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An
Elder Suicide Primer
An Introduction to a Late Life Tragedy
http://lifegard.tripod.com/elder.html
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:
...it is best to look upon any suicidal act as an effort by an
individual to stop unbearable anguish...by "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
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