Suicide in Older Adults

Suicide in Older Adults

Summary

Older adults commit suicide proportionately more often than any other age group in the United States. White men over age 85 have the highest suicide rate.

The high rate of suicide among this population may be due to several factors. Suicidal thoughtsSuicidal thoughts and behavior are most commonly seen in older adults as symptoms of depression. Depression in elderly people is often associated with physical illness, chronic pain and stressful life events, such as the loss of a loved one, physical or mental impairment, retirement and social isolation.

Some of the same risk factors for depression put older adults at an increased risk of suicide. These include social isolation, recent personal loss and the challenge of physical or emotional difficulties. In general, retired men living alone face a greater risk of suicide than women, married men or those actively engaged in structured, productive activity.

Some suicides among elderly people are homicide-suicides, meaning a person commits suicide after first killing another person. In most cases, an elderly man kills his spouse and then himself. People age 55 and older account for the majority of the estimated 1,500 deaths caused by homicide-suicide every year. Physician-assisted suicide (PAS) occurs when a physician supplies lethal information or means, but the patient carries out the act.  PAS may also affect the elderly, although it occurs infrequently because it is legal in very few jurisdictions.

There are some specific warning signs and techniques on approaching an elderly person about suicide. For example, irritability, chronic abdominal pain or headaches and changes in appetite or sleeping patterns may indicate suicide risk in older adults. Social interaction with loved ones may help distract the elderly from thoughts of suicide. Primary care physicians can screen elderly patients for depression as a method of monitoring suicidal behavior.

About suicide in older adults

Older adults are more likely to commit suicide than any other age group in the United States. According to the National Institute of Mental Health (NIMH), adults age 65 and older comprised 13 percent of the U.S. population in 2000, yet they accounted for 18 percent of all suicide deaths that year.

For men in this age group, the risk of suicide increases as they get older. White men over age 85 have the highest number of suicide deaths, according to NIMH.  

Older adults are physically less likely to recuperate from suicide attempts, which may account for the high number of suicide death for this age group.  Although many elderly suicides involve guns and medication overdoses, elderly people sometimes use unconventional suicide methods, such as refusing to eat or take medications. Thus, access to a gun or other lethal means may not be necessary in order to accomplish suicide.

The occurrence of suicide among elderly people is strongly associated with depression. The symptoms of depression in older adults often go unrecognized and untreated – increasing the risk of suicide for this population. Of the 35 million Americans age 65 and older, 7 million display symptoms of depression, according to the National Institute of Mental Health(NIMH).

In addition, the use of medication to treat depression may be problematic among elderly people. Most antidepressant medications must be taken regularly and may take several weeks to become effective. According to the National Alliance on Mental Illness(NAMI), the majority of depressed older adults fail to take all of their medications, which may lessen the effectiveness of their drugs. Also, older adults may not be able to take certain antidepressants due to their side effects.

Suicides in older adults may also be incidents of homicide-suicide (killing a person before committing suicide). The total number of homicide-suicides in the United States is unknown, but estimates indicate there are approximately 1,500 deaths annually. People age 55 and older account for the majority of these deaths.

Most homicide-suicides involve killing a spouse. Often it is the husband who kills his wife and then himself. When this occurs in older adults, issues of separation are usually involved (e.g., the declining health of one or both partners, a change in the status of the relationship). Research on elderly homicide-suicides has shown that most cases involve couples who are highly dependent on one another and illness or the perception of change in their roles and abilities. Depression, isolation and the strain of caregiving for an ill spouse can trigger the act. Other cases of homicide-suicide occur when both spouses become seriously ill. Cases that involve marital conflict or domestic violence, which are the more common model of homicide-suicide in younger couples, are less common in elderly people.

In the past, homicide-suicides were considered mercy killings or suicide pacts. However, they may be acts of desperation. They are most often carried out by a depressed husband who kills his sick wife. Also, the extent to which the wife is a willing participant in the act has been questioned. It is believed that depression, not altruism, is the bigger motivator behind homicide-suicide in older adults.

Physician-assisted suicide (PAS), in which physicians provide lethal information or means but patients carry out the act, may also affect older adults. PAS may occur less frequently than other forms of suicide because PAS is legal in only a few jurisdictions throughout the world. In the United States, PAS is legal only in the state of Oregon. Opponents of PAS, such as the American Medical Association, believe it may lead to unnecessary death due to inadequate health care or financial considerations as well as undermine medical ethics. Proponents of PAS believe it may relieve suffering of dying patients when other treatment options and pain relief have failed. Public debate continues on this issue.Other deaths among elderly people are not considered forms of suicide. The use of living wills or Do Not Resuscitate(DNR)documents means that a person has indicated the levels of life-sustaining treatments they want used or withheld when they are gravely ill.  Euthanasia is where a physician carries out the act to end a person’s life. However, it is not legal in the United States or most other countries.

Risk factors for suicide in older adults

A number of factors can increase a person’s risk of suicide. These include easy access to lethal means (e.g., having a gun in the house), a history of suicidal thoughts or previous suicide attempts. Lethal means for the elderly sometimes includes the refusal to eat or take medications.

Suicidal thoughts or behavior can also occur as a symptom of various mood, personality, anxiety, psychotic or substance abuse disorders. For older adults, the risk of suicide is most often associated with depression. Chemical imbalances in the brain, heredity and stress (e.g., due to emotional, physical, financial or legal difficulties) all play a part in whether or not a person is at risk for depression.

In addition, the following may also increase the risk of suicide in older adults:

  • Social isolation. Older adults living alone and those with limited social contacts are at high risk of suicidal thoughts or behavior. This puts those who are single, widowed or divorced at higher risk than those who are married.
  • Gender. Men commit suicide four times more often than women. The risk of suicide for men increases as they age. Older men are especially at risk of suicide within six months after the loss of a spouse.
  • Lack of outside interests. Retirement involves a loss of structured, productive activity. It may also involve a change in role or social status and loss of income. All of these factors may increase a person’s risk of suicide.
  • Diagnosis of serious physical condition or terminal illness. Older adults are prone to a variety of serious medical conditions such as heart disease, stroke, diabetes, cancer and Parkinson’s disease. In addition, hip fractures, macular degeneration and vitamin deficiencies are common ailments among elderly people. These or any type of chronic or debilitating medical problem or terminal illness can lead to depression, which can increase a person’s suicide risk. Older adults with insomnia, delirium or agitation also increase their risk of suicide.
  • Recent personal loss. Older adults commonly face traumatic personal loss, such as the death or chronic illness of a spouse or family member. In addition, the stress of caring for an ill or disabled loved one can increase the risk of depression in older adults.
  • Alcoholism. The use of or dependence on alcohol can increase an older person’s risk of suicide by masking other disorders, such as depression. It can also decrease inhibitions and cause people to act more freely on impulses or feelings.
  • Increased dependence with change of living conditions. The loss of independence by moving from a long-time home or to assisted living or other care facilities may increase an older adult’s risk of suicide.
  • Poverty. Older adults with a low social and economic status in the community are at higher risk for suicide.

Warning signs of suicide in older adults

As with any age group, being able to identify and respond to warning signs can help prevent suicide among the elderly. Not all suicide attempts are preceded with a warning. However, most occur with at least some type of outward signal to friends or family members. Signs primarily seen in older adults include:

  • Worsening of physical health
  • Statements of hopelessness or worthlessness, such as:
    • I have nothing to live for
    • My family would be better off without me
  • Irritability, restlessness
  • Inability to concentrate
  • Lack of enjoyment in usual activities (anhedonia)
  • Fatigue or loss of energy
  • Changes in appetite
  • Sleeping too much or too little
  • Withdrawal from family or friends
  • Saying goodbye or expressions of guilt/regret
  • Writing a will or giving away possessions
  • Expressing specific plans to die

Approaching loved ones about suicide

Friends and family can help an older adult with suicidal thoughts or behavior. Primary care physicians can screen elderly patients for depression and monitor them for any potential suicidal behavior. Visits by family members, a change of environment or simply spending time recalling joyful memories from the past can help ward off feelings of depression.

Questions for your doctor regarding suicide

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following suicide-related questions:

  1. Do you have experience treating suicidal thoughts and behavior?
  2. Do I have an underlying disorder that is related to my suicidal thoughts or behavior?
  3. What do you think is causing my suicidal thoughts or behavior?
  4. Are there medications that may be appropriate for me? What are their side effects?
  5. What type of psychological therapy would be most effective for me?
  6. Can you recommend a therapist, mental health professional, group or other setting that may benefit me?
  7. Would you recommend hospitalization? What are the benefits and/or risks associated with inpatient psychiatric care?
  8. Are there other treatment methods I might benefit from?
  9. Does anything in my personal history increase my risk for suicidal thoughts or behavior?
  10. What can I do to lessen my risk of suicidal thoughts or behavior? Are there changes I can make to my environment that would help?
  11. Should I monitor my elderly parents for suicidal behavior? What should I look for?
  12. If an elderly person has attempted suicide once, how likely are they to try it again?
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