Primer on Suicide in Older Adults

Albert Camus, a French author and philosopher, once said in a famous essay, “There is but one truly serious philosophical problem, and that is suicide.”¹ When examining the question of whether life is worth living, how a person responds depends on, among other things, his or her physical and emotional health, personality, culture, religious and philosophical beliefs, sex, and age. In older adults, suicidal behaviors can be an especially complex phenomenon, as they may be wrongly attributed to comorbidities, and this population faces many more risk factors for suicide than younger individuals.

In this article, we focus on the factors that place elderly patients at higher risk for suicide. We also discuss the methods for identifying patients at risk and the interventions that can prevent suicide in these individuals.

Epidemiology

In 2007, suicide was the 11th leading cause of death in the general population in the United States, ranking behind kidney disease and septicemia.² In 2009, suicide rose to the 10th position. That same year, the prevalence of suicide in the general population was 11.9 events per 100,000 people, accounting for 36,547 deaths.³ The numbers are much higher for adults aged 65 years and older. In 2007, the prevalence of suicide among this population was 14.3 events per 100,000 people—more than double the rate among younger individuals (7.0 events per 100,000 among those 10-24 years old).⁴ In that year, there was one suicide committed by an elder every 97 minutes, or 15 suicides among elders every day, resulting in 5421 suicides annually among this population.⁵

Risk Factors

Although the focus of this article is on the geriatric risk factors for suicide, it is important to recall the risk factors for patients of any age, which include major depression, history of previous suicide attempts, specific plans for a suicidal act, and a family history of suicide. As people age, they experience more loss, both physically and emotionally, than their younger counterparts. Physically, they lose muscle mass and strength. They may develop chronic illnesses, which lead to functional loss and disability, and their memory and other cognitive functions often decline. These impairments may result in older persons giving up previously pleasurable activities, such as golf, tennis, or bridge, or exiting the workforce, leaving their work identity behind. The emotional pain related to these life changes is compounded further when elderly patients grieve for friends and relatives who have died before them and when their children move on with their own lives. These losses make elderly patients more susceptible to depression and increase their risk of suicide. What follows is a discussion of some of the key risk factors for suicide in elders, including sex, ethnicity, geographic location, depression, social isolation, medical illness, alcohol abuse, and access to firearms (Figure).

Sex
In addition to age, a person’s sex determines his or her suicide risk. Suicide is the 7th leading cause of death in men, whereas in women it is the 16th leading cause.⁶ Male suicide accounts for 79% of all suicides.⁶ In 2007, the suicide rate for men 75 years and older was 35.7 events per 100,000 people, which was almost twice the rate for men of all ages (18.4/100,000).⁵ Among women, the incidence of suicide peaks among those 45 to 54 years old (8.4/100,000).⁶ Contributing to this rate disparity between men and women is the way that men experience depression (such as through the denial of their affective symptoms and their inability to express their feelings), the traditional masculine values (stoicism and tough-mindedness) some men hold, and the stigma of chronic mental illness.⁷

Ethnicity
Among all persons 65 years of age and older, suicide rates were higher among whites (33.0/100,000) than among African Americans (11.0/100,000), Hispanics or Latinos (15.6/100,000), and Asian or Pacific Islanders (6.43/100,000) from 2005 to 2009.⁸ A study exploring belief systems among African Americans revealed strong religious and cultural taboos regarding suicide.⁸ Physicians, however, should be careful about generalizing cultural data, as all patients must be assessed individually for their suicide risk, independent of their race.

Rural Communities
Suicide rates are three times higher in rural areas than in urban ones, and rural areas also have a higher per capita population of elders, at 14.6% versus 11.9%, respectively.⁹ There are many likely reasons for the higher rates of suicide observed in rural areas. Rural communities tend to have more  individuals with depression, substance abuse, and cognitive impairment than urban communities. Rural residents have lower incomes, higher unemployment rates, less health insurance, and more substandard housing. These communities also receive less mental health funding. In addition, they often cannot raise sufficient local funds to qualify for matching state or federal grants, and they also have difficulty recruiting or keeping mental health professionals: 55% of rural counties in the United States lack the services of a psychiatrist, social worker, or psychologist.¹⁰ Although rural areas have fewer mental health resources, one study noted that this deficit may be partially offset by the large social support systems of family and friends in these communities.¹¹

Depression
Many studies have linked suicide to late-onset depression. An estimated 2 million elderly persons have depressive illnesses.¹² The incidence of major depression ranges from 1% to 5% among community-dwelling elders, but is as high as 11.5% among those who are hospitalized and 13.5% among those who require home healthcare.¹² It is also estimated that an additional 5 million elders have subclinical depression that fails to meet diagnostic criteria.¹³

The high prevalence of subclinical depression is likely due to the difficulty of diagnosing depression in elderly patients. Common symptoms of depression, such as fatigue, insomnia, and weight loss or gain, may be wrongly attributed to chronic illnesses, including congestive heart failure, chronic kidney disease, and chronic obstructive lung disease, whereas poor concentration, sadness, and memory problems may be wrongly attributed to normal aging or to grief reactions.

A symptom of depression that should be carefully evaluated for is somnipathy, or sleep disorder, as the presence of this neurovegetative symptom of depression has been shown to increase suicide risk. In the GAZEL cohort study,¹⁴ 16,989 participants (age 35-50 years) were asked validated questions on sleep disturbances in an effort to determine the effects of these disturbances on mortality rates. Patients were evaluated over a 10-year period, and fewer than 1% were lost to follow-up. The researchers found that the presence of three or more sleep disturbances (eg, early morning awakening, not being able to fall asleep, self-reported poor sleep quality, use of a sleep medication) was associated with a five times higher risk of death due to suicide (hazard ratio, 4.99; 95% confidence interval, 1.59-15.7) in men.¹⁴ In elders, the change in sleep architecture that occurs with aging, along with the neurovegetative symptoms of depression causing sleep disorders, may compound suicide risk.

Special consideration should also be given to patients with chronic pain, as it can often worsen depression and is an independent risk factor for suicide. In a Canadian study, 1354 elderly patients who committed suicide were retrospectively reviewed for risk factors predisposing to suicidal behavior.¹⁵ Moderate and severe pain had a strong correlation with suicide, with odds ratios of 1.91 and 7.52, respectively.

Social Isolation
Social isolation due to bereavement or loss of social support increases the risk of suicide. A 12-year study by Li¹⁶ that included 6266 white married persons and 3486 white widowed persons (age ≥60 years) reported suicide rates of 28.7 events per 100,000 person-years and 40.4 events per 100,000 person-years in these groups, respectively. The risk of suicide for widowed men was 3.3 times higher than for married men, but the risk of suicide for widowed women did not increase over that for married women.¹⁶ Social isolation may also result from medical illnesses that impair mobility, social interactions, and independence. Pain, visual problems, hearing loss, fatigue, memory loss, and arthritis often increase with age, making socialization with others more difficult for elderly individuals.

Medical Illness
Medical illnesses alone may impact suicide risk. Swedish investigators compared the records of 46 men and 39 women who were aged 65 years or older and had committed suicide with those of a control population of 84 men and 69 women of the same age who were living in the same geographic area.¹⁷ After conducting interviews with the relatives of the suicide victims and control persons, the investigators found that impaired vision, neurologic disorders, and malignant disease were all independently associated with suicide. When the sexes were analyzed separately, serious physical illness seemed to be a stronger predictor in men than in women.¹⁷

Alcohol Abuse 
Many adults of all ages cope with loss, regret, and disappointment by drinking alcohol. As noted previously, elders are prone to having experienced more loss in their lives. Changes in late life, such as the development of chronic medical illnesses and the loss of loved ones, can serve as a nidus for alcohol abuse.¹⁸ Alcohol is also metabolized differently in older adults, making them more susceptible to its toxic effects. Disinhibition from alcohol and the decrease in serotonin metabolism caused by excessive alcohol consumption increase impulsivity and aggression, enhancing suicidal behaviors.¹⁹

In 2009, the National Survey on Drug Use and Health reported that 39.1% of older adults consume alcohol, with 9.8% of these individuals engaging in binge drinking and 2.2% reporting heavy alcohol use.²⁰ A retrospective case-control study discovered a history of alcohol dependence or misuse in 35% of elderly men and in 18% of elderly women who died by suicide.²¹ Alcohol abuse was uncommon among persons in the control group (2% of the men and 1% of the women). Based on this finding, the authors concluded that alcohol use disorder is an independent predictor of suicide for both sexes.²¹

Access to Firearms
In the United States, firearms are the leading mechanism of death by suicide, with approximately 55% of suicides carried out this way.²² A probability study of 300 primary care physicians in Illinois revealed that a sizable proportion of them (42%) did not ask depressed or suicidal patients whether they had access to a firearm.²³

Older adults are more successful than their younger counterpart in their attempts to kill themselves.²⁴ Among individuals 15 to 24 years old, there are approximately 100 to 200 suicide attempts for every completed act, whereas among adults 65 years and older, there are approximately four suicide attempts for every completed act.²⁵ The increased propensity for older adults to be successful in committing suicide is the result of several factors: (1) they tend to be frailer, making it more difficult for them to withstand or recover from an injury; (2) they have less opportunity for rescue because they are more likely to live alone or be socially isolated; and (3) they tend to use more lethal means to complete their suicide because they also have a greater intention to die.²⁶

Screening

The US Preventive Services Task Force has concluded that there is insufficient evidence for or against recommending routine screening by primary care clinicians to detect suicide risk in the general population.²⁷ Screening for suicidal ideation should be targeted at high-risk subgroups based on knowledge of psychological, physical, and social factors.²⁷ Most suicide assessment measures have been developed for children, adolescents, and college students, but few measures have been designed specifically for older adults.²⁸

Physicians may use existing tools to detect suicidal ideation, such as the Yale Evaluation of Suicidality scale and  the Beck Scale for Suicide Ideation (BSS). The BSS is one of the most widely used measures of suicide ideation. It has high predictive validity for completed suicide; however, it can take 5 to 10 minutes to administer, making it too time-consuming to use in primary care settings.

Since depression is often linked to suicidal ideation, clinicians often use depression scales, such as the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Geriatric Depression Scale (GDS), the latter of which has been examined in multiple studies as a tool to screen for suicidal ideation among older adults.²⁹ The GDS is a validated tool that can help diagnose depression. The original test consists of 30 questions; however, the 15-question test (short form) can be administered in 2 to 3 minutes and is an effective screening test in the primary care setting. One study examined the use of a 5-item GDS subscale designed to screen for suicidal ideation (GDS-SI).³⁰ Both tools (GDS and GDS-SI) were administered to a cross-sectional cohort of 626 primary care patients (235 men, 391 women) who were at least 65 years old. The study showed that if one item was positive on the GDS-SI, it had a high sensitivity and specificity for suicidal ideation.³⁰

Research has shown that early intervention in depression reduces suicidal ideation in older adults with depression.^31,32 Primary care providers play an important role in identifying these patients, as most of these individuals seek out care from primary care providers, rather than from psychiatrists and mental health professionals.³³ It is estimated that 20% of elderly persons who commit suicide visit a physician within 24 hours of their fatal act, 41% visit within a week of their suicide, and 75% are seen by a physician within 1 month of their suicide.³⁴

As noted previously, depression is difficult to diagnose in elderly patients with multiple medical problems. The risk factors outlined in this article should alert physicians to patients who must be screened more regularly for depression and suicidal ideation. Physicians should also be diligent about screening during their patients’ major transitions in life, such as the period of grieving following the loss of a loved one or during recovery from a medical illness.

Management

Elderly patients in whom depression and suicidal ideation are diagnosed will benefit from a multifaceted intervention. Tricyclic antidepressants and selective serotonin reuptake inhibitors have been shown to be equally effective in treating depression in elders,³⁵ but a comprehensive discussion of their use is beyond the scope of this article. Physicians should also refer their patients to appropriate mental health professionals and provide access to emergency help lines and counseling services (Table), as a collaborative approach to suicide prevention has been shown to be the most effective management strategy.

In two randomized controlled trials, PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial)³⁶ and IMPACT (Improving Mood-Promoting Access to Collaborative Treatment),³⁷ investigators studied a collaborative care model involving psychotherapy, use of depression care managers, and close follow-up. The PROSPECT trial included patients aged 60 years and older from 20 primary care practices in New York City, Philadelphia, and Pittsburgh, and the IMPACT trial included 1801 adults aged 60 years and older with major depression, dysthymia, or both from 18 participating primary care clinics affiliated with seven healthcare organizations in five states. Both studies demonstrated a reduction in depression and suicidal ideation with use of collaborative care.^36,37

Among patients who received collaborative care in the PROSPECT trial, the rate of suicidal ideation declined faster (P=.01) than that among patients who received usual care. At 4 months, the rate of suicidal ideation declined 12.9% in the intervention group compared with only 3.0% in the usual care group. Among patients who reported suicidal ideation, resolution of ideation occurred significantly faster among those who received the collaborative intervention (P=.03). The difference between the two treatment groups was greatest at 4 months.³⁶

In the IMPACT trial, patients who received the IMPACT program had access to a depression care manager for up to 12 months, whereas those randomly assigned to usual care received the treatments typically available to them in their primary care clinic (eg, antidepressants).³⁸ At 12 months, 45% of IMPACT patients had a ≥50% reduction in depressive symptoms compared with only 19% of those in the usual care group. A study assessing the long-term efficacy of the IMPACT intervention found that these results were maintained at 6 and 12 months following withdrawal of the intervention.³⁹

Although few studies in the United States support their use,⁴⁰ community educational programs addressing mental illness, substance abuse, and suicidal ideation may be beneficial. Cohort studies in Japan have shown benefits from such programs.^41,42 These studies included community-based outreach programs in rural Japanese areas with high suicide rates among elders. Annual depression screenings, mental health workshops, and other educational activities for older adults were offered. Patients who demonstrated positive screening results were referred to psychiatrists or general practitioners.

A meta-analysis of five studies evaluating Japanese community-based outreach programs demonstrated their efficacy in reducing suicide rates among individuals aged 65 years and older living in regions of Japan where suicide is prevalent (>150/100,000).⁴³ Various interventions, including mental health workshops, annual depression screens, and group activities that included exercise, volunteering, and socialization, were conducted. The analysis of the studies revealed a difference in the response to interventions based on sex. Only two of the five studies demonstrated a reduction in suicide rates in men, and this appeared to correlate with educational activities where prevention of suicide was emphasized. A 70% reduction in suicide risk was observed in women, particularly among those who participated in annual screening and group activities.⁴³ As this meta-analysis demonstrates, suicide interventions need to be individualized to the patient.

Conclusion

Older adults often experience impaired physical and cognitive function from aging and chronic illnesses and are more likely to experience bereavement. These physical, mental, and emotional distresses may reduce their physical and mental resilience, making them more susceptible to depression and suicide, both of which are common problems among elders. Other risk factors for suicide in the elderly include male sex, rural residence, alcohol abuse, white race, and access to firearms.

Depression and suicidal behavior can be difficult to diagnose in elders, as symptoms such as fatigue and weakness may be mistaken for manifestations of chronic illnesses or wrongly attributed to normal aging. As physicians, we are in a unique position to identify those at risk of suicide. By using depression screening tools, such as the GDS, and paying close attention to risk factors for suicide, we will be better equipped to identify vulnerable patients. Once suicidal patients are identified, a collaborative care model that includes physicians, psychiatrists, and behavioral psychologists to manage the medical and psychological aspects of therapy should be initiated.

The authors report no relevant financial relationships.

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