By Dr. Cheryl France, M.D.
Board Certified Geriatric Psychiatrist
Suicide is a major public health concern for elderly individuals in the US. Suicide rates have increased steadily in this century with the highest rates for males over age 85. The rates among females aged 65-74 has increased 55% from 2000 to 2016 with narrowing of the ratio of male to female suicides.1
Elderly individuals have a higher suicide completion to attempt ratio than younger suicidal persons (1:4 in men over 65 vs. 1:200 in young women), elders give fewer warnings of intent and show more planning, are more determined and are more likely to use highly lethal means, firearms being the most common.
The greatest risk factors are becoming a widower/widow, having other mental disorders, prior attempts, substance use, physical illness and bereavement.
Depression with co-morbid anxiety is involved in one of every 6 elder suicides.
Cognitive impairment has also been found to be a risk factor for suicidal ideation and behavior, and brief questioning of a cognitively impaired patient regarding thoughts of ending their life or committing suicide has been shown to validly reflect risk; whether diagnosis disclosure impacts this risk is not known. But the neurocognitive evaluation of suicide attempters with cognitive dysfunction reveals the impaired capacity to consider prior experiences and probable consequences of their decisions, impaired cognitive inhibition leading to an inability to inhibit intrusive suicidal thoughts, inadequate processing of information for decision-making, and deficits in problem-solving.2
Suicidal patients have reported low social support, low sense of belonging, and high levels of chronic interpersonal difficulties. Suicidal ideation can result from social disconnection and especially perceived burdensomeness. Repeated experiences of this disconnection can lead to an individual acquiring the capability to commit suicide, especially when combined with depression, anxiety, and impaired cognitive processes. Conversely, strong social support has a protective effect on late-life stressors and may mitigate their impact on suicide risk.2
In nursing homes, suicide or suicide attempts were found to be among the top 5 most common serious adverse events.3
But suicidal behavior in LTC is difficult to assess: the patients are vulnerable, physically and mentally compromised, and may engage in self-injurious behaviors (e.g., falling, refusing food, oxygen, or CPAP) with variable intentions. Death ideation may be a normal part of approaching the end of one’s natural life, and it may be hard to differentiate from suicidal intent. The presence of staff and lack of access to means such as firearms reduce the access to suicide.
A meta-analysis of LTC completed suicides showed that the majority are male with a mean age of 76. Hanging and falling from height were the most common means of drug toxicity, drowning, and cutting. The highest risk factors were depression, duration of LTC stay <12 months, and decline in physical health. Depressive symptoms were commonly documented, but two-thirds of residents diagnosed with depression who suicided were not receiving any pharmacologic treatment at the time of death. Other risk factors such as social isolation, death of a spouse, mild cognitive impairment, and substance use (if available) likely apply in LTC. But a history of prior attempts was found to be only a minor risk factor in completed suicides in LTC, reflecting the research that has found previous suicidal behavior is more prevalent among attempted suicides than completed ones. On a facility level, higher rates have been found in large facilities with high staff turnover.4
Long-term care facilities are now mandated by CMS through implementation of MDS 3.0 to administer the PHQ-9 as a screen for mental disorders, including thoughts about death or hurting oneself.
Additionally, SAMHSA has developed a toolkit which can be used to help staff recognize warning signs for suicide risk. However, it does not provide actual protocols to follow nor how to determine level or severity of suicide risk. LTC facilities may choose to use a suicide-specific tool such as the P4 screener5 to further stratify risk.
Protocols that call for immediate ER evaluation or psychiatric hospitalization are costly and can be detrimental to the patient by inducing shame or rejection. Also, the patient may return to the LTC at a higher risk for suicide than before the hospitalization; suicide-specific treatment goals are often not addressed while inpatient so do not result in improvement, and suicide rates are 3-7 times greater in the first month post discharge than other times.6 Additionally, efficacy, standard procedures, and discontinuation criteria for close observation or 15 minute checks for suicide prevention have never been demonstrated and they are also costly and staff-intensive.7 Creation and implementation of an LTC protocol for assessment, management, and documentation for potentially suicidal patients can serve as a guide for staff, improve patient care and reduce liability.8
Residents exhibiting suicidal behaviors are clearly in significant distress. The good news is that research shows many risk factors of suicide are amenable to change.
Obtaining a mental health consultation with MediTelecare can help clarify diagnosis, assess long term and more immediate risk, develop and implement a treatment plan of psychopharmacologic, psychological and behavioral interventions targeting modifiable risk factors.