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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 101-103

Suicide in the elderly: A neglected facet


Consultant Psychiatrist, Desousa Foundation, Mumbai, Maharashtra, India

Date of Submission11-Oct-2021
Date of Decision18-Oct-2021
Date of Acceptance20-Oct-2021
Date of Web Publication28-Oct-2021

Correspondence Address:
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai 400054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2588-8358.329461

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How to cite this article:
De Sousa A. Suicide in the elderly: A neglected facet. Ann Indian Psychiatry 2021;5:101-3

How to cite this URL:
De Sousa A. Suicide in the elderly: A neglected facet. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Dec 6];5:101-3. Available from: https://www.anip.co.in/text.asp?2021/5/2/101/329461



Suicide in the elderly is often underresearched in India and poses a major challenge to psychiatrists and physicians that work with elderly patients in the community. The risk of suicide in the elderly is often neglected and not appreciated during clinical assessment of such patients.[1] Many elderly patients may not voice suicidal concerns unless asked about the same and may be reluctant to speak about the same. Mental health issues in the elderly have often been neglected, and it is often thought that elderly may have these symptoms are these are routine in normal aging. Lack of geriatric mental health services in many areas has also compounded the problem in many ways. The lack of appreciation of mental health problems by the elderly may also result in them not seeking help for the same.[2] Most elderly with a suicide attempt in old age often have a past history of a suicide attempt in their adulthood. They also have a family history of suicide that is often reported. Many elders have a history of psychiatric disorders in their adult life which very often may exacerbate in old age and thus be the cause of a suicide attempt.[3] The frailty of the elderly very often results in the physician not asking about suicidal ideations and elderly patients with depression having suicidal ideas thus go undetected and undiagnosed and thereby elderly suicide very often missed clinically. There are various biological, social, psychosocial, and psychological factors in the pathogenesis of elderly suicide. A careful psychiatric history needs to be taken so that multiple factors that could be leading to suicide are elucidated and high-risk cases are identified and monitored. The present editorial is a clinical viewpoint on the neglect of elderly suicide and aimed at sensitizing the busy psychiatrist in clinical practice to this facet.


  Facts about Elderly Suicide Top


Epidemiological studies report high overall suicide rates in both the age groups 15–25 years and above the age of 55 years which has remained rather unchanged over the past 2 decades. It has also been noted that suicide attempts are far less in the elderly while the proportion of completed suicides is higher than in younger populations. Studies however report a trend of an equal prevalence of completed suicides in the young and the older subjects. While the thrust of most suicide prevention initiatives is toward younger populations and adolescence, suicide in the elderly is often neglected and very few prevention initiatives for elder subjects have been carried out. The suicide rate is known to increase in the elderly with increasing age and is greatest in the oldest old populations above the age of 80 years. The suicide rate in people aged 85 or more is usually 5–6 times that of the general population.[4] There have also been reports of suicide seen in patients with bedridden medical illnesses and dementia in the elderly. Male elderly usually show preponderance for suicide when compared to females.[5] The elderly who are lonely, widowed, divorced, and in old-age homes are more likely to attempt suicide than those who are married. Suicide risk is the highest in the first 24 months after the death of a spouse and due to chronic pain from cancer or chronic medical conditions. Living alone and loneliness has been identified by some studies as a risk factor for suicide more so in India where parents live all by themselves and children are abroad. Death as a result of an overdose of medication that the elderly is already consuming is the most common method used. They may overdose on their antihypertensive and antidiabetic medication or sleeping medication that they have been prescribed. They may also deny a suicide attempt when asked after being found in semi-conscious state.


  Risk Factors for Elderly Suicide Top


There are many risk factors with regard to suicide in the elderly; these include biological factors as well as psychosocial factors and some psychological issues that might result in the suicide attempt. The most common factors include:[6]

  • Presence of a psychiatric disorder (seen in 70%–90% of cases)
  • Major depression (80%–85%)
  • Recurrent major depression, dysthymia, and minor clinical depression
  • Alcohol and substance abuse is a risk factor
  • Loneliness and staying alone
  • Financial difficulties and loss of property
  • Chronic medical illnesses and disability
  • Medical illnesses and terminal illnesses like cancer
  • Disorders that affect movement and chronic pain
  • Residents at old-age homes living alone who have been neglected by their family or if the children are abroad and do not visit them for years
  • Recurrent elder abuse
  • Presence of a stroke and presence of paralysis
  • Advanced stages of dementia
  • Previous diagnosis of a personality disorder
  • Previous suicidal attempt in adulthood
  • Family history of affective disorders and suicide
  • Presence of obsessional and rigidity in personality
  • Muting of affective responses
  • Presence of psychosomatic medical illnesses
  • Physical illness generates stress in life, increases burden on caregivers, causes family discord, and drains financial resources
  • Some tumors having direct effects on mood
  • Problems in interpersonal relationships
  • Loss of a limb
  • Death of a spouse
  • Repeated hospitalizations for chronic medical conditions.



  Assessment Top


Assessing suicide in the elderly is the first step toward actively preventing suicide in those individuals. Assessment of suicide can be simply done in an unstructured format by clinical assessment and directly assessing the suicidal ideation, suicidality, trajectory, and lethality of the suicidal plan if any. For the elderly, suicide-preventive interventions could be grouped as either “selective” or “indicated.” Selective suicide-preventive interventions in the elderly target individuals or subgroups of the population with a higher than average risk of suicide while indicated interventions target high-risk individuals, those in more immediate danger. There are some specific rating scales and assessment measures like projective tests that can be used in the assessment of suicidality in the elderly.[7]

The following scales have been used in the assessment of geriatric suicide:

  1. Geriatric Depression Scale (GDS): The GDS is a self-report measure of depression in older adults. Users respond in a “yes/no” format. The GDS was originally developed as a 30-item instrument. Briefer 15-item versions are also available. It is a common screen for late-life depression, with reference to the presence of suicide ideation in a primary care sample of older adults. The GDS does not assess many somatic symptoms of depression which are common among older adults, and the use of depression measures to assess somatic symptoms might artificially inflate the prevalence of late-life depression. The GDS yes/no response key is easy to score, and the shorter (15-item and 5-item) formats have good reliability and validity. The GDS does not include an item to directly assess the presence of suicide ideation, which is an obvious limitation. However, research indicates that GDS total scores and a 5-item subscale can effectively differentiate older adults with higher versus lower levels of suicide ideation[8]
  2. Hamilton Rating Scale for Depression (HAM-D): The Hamilton Rating Scale for Depression (HRSD), also called the Hamilton Depression Rating Scale, sometimes also abbreviated as HAM-D, is a multiple-item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery and assess somatic symptoms of depression. Given that somatic symptoms are common among older adults, the use of depression measures to assess somatic symptoms might artificially inflate the prevalence of late-life depression. The HAM-D focuses on physiological symptoms (sleep, appetite, mood, and others), significantly. A 17-item scale, the HAM-D, is a comprehensive scale used in adults and the elderly as a primary screening for depression. It is widely used by researchers as well in many studies that have looked at geriatric depression[9]
  3. Patient Health Questionnaire (PHQ)-9: The PHQ is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) criteria as “0” (not at all) to “3” (nearly every day) and is increasingly being used as a screen for depression in primary care. Benefits of this scale include its relative brevity, standardized administration and scoring, and item content reflecting the 9 DSM-IV symptoms of major depressive disorder. The items on PHQ-9 measure suicidal ideation instructs patients to report on the frequency of “thoughts that you would be better off dead, or of hurting yourself in some way” during the previous 2 weeks, conflates death ideation with suicide ideation. Little research exists assessing the operating characteristics of the PHQ-9 suicide ideation item with older primary care patients. Research has also shown that the late-life risk of suicide may not be as precisely detected from the administration of PHQ-9.[10]


Besides these, the use of projective psychological tests can yield valuable information about the various factors that bother the elderly and also the underlying thoughts that may build up toward the feeling of ending one's life.


  Preventive Strategies Top


Like mentioned earlier, geriatric suicide is a neglected facet of mental health. There is a need for various preventive measures to be implemented so that we have a society that is free from elderly suicide. There are many different interventions that can be tried, and some of the ones that are effective have been listed below:[11]

  • It is of foremost importance that we spread awareness in the area of mental health for the elderly and geriatric suicide
  • Treatment of disorders that increase suicide risk is of paramount importance in reducing suicidality, but this hypothesis has not yet been adequately tested in the geriatric group
  • Various population-based general strategies may be implemented by the government such as restricting access to lethal means, crafting better economic policies, and improving access to palliative and mental health care
  • One must conduct workshops in various old-age homes, and community and geriatric mental health clinics need to be established for the same
  • There is also a growing need to reduce ageism and elder abuse. Over-the-counter dispensation of medications that may be fatal in overdose without a valid doctor's prescription must be stopped
  • There is a need for specific suicide prevention initiatives that can be implemented at the community level itself
  • Suicide prevention initiatives can be designed for implementation by the primary care physician treating the elderly
  • Psychoeducation with regard to diagnosis and treatment of geriatric depression along with proper screening and treatment algorithms is essential
  • An active collaboration between primary care physicians and psychiatrists is important to achieve this end
  • There is a need for outreach programs in suicide prevention. This is essential for those with physical disability, immobility, and lack of access to managed care
  • Home visits by community health workers have yielded little success, with many elders declining help and many preferring to be alone
  • Strategies that identify circumscribed problems, seeking a well-defined and motivated target population, and tailor-made interventions are essential for treatment and prevention of geriatric suicide
  • People and medical professionals need to be educated and myths regarding geriatric suicide need to be dispelled. It is only when depression in old age is no longer left untreated, will geriatric suicide prevention be a reality.



  Conclusions Top


Geriatric suicide is an important public health problem that needs attention. There is a need for clinicians to recognize suicide in the elderly and treat the same when the case arises. Very often depressed elderly may not mention that they have suicidal ideas and hence it is needed that this issue be kept in mind by clinicians in geriatric psychiatry. There is a need for more sensitivity and attention to geriatric mental health programs, and suicide prevention in the elderly must get its due.



 
  References Top

1.
Minayo MC, Cavalcante FG. Suicide in elderly people: A literature review. Rev Saude Publica 2010;44:750-7.  Back to cited text no. 1
    
2.
Kjølseth I, Ekeberg O, Steihaug S. Why suicide? Elderly people who committed suicide and their experience of life in the period before their death. Int Psychogeriatr 2010;22:209-18.  Back to cited text no. 2
    
3.
Brooks SE, Burruss SK, Mukherjee K. Suicide in the elderly: A multidisciplinary approach to prevention. Clin Geriatr Med 2019;35:133-45.  Back to cited text no. 3
    
4.
Yur'yev A, Leppik L, Tooding LM, Sisask M, Värnik P, Wu J, et al. Social inclusion affects elderly suicide mortality. Int Psychogeriatr 2010;22:1337-43.  Back to cited text no. 4
    
5.
Demirçin S, Akkoyun M, Yilmaz R, Gökdoğan MR. Suicide of elderly persons: Towards a framework for prevention. Geriatr Gerontol Int 2011;11:107-13.  Back to cited text no. 5
    
6.
Suresh Kumar PN, Anish PK, George B. Risk factors for suicide in elderly in comparison to younger age groups. Indian J Psychiatry 2015;57:249-54.  Back to cited text no. 6
    
7.
Kjølseth I, Ekeberg Ø, Steihaug S. Elderly people who committed suicide – Their contact with the health service. What did they expect, and what did they get? Aging Ment Health 2010;14:938-46.  Back to cited text no. 7
    
8.
Pracheth R, Mayur SS, Chowti JV. Geriatric depression scale: A tool to assess depression in elderly. Int J Med Sci Public Health 2013;2:31-5.  Back to cited text no. 8
    
9.
Zimmerman M, Martinez JH, Young D, Chelminski I, Dalrymple K. Severity classification on the Hamilton depression rating scale. J Affect Disord 2013;150:384-8.  Back to cited text no. 9
    
10.
Manea L, Gilbody S, McMillan D. A diagnostic meta-analysis of the patient health questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. Gen Hosp Psychiatry 2015;37:67-75.  Back to cited text no. 10
    
11.
Ho RC, Ho EC, Tai BC, Ng WY, Chia BH. Elderly suicide with and without a history of suicidal behavior: Implications for suicide prevention and management. Arch Suicide Res 2014;18:363-75.  Back to cited text no. 11
    




 

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