Michigan Older Adult Substance Abuse Network

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Network Profile, Summer 2003

Articles

• Older Adult Suicide: The Reality Behind the Statistics
• Older Adult Suicide: Recognizing the Risk Factors
• Assessing Older Adult Suicide Risk: Methods, Tools, and Resources
• Variables in Assessing Suicidal Potential
• Managing and Coping with a Suicidal Crisis
• References For This Issue

Older Adult Suicide: The Reality Behind the Statistics

Suicide rates among older adults are the highest of any age group. Every 95 minutes someone age 65 or over completes suicide. The rate of older adult suicide is sixteen times higher than our national average (with the national average being 1.2 suicides per 100,000 individuals, and the rate of older adult suicide being 20.1 per 100,000 individuals).

In view of these numbers, it is critical that we recognize this problem, learn about the risk factors for older adults, and develop effective suicide prevention strategies - locally and nationally.

Statistic after statistic reaffirms this grim problem:

• Comprising only 13% of the U.S. population, individuals over 65 account for approximately 20% of all suicide deaths.
• The 85 years or older age group is the fastest growing subpopulation of older adults in the United States, and also the group of older adults with the highest suicide rate.
• 1 out of 2 suicide attempts among the elderly succeeds, as compared to 1 out of 200 for those under 25 (the group with the second highest suicide rate).
• Suicide rates in Nevada, Montana, New Mexico, Arizona and Wyoming were 2 to 3 times higher than New York and the Mid-Atlantic states.
• "Double Suicides" involving spouses or partners occur most frequently among the aged.
• Firearms were the most common method of suicide by older adult 65 years and older in 1998, accounting for 78.5 % of male and 35% of female suicides.
• It is felt that many older adult suicides are underreported and mistaken for a natural or accidental death, causing an even greater urgency to detect and treat possible suicide attempts.
• According to a recent study, many older adults who commit suicide have visited their primary care physicians very close to the time of suicide - 20% on the same day, 40% within one week, and 70% within one month of the suicide.

Suicide, ethnicity and gender

• The suicide rate for white men over 80 years old is 6 times the current overall rate.
• Men accounted for 84% if suicides for older adults in 1999.
• Suicide rate in older adults are highest for individuals who are divorced or widowed.
• Suicide rates for African-Americans and Native American males peak around 35 years of age and decrease thereafter.
• Recent research suggests support from community, family and religion may explain why older African-Americans have a lower suicide rate.
• White males are at nearly 10 times the risk for suicide as nonwhite males.
• The overall suicide rate for males is more than four times higher than the overall rate for females.
• Access to handguns is a risk factor for suicide in older adult white males.

As the baby boomers age, and the numbers of older adults increase, there is a growing necessity to address this concern. This issue of Network Profile focuses on older adult suicide, its warning signs, risk factors, identification and intervention of at risk individuals, and resources for further exploration of this problem.

Older Adult Suicide: Recognizing the Risk Factors

Although we cannot predict with 100% certainty who will attempt or complete suicide, there are certain factors which place individuals at higher risk. For significant numbers of older adults, feeling isolated from the community, coping with the loss of loved ones, managing the physical changes that occur as part of aging, and dealing with ongoing health concerns strain the resiliency they have developed over the years.

Research has identified other risk factors that may help alert us to older adults at risk of suicide:

• Chronic illness – especially with disorders of the central nervous system, HIV, peptic ulcer disease, kidney disease, systemic lupus, and most cancers
• Unremitting pain – either physical or mental
• Recent losses
• Depression
• Substance abuse (alcoholism, misuse of prescription medications, use of illegal substances)
• Divorce, marital separation, widowhood (This doubles the risk of suicide in men.)
• Family history of suicide
• Previous history of suicide attempts
• Paranoid attitude – suspicion of others
• Rejection of help – a suspicious and hostile attitude toward helpers
• Feelings of helplessness
• Feelings of hopelessness
• Financial stressors
• Presence of handguns in the home
• Individuals with neuroticism and lower openness to experience

As noted earlier, while males are particularly at risk for suicide after a divorce or separation. The social networks that women build outside their marriages prove to be stronger, providing a range of interactive relationships, with deeper levels of intimacy and interconnectedness, providing meaningful and effective support. Older women demonstrate more effective communication skills, especially related to their needs.

With the current generation of older adults, women generally seem to be able to seek out and receive support. Unfortunately, a significant number of older adult males seem to lack social connections, having relied on their partners in the past for these functions, placing men more at risk when losing a partner. When identifying risk factors, it is important to note that older adults are often experiencing multiple risk factors, and that these factors in turn affect each other, and may further increase the risk. For example, individuals who have lost a spouse are at higher risk of suicide for up to four years following the death. If they also have a history of psychiatric illness, substance use disorder, and a history of significant losses experienced in early life, the bereavement experience in older adulthood can place them at special risk.

The strongest risk factor is psychiatric illness. In a recent study (1999) by Yeates Cronwell, M.D. of the University of Rochester, it was found that 90% of the individuals over 50 successfully completing suicide had a diagnosable mental illness or substance abuse disorder (an Axis-I disorder in the DSM-IV).

In addition to the psychosocial, physical and sociological factors associated with older adult suicides, the use of drugs and alcohol by older adults may become complicating factors in identifying individuals at risk.

• The average 65 year old individual uses 4.5 prescription medications on a daily basis.
• 30% of individuals over 65 take 8 or more prescription medications each day

As a result of aging related changes in medication metabolism as well as the high number of medications taken concurrently, there is a greater risk for adverse drug reactions and interactions. If older adults also drink, there is increased likelihood of medication and alcohol interactions and problems, resulting in confusion, disorientation, accidental overdoses.

Assessing Older Adult Suicide Risk: Methods, Tools, and Resources

Warning Signs That May Signal Suicide

• Loss of interest in things or activities the person previously found enjoyable
• Experiencing or expecting a significant personal loss
• Putting affairs in order, giving away possessions, making changes in wills
• Breaking medical regimens (e.g. going off diets, prescriptions) or refusing medical treatment
• Saying goodbyes
• Reducing social interaction and involvements
• Neglecting self-care, grooming and pet care
• Stock-piling medication
• Obtaining a weapon or other lethal means or self-harm
• A sudden improvement in mood of someone who has been very depressed
• Hinting or alluding to a plan to solve one's problems once and for all
• Feeling hopeless or worthless

The presence of any of these signs is not a definite predictor the individual is suicidal, for example, a normal and responsible part or the aging process is putting one's affairs in order.

However, if there are concerns, it is important to further assess the situation, and usually talk with the person directly about his/her intentions. Directly asking the question: "Are you thinking about suicide?" will not provoke suicidal thoughts or cause more harm than already present. In actuality, asking about suicide breaks through the isolation and provides an opportunity to assist the person considering suicide.

Tools for Assessing Suicide Potential

The use of mnemonic devices such as "PLAID PALS" may be a helpful tool in assessing suicide potential.

Plan – Do they have one?
Lethality – Is it lethal? Can they die?
Availabiltity – Do they have the means to carry it out?
Illness – Do they have a mental or physical illness?
Depression – Chronic or specific incident(s)?

Previous attempts – How many? How recent?
Alone – Are they alone? Do they have a support system?
Loss – Have they ever suffered a loss? Death, job, relationship
Substance Abuse – Drugs, alcohol, medicine?

Responding positively to many of these questions flags a warning sign for a possible suicide, and an indication that further assessment should immediately be done. From the Website www.sfsuicide.org.

A similar device, the "SAD Person Scale" provides an acronym for assessing suicide potential:

Sex (Males are more likely to commit suicide.)
Age (Individuals over 50 are at higher risk.)
Depression (Individuals with depression are at higher risk.)

Previous attempt (Those who have previously attempted suicide are at higher risk of suicide.)
Ethanol use (Individuals who are drinking or abuse alcohol are more likely to attempt suicide.)
Rational thinking loss (Individuals with cognitive losses are at higher risk.)
Social supports lacking (Those who have poor social support systems are at higher risk.)
Organized plan (If the individual has an organized plan, with lethal means available, s/he is at higher risk.)
No spouse (Those who are widowed or divorced are also at higher risk.)

Adapted from Preventing Patient Suicide. Joint Commission on the Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 2000.

Variables in Assessing Suicidal Potential

According to the Comprehensive Textbook of Psychiatry, there are four variables that must be assessed in order to predict a possible suicide attempt. Analyzing each of the factors, not only individually, but in relationship to each other, is an important tool in assessing suicide potential.

1. Lethality
   • Availability of method / Specificity of time and place
   • Intention to die
   • Degree of social isolation
2. Subjective Distress
   • Hostility,
   • Shame, Guilt, Boredom
   • Hopelessness, Despair
3. Precursory Clues
   • Changes in interest / lifestyle
   • Exhibiting vegetative signs
   • Severing "ties to life"
4. General Lifestyle
   • Self-defeating patterns
   • Drug/alcohol abuse
   • Self-injurious behavior

Other Suicide Risk Instruments

Beck Depression Inventory (BDI)

Measures presence and severity of depressive symptoms.

Hopelessness Scale

Twenty-nine true / false questions completed by the individual. Measures ideation reflecting hopelessness.

OPRT – H Suicide Risk Management Inventory – Hospital Version

Used in inpatient, outpatient, and partial hospitalization programs. A risk detection, assessment and management tool used as an interview guide.

Reason for Living (RFL) Inventory

Assesses individual's reasons that prevent self-destructive behavior. Uses a positive approach to assess suicidal intent. Six scales – survival and coping beliefs, responsibility to family, child-related concerns, fear of suicide, fear of social disapproval, and moral objections.

Assessing if an older adult is at risk of suicide is a serious task, and in most communities there are resources available to assist. In Michigan, contact your local Community Mental Health Office. Consultation and emergency help are available 24-hours a day, 365 days per year.

Managing and Coping with a Suicidal Crisis

What can we do to help in a suicidal crisis? What forms of intervention are appropriate?

As a nonprofessional, there are various ways to aide a loved one, friend, or acquaintance with suicide potential. It is important to keep in mind that many older adults who attempt suicide feel isolated, worthless and hopeless. Offering them a positive, supportive means of communication and friendship not only prevents possible suicides, but also can be a helpful part of deterring someone considering suicide.

1. If you think the person is considering suicide, talk about it directly.
2. Express your feelings of concern and caring.
3. Focus the discussion.
   • Stay focused on the problem that suicide is designed to resolve.
   • Separate and define specific problems to alleviate confusion and feelings of hopelessness.
4. Build hope, help the individual make plans.
5. Emphasize temporary nature of crisis.
• Use their ambivalence to your advantage.
• Discuss alternatives to suicide.
6. Mobilize available resources
   • Internal - their own strengths, previous coping methods.
   • External - family, friends, Community Mental Health. other professionals, clergy, police, etc.
7. Make a referral/connect with Community Mental Health. a therapist, etc.
8. If you feel the person is at high risk, do not leave him /her alone – call for someone to help you.

We can reduce the high rate of older adult suicide with awareness and action. We can prevent possible suicides by watching for the warning signs and assisting older adults in dealing with problems and challenges in an active and constructive way. We can improve the lives of older adults by decreasing isolation.

In closing, E.S. Scheidman, author of "Psychotherapy With Suicidal Patients" offers valuable advice to those who would seek to prevent older adult suicide.

"...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."

Whether, professionals, friends, family members, or acquaintances, our actions can make a difference.

References For This Issue

• Elder Suicide & Post-acute Care: A Gatekeeper Role for Providers
• Knowlton, Leslie, An Interdisciplinary Approach to Healthy Aging, Geriatric Times, Treating Suicidal Elders.
• McIntosh, John, The Suicide of Older Men and Women: How you can help Prevent Tragedy
• Medscape, Researchers Investigate Causes of Suicide Among Seniors, Mental Health Weekly
• National Institute of Mental Health (NIMH), Older Adults: Depression and Suicide Facts
• New York Academy of Sciences, Media Advisory, Preventing Suicide in Older Adults
• Plaid Pals: A Mnemonic for Evaluating Suicide Risk, San Francisco, Suicide Prevention: Evaluating a suicide risk
• Richman, Joseph (1993), "Preventing Elderly Suicide." New York: Springer
• Redfield Jamison, Kay (1999), "Night Falls Fast: Understanding Suicide." New York: Alfred A. Knopf
• Rudd, M. David, Joiner, Thomas, M. Hasan, Rajab (2001), "Treating Suicidal Behavior: An Effective, Time-Limited Approach." New York, London: The Guilford Press.
• Suicide Assessment Instruments, Adapted from Preventing Patient Suicide. Joint Commission on the Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 2000
• Suicide Prevention Fact Sheet – National Center for Injury Prevention and Control, Suicide Among the Elderly
• Suicide Statistics, 1997 National Suicide Statistics and Facts, 1996 National Suicide Statistics and Facts, Rate, Number, and Ranking of Suicide for Each USA State 1996.

Web Resources

• American Association of Suicidology
• American Foundation for Suicide Prevention
• Anxiety Disorders Association of America
• Centers for Disease Control and Prevention, National Center for Injury Control and Prevention
• Depression and Related Affective Disorders Association
• Health Resources and Services Administration
• National Alliance for Research on Schizophrenia and Depression
• National Alliance for the Mentally Ill
• National Depressive and Manic-Depressive Association
• National Institute on Alcohol Abuse and Alcoholism
• National Institute of Mental Health
• National Institute of Mental Health Suicide Research Consortium
• National Institute on Drug Abuse
• National Mental Health Association
• National Mental Illness Screening Project
• SA/VE –Suicide Awareness/Voices of Education
• Substance Abuse and Mental Health Services
• Suicide Information and Education Centre
• Suicide Prevention Advocacy Network
• Suicide Research Consortium
• Surgeon General of the United States

Print Resources

• Karel, Michele J., Ogland-Hand, Suzann, Gatz, Margaret with Jurgen Unutzer (2002). "Assessing and Treating Late – Life Depression." New York: Basic Books, Perseus Books Group
• Leenaars, A.A, Maris, R.W., McIntosh, J.L. & Richman, J. (Eds.), (1992), "Suicide and the Older Adult." New York: Guilford Press.
• McIntosh, John L., Santos, John F., Hubbard, Richard W. and Overholser, James C. (1994), "Elder Suicide: Research, theory and treatment." Washington, D.C.: American Psychological Association
• Osgood, N.J. (1992), "Suicide in later life: Recognizing the warning signs." New York: Lexington Books
• Osgood, N.J. (1991), "Suicide among the elderly in long-term care facilities." Westport, CT: Greenwood Press.
• Richman, J. (1993), "Preventing elderly suicide: Overcoming personal despair, professional neglect, and social bias." New York: Springer.