Persons aged 65 and older, who comprise nearly 13% of the US population, commit 17% to 25% of annually reported suicides. The percentage of older persons taking their own lives is on the rise. The rate of suicide for this age group has increased steadily fe>m 17.1 (per 100,000) in 1981, to 21.5 (per 100,000) in 1986. The rate of suicide for all individuals in 1986 was 12.1 (per 100,000).1
Approximately 1.5 million individuals live in more than 24,000 long-term care facilities in this country.2 These numbers are expected to increase more than 50% by the year 2020.3 In comparison with older adulte living in the community, institutionalized elderly are older, sicker, and more likely to have no living family members; factors that place them "at risk" for suicide. Although studies of suicide in the elderly have been conducted over the past 2 to 3 decades, limited research to date has focused on the older population in the institutional environment. Preventing suicide and other forms of selfdestructive behavior among the institutionalized elderly is a major consideration from humanitarian, professional, and legal points of view.
The first national study of suicide in the elderly in long-term care facilities was conducted by Osgood and Brant in 1986.4 The major purpose of the study was to identify factors related to suicide in the institutionalized elderly. Questionnaires were mailed to a random sample of 1,080 administrators and directors of nursing of long-term care facilities in all parts of the United States. Information was gathered on the number of overt suicides (eg, shooting, hanging), and intentional life-threatening behaviors (eg, refusal of food, fluid, or medication) occurring in 1984 and 1985. Information was also collected on facility characteristics such as size, per them cost, staff turnover rate, staff-to-patient ratio, case mix, auspice (public, private, religious, and other), and level of care. Of the 463 facilities (43%) that responded to the survey, 84 reported at least one instance of suicidal behavior during 1984 and 1985. Other respondents reported one to nine suicidal behaviors.4
Based on data reported during the course of the initial study, research efforts were expanded in 1987 to complete 3-week community studies in each of four consenting nursing homes in which suicide had been reported in the original research. Nursing homes participating in the community study were located in New England and the Midwestern section of the United States. Data for this study were collected through participant observation and interviews with staff, residents, and families, when available. Retrospective analyses of the medical records of all suicides for the years 1981 to 1985 were completed.
This article reports three case studies chosen to invite the reader to understand the psychosocial elements of aging that contribute to self-destructive behaviors in older residents of long-term care facilities. These cases illustrate the complexity of the problems experienced by the aged and the multiple pathways to self-destruction. Case illustrations have been reconstructed from interviews, participant observations, and medical record data collected in the nursing homes involved in the study. The cases typify suicidal behaviors found among residents in long-term care institutions who died from engaging in overt suicide or intentional life-threatening behavior. Names, places, and dates have been changed to protect the anonymity and privacy of persons and research sites.
In 1986, Jake, a 91-year-old retired railroad conductor, and Gertrude, his wife for 63 years, moved from a small rural Midwestern town to a nursing home in a large city far from their home. Although they would have preferred the closeness and familiarity of the town in which they had lived for more than 50 years, no long-term care facilities were available there. Gertrude's health was failing and Jake was unable to provide for her needs in their home.
Jake and Gertrude shared a small room in the institution and were constant companions, spending each day together in some activity; they were inseparable. The couple took short walks when Jake could persuade his spouse to accompany him. They often were observed holding hands as they strolled around the grounds. The nursing home staff described Jake as an affable, healthy, happy person always ready for a joke, fewer than 3 months after the couple's admission to the nursing home, Jake's emotional and physical well-being changed noticeably. To Gertrude's disappointment, he chose not to accept the children's invitation to Thanksgiving dinner, complaining of severe headache and stomach pains. This was not the first such episode since his admission. Over the holidays, headaches, abdominal pains, nausea, loss of appetite, changes in stool, and sleep disturbances occurred. Jake was hospitalized for 3 weeks with a diagnosis of peptic ulcers.
After discharge to the nursing home, Jake became more anorexic and physically deteriorated, appearing thin, pale, and despondent. "Why doesn't the Lord take me?" he cried frequently. He and Gertrude were soon moved to a wing for less functional residents. It was then that Jake clearly exhibited signs of giving up. He became less mobile, spoke very little, engaged less and less in activities of daily living, and rarely left his room, preferring to lie in bed and repeat to himself, within earshot of Gertrude, "I want to die. I just want to die." Jake and Gertrude moved several more times within the nursing home after his initial hospitalization because of increased dependency needs. His adjustment to each new surrounding became more difficult and often incomplete.
This once acutely alert gentleman became confused, disoriented, and more depressed. Still painfully able to utter the despair that was now a part of him, lake would cry aloud, "We're so sick, why does God make us live so long? We're no good to anyone. Our families are so far away. We can't enjoy anything now. It's cruel for God to keep us alive." At times, Gertrude responded to lake's cries with anger ~f. unpleasantness, as she perceived the absolute hopelessness of their situation. Often she would sob aloud, "I'm so homesick and lonesome!" The staff expressed sadness in seeing this once loving couple of 63 years reduced to fear and bitterness.
Jake focused on his nihilistic obsessions: "I can't fight this anymore. I'm finished. I just want it to be over." He chose not to have his family visit, stopped eating and drinking entirely, and refused all medication and social contact. He slept most of the day, and at night he would scream or pray, or both. lake was transferred to the local hospital where attempts to administer intravenous fluids and medications were unsuccessful because of Jake's detennination to remove the IVs. In light of his deteriorated condition, the family agreed to a "no code" status; and, 2 weeks later, his battle fmally won, lake died.
Lenny, a 78-year-old bachelor, was a former high school teacher, wellknown in the community for his prof?ssional contributions and accomplishments. Lenny had made a comfbrtable salary and maintained financial hidependence during his adult ilk. After his retirement, Lenny lived with his younger sister, his only living relative. Both maintained active and independent lifestyles, shared in the financial operation of the home, and participated in community functions. In 1986, Lenny was hospitalized for a minor stroke, and with prescribed therapy, regained the use and control of his lower extremities. Six months after hospitalization, Lenny had resumed near normal activities; by the end of the ninth month, he was able to drive his car short distances. One of Lenny 's main enjoyments in life was to drive his car, to exercise his "freedom." With the exception of a slight speech impediment, Lenny considered his recovery complete. Unexpectedly, in the spring of 1987, Lenny's sister determined that it would be best for both of them if Lenny to move to a nursing home to be properly cared for after the stroke. With protests, Lenny reluetantly agreed to a trial stay.
Lenny was tall, handsome, and well-groomed, yet the staff described him as an angry man. A series of events shortly after his admission confirmed their observations. The sister had taken Lenny's car keys to protect him from harm. An argument ensued, and Lenny lashed out loudly, "That's (the keys) a man's independence. Take that away and you take his whole life away." To no avail he begged his sister to take him home to live.
Lenny became more angry and suspicious when his sister drove to the nursing home in a new car 2 weeks after his admission. Thereafter, his sister's sporadic visits usually ended in arguments. Tentative plans for or for a ride were postponed or canceled. Lenny* s rejection was manifest in feelings of loneliness, frustration, and anger. These feelings and behaviors increased in frequency, and depression surfaced. Increased dependence on others was apparent to the staff. Agitation and depression became more severe after a move from a private room on an intermediate care unit to a four-bed room on a skilled care unit. To Lenny, the move symbolized a further loss of independence, personal control, privacy, and freedom.
Although Lenny experienced other moves during Ae year, the move to the four-bed room was particularly traumatic. Lenny objected vehemently to living with persons whom he disliked and to his limited privacy. If a disoriented resident wandered into his room, or if his roommates occupied the bathroom when he needed it, Lenny would become enraged, often throwing a urinal at his roommate. Lack of sleep contributed to his irritable behavior.
Lenny became actively suicidal. Acquiring a razor blade from an unsuspecting aide, he cut his wrist, but failed in the suicide attempt. Lids of tin cans were not effective to accomplish the act. Suicidal thoughts such as, "Just give me a revolver so I can end it all," or 'Open the back door and throw me in the trash barrel," were repeatedly verbalized.
The nursing home team responded by placing Lenny on 24-hour nursing observations and increasing the dose of doxepin at night. Haloperidol was increased to twice daily, and alprazolam was prescribed at hour of sleep to relieve anxiety. However, Lenny's deep and continuing depression affected his eating, sleeping, and overall function. When a meal was served to him, Lenny would respond "To hell with this, it's time to shove off anyway." Food and fluids were adamantly refused. Vulnerable, Lenny developed pneumonia and died 5 months after his admission.
Sadie, aged 79 and widowed, was described as an intense but pleasant person. A former supervisor for the local phone company in a New England city, Sadie retired after the death of her husband to tend her home and spend more time with her grown children and grandchildren, her only living relatives. Sadie was active in civic affairs; maintained her interests in reading, handwork, and current events; and managed her life independently for 15 years after her husband's death.
The children, noticing subtle changes in behavior, admitted Sadie to a nursing home. Sadie, perceiving herself as able to manage in her own surroundings, was bewildered and angered by the family's insistence that she go to a nursing home against her wishes.
Admission assessment revealed an adequately nourished, alert, knowledgeable individual who was functional in all areas of activities of daily living. A pre-admission history revealed that Sadie experienced occasional urinary leakage, which she managed at home. The physician had been treating her for cardiac irregularities, borderline hyperglycemia, hypertension, arthritis, and possible AIzheimer's disease. Facial pain, exacerbated by tension and irritability, was relieved by ibuprofen. Nitroglycerine was prescribed as needed for chest pain. The medication regimen remained unchanged after admission.
Because she seemed to be adjusting well to the routine, Sadie was moved to a permanent double room with a roommate for company. Within weeks Sadie was unable to eat her meals. When staff expressed concern about her diminishing appetite and limited intake, she responded, "I'm too angry with my son to eat. When my son comes to take me out of here, I'll eat; otherwise, I don't care whether I ever eat." Sadie accused the family of pulling a fast trick on her. Increased irritability, severe facial pain, and a fall ensued during this period, accompanied by social withdrawal and requests to be left alone. Sadie was hospitalized after episodes of vomiting and weakness, and she frequently fainted on the unit. Following hospitatization, she was increasingly tense, communicated little, and refused to leave her room for meals or activities.
Sadie attempted unsuccessfully to leave the nursing home with her few possessions. Unable to do so, she asked for the "big pill" and stopped accepting most medications. Finally, she confined herself to bed, spat out food and medicine, and refused to open her mouth. Dependence on nursing staff for activities of daily living increased. The family, confronting Sadie with concern about the consequences of her actions, told her she could become ill or die; Sadie rejected her family's concern.
Institutional life seemed literally intolerable for her at that point. Confusion, physical deterioration, and ultimate refusal of all treatment culminated in the development of respiratory complications. The family requested a "no code." Sadie died 6 months after leaving her home.
Jake, Lenny, and Sadie are representative of older residents living in longterm care facilities who suffer from loss, loneliness, and depression. Factors that contributed to their decision to stop living are common to many residents who contemplate or complete suicide. Depression, social isolation, social withdrawal, family abandonment and rejection, and physical moves within their environment all occasions of difficulty. Loss is a major factor contributing to suicide among residents in long-term care institutions. Significant losses include loss of spouse, Mends, pets, money, control, independence, physical mobility, and sensory-perceptual losses. A theme in each of the cases presented here was loss: Jake, Lenny, and Sadie all suffered major physical losses, and, in addition, loss of home, possessions, freedom, independence, autonomy, and privacy when they moved to the institution.
A man in control of his lifestyle over the years, Jake found that the freedom, autonomy, and control necessary to maintain and preserve person-environment balance in his new surroundings were gone. His emotional pain was more than he could endure. Jake shut himself away from the world by withdrawing from human contact. The will to live under these circumstances rapidly disintegrated. Lenny lost his independence and privacy. The power for decision-making was assumed by his sister and the nursing home administrator. The forced dependency of institutional living on someone as independent as Lenny fostered a loss of selfesteem and self-worth. Diminished self-esteem and a sense of powerlessness can adversely affect the older person's ability to cope. Sadie's perceived loss of control, independence, individual rights, family, home, and health prompted a chain of reactions and repercussions that pervaded her institutional stay. Feelings of abandonment, anxiety, despair, and loss fluctuated in intensity; often more than Sadie could cope with rationally at this crucial time in her life.
Sharing space with another human being, a stranger, may have served to increase anxiety for Lenny and Sadie since they were accustomed to living alone. Family rejection and abandonment are important factors contributing to suicidal behavior among residents. Each of these individuals experienced feelings of separation, rejection, and abandonment by their families - Lenny by his sister, Sadie by her son, and Jake by his children.
Like other residents, Jake, Lenny, and Sadie experienced multiple moves within the facilities. With each move, they were confronted with new roommates, new staff, and new routines. The lack of consistency and constant adjustment were difficult for each of them. Jake, Lenny, and Sadie demonstrated signs and symptoms of depression, ftelings of hopelessness, worthlessness, loss of love and concern permeated their daily lives. Suicidal ideation was clearly expressed. Nourishment lost all appeal. Increased social withdrawal and isolation characterized their final days.
CLINICAL IMPLICATIONS FOR NURSING
The elements of diminished physical vigor, functional incapacity, aberrant or atypical behavior, persistent refusal of food and fluid, perceived loss of control, lack of a strong family support network, loneliness, social isolation, and withdrawal are but a few of the essential warning clues to lifethreatening behavior in the elderly, particularly in the old-old (75 years and older). Somatic or masked complaints, common in many elderly who are depressed, cannot be taken lightly under such conditions. Unfortunately, these symptoms are not always recognized as indicative of elderly depression, perhaps because it is falsely assumed that symptoms expressed by the older adult are normal concomitants of aging. What is critical to understanding suicide in the young-old (65-74) and the old-old is that depression, often masked and unrecognized, is a precursor to overt and intentional life-threatening suicidal behavior among these age groups.
The family is an important consideration in planning and implementing therapeutic interventions with the depressed, suicidal elder in long-term care institutions. Strengthening and extending family roles in supporting the elder is vital in reducing loneliness, emotional pain, loss of independence, and is also vital in increasing selfconcept. By the same token, families can attend to resolving their own grief, loss, and guilt in involvement rather than withdrawal. As a social system, neither elders nor their families can be treated in isolation. Expanding our knowledge of mental health needs of older adults and their families is criticai in prevention as well as in care planning and delivery. A major step toward prevention is the recognition of depressive symptomatology and key elements and clues to suicide in the elderly in long-term care institutions. Recognizing key elements, those important clues to suicide in the elderly, can be the first step to prevention.
- 1. National Center for Health Statistics. Advance report of final mortality statistics, 1986. NCHS Monthly Vital Statistics Report. 1988; 37(6, Suppl.).
- 2. Harper MS. Introduction. In Harper MS, Lebowitz BD, eds. Menial Illness in Nursing Homes: Agenda for Research. Washington, DC; Department of Health and Human Services; 1986:1-6.
- 3. Kramer M. Trends of institutionalization and prevalence of mental disorders in nursing homes. In Harper MS, Lebowitz BD, eds. Mental Illness in Nursing Homes: Agenda far Research. Washington, DC: Department of Health and Human Services; 1986:7-26.
- 4. Osgood NJ, Brant BA, Lipman A. Patterns of suicidal behavior in long-term care facilities: A preliminary report on an ongoing study. OMEGA. 1987-1988; 19(1):59-65.