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Robin Bonifas, PhD, MSW Assistant Professor

College of Public Programs SCHOOL OF SOCIAL WORK

Kristen Rathjen Rebecca Ong Debra Hobaica Natalie Goff Holly Gilbert Carmen Calderon

       The national rate of suicide for older adults age 60 and older was 14.7 per 100,000 in 2005 (McDermott, 2009).

In 2006, 5,299 older adults killed themselves. This is equivalent to 14 deaths per day. In 2006, the state of Arizona ranked at #4 in the United cases per 100,000 people. Compare: 10 cases per 100,000 in the population vs. 15 older adult cases per 100,000 In 2006, older adults made up 12.5% of the U.S. population and accounted for 15.9% of all suicides. per 100,000.

According to the Centers for Disease Control and suicide in 2003 (Reiss & Tishler, 2008).

 National statistics are not clear on the prevalence of suicides in nursing homes  Very little information has been published but there are studies that give insight to this issue

 A study examined the number of suicides from 1990-2005 of NYC residents aged 60 and older that were residing in long term care (LTC) facilities compared with those that were residing in the outside community: » There were 47 suicides by residents in LTC facilities.

» » » There were 1,724 suicides by people residing in the community.

The LTC group was relatively older (a mean age of a 76.2) compared to than the community-dwelling group (a mean age of 72.9).

In both groups, most decedents were male (61.7% of LTC and 69.7% of community-dwelling groups) and non Hispanic white (68.1% of LTC and 72.0% of community dwelling groups).

Mezuk, B., Prescott, M., Tardiff, K., Vlahov, D., & Galea, S. (2008). Suicide in older adults in long-term care: 1990 to 2005. Journal of the American Geriatrics Society, 56(11), 2107-2111.

    Suicides in LTC were less likely to be due to firearms and more likely to be due to a long fall compared to the community-dwelling group.

Over the 15-year period, there was a decrease in the number of suicides per year in the community-dwelling group.

There was no change in the number of suicides in the LTC group.

LTC residents should be routinely screened and periodically reassessed for psychiatric disorders associated with suicide risk, including depression and dementia, and appropriately treated.

Mezuk, B., Prescott, M., Tardiff, K., Vlahov, D., & Galea, S. (2008). Suicide in older adults in long-term care: 1990 to 2005. Journal of the American Geriatrics Society, 56(11), 2107-2111.

 As a part of the National Suicide Prevention Project, a study in Finland looked at suicides among older adults in nursing homes during a 12-month period: » 1,397 suicides occurred between April 1, 1987 and March 31, 1988.

» » » » 12 residents aged 60 or older took their own lives, which represented 0.9% of all suicides in the study.

The mean age was 76.1 plus or minus 5.7 years.

75 % were male.

The most common suicide method was hanging (67%).

Suominen, K., Henriksson, M., Isometsa, E., Conwell, Y., Heila, H., & Lonnqvist, J. (2003). Nursing home suicides – a psychological autopsy study. International Journal of Geriatric Psychiatry, 18, 1095-1101.

  Five residents (42%) had been placed in a nursing home during the last year before their deaths.

Four (33%) residents had reported pain and four (33%) had previously attempted suicide.

  Nine (75%) residents were diagnosed with a depressive syndrome.

Three (25%) residents were diagnosed with alcohol dependence or abuse.

 None of the three cases with diagnosable major depression was receiving antidepressant.

 The nursing home residents who died by suicide had highly co-morbid somatopsychiatric disorders, compared to older adults in general.

 A computerized database search was conducted to identify cases of completed suicide between 1981 and 1997 in Olmsted County, Minnesota and surrounding communities where there are 846 nursing home beds: » Five cases of completed suicide and three suicide attempts were identified, including six men and two women.

» » » » Deaths were the result of drowning, hanging or medication overdose.

The age ranged from 69 to 87 years old.

Most had been nursing home (NH) residents for less than 6 months.

Suicide risk among NH residents seems to be highest among men and those recently admitted to facilities.

Menghini, V. & Evans, J. (2000). Suicide among nursing home residents: A population-based study. Journal of the American Medical Directors Association, 1(2), 47-50.

» » » » » Giving away belongings Withdrawal from family, friends and caregivers Loss of interest in enjoyable activities Abuse of alcohol and/or drugs Irresponsible behavior » » » » » » Impulsivity Self-mutilation Lack of interest in appearance Disturbed sleep Change or loss of appetite and in weight Physical health complaints (Living Works Education USA, 2008)



Types of Feelings

» Desperate » » » » Angry Guilty Worthless Lonely » » » Sad Hopeless Helpless  » » » » » »

What might be said:

“I won’t be needing this anymore” “I can’t take it anymore” “Everything will be over soon” “You are all better off without me” “I wish I were dead” “All of my problems will be over soon”

(Living Works Education USA, 2008)

Reviewer Anonymous:

It would be helpful to include some information about what a safe plan might entail.

     Ask clearly and directly about thoughts of suicide: »

Are you having thoughts of suicide?

» »

Do you have a plan?

Are you in so much pain that it feels unbearable?

Listen for their reasons for wanting to die.

Listen for their reasons for wanting to live.

Implement a safe plan.

Follow-up with client.

(Living Works Education USA, 2008)

(Living Works Education USA, p.14, 2008)

  Direct or overt actions that will most-likely cause injury or death: » Includes wrist slashing, jumping, hanging, smothering, gunshot and overdose (Reiss & Tishler, 2008) Indirect self-destructive behavior: » Refusing to eat or drink » » Refusing medications Refusing to follow medication directions (Reiss & Tishler, 2008).

  Presence of mental illness Mood disorders such as depression: » In many cases, depression in older adults is not recognized by staff.

» » » Those who are treated for depression are frequently undertreated.

When comorbid with anxiety, suicide risk goes up.

Hopelessness also increases risk of suicide.

 Physical illness & functional impairment: » » Physical illness accompanied by pain Medical conditions such as stroke, cancer, dementia (Reiss & Tishler, 2008)

  Stressful life events: » Loss of Health » Loss of autonomy » » Loss of family and friends

Loss of support system

» Change in important roles (Reiss & Tishler, 2008)

Environmental Stressors:

» NH environment can generate suicidal behavior when there is a high prevalence of staff turnover and attention is not given to the impact of a loss or decrease in decision making and independence of residents. (Reiss & Tishler, 2008)

 Risk factors for suicide in older adults include refusal to eat, refusal to take medications and medical non-compliance. However, these signs are many times ignored, misinterpreted or unidentified.

 Walker and Osgood (2000) found that LTC staff are in need of better training to identify risk factors and intervention strategies.

 » Training should focus on: Learning to identify the methods of suicide by older adults » » » Understanding why dementia increases the risk of suicide Identifying hopelessness and major life changes as potential triggers of suicidal ideation Identifying primary and secondary treatment options  The results of the study done by Walker and Osgood (2000) indicate that after a training curriculum, the majority of staff were able to identify a gun shot as the most common method of suicide among older adults. The staff also increased their knowledge of depression, hopelessness and suicide.

 Screening should include: » Brief Interviews » » » A standardized rating scale A geriatric depression scale for NH residents who do not have cognitive issues Use of the Cornell Scale for Depression in Dementia for NH residents with cognitive difficulties (Reiss & Tishler, 2008)

 After screening for depression, clinicians should screen for suicidal ideation.

 Examples of questions to ask: »

“Have you been feeling so sad lately that you were thinking about death or dying”?

» »

“Have you had thoughts that life is not worth living”?

“Have you been thinking about harming yourself”?

(Reiss & Tishler, 2008, p. 267)

   Medications Psychotherapy: » » Supervised peer volunteer programs Group cognitive therapy » » Bright light therapy Reminiscence/life review Adjusting environments to include: » Photographs of residents and family members » » » » Interesting reading materials Pets Music Enjoyable activities (Reiss & Tishler, 2008)

References

American Association of Suicidology. (2009a).

Suicide and the

elderly [Fact sheet]. Retrieved from http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-158.pdf

American Association of Suicidology. (2009b).

USA suicide: 2006 official final data

[Fact sheet]. Retrieved from http://www.suicidology.org/c/document_library/get_file?

folderId=228&name=DLFE-142.pdf American Association of Suicidology. (n.d.).

USA state suicide rates and rankings among the elderly and young, 2006

[Fact sheet]. Retrieved from http://www.suicidology.org/c/document_library/ get_file?folderId=228&name=DLFE-144.pdf

Living Works Education USA, I. (2008).

Applied suicide intervention skills training.

Fayetteville, NC.

McDermott, B. (Researcher). (2009, March 1).

Older adult suicide in Maricopa County: trends and needs

. Phoenix, AZ: Area Agency on Aging, Region One ElderVention.

Menghini, V. & Evans, J. (2000). Suicide among nursing home residents: A population-based study.

Journal of the American Medical Directors Association

, 1(2), 47-50.

Mezuk, B., Prescott, M. R., Tardiff, K., Vlahov, D., & Galea, S. (2008). Suicide in older adults in long-term care: 1990 to 2005.

Journal of the American Geriatrics Society

(11), 2107-2111.

References continued

National Institute of Mental Health, NIHM. (2007, April). Older adults: depression and suicide facts. Retrieved from http://www.nimh.nih.gov/health/publications/older-adults-depression-and suicide-facts-fact-sheet/index.shtml#conwell-later-life Reiss, N. S., & Tishler, C. L. (2008). Suicidality in nursing home residents: Part I. prevalence, risk factors, methods, assessments and management.

Professional Psychology: Research and Practice, 39(3), 264-270.

Reiss, N. S., & Tishler, C. L. (2008). Suicidality in nursing home residents: Part II. special issues. Professional Psychology: Research and Practice, 39(3), 271-275.

Scocco, P., Fantoni, G., Rapattoni, M., Girolamo de, G., Pavan, L. (2009). Death ideas, suicidal thoughts, and plans among nursing home residents. Journal of Geriatric Psychiatry and Neurology, 22(2), 141-148.

Suominen, K., Henriksson, M., Isometsa, E., Conwell, Y., Heila, H., and Lonnqvist, J. (2003). Nursing home suicides: A psychological autopsy study [Electronic version]. International Journal of Geriatric Psychiatry, 18, 1095-1101.

Walker, B.L., and Osgood, N. J. (2000). Preventing suicide and depression: A training program for long term care staff. OMEGA, 42(1) 55-69. Zarit, S. H., & Zarit, J. M. (2007). Mental disorders in older adults. New York: Guilford Press.