Suicidal Behavior in Elders

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Suicide is a major public health concern for older adults, who have higher rates of completed suicide than any other age group in most countries of the world. Older men are at greatest risk. Reduction of suicide-related morbidity and mortality in this age group hinges on systematic study at each point in the suicide preventive intervention research cycle. Improvements in systems for surveillance of late-life suicidal behavior, particularly attempted suicide, are needed to further develop the foundation on which to evaluate differences in the elderly subgroup, over time, and in different locations, and to better assess changes in response to interventions. This article provides an overview of suicide in later life and a foundation on which to base decisions about the design and implementation of preventive interventions.

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Challenges to Late-life Suicide Prevention

Developing suicide prevention strategies in older adults is particularly challenging because of a range of factors at the individual, provider, systems, and even social/cultural levels. To the extent that suicide prevention relies on timely and effective detection and treatment of mental disorders, older adults face multiple barriers to the acquisition of care [1]. At the service system level, discriminatory barriers still exist in access to mental health care. Medicare recipients are required

Scope of the Problem: the Epidemiology of Suicide in Later Life

Each year in the United States approximately 32,000 deaths result from suicide, of which more than 5000 (14%) are among people older than 65 years [12]. Fig. 2 illustrates the complex relationships among suicide risk, age, gender, and race. At each point in the life course, suicide rates are higher for men than women and for whites than non-whites. One notable exception is American Indian youth, who have higher rates of suicide than their white counterparts. The rise in suicide risk for older

Risk and Protective Factors

Much of what we know about risk factors for suicide in later life is derived from “psychological autopsies” (PAs), a research method in which mental and physical health status and social circumstances are reconstructed from records and interviews with next of kin and other knowledgeable informants [21]. Findings from several PAs of older adult suicides were recently published [22], [23], [24], [25], [26], including a handful that used matched comparison groups [19], [27], [28], [29], [30], [31]

Axis I: Major Psychiatric Illness

Table 1 lists the distribution of psychiatric diagnoses among older adults who committed suicide and underwent PA. Affective illness was the most common disorder, present in 54% to 87% of cases. Major affective disorder accounted for most of these affective syndromes. The prevalence of substance use disorders varied widely, from 3% to 46%, reflecting the different age groups, locations, and dates of studies; those conducted more recently and in Western countries tend to have higher rates.

Axis II: Personality Traits and Disorders

Investigators have long noted associations between late-life suicides and traits such as timidity and shy seclusiveness [35], hostility, and a rigid, independent style [35], [36]. Only one case-control PA study examined whether personality disorders elevate risk in this age group. Harwood and colleagues [32] found that levels of anankastic (obsessional) and anxious traits significantly distinguished suicides from natural deaths, but personality disorder per se did not.

Using an informant-report

Axis III: Physical Illness

Because physical illnesses are so common in older adults, the relative risk for suicide associated with them, and their usefulness in identifying any individual in need of acute intervention, is low. Furthermore, the association between physical illnesses and suicide in later life could be partly explained by the mediating effect of depression (physical illness causes depression and depression increases risk for suicide).

Studies linking death records with disease registries have found

Axis IV: Life Event StressorS and Social Circumstances

The life events associated with suicide in older adults are those typically associated with aging: bereavement, financial stressors associated with retirement and living on reduced means, family discord and loss of social support, and the social and psychological impacts of physical illness. Controlled PA studies again help define whether these stressors are present before suicide more often in older adults than in the general older adult population.

In her PA study of older adults in New

Axis V: Functioning

Measurement of functional status is a core component of comprehensive clinical assessment in geriatric medicine and psychiatry because it is often a sensitive indicator of underlying physical and psychological problems. Defining associations between functional decrements and suicidal behavior in older adults, therefore, may also help identify those in need of further assessment and intervention. Typical measurements include activities of daily living (ADLs), such as dressing and feeding

Other Factors and Potential Mechanisms

Another potential risk factor with implications for prevention is access to lethal means. Older adults tend to act on suicidal thoughts with greater lethality of intent and implementation, and use more immediately lethal means, particularly firearms. In his PA study of older men who took their own lives, Miller [49] observed that, although no difference was seen between men who completed suicides and controls in the proportion who owned a firearm, a significantly greater proportion of men who

Points of Access: Where to Find Seniors at Risk

This article next consider where preventive interventions can be most effectively implemented: what settings provide the greatest access to older adults, both those at high risk and those amenable to interventions designed to prevent development of risk states? Fig. 4 illustrates the primary targets. Given the strong link between suicide and psychiatric illness, mental health providers and clinics would be a logical starting point. However, older adults rarely use these services. Instead, they

Approaches to Prevention

With knowledge of the epidemiology of suicide in older adults and the settings best suited for case finding, the next step in the prevention research cycle involves the design and testing of preventive interventions. These may be characterized as addressing suicide at one or more of three levels: indicated, selective, and universal [64]. Table 3 provides a definition and general example for each, and Table 4 lists published studies in which the impact of an intervention on suicidal ideation or

Summary

Suicide is a major public health concern for older adults, who have higher rates of completed suicide than any other age group in most countries of the world. Older men are at greatest risk. Reduction of suicide-related morbidity and mortality in this age group hinges on systematic and methodological study at each point in the suicide preventive intervention research cycle. Improvements in systems for surveillance of late-life suicidal behavior, particularly attempted suicide, are needed to

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    This work was supported by Grant #T32MH20061 and #P20 MH071897 from the National Institute of Mental Health.

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