NEW ORLEANS — Suicidal thoughts and actions are not rare among the elderly and seem to have diverse drivers, including physical disability, pain, and loneliness. Overall, about 6% of those 65 and older expressed some sort of death wish or suicidal behavior, a large population-based study has found. But that number almost tripled among subjects who had high levels of functional disability, Margda Waern, MD, PhD, reported at the annual meeting of the American Association for Geriatric Psychiatry. Dr. Waern, a psychiatrist at the University of Gothenburg, Sweden, discussed a pooled analysis of the classic EURODEP study, which examined the relationship between depressive symptoms and physical functioning in 14 cross-sectional European cohorts. EURODEP is comprised of almost 23,000 respondents 65 years and older and has been mined many times since its original publication in 2004. Dr. Waern examined pooled data from 11 of the EURODEP studies, comprising 15,580 subjects. Most of the centers — but not all — used the Katz Index of Independence in Activities of Daily Living scale to assess physical function. In order to harmonize the data on functional disability, Dr. Waern instead trichotomized them into no disability, intermediate disability, and high disability. She also examined a broad measure of suicidality — “death wishes” — which she said encompassed the continuum of suicidal thoughts to active ideation. “We saw what I would call a very nice dose-response relationship between high levels of functional disability and death wishes,” she said. About 4% of those without a functional disability expressed ever having had a death wish, compared to 8% of those with moderate disability, and 17% of those with high functional disability. Those findings were similar among both men and women. She tried to tease out more detailed data with a multivariate regression model of 11,000 subjects. In this model, functional disability remained a strong independent risk factor. Intermediate disability conferred a 60% increased risk of death wish, and a high level more than doubled the risk (OR, 2.4). Perceived loneliness also was a strong independent risk factor, associated with a near tripling, compared with those who did not feel lonely (OR, 2.7). Subjects with chronic illnesses also were at significantly higher risk of having death wishes, Dr. Waern said. She also discussed a population-based study of suicidal feelings in people 97 years and older. All residents of Gothenburg who had reached that age were invited to participate in the survey. Dr. Waern had a 60% response rate — about 600 residents. Of these, 269 without a diagnosis of dementia participated in the survey, which asked about suicidal thoughts and actions in the previous month. There were no recent suicide attempts, she said. But 12% of the cohort reported some kind of suicidal feeling or thought during that time frame. These included the idea that “life is not worth living” (8%), death wishes (10%), and thoughts about committing suicide (4%). She looked for associations between these thoughts and several physical characteristics. Most (77%) of those who reported such feelings fulfilled criteria for neither major nor minor depression. There were no associations with vision or hearing loss, overall motor function, or with a perception of poor physical health. Suicidal feelings were significantly more common among those who had experienced a stroke (23% vs. 16%) and among those who reported living with physical pain (41% vs. 24%). “In a multivariate model, however, pain fell out as an independent predictor,” Dr. Waern said. “What did show up was problematic sleep and also the feeling of having deficient social contacts.” Sleep difficulties were associated with a tripling of the risk (OR, 3.5). Three forms of social isolation conferred a significant increase in the risk of suicidal thoughts: too little time spent with neighbors (adjusted OR, 5.0), too little time spent with friends (OR, 6.6), and perceived loneliness (OR, 3.3). Dr. Waern had no financial disclosures. Michele G. Sullivan is with the Mid-Atlantic bureau of Frontline Medical News. There is nothing surprising about the findings in this study. We have all observed the correlation between functional disability and depressive symptoms, even if subsyndromal. Thoughts of death, or statements like “I pray every night that God will take me” or “My life is not worth living anymore” are not rare in substantially functionally dependent elders. The connections between these kinds of thoughts and poor sleep, isolation, or pain are similarly unsurprising. Increasingly, for all age groups, the importance of good restorative sleep, a supportive social network, and absence of physical pain is being recognized as a determinant of quality of life. We should consider these factors when evaluating our patients, and try to implement appropriate interventions to improve them whenever possible. —Karl Steinberg, MD, CMD Editor in Chief
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