Lisa M. O'Neill, DBH, MPH and Coco V. Tirambulo, BS, University of Arizona Center on Aging
TIPS FOR DEALING WITH SUICIDE RISK IN OLDER ADULTS
Suicide is the 10th leading cause of death in the United States and continues to be a growing public health concern as rates in all age groups continue to rise. Each year almost 45,000 Americans die by suicide, and for every suicide, there are 25 attempted suicides. Suicide rates are highest among Caucasians and Native Americans/Alaska Natives, and lowest among Hispanics and Blacks. Suicide is more common in men, while attempts are more common in women.
Older adults are particularly at risk due to factors such as chronic illness, neurocognitive impairment, psychological pain, and social isolation. Research suggests that up to 45% of patients who die by suicide have visited their primary care physician within a month of their death. Given this, primary care practices have the potential to help prevent suicide. Although the US Preventive Services Task Force has concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for suicide risk, clinicians should be educated on risk factors, warning signs, and preventive steps.
Suicidal ideation (thinking about, considering, or planning suicide) can be difficult to detect in clinical settings, and there is no typical suicidal patient. Clinicians will treat individuals with known risk factors who do not attempt suicide, along with individuals with no obvious risk factors who do attempt suicide. Clinicians should thus avoid considering only certain patients at risk.
Risk factors to be aware of include: (a) recent loss of a spouse or loved one; (b) recent change in living situation or work status (retired or can no longer live independently); (b) prolonged or terminal illness; (c) substance abuse or addiction; (d) chronic pain; (e) dementia diagnosis; (f) loneliness/social isolation; (g) prior suicide attempt(s) or a family history of suicide; and (h) mental health conditions. It is not uncommon, however, for those who have attempted suicide to have unknown/undiagnosed mental health conditions. Older adults who have a history of intentional self-harm are also at risk. Intentional self-harm can include cutting, burning, drug ingestion, or participating in unsafe sex. Other high-risk factors are following transitions from outpatient to in-patient care, transitions from primary care clinicians to behavioral health providers, and following hospital discharge to home or nursing homes. Research shows that the presence of guns in the home can increase suicide risk. If guns are a concern, clinicians should offer clear advice about gun safety and storage.
Suicide rates are particularly high among adults 85+ years old, and suicide attempts are much more likely to result in death than attempts by younger persons. When providing care for older adults, clinicians should listen closely for certain phrases used in conversations or when answering questions. For example, patients may talk about others who have committed suicide, or talk about when they "will be gone." They may develop a preoccupation with death and dying and use phrases like "I'd be better off dead" or "I won't be around much longer." They may talk about being trapped, being in "unbearable" pain, or being a "burden" to others. Suicidal patients may not answer all questions because in their mind, the answer won't change anything. They may not use the word "depressed," but instead describe themselves as sad, anxious, or even irritated.
Behavioral warning signs include withdrawal from friends or activities they used to enjoy or losing interest in their personal appearance. They may start speaking with unusual speed or slowness; become angry very easily or be unnaturally aggressive; or start giving away prized possessions. Often older adults will have deep and meaningful conversations with friends and loved ones, and later those individuals will recognize the older adult was saying goodbye.
Another important warning sign is a sudden calmness, especially after a period of moodiness or depression. The person may become quiet and appear at peace. This change can be a signal they have made a decision to act on their suicidal ideation.
In addition to being aware of the warning signs and risk factors for suicide, clinicians should take preventive steps to identify mental health issues such as depression, anxiety, and bereavement to assure proper treatment. Some common symptoms to be alert for include confused thinking, excessive fears, worries or anxieties, changes in eating or sleeping habits, and strong feelings of sadness or anger. Clinicians should also work to identify alcohol and drug use disorders; symptoms may include changes in personality and behaviors, irritability, lack of concern for personal hygiene, shakes, slurred speech, or bloodshot eyes.
If a patient is experiencing or expressing passive or active suicidal thoughts, timely and appropriate intervention can prevent suicide. Be sure to know what healthcare agencies in your community can offer assistance, and have their contact information easily accessible. Take the threat seriously, and talk openly and directly with your patient about your concerns. They may get angry or laugh it off, but continue the conversation so they know you are listening and willing to talk and help them.
Questions to ask include: Are you thinking about hurting yourself? How long have you been thinking about suicide? Do you have a plan? Do you have a way to carry out your plan? Have you attempted suicide in the past? The responses can help determine the frequency and intensity of their suicidal ideation, assess the need for medication (e.g., antidepressants), as well as the need to contact a crisis team, call 911, or get the patient hospitalized. If you feel the patient can go home, be sure they have strong social support and don't have access to guns or other dangerous weapons. If they live alone, help them create a list of people they can call if they feel suicidal, including resources shown in Table 1. Be sure to schedule follow-up appointments to make sure they are closely monitored.
In addition to good physical and mental health, social relationships and belief systems have shown to be protective factors in reducing the risk of suicide. Close relationships with a live-in partner or spouse and/or caring for children or grandchildren can help older adults feel less lonely and isolated. Outside community connections can also be helpful in providing a sense of purpose. Personal spirituality, beliefs that oppose suicide, and a resilient personality - the ability to bounce back from struggles and find other solutions to problems - are also beneficial.
Refusing Medical Treatment
It is important to note that not all older adults who refuse medical treatment are depressed or suicidal. Their long term and end-of-life goals should be taken into account.
The Columbia-Suicide Severity Rating Scale (C-SSRS) and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) can be found here.
|Table 1. Help Lines and Trainings
References and Resources
- American Foundation for Suicide Prevention.
- Centers for Disease Control and Prevention, MMWR Vital Signs: Trends in Suicide Rates - United States 1999-2016, Vol 67(22).
- Conejero I, Olie E, Courtet P, Calati R. (2018) . Suicide in older adults: current perspectives. Clin Interv Aging, 13: 691-699. doi 10.2147/CIA.S130670.
- National Alliance on Mental Health.
- The Joint Commission R3 Report. National Safety Goal for Suicide Prevention.
- Wible P. Why 'Happy' Doctors Die by Suicide. Medscape. 2018.