1. What's the problem?
Elder suicide is a serious problem which stands to get worse as the older population grows. Someone age 65 or over completes suicide every 90 minutes. Suicide among the elderly increases with age and correlates with gender and race. White males over age 85 complete suicide at almost six times the national average. Elder suicide is most rampant among the fastest growing aged cohorts. It will increase simply as a consequence of the "age wave" sweeping across our society. Elder suicide is under-reported. Often omitted are deaths from deliberate medical noncompliance, self-starvation, and "accidents."
2. What are the causes?
Elder suicide is driven by both psycho-social and neuro-biological variables. It is associated with depression and with factors causing depression, e.g., chronic illness, physical impairment, unrelieved pain, financial stress, loss and grief, social isolation, and alcoholism. The elderly face "double jeopardy." Depression is tied to low serotonin levels. Serotonin, which decrease with age, is a neurotransmitter which limits violent and self-destructive behavior.
3. What are the warning signs?
Some of the following present for two weeks or longer may indicate serious risk:
Loss of interest in usually pleasurable activities. Reducing social interaction, self-care, and grooming. Complaining of decreased energy or fatigue. Chronic pain syndromes; aches and pains that do not respond to treatment. A sudden interest or disinterest in religion. Feeling of hopeless and worthless ("My family is better off without me"). Putting affairs in order, giving things away, or making changes in wills. Stock-piling medication or obtaining other possible means of suicide.
4. Why aren't providers doing more?
Elder suicide occurs all along the post-acute continuum. There has been some attention, but not very much. Some possible explanations are:
Providers are not involved with the population at greatest risk, elderly men (less than one-third of those served by HHAs and SNFs are men) Providers are rehabilitation-oriented and committed to enhancing self-sufficiency and autonomy which may inhibit intervention; Providers may hold misconceptions about suicide and may regard some of the warning signs as "normal" consequences of aging; and Despite interest in gero-psychiatric care, screenings for depression is not consistently and continuously done in many post-acute care settings.
5. What can providers do?
Post-acute care providers must optimize their preventative potential by:
Much can be done to keep individuals from becoming suicidal. Much can be done to keep those who become suicidal from becoming victims.
6. What about assisted suicide?
Assisted suicide is a form of elder suicide, and part of the problem. Post-acute care providers need to recognize the following research findings:
Persistent thoughts of suicide are uncommon in the absence of depression, other psychiatric disorders, or uncontrolled physical symptoms and pain. Suicide is often felt to be a strategy for regaining control among those who feel they have lost control to depression, illness, and pain. Fear of severe pain drives requests to physicians for assisted deaths. Pain clinics report many cases where adequate pain management has led to an abatement of suicidal behavior in patients with severe pain. Inadequately controlled severe pain has been identified as a problem among many who complete suicide.
There is a lot to be done to assure that assisted suicide is the "last resort" among those served by post-acute care providers.
December 1998
