after-hours support.
6. Read and continually review CCSMH National Guidelines and
other appropriate treatment guidelines.
7. Work within a culturally competent model of care.
8. Work within an inter-disciplinary care model where possible:
 Develop relationships with mental health teams for support and
ongoing follow-up.
 Be aware of community resources and referral sites / processes.
Suicide Assessment & Prevention
for Older Adults: Treatment & Management
Treatment and Management: Suicidal Seniors
 Foster hope in clients who are suicidal
 Assist in finding and maintaining meaning and purpose in life
 Attend to the therapeutic relationship
 Work in a team setting - don’t work alone (collaborative care)
 Consult colleagues, keep detailed notes, use crisis services
 Restrict access to lethal means
 Mental health outreach
Suicide Assessment & Prevention
for Older Adults: Treatment & Management
Recommendation: Treatment and Management
 Health care providers working with suicidal older adults
should ensure that their clients are appropriately assessed and
treated for depression. (Please refer to the National
Guidelines for Seniors’ Mental Health: The Assessment and
Treatment of Depression by the CCSMH, 2006) [B]
 Copies of the CCSMH National Guidelines for the Assessment and
Treatment of Depression, can be downloaded for free at
www.ccsmh.ca.
Suicide Assessment & Prevention
for Older Adults: Treatment & Management
SYMPTOMS OF DEPRESSION: REMEMBER SIG E CAPS
(Source: Michael Jenike, 1989)
S Sleep is disturbed
I Interest is decreased
G Guilt (feelings of guilt or regret)
E Energy is less than usual
C Concentration is poor
A Appetite is disturbed
P Psychomotor agitation or retardation
S Suicidal Ideation, including passive wish to die
Suicide Assessment & Prevention
for Older Adults: Treatment & Management
SYMPTOMS OF DEPRESSION:
 Depressed people often experience sadness, despair, and low
energy. However, many depressed older adults do not appear
obviously sad. It is important to assess for "hidden depression".
Suicide Assessment & Prevention
for Older Adults: Summary
SUMMARY
 Older adults have high rates of suicide and the population of older
Canadians is growing.
 Detection of elevated suicide risk is essential for suicide
prevention efforts for seniors.
 Barriers exist to effective risk detection and treatment.
 New assessment instruments appear very promising.
 Efforts are underway to develop/modify clinical interventions for
at-risk older adults.
Suicide Assessment & Prevention
for Older Adults: Summary
SUMMARY
 Practice guidelines are now available through the CCSMH to help
address the need for evidence-based recommendations for
improving detection of at-risk older adults and prevention of
suicide.
 These highlight the need to listen to and empathize with older
patients/clients, develop clinical rapport, and endeavour to work in
team settings.
 Increasing attention to the problem of late life suicide may help
decrease risk of loss in a growing and valued segment of our
population.
Discussion Questions
Chapter 1:
Suicide Assessment
 What makes it difficult to assess depression and suicide
risk in older adults?
Discussion Questions
Chapter 1:
Suicide Assessment
 What did the physician do to assess Mr. Johnson’s
depression and suicide risk?
 Was this adequate? What else, if anything, could the
doctor have done differently?
Discussion Questions
Chapter 1:
Suicide Assessment
 What are some of the risk management strategies shown
or discussed in the DVD?
 What will be important in terms of ongoing risk
management for Mr. Johnson?
Discussion Questions
Chapter 1:
Suicide Assessment
 What resources could you access to help a suicidal
patient / client?
 What can you do in advance to be prepared for potential
crises?
Discussion Questions
Chapter 1:
Suicide Assessment
 In your own practice setting, what can you do to inspire
hope with your patient / client?
Discussion Questions
Chapter 1:
Suicide Assessment
 The DVD suggests some key questions to ask people at
risk for suicide. Can you think of other questions to ask?
Discussion Questions
Chapter 2:
Suicide Risk & Resiliency Factors

What are the risk factors for suicide?
Discussion Questions
Chapter 2:
Suicide Risk & Resiliency Factors

What are the greatest risk factors?
Discussion Questions
Chapter 2:
Suicide Risk & Resiliency Factors

Which of these risk factors can be modified?
Discussion Questions
Chapter 2:
Suicide Risk & Resiliency Factors

What are some resiliency / protective factors?
Discussion Questions
Chapter 3:
Suicide Warning Signs

What does “IS PATH WARM” stand for? What are the
warning signs for suicide risk?
Discussion Questions
Chapter 3:
Suicide Warning Signs

Should the mnemonic “IS PATH WARM” be used as a
checklist? Why or why not?
Discussion Questions
Chapter 4:
Suicide & Stigma: Survivors’ Voices

How can the stigma about suicide and depression
affect your assessment and treatment strategies?
Discussion Questions
Chapter 4:
Suicide & Stigma: Survivors’ Voices

What factors can contribute to the stigma surrounding
depression and suicide?
Discussion Questions
Chapter 4:
Suicide & Stigma: Survivors’ Voices

Take time to reflect on your personal feelings /
experiences with late life depression and late life
suicide.
Discussion Questions
Overall:

What was your overall reaction to the DVD?

Can you list 1-2 new points or concepts you learned in
this session?

In what ways did the DVD affect your attitudes toward
depression and suicide in older adults?

What changes will you make in your practice as a
result of what you’ve learned in the DVD?

If you are experiencing stress or burn-out while doing
this type of work, what resources can you access?
Suicide Assessment & Prevention
for Older Adults
Thank you!
We welcome your feedback online:
www.ccsmh.ca/en/projects/suicide.cfm