Wednesday, September 15, 2010

Suicide in the Elderly Population





Statistics

The elderly (defined as those over 65 years old) have, historically and currently, the highest suicide rates in most, but certainly not all, countries of the world.

The death rate in adolescent suicide attempts is roughly 2%; among men over 45 years old, R. W. Maris found 88% of first-time attempts are fatal. Other estimates are lower, but still on the order of 25-50%, though psychiatrist Herbert Hendin, questioning these numbers, points out that there seem to be many more elderly survivors of suicide attempts than there are suicide deaths in this age group.

Despite recent decreases in old-age suicide frequency and increases in youth suicide, the suicide rate for the elderly in the U.S. is still more than 50% higher than that of 15-24 year-olds.

26 percent of the population is over 50 years old; 39% of suicides are from this group, a rate 1.5 times the national average. White males over 50 years old are about 10 percent of the population, but 33 percent of the suicides in the U.S. Elderly white males have a suicide rate 5 times the national average.

Among people over 65 years old (12% of the population), the suicide rate was about 22 per 100,000 (21% of suicides) in 1986, or almost twice the national average. The actual rate for the elderly is probably a good deal higher, since, "Many deaths from suicide are never investigated and are reported mistakenly as accidents or deaths from natural causes, particularly when the victim was old."

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The annual suicide rate for elderly women (6.7/100,000) is lower than that for middle-aged women (7.9/100,000), and about one sixth that of elderly men (around 40/100,000); however the rate for women is relatively under-reported, since they tend to use methods (e.g. overdose) that leave room for other verdicts. Since American men most often use guns, these deaths are harder to attribute to "natural causes".

Nevertheless, the fact that American male suicide rates peak in old age while female rates are at their maximum during middle age is difficult to explain. The unpleasant realities of old age, increasingly poor health, death of a husband or wife, relegation to a nursing home, fall more frequently on women than men, due to the former's greater longevity.

On the other hand, women are generally better than men at maintaining social and family contacts. And men, due to the higher status and more competitive nature of their activities (e.g., business, sports, war) lose more social standing to the infirmities of old age than do women, who generally have lower rank and thus less distance to fall.

Reasons for these high rates seem to include:
(1) Social isolation and loneliness, especially among widowers.
(2) Physical isolation: because many old people live alone, a suicide attempt may not be discovered soon enough to survive it.
(3) The accumulation of losses, such as friends, physical and mental abilities, social status, and health.
(4) The elderly use more lethal methods than do younger people.
(5) Old people are less likely to survive any given level of injury than are younger, healthier, ones.

Some specific reasons were identified among elderly suicides from the Miami area. The single most-cited cause was "physical health concerns", which were more frequent than the next two reasons ("depression" and "unknown") combined.

Such health concerns are not necessarily accurate. In one study of 248 suicides, more people (8) killed themselves in the mistaken belief that they had cancer than the number of suicides who, in fact, had terminal cancer.

The real rates are probably a good deal higher than the official ones. This is because many drug overdoses have no witnesses, no wounds, and look like a natural death. Since serious pre-existing illness is common in the elderly, such deaths are particularly likely to be misdiagnosed as "natural." In one study, 15,000 autopsies in apparently-natural deaths were reviewed. 764 (5.1%) bodies contained enough poison to account for death.

About half of the elderly who commit suicide are "depressed", but depression is common amongst old people. Both psychiatric and physical illness are more common in elderly suicides than in younger ones, whose deaths are more often precipitated by relationship, school, job, or jail problems. Between 60 and 85 percent of elderly suicides had significant health problems and in four out of every five cases this was a contributing factor to their decision. On the other hand, non-suicidal elderly had similar rates of physical illness as the suicidal.

Does depression affect willingness to accept treatment for other medical problems? In one study, depressed patients were less inclined than non-depressed ones to want medical treatment when the likelihood for improvement in some physical disease was good, but there was no difference between the two groups when the prognosis was poor. It seems that both groups were equally realistic about a poor prognosis, but that the lower quality-of-life and hopes-for-the-future among depressed patients decreased their willingness to seek or accept help when the probability of improvement was good.

This is consistent with other data. For example, a survey of elderly (60-100 years-old) visitors to senior centers in Indiana found that depression, low self-esteem, and loneliness were not associated with a decision to end their lives if faced with terminal, or debilitating chronic, illness. Again, both the depressed and non-depressed elderly were similarly pragmatic about their options under these circumstances.

However, when the severity of the depression is taken into account, differences appear. Elderly patients who were hospitalized for major depression were asked, before and after anti-depressant medication, whether they wanted life-sustaining treatment for their current physical health problems and for two hypothetical physical illnesses.

In the relatively "mild" to "moderate" cases, remission of their depression did not increase their willingness to accept medical intervention; however in the most severely depressed people, it did. This suggests that people in the midst of severe depression should probably not make life-and-death decisions, because their views are likely to change after anti-depressant treatment.

Poverty is not a good suicide predictor. Sweden and Denmark both have high per-capita income as well as comprehensive social welfare for the aged. They also both have high suicide rates among the elderly, as well as in the general population. Greece and Mexico, which have a far lower (economic) standard-of-living than Sweden and Denmark, have particularly low rates, though higher in the elderly than in the general population.

Interestingly, during times of economic prosperity, the elderly suicide rate goes down while the suicide rate of younger adults goes up in the U.S.

A final observation: suicide notes left by the elderly tend to show a desire to end their suffering, rather than dwell on interpersonal relationships, introspection, or punishing themselves or others, which are common themes in younger suicides.

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Risk Factors for Elderly Suicide

Suicide can happen in any family. However, life events commonly associated with elderly suicide are: the death of a loved one; physical illness; uncontrollable pain; fear of dying a prolonged death that damages family members emotionally and economically; social isolation and loneliness; and major changes in social roles, such as retirement.

Among the elderly, white men are the most likely to die by suicide, especially if they are socially isolated or live along. The widowed, divorced, and recently bereaved are at high risk. Others at high risk include depressed individuals and those who abuse alcohol or drugs.

Contributing Factors of Elderly Suicide

Suicide is typically an outcome that can be attributed to any combination of acute factors. Where suicide is considered an impulsive act at any age, elder suicide is often a grim outcome derived from the manifestation of tendencies experienced over an extended period of time. In the United States, suicide is the eleventh leading cause of death in the nation. What is more alarming is that eleven deaths per 100.000 Americans are suicides carried out by white males aged 65 and older, almost triple that of the national average.

Loss and mourning
Life events can trigger suicidal thoughts and often involve the loss of a loved one and/or pet. In these situations, bereavement can last up to two years. It is during this period; elderly persons are most susceptible to suicide.

Irreversible changes in lifestyle
Changes in retirement, a move from one's home to a nursing facility or loss in mobility are it sudden or gradual, mechanical or physical, can also become a trigger for elderly suicide. In a broadcast for Northern Irelands BICNews 6 in December of 1997, Dr. Ivan Boksay stressed the importance of noticing early warning signs that may indicate suicidal tendencies in an elderly subject. Boksay further emphasized the heightened degree of risk elderly subjects were faced with given prior suicide attempts.

Sleep disturbances
Recent research has indicated an intrinsic link between elderly suicide and sleep deprivation. Excessive loss in sleep can result in the manifestation of several problems. Older adults who suffer sleep loss are more likely to suffer from depression, memory loss, problems concentrating excessive daytime drowsiness, more injuries accrued during evening hours and the abuse of over-the-counter sleeping aids. This of course results in a poorer quality of life. Insomnia is among the highest of sleep complaints from persons aged 60 and older.

Clues to Look For

There are common clues to possible suicidal thoughts and actions in the elderly that must be taken seriously. Knowing and acting on these clues may provide you the opportunity to save a life. In addition to identifying risk factors, look for clues in someone's words and/or actions.

It is important to remember that any of these signs alone is not indicative of a suicidal person. Bur several signs together may be very important. The signs are even more significant if there is a history of previous suicide attempts.
A suicidal person may show signs of depression, such as:
  • changes in eating or sleeping habits
  • unexplained fatigue or apathy
  • trouble concentrating or being indecisive
  • crying for no apparent reason
  • inability to feel good about themselves or unable to express joy
  • behavior changes or are just "not themselves"
  • withdrawal from family, friends or social activities
  • loss of interest in hobbies, work, etc.
  • loss of interest in personal appearance
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A suicidal person also may:
  • talk about or seem preoccupied with death
  • give away prized possessions
  • take unnecessary risks
  • have had a recent loss or expect one
  • increase their use of alcohol, drugs or other medications
  • fail to take prescribed medicines or follow required diets
  • acquire a weapon.

Immediate Action Is Needed If The Person Is Threatening Or Talking About Suicide If you have contact with older adults, look for these clues to a potentially suicidal person. Your observing, caring about, and a suicidal older adult the difference between life and death.

You See the Warning Signs of Suicide. What Now?

Some DOs and DON'Ts include:
  1. DO learn the clues to a potential suicide and take them seriously.
  2. DO ask directly if he or she is thinking about suicide. Don't be afraid to ask. It will not cause someone to be suicidal or commit suicide. You will usually get an honest answer. But don't act shocked, since this will put distance between you. (Some people may deny feeling suicidal but may still be very depressed and need help. You can encourage them to seek professional help for their depression. It's treatable.)
  3. DO get involved. Become available. Show interest and support.
  4. DON'T taunt or dare him or her to do it. This "common remedy" could have fatal results.
  5. DO be non-judgmental. Don't debate whether suicide is right or wrong, or feelings are good or bad. Don't lecture on the value of life.
  6. DON'T be sworn to secrecy. Seek support. Get help from persons or agencies that specialize in crisis intervention and suicide prevention. Also seek the help of the older person's social support network: his or her family, friends, physician, clergy, etc.
  7. DO offer hope that alternatives are available but do not offer glib reassurance. It may make the person feel as if you don't understand.
  8. DO take action. Remove easy methods they might use to kill themselves. Seek help.




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