Suicide In Dementia Research Articles

Euthanasia and Assisted Suicide in Dementia - the European Perspective

In 2002, the Netherlands was the first jurisdiction worldwide that has legalized euthanasia and physician assisted suicide. Although the number of jurisdictions that has legalized euthanasia and medical assisted suicide has gradually increased over the years, the Dutch law is still progressive allowing euthanasia and physician assisted dying in non-terminal illnesses as well as advanced stages of dementia. This legislation has been praised as well as criticized. Proponents point to the principles of justice, mercy, the right to a dignified end of life, the responsibility of a doctor for a good life, including a good end of life, and the right of self-determination of people. Critics point to conflicting treatment goals, problems due to countertransference, complexity of the interpretation of due diligence, the distinction with chronic suicidality and finally the fact that many psychiatrists do not feel competent to perform euthanasia with due medical care.First, we will briefly present the current Dutch procedure, including the independent role of so-called SCEN-physicians. The Support and Consultation of Euthanasia in the Netherlands (SCEN) is a training and licensing program of the Royal Dutch Medical Association. In the first presentation, Radboud Marijnissen will present an overview of the development and current practice of euthanasia in dementia in the Netherlands. Thereafter, Lia Fernandes will present and discuss the debate on the legislation of euthanasia in Portugal, which is still controversial being a primarily Catholic country. The third presentation is a scientific evaluation of the assessment of mental capacity in 60 dementia cases that received euthanasia in the Netherlands. After the three presentations, the pros and cons of euthanasia in dementia as well as the current legislation will be discussed.

External causes of death from death certificates in patients with dementia

AbstractBackgroundThe external causes of death, including unintentional injuries, falls, suicide, and complications of medical and surgical care, in dementia are not well‐established, particularly in rare dementias. We compared risk of death from specific external causes in patients with dementia and control participants.MethodThis was a nationwide population‐based cohort study in Sweden integrating 6 national registers from May 1, 2007, through December 31, 2018. We included all dementia patients aged 40 years or older identified from the Swedish Dementia Register‐SveDem and the national patient registry during the period and up to four control participants who were matched on the year of birth (± 3 years), sex and region of residence. Causes of death were obtained from death certificates compiled in the death registry. Hazard ratios (HRs) and 95% confidence intervals (CIs) of dementia on external cause‐specific mortality were calculated using Cox proportional models, adjusted for sociodemographic variables, comorbidity, and psychiatric disorders.ResultThe study cohort included 241 569 patients with dementia (99 380 men [41.1%]; mean [SD] age, 81.5 [8.5] years) and 794 562 control participants (352 295 men [44.3%]; mean [SD] age, 79.9 [8.6] years), over 3 871 433 person‐years. People with dementia presented higher incident rates for unintentional injuries and falls during old age, and suicide in middle aged dementia patients, while the reverse trend for suicide in dementia was observed after 75 years. The association varied according to time since diagnosis. Compared with control participants, people diagnosed with dementia had an adjusted HR of 2.66 (95% CI, 2.58‐2.74) for unintentional injuries, 2.10 (95% CI, 2.01‐2.20) for falls, 0.48 (95%CI, 0.40‐0.58) for suicide, 0.94 (95%CI, 0.89‐1.00) for complications of medical and surgical care, and 2.61 (95%CI, 2.04‐3.34) for other external causes. Compared with control participants, patients with frontotemporal dementia had the highest risk of unintentional injuries and falls, while participants with mixed dementia were less likely to die from suicide and complications of medical and surgical care.ConclusionSuicide risk screening in early‐onset dementia and early interventions for unintentional injuries and falls prevention in older patients with dementia should be provided.

P130: Suicide risk after dementia diagnosis - what do we know and what to expect?

Objective:The purpose of this research is to review the association between the dementia diagnosis and suicide risk, to debate what to expect on this topic in the future, and to identify some strategies to control suicide risk after dementia diagnosis.Methods:Non-systematic review of the literature with selection of scientific articles published in the last 10 years, using PUBMED as database and the following keywords: «suicide», «dementia» and «dementia diagnosis». Nine studies were included.Results:Nowadays, suicide account for one million deaths worldwide per year. Suicide rates are up to 8 times higher in the elderly than in general population, in relative numbers. Dementia is an incurable diagnosis and usually result in loss of mental competence. After being diagnosed with dementia, people face emotional challenges and use to feel loss, anger, and uncertainty.Different studies found dementia as an independent risk factor for suicide. Also, some factors that increase the risk for suicide in dementia are described: the existence of psychiatric comorbidity, such as depression, anxiety, psychosis and substance use; The initial stages of dementia, often within three months of diagnosis, because the person perceive a higher threat to his life, with progressive physical and cognitive impairment, increasingly higher levels of dependence and concern on becoming a burden for their family, and, at the same time, preserving intellectual and volitive capacities to plan and carry out suicide; And younger age at dementia diagnosis, with higher difficulties in adjusting to the diagnosis.We are moving towards pre-symptomatic and early dementia diagnosis utilizing biomarkers and genetic tests. This implies that the diagnosis is made in younger people, so concerns have been raised about a potential increase for suicidal behavior.Conclusion:The findings of this research highlight the importance of providing support and paying attention to people with recent dementia diagnosis, particularly in the first year and for patients aged < 75 years. We suggest active management of pre-existing mental disorders, suicide risk evaluation, assessment of patient and caregiver needs and restricting access to lethal means.

Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence.

There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Advocacy for this position is often based on utilitarian philosophical principles, on appeals to the quality of life of the patient and their caregiver(s), or on economic constraints faced by caregivers as well as healthcare systems. In this paper, two lines of evidence against this position are presented. First, data on attitudes towards euthanasia for twenty-eight countries, obtained from the World Values Survey, is analyzed. An examination of this data shows that, paradoxically, positive attitudes towards this procedure are found in more economically advanced countries, and are strongly associated with specific cultural factors. Second, the literature on existing attitudes towards PAS in cases of dementia, along with ethical arguments for and against the practice, is reviewed and specific hazards for patients, caregivers and healthcare professionals are identified. On the basis of these findings, the author suggests that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers.

Physician assisted suicide in dementia: A critical review of global evidence and considerations from India.

Dementias are a group of gradually progressing neurodegenerative conditions, leading to significant impairment in cognition, functioning, decision-making, capacity and autonomy. With the rise of human rights and patient-centred perspectives in psychogeriatric management, physician-assisted suicide (PAS) has emerged as an important and integral part of end-of-life care in advanced dementias. With only few original studies in the area, this paper takes a narrative and critical approach to review the global legislations, treatment decisions, debates as well as perspectives from patients, families and medical professionals. PAS and euthanasia are legally allowed in countries like Belgium, Netherlands, Switzerland and few states of the United States (U.S.). Germany has fewer clearer legislations in this regard. The Oregon state requirement and care criteria of the Dutch euthanasia act form the basis of most such laws. Even in the presence of these provisions, PAS is fraught with multiple medical, ethical, moral and legal dilemmas and physicians as well as caregivers are quite heterogenous in their outlook. While right to live with dignity and need to end incurable suffering form the main arguments for PAS, several arguments against it are possibility of undue influence, impaired judgement leading to biased decision-making such as depression and suicidality, inappropriate assessment of capacity, and that all deaths are not necessarily painful. These dilemmas are critically discussed in light of autonomy, decision-making and advanced directives in people living with dementia as well as the rationality of ending life and 'right to live vs right to die'. Based on the findings, certain balanced strategies are highlighted for the health professionals. The 'slippery slope' of PAS needs to be carefully evaluated from a social justice and human rights perspective to improve dignified end-of-life care in dementia. Considerations are also discussed from India, a rapidly-ageing nation with no current provisions for PAS.

The role of impairment of higher mental functions in suicidogenesis in the dementia caused by Alzheimer's disease

Background Dementia is the age-related disease. At the same time, the elderly age has one of the peaks in the number of suicides. Psychology of patients with demetia is characterized by the feeling of hopelessness, pessimism, awareness of own insolvency, dependence on others, that affects the risk of suicide. It is established that the highest risk of suicide in the early stages of dementia with the progression of cognitive deficit, the risk of suicide decreases. Aim To study the role of impairment of higher mental functions (perception, reasoning, attention, memory, emotions, will, speech) in the formation of suicidal behaviour in patients with dementia in Alzheimer's disease. Materials and methods There were examined 75 patients with dementia in Alzheimer's disease, 36 patients with a history of suicidal behavior composed the main group, and 39 patients without the signs of suicidal behavior composed control group. The study was carried out using clinical-anamnestic, psychopathological methods and mathematical statistical methods. Results The high risk of suicide in dementia caused by Alzheimer's disease is combined with the inhibition of thinking, the delusional ideas of self-blame and self-effacement (p ≤ 0.05); depressed mood, inner agitation, anxiety, feeling of despair, hopelessness, guilt, melancholia, apathy (p ≤ 0.05); effector-volitional disorders in the form of hypobulia, hypokinesia, hypomimia, decreased libido (p ≤ 0.05); speech disturbance in the form of bradylalia p ≤ 0.05; greater exhaustion and decreased attention (p ≤ 0.05). On the contrary, the following peculiarities of higher mental functions, namely thought disorder are referred to the anti-risk factors of suicide in dementia caused by Alzheimer's disease: the delusional ideas of relation and damage (p ≤ 0.05); emotions: the feeling of fear (p ≤ 0.05); effector-volitional sphere: parabulia and hyperkinesia (p ≤ 0.05). Conclusion On the basis of clinical and psychopathological study of patients with dementia in Alzheimer's disease, the specific impairment of higher mental functions and emotional-volitional spheres reasoning, memory, attention, perception, speech, emotions) are identified associated with high risk of suicide.

Suicide and assisted dying in dementia: what we know and what we need to know. A narrative literature review.

Evidence-based data on prevalence and risk factors of suicidal intentions and behavior in dementia are as scarce as the data on assisted dying. The present literature review aimed on summarizing the current knowledge and provides a critical discussion of the results. A systematic narrative literature review was performed using Medline, Cochrane Library, EMBASE, PSYNDEX, PSYCINFO, Sowiport, and Social Sciences Citation Index literature. Dementia as a whole does not appear to be a risk factor for suicide completion. Nonetheless some subgroups of patients with dementia apparently have an increased risk for suicidal behavior, such as patients with psychiatric comorbidities (particularly depression) and of younger age. Furthermore, a recent diagnosis of dementia, semantic dementia, and previous suicide attempts most probably elevate the risk for suicidal intentions and behavior. The impact of other potential risk factors, such as patient's cognitive impairment profile, behavioral disturbances, social isolation, or a biomarker based presymptomatic diagnosis has not yet been investigated. Assisted dying in dementia is rare but numbers seem to increase in regions where it is legally permitted. Most studies that had investigated the prevalence and risk factors for suicide in dementia had significant methodological limitations. Large prospective studies need to be conducted in order to evaluate risk factors for suicide and assisted suicide in patients with dementia and persons with very early or presymptomatic diagnoses of dementia. In clinical practice, known risk factors for suicide should be assessed in a standardized way so that appropriate action can be taken when necessary.

Suicidal behavior and assisted suicide in dementia

Concerns about suicide risk in people with dementia have been increasing in recent years along with a discourse about rational suicide and assisted suicide. A systematic narrative literature review of suicidal behavior and assisted suicide in persons with dementia. Most studies that have examined the spectrum of suicidal ideation, attempted suicide and suicide in dementia have methodological limitations but the overall suicide risk does not appear to be increased. When suicidal behavior does occur, common themes include the presence of psychiatric comorbidity, mainly depression; occurrence early in the dementia course with preserved insight and capacity; and an increased risk in younger people. The emerging discourse on rational and assisted suicide has been spurred by early and pre-symptomatic diagnosis and poses a number of ethical challenges for clinicians including the role of proxy decision-makers. Although dementia might not confer a significant overall risk for suicidal behavior, clinicians still need to consider the potential for suicide in vulnerable individuals particularly early in the dementia course.

Euthanasia and physician-assisted suicide in dementia: A qualitative study of the views of former dementia carers

Background: Despite media and academic interest on assisted dying in dementia, little is known of the views of those directly affected. Aim: This study explored the views of former carers on assisted dying in dementia. Design: This was a qualitative study using thematic analysis. Setting/participants: A total of 16 former carers of people with dementia were recruited through national dementia charities and participated in semi-structured interviews. Results: While many supported the individual’s right to die, the complexity of assisted dying in dementia was emphasized. Existential, physical, psychological and psychosocial aspects of suffering were identified as potential reasons to desire an assisted death. Most believed it would help to talk with a trained health professional if contemplating an assisted death. Conclusion: Health workers should be mindful of the holistic experience of dementia at the end of life. The psychological and existential aspects of suffering should be addressed, as well as relief of physical pain. Further research is required.

Suicide Risk in Frontotemporal Lobe Degeneration

Suicide is difficult to ascertain in elderly patients, and dementia might represent a risk factor, though predictors of suicide in dementia are still unknown. We report the case of a patient recently diagnosed as having a behavioral variant of frontotemporal lobar degeneration (FTLD), apathetic syndrome, who committed suicide by hanging. His personal and family history was negative for mental disorders; a depressive syndrome was diagnosed 1 year before FTLD diagnosis, and treated unsuccessfully. To the best of our knowledge, no data are available about self-harmful events in FTLD. This case report argues for the urgent need for developing specific tools for the assessment of suicidal ideation among at-risk population.

Ärztliche Suizidassistenz bei Demenzerkrankungen?

Physician-assisted suicide in Germany is limited by criminal law and disapproved by professional authorities. A physician who is willing to help a demented patient in terminating his life has to be definitely sure that the disease does not interfere with the patient's capacity for decision-making. In cases of early dementia the reason why assisted suicide will usually be requested is not the actual suffering of the patient but his negative expectations for the future. As long as there are sufficient opportunities for palliative care, the progressive course of the dementia process does not imply a state of unbearable suffering which could justify an assisted suicide. Nevertheless there may be certain circumstances--as for instance the value that an individual attributes to his integrity or to the narrative unity of his life--which might possibly provide an ethical justification for the assistance in life termination. A physician who helps a demented person in performing a suicidal act does not necessarily oppose essential principles of medical ethics. Yet, especially with regard to possible societal consequences of physician-assisted suicide in dementia, the rejecting attitude of medical authorities against that activity must be considered as well founded and legitimate. Deviations from these general guidelines ought to be respected as long as they are limited to exceptional situations and correspond to a thorough consideration of a physician's professional duties. They should remain open to public control, but not be ultimately specified by unequivocal normative regulations.

Dementia and suicidal behavior: a review of the literature

While dementia is more common in older people and suicide rates in many countries are higher among the elderly, there is some doubt about the association between these two phenomena. A search of the major relevant databases was carried out to examine the evidence for this possible association. The association between dementia and suicide and also non-fatal self-harm did not appear strong but many studies have significant methodological limitations and there are few studies of suicide or self-harm in vascular, frontotemporal, Lewy body and HIV dementia where such behavior might be expected to be more common. Rates of self-harm may be increased in mild dementia and are higher before than after predictive testing for Huntington's disease. Overall, the risk of suicide in dementia appears to be the same or less than that of the age-matched general population but is increased soon after diagnosis, in patients diagnosed with dementia during hospitalization and in Huntington's disease. Putative risk factors for suicide in dementia include depression, hopelessness, mild cognitive impairment, preserved insight, younger age and failure to respond to anti-dementia drugs. Large, good quality prospective studies are needed to confirm these findings. Further research should be undertaken to examine how rates of suicide and self-harm change during the course of the illness and vary according to the specific sub-type of dementia.

Suicide in dementia: 9-year national clinical survey in England and Wales

Knowledge of suicide in people with dementia is limited to small case series. To describe behavioural, clinical and care characteristics of people with dementia who died by suicide. All dementia cases (n=118) from a 9-year national clinical survey of suicides in England and Wales (n=11 512) were compared with age- and gender-matched non-dementia cases (control group) (n=492) by conditional logistic regression. The most common method of suicide in patients with dementia was self-poisoning, followed by drowning and hanging, the latter being less frequent than in controls. In contrast to controls, significantly fewer suicides occurred within 1 year of diagnosis in patients with dementia. Patients with dementia were also less likely to have a history of self-harm, psychiatric symptoms and previous psychiatric admissions. Known indicators of suicide risk are found less frequently in dementia suicide cases than non-dementia suicide cases. Further research should clarify whether suicide in dementia is a response to worsening dementia or an underappreciation of psychiatric symptoms by clinicians.

Morality of Suicide in Dementia

Morality of Suicide in Dementia