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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

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During those first critical days after you have been diagnosed with a chronic illness are important.  Your life is not over—the prophets have been dead for many centuries, so who is telling you that your life is over.  You still have a life. 


An Elder Suicide Primer
An Introduction to a Late Life Tragedy

What's the problem?
Someone age 65 or over completes suicide every 90 minutes -- 16 deaths a day. Elders account for one-fifth of all suicides, but only 12% of the population. White males over age 85 are at the highest risk and complete suicide at almost six times the national average. The suicide rate among elders is two to three times higher than in younger age groups. Elder suicide may be under-reported 40% or more. Omitted are "silent suicides", i.e., completions from medical noncompliance and overdoses, self-starvation or dehydration, and "accidents." The elderly have a high suicide rate because they use firearms, hanging, and drowning . The ratio of suicide attempts to completions is 4:1 compared to 16:1 among younger adults. "Double suicides" involving spouses or partners occur most frequently among the aged. Elder attempters have less chance of discovery because of greater social isolation and less chance of survival because of greater physical frailty and the use of highly lethal means.
In Why People Die by Suicide (2006)Thomas Joiner offers a theory that helps explain elder suicide. He notes that two conditions must be present to overcome the instinct for self-preservation: (1) a desire to die caused by a lost sense of social belonging and the perception that one is a burden; and (2) the capacity for lethal self-harm acquired by experience with abuse, pain, and other factors. Both must be present for a completed suicide and both occur in elders.


What are the causes?
Elder suicide is associated with depression and factors causing depression, e.g., chronic illness, physical impairment, unrelieved pain, financial stress, loss and grief, social isolation, and alcoholism. Depression is tied to low serotonin levels. Serotonin, which decreases with aging, is a neurotransmitter which limits self-destructive behavior. Depression remains under diagnosed and undertreated in the elderly. Conwell (2001) reminds us that while these variables are significant, elder suicide has a complex and multivariate etiology:
"General understanding of suicide among older people is often oversimplified, ascribed to a single factor such as severe physical illness or depression. The reality is far more complex. There is no single cause for any suicide, and no two can be understood to result from exactly the same constellation of factors."
What are some of the key risk factors of elder suicide?
•      Loss of spouse.
•      A late onset depressive disorder.
•      A debilitating and/or terminal illness.
•      Severe chronic/intractable pain.
•      Decreasing independence and self-sufficiency.
•      Decreased socialization and social supports.
Risk often accumulates among the elderly. An individual may be white, male, and an alcohol misuser and then become a widower or depressed.
What are some of the myths of elder suicide?
•      It is the outcome of a rational decision and justified.
•      Elder victims are usually seriously or terminally ill.
•      Only very severely depressed elders are at risk of suicide.
•      Suicidal elders never give any indication of their intent.
•      The suicide of an older person is different from that of a younger individual.
What are the warning signs?
The following may indicate serious risk:
•      Loss of interest in things or activities that are usually found enjoyable
•      Cutting back social interaction, self-care, and grooming.
•      Breaking medical regimens (e.g., going off diets, prescriptions)
•      Experiencing or expecting a significant personal loss (e.g., spouse)
•      Feeling hopeless and/or worthless ("Who needs me?").
•      Putting affairs in order, giving things away, or making changes in wills.
•      Stock-piling medication or obtaining other lethal means.
Most elder suicide victims saw a doctor within a month of their deaths. Nearly 40% did so within a week. Physicians may not recognize such patients as depressed.


Other clues are a preoccupation with death or a lack of concern about personal safety. "Good-byes" such as "This is the last time that you'll see me" or "I won't be needing anymore appointments" should raise concern. The most significant indicator is an expression of suicidal intent.
Why aren't community agencies or providers doing more?
Service involvement with older men:
Community agencies basically serve elderly women who have a suicide rate well under the national mean for all ages. Community agencies may be little concerned because elder suicide is uncommon in their caseloads.
Agency philosophy:
The prevailing value in most services for the aged is to optimize self-sufficiency in terms of individual capability and safety. A commitment to autonomy may cause community agencies to let the client or patient control decisions on referrals to other resources, alerting relatives, or involving available services.
Agency Misconceptions:
Community agencies and providers may accept some of the myths about suicide such as:
•      If someone's determined to kill themselves, no one can stop them.
•      Those who complete suicide do not seek help before their attempt.
•      Those who kill themselves must be crazy.
•      Asking someone about suicide can lead to suicide.
•      Pain goes along with aging so nothing can be done.
•      It makes sense for an old person to want to end their suffering.
•      Old people are used to death and loss and don't feel them like younger folks.
•      Those who talk about suicide rarely actually do it.
How many health or human service professionals, other staff, and volunteers believe these statements to be true?
Lack of risk assessment:
A lack of attention to elder suicide and a concentration on client or patient self-determination and self-sufficiency may limit community agencies' response. Most community agencies do not recognize the problem and consequently do little or no screening for it among their clientele.
For a brief case study on how miscommunication and noncommunication almost led to a tragedy see "How Elder Suicides Happen"(MS-WORD).
Most elder suicide victims either live with relatives or are in regular contact with family or friends. This implies that depression is more a factor than social isolation.

What can community agencies do?
Individual prevention must focus on what drives suicide. Shneidman (1995) notes: is best to look upon any suicidal act as an effort by an individual to stop unbearable "doing something." ...The way to save a person's life is also to "do something." Those "somethings" include putting that information (that the person is in trouble with himself) into the stream of communication, letting others know about it, breaking what could be called a fatal secret, talking to the person, talking to others, proffering help, getting loved ones interested and responsive, creating action around the person, showing response, indicating interest, and, if possible, showing deep concern.
"Doing something" basically comes down to caring.
Community level prevention of late life suicides will require "creative partnerships of primary care providers, the mental health sector, aging services, and other agencies and insurers..." (Conwell 2001). This means that senior centers, home care providers, hospices, adult day care, home-delivered meals programs, para-transit, and other organizations serving the elderly are going to have to team up with community mental health centers. This must start soon as the high risk "old old" segment of the aged population is growing rapidly and the oldest baby boomers are within a few years of turning 65. The boomers will arrive in their "golden years" having manifested higher suicide rates on the way than prior generations (McIntosh 1992). In 1983, Haas and Hendin observed that in the absence of meaningful prevention demographics alone will drive a possible doubling of the incidence of elder suicide by 2030.


The issues raised here are more fully developed in Salvatore, T., "Elder Suicide: A Gatekeeper Strategy for Home Care" Home Heathcare Nurse 18(3), March 2000, pp.180-186. Hard copies are available on request.
See article on elder suicide done for suburban Philadelphia daily: "Elder Suicide - A Late Life Tragedy" and an op-ed piece for the Philadelphia Inquirer on reporting on elder suicides.
See "PA Elder Suicide Prevention FAQ"
Clinicians should see Patricia Holkup, Evidence-based protocol. Elderly suicide: secondary prevention. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2002; 56 p. [120 references].
For a thought-provoking ethical perspective on elder suicide see "Does Old Age Make Suicide Ethical?" by Rob Elder of the Markkula Center for Applied Ethics at Santa Clara University.
© Tony Salvatore, 1999-2009