Clue In to Suicide Risk Among Elderly Patients

Abstract

Mitchel L. Zoler is with the Philadelphia bureau of Elsevier Global Medical News. PHILADELPHIA — Suicide is more common among the elderly, particularly older men, than it is in other demographic groups, Patrick Arbore, Ed.D., said at a conference of the American Society on Aging. In California, reported suicides in 2004 occurred in 23 per 100,000 individuals aged 85 or older, or at a rate that is about 30% higher than for the 75–84 age group. In turn, people aged 75–84 had a suicide rate about 38% higher than younger groups in the California data, said Dr. Arbore, founder and director of the Center for Elderly Suicide Prevention at the Institute on Aging in San Francisco. In addition, older people are more likely to use a lethal method and complete the act of suicide. For every four suicide attempts among the elderly, one is completed. In the general pupulation, for every 8–25 attempts, 1 is completed. Women are three times more likely to attempt suicide than are men in the United States, but men are four times more likely to actually complete the act, Dr. Arbore said. However, there is no distinctive type of elderly suicide. The range of episodes among this group is the same as it is for younger people. The elderly can have protest suicides, often because of an inability to adjust to physical decline; preemptive suicides, in which a person observes and perceives the death of a loved one to be a terrifying experience and chooses to end his own life; or murder–suicides, in which a person first murders someone else (such as a spouse), then takes his or her own life. An elderly person contemplating suicide often will see a physician before attempting the act, although suicidal ideation usually is not brought up by the patient, and the patient's depression is hidden or missed. In fact, elderly patients are much less likely to communicate their depression than are younger patients. Covert depression is especially prevalent in elderly men. Assessment of an elderly person, then, should include consideration of depression, as well as cognitive function, demoralization, paranoia, substance abuse, psychopathology, personality, environment, social context, and suicide risk. “The goal is not to predict suicide but to place a person on a risk continuum, to appreciate the basis for suicidality, and to allow for a more informed intervention,” Dr. Arbore said. People are especially at risk if they are impulsive, anguished, unable to see a solution to their problems, or have access to a lethal weapon. Psychiatric disorders also boost risk. Depression is the most common factor. An evaluation of clients in Dr. Arbore's San Francisco program showed that changes in vision, hearing, and mobility often were accompanied by increases in depression and hopelessness. Furthermore, suicide risk was associated with physical illness and functional limitations and the interplay of these with depression. One estimate is that 12%–20% of elderly people living in the community have significant symptoms of depression, but many may not meet definitions of the severity threshold for major depression, Dr. Arbore said. A 1999 report found major depression played a pivotal role in 60% of reported suicide cases and 80% of suicides in the elderly. “There is a pressing need for early identification of older adults who have treatable depression and can be helped,” Dr. Arbore said. He recommends the Geriatric Depression Scale and the Geriatric Hopelessness Scale for assessing patients. He also uses the Michigan Alcohol Screening Test–Geriatric version for an assessment. A key to intervention is talking with the person about his pain, such as asking, ‘How much do you hurt?’ Caregivers also should use active listening and convey hope.