A Gatekeeper Role for Providers

Adult day care centers, home care agencies, hospices, assisted living facilities, and nursing homes make up the post-acute care continuum. Such providers are positioned to impact the most serious problem of the aged in our society - elder suicide. This aim of this site is to get post-acute care providers informed and involved with this problem.

© HCMA, Ltd., 1999

What's the problem?

Someone age 65 or over completes suicide every 90 minutes -- 16 deaths a day. Elders account for one-fifth of all suicides, but only 12% of the population. White males over age 85 complete suicide at almost six times the national average. Elder suicide may be under-reported 40% or more. Omitted are "silent suicides", i.e., deaths from medical noncompliance and overdoses, self-starvation or dehydration, and "accidents." The elderly have a high suicide "success rate" because they use firearms, hanging, and drowning . "Double suicides" involving spouses or partners occur most frequently among the aged.

What are the causes?

Elder suicide is associated with depression and factors causing depression, e.g., chronic illness, physical impairment, unrelieved pain, financial stress, loss and grief, social isolation, and alcoholism. Depression is tied to low serotonin levels. Serotonin, which decreases with aging, is a neurotransmitter which limits self-destructive behavior.

What are the warning signs?

The following may indicate serious risk:

• Loss of interest in things or activities that are usually found enjoyable
• Cutting back social interaction, self-care, and grooming.
• Breaking medical regimens (e.g., going off diets, prescriptions)
• Experiencing or expecting a significant personal loss (e.g., spouse)
• Feeling hopeless and/or worthless ("Who needs me?").
• Putting affairs in order, giving things away, or making changes in wills.
• Stock-piling medication or obtaining other lethal means.

Other clues are a preoccupation with death or a lack of concern about personal safety. "Good-byes" such as "This is the last time that you'll see me" or "I won't be needing anymore appointments" should raise concern. The most significant indicator is an expression of suicidal intent.

Why aren't providers doing more?

Service involvement with older men:

Post-acute care philosophy:

Provider Misconceptions:

• If someone's determined to kill themselves, no one can stop them.
• Those who complete suicide do not seek help before their attempt.
• Those who kill themselves must be crazy.
• Asking someone about suicide can lead to suicide.
• Those who talk about suicide rarely actually do it.

Lack of risk assessment:

What can providers do?

Prevention must focus on what drives suicide. Shneidman (1995) notes:

...it is best to look upon any suicidal act as an effort by an individual to stop unbearable anguish...by "doing something." ...The way to save a person's life is also to "do something." Those "somethings" include putting that information (that the person is in trouble with himself) into the stream of communication, letting others know about it, breaking what could be called a fatal secret, talking to the person, talking to others, proffering help, getting loved ones interested and responsive, creating action around the person, showing response, indicating interest, and, if possible, showing deep concern.

"Doing something" comes down to caring.

Preventing Elder Suicide for Dummies

There are three stages to prevention:

1. Primary prevention - community-wide or population-oriented programs.
2. Secondary prevention - intervention with a particular individual at some point in the suicidal process.
3. Tertiary prevention - intervention with suicide attempters.

Shneidman (1977) notes that suicidal individuals be helped through:

Prevention (acting before an individual is in crisis)
Intervention (acting when an individual is in crisis)
Postvention (acting to help after the crisis)

Decreasing elder suicide involves reducing the number of individuals who become suicidal. Given that the elderly make fewer attempts and use lethal means the most effective prevention strategy would target high risk populations rather than high risk individuals (see Rosenman).

Rickgairn (1990) sees intervention in terms of levels:

1. "Everyperson" - Basic interpersonal caring response by concerned lay person
2. "Skilled Helper" - Programmed response by a trained paraprofessional (e.g., nursing assistant)
3. "Professional" - Clinical response by a physician, RN/LPN, social worker, etc.

We would add a fourth level, the institutional, for providers. These levels provide a framework for outlining preventative measures:

Everyperson Level

a. Means restrictions: Control access to guns and lethal meds

b. Public education about the signs and symptoms of depression

c. Public education about availability of pain management

d. Public education about the myths and warning signs of suicide

e. Public education about basic intervention techniques

Skilled Helper Level

a. Educate paraprofessionals about warning signs of elder suicide

b. Educate paraprofessionals about the myths of aging

c. Educate paraprofessionals about treatment of victim's family and significant others

d. Educate aides, orderlies, and personal care workers about signs of depression in the elderly

Professional Level

a. Screen for depression by RNs, medical directors, primary physicians

b. Screen for "psychache" (psychological pain) by RNs and MSWs

c. Screen for suicidality

d. Standards of care for treatment of at-risk individuals

e. Adoption of confidentiality waivers permitting disclosure of-risk

f. Mobilize personal support systems with at-risk patients or residents.

g. Use "no suicide contracts" as appropriate

Institutional Level

a. Promulgation of a organizational suicide policy

b. Mandatory annual caregiver in-services on suicide

References

Rickgairn, R. (1990) "Intervention Can Prevent Suicide" in T. Roleff (Ed.), Suicide: Opposing Viewpoints 126-130.
Shneidman, E. S. (1977) Deaths of Man 33-41.
Shneidman, E. S. (1996) The Suicidal Mind.

Off-line Reading:

Blumenthal, S., and Kupfer, D. (Eds.), Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients Washington, DC: American Psychiatric Assn., 1990.

Kachur, S., Potter, L., James, S, and Powell, K. Suicide in the United States, 1980-1992. Atlanta: Center for Disease Control and Prevention, National Center for Injury Prevention and Control, 1995. Violence Surveillance Series, No. 1.

McIntosh, J., "Suicide Prevention in the Elderly". In Silverman, M., and Maris, R., (Eds.), Suicide Prevention: Toward the Year 2000 New York: Guilford Press, 1995, pp. 180-192.

Morgan, A., "Special Issues of Assessment and Treatment of Suicide in the Elderly" in Jacobs, D., and Brown, H., (Eds.), Suicide: Understanding & Responding Madison, CT: International Universties Press, 1990, pp. 239-255.

Osgood, N., Suicide in Later life: Recognizing the Warning Signs. New York: Lexington Books, 1992.

Osgood, N., and Brandt, B., "Suicidal Behavior in Long Term Care Facilities" Suicide and Life Threatening Behavior 20(2) 1990, pp. 113-122.

Osgood, N., Brandt, B., and Lipman, A., "Patterns of Suicidal Behavior in Long Term Care Facilities: A Preliminary Report of an Ongoing Study" Omega 19(1) 1988-89, pp. 69-78.

Osgood, N., and McIntosh, J. Suicide and the Elderly: An Annotated Bibliography and Review. Westport, CT: Greenwood Press 1986.

Raymer, M., "Responding to Suicide" The Hospice Professional (Summer 1997) pp. 1-4.

Richman, J., Preventing Elder Suicide: Overcoming Personal Despair, Professional Neglect, and Social Bias New York: Springer, 1993.

Rifar, A., Reynolds, C., and Mann, J. "Biology of Elderly Suicide" in Leenaars, A., Maris, R., McIntosh, J., and Richman, J. (Eds.) Suicide and the Older Adult. New York: Guilford Press, 1992, pp. 48-61.

Shneidman, E., "Psychotherapy with Suicidal Patients" in Maltsberger, J., and Goldblatt, M., (Eds.) Essential Papers on Suicide. New York: New York University Press, 1995, pp. 417-425.

Stillman, J., McDowell, E., and May, J., Suicide Across the Life Span - Premature Exits. New York: Hemisphere Publishing, 1989.

Thobaben, M. "Suicide Myths and Health Care Provider Bias" Home Care Provider. 2 (June 1997), pp. 109-111.

Valente, S., "Suicide and Elderly People: Assessment and Intervention" Omega 28(4) 1993-94, pp. 317-331.

Links on Elder Suicide

Background and Statistics

Facts on Elderly Suicide
Suicide Among Older Persons 1980-1992, United States
Suicide Among Older People [Sorry Out of Order]
Suicide and the Elderly
Suicidal Behaviour in the Elderly (SNF and LTC focused)
Some facts About Suicide in the Elderly
Suicide Rates Highest Among Seniors
Elderly Suicide Rate Up
US Says Elderly Suicide Rates Up Based on same report as link above.
Experts See Suicide "Epidemic" Among Elderly
Suicide Among Elderly Men on Rise
Silent Suicide in the Elderly
Senior Suicide -- A National Tragedy
Suicide Rate Rises as Eldely People Live Longer

City/State Data

Elderly Suicide Rates in Los Angeles, 1970-93

Other Countries

Suicide at Age 75 and Older, Australia
Elderly suicide in Ireland
Suicide Prevention: Youth and Elderly Populations (British Columbia)

Case Studies/Individual Reports

Case Study: Attempted Suicide in the Elderly
Why Depression is a Silent Killer
Elderly Couple in Apparent Suicide Pact (UK News Report)

Research Studies and Reports

The Relationship of Personality and Clinical Symptoms to Suicidal Thinking in Older Adults

Programs and Services

ElderVention (A prevention program in AZ.)
Suicide Phone Counseling for Seniors (A university sponsored program in St. Louis, MO)

Related Topics and Issues

Older Suicide Victims Visit Doctors Week Before Killing Themselves
Elder Suicide and Mental Health
Brain's Serotonin System Declines With Age
Many Older Adults Choose Life Over Death No Matter the Quality
Cancer and Suicide Among Older Men
Depression Leads Some Elderly to kill Spouses

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