Journal of Gerontological Nursing

Evidence-Based Practice Guideline 

Evidence-Based Practice Guideline: Secondary Prevention of Late-Life Suicide

Howard K. Butcher, RN, PhD; Todd N. Ingram, MA, RN

Abstract

Suicide is a tragic, traumatic loss, and one of the most emotionally devastating events families, friends, and communities experience. Suicide claims more than 800,000 lives every year, and some of the highest rates of suicide in the United States and globally are among older adults. The purpose of this evidence-based guideline is to help health care providers recognize those at risk for suicide and recommend appropriate and effective secondary suicide prevention interventions. The information in this guideline is intended for health care providers who work in a variety of settings, including hospitals, nursing homes, rehabilitation centers, out-patient clinics, mental health clinics, home health care, and other long-term care facilities. Assessment and preventive treatment strategies were derived by exhaustive literature review and synthesis of the current evidence on secondary prevention of late-life suicide across practice settings. [Journal of Gerontological Nursing, 44(11), 20–32.]

Abstract

Suicide is a tragic, traumatic loss, and one of the most emotionally devastating events families, friends, and communities experience. Suicide claims more than 800,000 lives every year, and some of the highest rates of suicide in the United States and globally are among older adults. The purpose of this evidence-based guideline is to help health care providers recognize those at risk for suicide and recommend appropriate and effective secondary suicide prevention interventions. The information in this guideline is intended for health care providers who work in a variety of settings, including hospitals, nursing homes, rehabilitation centers, out-patient clinics, mental health clinics, home health care, and other long-term care facilities. Assessment and preventive treatment strategies were derived by exhaustive literature review and synthesis of the current evidence on secondary prevention of late-life suicide across practice settings. [Journal of Gerontological Nursing, 44(11), 20–32.]

At any age, suicide is a tragic, traumatic loss and one of the most emotionally devastating events families, friends, and communities can experience. Suicide claims more than 800,000 lives every year, and some of the highest suicide rates in the United States and globally are among older adults (World Health Organization [WHO], 2018). Although suicide attempts are more frequent among adolescents and young adults, older men and women have the highest suicide rate in the United States, with rates reaching as high as 48.7/100,000 among White older men (Conejero, Olié, Courtet, & Calati, 2018).

The Centers for Disease Control and Prevention (CDC) released a report on June 7, 2018, indicating that approximately 45,000 suicides (15.6/100,000) occurred in the United States in 2016. Most concerning was that, between 1999 and 2015, suicide rates increased among men and women, all racial/ethnic groups, and in all levels of urbanization. In 2016, the highest suicide rate (19.72/100,000) was among adults between ages 45 and 54, and the second highest rate (18.98/100,000) occurred in individuals 85 or older. Suicide rates increased in approximately every state from 1999 through 2016. Together, suicide and self-harm injuries cost the nation approximately $70 billion per year in direct medical and work loss costs (Stone et al., 2018).

Although the rate of suicide increases with age (Shah, Bhat, Zarate-Escudero, De Leo, & Erlangsen, 2016), suicide in later life receives much less media attention in all societal realms, less federal funding, and fewer health care initiatives to address this rising public health issue (Van Orden & Deming, 2018). Van Orden and Deming (2018) propose that although “no studies have directly addressed the links between ageism and late life suicide, there may be both direct and indirect links” (p. 80) accounting for the decreased visibility of late-life suicide. A direct link between ageism and suicide can be found in studies across cultures that demonstrate how older adults internalize negative stereotypes of aging, which affects their well-being due to decreased cognitive and physical functioning as well as decreased will to live (Nelson, 2016). There may be a number of indirect links from ageism to suicide in older adults, such as discriminatory practices showing that health care providers prefer treating younger patients, equating aging with illness, and viewing older adults as a burden on society. For example, it is common for health care providers to view suicidal thinking as a normal reaction in older adults (Van Orden & Deming, 2018). A study of emergency department nurses found that the use of universal screening tools and protocols to assess for potential self-harm/suicide decreases with patient age, from 81% in younger patients to 68% in adults 85 and older (Betz et al., 2016).

However, media attention concerning increasing suicide rates occurred on June 8, 2018, when a well-known celebrity chef and CNN personality, Anthony Bourdain, was found dead in his hotel room hotel in France by suicide. His death occurred just 1 day after the CDC released a harrowing study (access https://www.cdc.gov/media/releases/2018/p0607-suicide-prevention.html) on the rising suicide rates. Bourdain's suicide occurred only 3 days after well-known celebrity designer Kate Spade took her life in her New York apartment.

Suicide is an enormous public health crisis and a challenge of all health care professionals. In response to the CDC report findings, Principal Deputy Director Anne Schuchat stated: “From individuals and communities to employers and health-care professionals, everyone can play a role in efforts to help save lives and reverse this troubling rise in suicide” (CDC, 2018 [access www.cdc.gov/media/releases/2018/p0607-suicide-prevention.html]).

Purpose

The purpose of the current evidence-based guideline is to help nurses and other health care providers recognize individuals at risk for suicide in late life and guide providers toward appropriate and effective secondary suicide prevention interventions for older adults who are at risk for self-harm. This article is a condensed and updated version of the evidence-based guideline, Late Life Suicide: Secondary Prevention (Ingram & Butcher, 2016) published by the Barbara and Richard Csomay Center for Gerontological Excellence at the University of Iowa College of Nursing. The full guideline, with graded levels of evidence for assessment, identification of risk factors, prevention and treatment interventions, evidence-based interventions, and assessment tools, is available in electronic format from http://www.uiowacsomaygeroresources.com. The full guideline also includes recommended nursing interventions based on the Nursing Interventions Classification (NIC) (Butcher, Bulechek, Dochterman, & Wagner, 2018) and nursing outcomes based on the Nursing Outcomes Classification (NOC) (Moorhead, Swanson, Johnson, & Maas, 2018). The information in this guideline is intended for nurses and other health care providers who work in a variety of settings, including hospitals, nursing homes, rehabilitation centers, outpatient clinics, mental health clinics, home health care, and other long-term care facilities. Assessment and preventive treatment strategies were derived by exhaustive literature review and synthesis of the current evidence on secondary prevention of late-life suicide across practice settings.

Definition of Terms

Although the meaning of “late life” and aging categories are socially constructed, highly contextualized, and fluid across social settings (Zubair & Norris, 2015), for the purposes of this evidence-based practice guideline, late life and older adults refer to individuals 65 and older. Secondary prevention focuses on care based on the earliest identification of suicide risk so that it can be more readily treated, managed, and prevented (Stanhope & Lancaster, 2015). Suicide refers to death caused by self-directed injurious behavior with an intent to die as a result of the behavior (CDC, 2017), and suicidal ideation is thinking about, considering, or planning suicide (CDC, 2017).

Overview

Late life is a time of enhanced well-being for most older adults, but it is also a time of increased risk for suicide. More significantly, suicidal behavior in older adults is more likely to result in death than at younger ages (Van Orden & Conwell, 2016). In 2013, the WHO (2014) estimated that 8.2% of the world population was 65 or older, yet approximately 17% of suicide deaths were recorded in this age group. The significance of suicide in late life is compounded because people around the world are living longer and the number of older adults is increasing. Between 2015 and 2030, the number of individuals worldwide age 60 or older is projected to grow by 56%, from 901 million to 1.4 billion, and by 2050, the global population of older adults is projected to more than double its size in 2015, reaching approximately 2.1 billion (United Nations, 2015).

Suicide in late life differs in important ways from suicidal behavior that occurs earlier in the life span. Individuals in late life are also more likely to use lethal means and are less likely to report suicidal thoughts to others, including health care professionals (Fiske & O'Riley, 2016). Unique risk factors that distinguish suicide in older adults are associated with life changes due to the aging process. Although many older adults maintain highly functional lifestyles, others may experience mental health problems such as anxiety and depression related to the stress of sensory losses, decline in functional status, and social isolation. Late life is often referred to as the “season of losses” (Osgood, 1992, p. 51), and losses can be associated with depression and increased suicidal risk due to: loss of a job at retirement; loss of significant others such as a spouse, siblings, and friends; loss of a social role; loss of health, strength, and agility; decline in economic stability; relocation from one's home; loss of personal freedom; loss of mental abilities; alterations in self-image; changes in the senses, such as vision and hearing loss; and loss of dreams (Butcher, 2017; Chang, Chang, & Yip, 2017; Draper, 2014; Osgood, 1992; Stone et al., 2018).

Although late-life suicide is often attributed solely to mental health conditions, it is rarely caused by a single factor. Indeed, more than one half of individuals who die by suicide do not have a diagnosed mental health condition at the time of their death (Stone et al., 2018). It is imperative for nurses and other health care professionals to adequately assess older adults for suicide risk and implement secondary prevention measures to reduce the risk of suicide. In addition, professionals should be prepared to educate family members of aging individuals as well as the public on suicide assessment and prevention strategies.

Factors that Increase Suicide Risk

Suicide is not a normative event to the challenges of aging, and suicide prevention efforts can reduce suffering and prevent loss of life among older adults (Van Orden & Deming, 2018). It is important to note that despite concerns about the rising suicide rate among older adults, the majority of older adults believe they have productive lives, are depression free, and experience later life as a time of fulfillment and satisfaction. However, for some older adults, later life can be a time of dissatisfaction with the past and present. Some older adults experience so much physical and emotional pain that they feel hopeless about being able to change and improve their life.

Suicide is a result of a convergence of a multitude of genetic, psychological, social, and cultural risk factors often combined with experiences of trauma and loss (Zalsman et al., 2016). The complexity of risk factors makes research and suicide prevention programs challenging; however, comprehensive evidence-based suicide prevention programs must be a public health priority. A major means for reducing the tragedy of suicide death in late life is early detection of individuals at risk for self-harm (Conwell, 2014).

Assessing for Suicidal Risk in Older Adults

Early detection for suicide risk is the focus for secondary suicide prevention. Research has demonstrated that more than two thirds of adults who die by suicide are seen by a primary care physician within 1 month of their death (Van Orden & Conwell, 2016). Thus, assessing and screening for suicide risk with tools that are quick and easy to use are major strategies for detecting suicide risk. Assessment of at-risk older adults begins with a comprehensive psychosocial assessment. Table 1 lists components of a comprehensive assessment for suicide in older adults. There are several comprehensive psychosocial assessment tools, and one is included in the Appendix of the complete Late Life Suicide: Secondary Prevention guideline (Ingram & Butcher, 2016). Health professionals interviewing older adults who may be depressed should consider using shorter sentences and giving older adults enough time to answer. Terms used by professionals often need to be clarified, as the term depression has different meanings to individuals. It is important to acquire precise information, striving to obtain an accurate picture of the related factors or causes of depression and the time frame, including the time of onset and progression of events and symptoms. After the basic psychosocial assessment, the health care provider should follow up with more specific tools that assess depression, cognitive impairment, and suicide risk. Recommended tools for assessing for suicide risk are listed in Table 2.

Comprehensive Assessment for Late-Life Suicide Risk in Older Adults

Table 1:

Comprehensive Assessment for Late-Life Suicide Risk in Older Adults

Assessment Tools for Late-Life Suicide Risk in Older Adultsa

Table 2:

Assessment Tools for Late-Life Suicide Risk in Older Adults

Identifying Risk Factors for Late-Life Suicide

Risk factors are measurable characteristics, variables, or hazards that precede suicidal behavior and increase the likelihood of the development of an adverse outcome (Moscicki, 1997). Risk factors for late-life suicide fall into three general categories: (a) history of psychiatric–mental health problems; (b) sociodemographic factors; and (c) life stressors.

Although 54% of suicides in 27 states in 2015 were found in individuals without a known mental health condition (Stone et al., 2018), there is strong evidence that individuals who have a history of psychiatric–mental health problems are at higher risk for suicide. A history of suicide attempts is among the strongest predictors of ultimately ending one's life (CDC, 2016; De Leo, Draper, Snowden, & Kõlves, 2013; Dennis, Wakefield, Molloy, Andrews, & Friedman, 2007; Lamprecht, Pakrasi, Gash, & Swann, 2005; Lebret, Perret-Vaille, Mulliez, Gerbaud, & Jalenques, 2006; Miller, Morgun, Azrael, Hempstead, & Solomon, 2008; Tadros & Salib, 2007).

Depression, the most common major mental health disorder in later life, is strongly related to suicide (Butcher, 2017; Conwell & Thompson, 2008; Draper, 2014; Garand, Mitchell, Dietrick, Hijjawi, & Pan, 2006). Major depression is present in 54% to 87% of older adults who die from suicide (Van Orden & Conwell, 2011). Although historically aging and depression have often been viewed as inseparable, depression is not an inevitable aspect of the aging process; rather, depression is a highly treatable condition (Butcher, 2017). Health professionals may believe individuals are simply slowing down or feeling down due to age, when in fact these individuals are showing signs or symptoms of depression (CDC, 2016; Dennis et al., 2007; Dombrovski, Szanto, et al., 2008; Fiske, Wetherell, & Gatz, 2009; Hirsch, Duberstein, Chapman, & Lyness, 2007; Ladwig et al., 2010; Lamprecht et al., 2005; Lebret et al., 2006; Miller et al., 2008; Neufeld & O'Rourke, 2009; Tadros & Salib, 2007). Laborde-Lahoz et al. (2015) found that 13.7% of older adults in the United States experienced major depressive disorder (MDD) in their lifetime and an additional 13.8% have experienced some form of subsyndromal depression (SSD) in their lifetime. SSD is characterized by elevated depressive symptoms that do not meet diagnostic criteria for MDD.

In older adults, SSD is associated with various psychiatric disorders, medical comorbidities, decreased functioning and quality of life, mortality, and financial costs to society (Pickett et al., 2014). In addition, SSD can be associated with increased risk for suicide in later life (Sadek & Bona, 2000). Forms of SSD that do not fall into usual diagnostic categories but cut across different depressive syndromes include existential depression (Blazer, 2002) and dispiritedness (Butcher & McGonigal-Kenney, 2005, 2010). Blazer (2002) believes it is essential that health care professionals working with older adults become aware of existential themes of depression such as a sense of meaninglessness, helplessness, a lack of will to live, and hopelessness. Meaninglessness is a feeling that life no longer has any purpose and may be expressed by statements such as: “What is the use of living; there is nothing to live for anymore; or I don't feel like doing anything anymore” (Butcher & McGonigal-Kenney, 2005). In a phenomenological study of the experience of dispiritedness in later life, Butcher and McGonigal-Kenney (2010) found dispiritedness was characterized by feelings of a loss of meaning and purpose, a sense of emptiness, feeling detached from meaningful connections, depleted energy, helplessness, and feeling restricted. The authors note that although dispiritedness is a transitory distinct existential syndrome that is not characterized by signs of MDD (e.g., recurrent thoughts of death, weight loss/gain, psychomotor agitation, difficulty in concentrating), dispiritedness may be present during episodes of depressive disorders and dispiritedness that “persists may lead to mild or more significant symptoms of clinical depression” (Butcher & McGonigal-Kenney, 2010, p. 160). Older adults with SSD have been found to have a 5.5-fold increased risk of developing MDD within 1 year (Lyness et al., 2006).

A history of mood disorders, such as bipolar affective and anxiety disorders, in addition to depression (Dennis et al., 2007; Draper, 2014; Ladwig et al., 2010; Miller et al., 2008) is associated with later life suicide. The role of anxiety disorders, including posttraumatic stress disorder, in relation to suicidal behavior in later life is somewhat unclear, with some studies finding an increased risk, although this is most often the case when the anxiety disorder is concurrent with a depressive disorder (Draper, 2014). Symptoms of anxiety are often subtle and can be misidentified as symptoms of dementia or a response to physical illness in the older adult population (Draper, 2014; Ladwig et al., 2010; Miller et al., 2008).

Although psychiatric illness and suicide are closely related, health care providers must realize that suicide prevention strategies should not be limited to identifying and treating the psychiatric illness. Suicide risk can also present from social, medical, and environmental factors. Van Orden and Deming (2018) believe social attitudes, such as ageism, are major factors contributing to lack of attention of suicide in later life. Recent reviews of research indicate that when older adults across cultures internalize negative images and attitudes of aging, health and well-being can be affected in the form of decreased cognitive and physical functioning, mental health, and even death. When older adults internalize ageist negative stereotypes and believe they are a burden to their families and society, their will to live diminishes (Nelson, 2016). It should be noted that individuals experiencing depression can have an altered sense of time and may describe recent events as if they happened long ago or distant events as if they occurred yesterday. Collecting a history from family and staff members is valuable to corroborate clinical impressions and provide additional pertinent clinical history. Because older adults are less likely to talk about their suicidal thoughts and plans, health care providers should pay close attention to verbalizations that may indicate the presence of depression, such as: “I feel like an empty shell”; “I just feel down in the dumps”; “I just don't feel like doing anything anymore”; or “No matter what I do, I can't do anything right” (Butcher, 2017).

Additional mental health conditions that are risk factors for late-life suicide include a history of borderline and antisocial personality disorders (Cukrowicz, Ekblad, Cheavens, Rosenthal, & Lynch, 2008; Dombrovski, Szanto, et al., 2008; Draper, 2014; Ladwig et al., 2010; Tadros & Salib, 2007), past or current symptoms of substance use disorders (CDC, 2016; Ladwig et al., 2010; Tadros & Salib, 2007), eating disorders (Ladwig et al., 2010; Tadros & Salib, 2007), and symptoms of hallucinations or delusions (Cutcliffe & Barker, 2004; Tadros & Salib, 2007). Lastly, a history of neurocognitive factors, such as mild cognitive impairment (Ayalon, Mackin, Arean, Chen, & McDonel Herr, 2007; Dombrovski, Butters, et al., 2008; Draper, 2014; Lebret et al., 2006; Van Orden & Conwell, 2016), and neurobiological factors, such as serotonergic neurotransmitter abnormalities and a finding of non-suppression of the dexamethasone suppression test (Draper, 2014), are risk factors for suicide.

Of note is the review by Haw, Haewood, and Hawton (2009), who found an association between dementia and suicidal behavior in late life. Although the authors call for the need for more research to clarify the circumstances of the association, evidence suggests that suicide risk may be increased soon after receiving a dementia diagnosis. In an editorial published in the journal Neurology entitled “The Terrorist Inside My Husband's Brain,” Susan Williams (2016) revealed that her husband, Robin Williams, the popular actor who committed suicide in 2014, was found to have Lewy body dementia. Williams was diagnosed with Parkinson's disease a few months before he died, a telltale sign of Lewy body dementia, which was discovered upon autopsy. The editorial chronicles Williams' desperation as he sought to understand a bewildering array of symptoms that started with insomnia, constipation, and an impaired sense of smell and soon spiraled into extreme anxiety, tremors, and difficulty reasoning.

In addition to a history of mental health conditions, there are several sociodemographic risk factors to consider in late-life suicide. Aging increases the risk for suicide (Dombrovski, Szanto, et al., 2008; Hirsch et al., 2007; Kissane & McLaren, 2006; Ladwig et al., 2010; Lebret et al., 2006; Mezuk, Prescott, Tardiff, Vlahov, & Galea, 2008; Miller et al., 2008) due to psychosocial, environmental, and biological challenges older adults face during the aging process (Van Orden & Conwell, 2016). Non-Hispanic White men older than 65 have the highest suicide rates (CDC, 2016; Dombrovski, Szanto, et al., 2008; Lamprecht et al., 2005; Stone et al., 2018). The recent CDC report (Stone et al., 2018) on suicides in all age groups found 76.8% of decedents to be men and 83.6% to be non-Hispanic White men. Multiple studies agree that divorced, widowed, or single individuals, especially men, are at greater risk for suicide (Ayalon et al., 2007; Conwell, Duberstein, & Caine, 2002; Cutcliffe & Barker, 2004; Draper, 2014; Ladwig et al., 2010; Lamprecht et al., 2005; Lebret et al., 2006). Unemployment (Ladwig et al., 2010; Stice & Canneto, 2008) and low socioeconomic status (De Leo, Draper, & Krysinska, 2009; Fiske et al., 2009; Ladwig et al., 2010) are also demographic factors associated with suicide in late life.

The third category for identifying individuals in late life at risk for suicide is major stressors. Social isolation (CDC, 2016; Dennis et al., 2007; Draper, 2014; Ladwig et al., 2010; Lamprecht et al., 2005; Lebret et al., 2006), family discord (Lebret et al., 2006; Stice & Canneto, 2008), and death of a family member (Lamprecht et al., 2005; Stice & Canneto, 2008) are major stressors that distinguish suicide in older adults from controls in numerous studies. These studies share common themes of social and psychological disconnectedness. Additional factors of social disconnectedness associated with late-life suicides are loneliness (Waern et al., 2002) and low social support (Turvey et al., 2002). Van Orden et al. (2015) found perceptions of being a burden, such as feelings of making life more difficult for others; wanting to escape to “get away from everything” (p. 539); social problems, such as family conflict; and thwarted belongingness were reasons older adults believed their deaths might be worth more to others than their lives.

Strong evidence links the stress from the presence of a diverse array of physical illnesses to increased incidence of suicide (Ayalon et al., 2007; Braden & Sullivan, 2008; Dennis et al., 2007; Dombrovski, Szanto, et al., 2008; Draper, 2014; Erlangsen, Vach, & Jeune, 2005; Ladwig et al., 2010; Lamprecht et al., 2005; Lebret et al., 2006; Mezuk et al., 2008; Miller et al., 2008; Preville, Herbert, Boyer, Bravo, & Seguin, 2005; Stice & Canneto, 2008; Tadros & Salib, 2007). Furthermore, research has shown the risk for suicide increases with the number of diagnosed illnesses (Juurlink, Herrmann, Szalai, Kopp, & Redelmeir, 2004), as with hospitalization for a medical illness (Erlangsen et al., 2005). Health care providers also need to be aware that the presence of physical pain is a particularly important risk factor for suicide in later life, especially in men (Van Orden & Conwell, 2011).

Although these factors contribute to experiencing major life stressors, impaired decision-making and problem-solving abilities also have been found to underlie late-life suicidal behavior (Clark et al., 2011; Gibbs et al., 2009). In a recent systematic review of suicidal behavior and personality, Szucs, Szanto, Aubry, and Dombrovski (2018) found only obsessive and avoidant personality traits were associated with death by suicide in later life, but this was only true in studies that did not control for depression. The authors concluded the inability to adjust to the aging process may help explain the association of obsessive-compulsive and avoidant personality disorders and suicide (Szucs et al., 2018).

Factors that Reduce Risk of Late-Life Suicide

The risk factors described above provide important information for health care providers assessing older individuals for suicidal ideation and/or intent. However, it is equally important to identify factors that reduce risk. Any comprehensive assessment for suicide risk needs to include risk and protective factors. Evidence shows that protective factors are mainly found in older adults' family relationships, social environment, cognitive functioning, and general attitude about life. Table 3 provides a summary of key protective factors.

Factors that Reduce the Risk of Late-Life Suicide in Older Adults

Table 3:

Factors that Reduce the Risk of Late-Life Suicide in Older Adults

Secondary Prevention for at-Risk Older Adults

Late-life suicidal ideation can become a life-threatening situation. Early detection is the first level of suicide prevention, and crisis intervention follows as a second level of suicide prevention support for older adults at high risk. All individuals 60 and older should be screened on a yearly basis. Individuals who have personal, medical, or situational risk factors should be screened every 6 months or more frequently at the clinician's discretion (Conwell, 2014; Conwell & Thompson, 2008; Cutcliffe & Barker, 2004). Careful assessment by a primary care provider or care team, including appropriate referrals to psychiatric professionals, will improve quality of life for older adults and may save lives.

The scales recommended in the current guideline are designed to screen for cognitive impairment, depression, or suicidal ideation. Kroenke, Spitzer, and Williams (2003) found the first two questions of the Patient Health Questionnaire (PHQ-9) were valid in detecting depression with a sensitivity of 83% and a specificity of 92% for MDD with a score of ≥3. The two questions are hallmarks for symptoms of depression related to mood (i.e., feeling down, depressed, hopeless, sad, blue) and having little interest or pleasure in doing anything. These two questions can easily be added to any health care history form. The U.S. Preventive Services Task Force (2014) recommends screening for suicide risk when depression is present; however, health care providers need to realize that the many other factors identified in this guideline may contribute to risk for suicide either alone or in combination with a psychiatric illness.

When gathering information about symptoms of depression, nurses need to be alert to life changes, especially recent significant losses, such as death of a significant person, or role changes, such as retirement. Attention needs to be given to assessing older adults' level of self-esteem, sense of helplessness and hopelessness, pessimism, and if they have any thoughts of self-harm or have attempted suicide in the past.

It is important during the assessment to ask older adults about suicidal ideation (i.e., does the individual have a suicide plan) and determine whether they have the means to harm themselves. Some professionals may find asking questions about a client's possible suicide ideation difficult. However, knowing what makes things better and what makes things worse regarding the onset, intensity, duration, and frequency of suicidal thoughts and feelings assists health care professionals in developing a plan of care. When assessing older adults for suicidal thoughts, it is important to convey empathy, compassion, genuine concern, and understanding of their feelings about wanting to relieve their intolerable pain. Knowing what situations in the future might engender the return of suicidal thoughts can help establish a mutually agreed upon safety plan, as well as strategies that can be used by the older adult to avoid or manage such situations. The presence of a suicide plan indicates that the individual has some intent to die and has begun preparing to die. It is important to know the possibilities and potential for implementation of the plan, the likelihood of being rescued if the plan is undertaken, and the relative lethality of the plan.

Some questions that might be asked include:

  • Over the past 48 hours or 1 month, have you been feeling hopeless about the present and/or future?
  • Have you thought that life is not worth living?
  • Have you been depressed or so sad lately that you have been thinking about death or dying?
  • Have you had any thoughts about hurting yourself or taking your own life?
  • When did you start having these thoughts, and have you thought about how you would take your own life?
  • Have you ever attempted suicide before?

Other immediate interventions are the use of direct but sensitive communication with the individual at risk, and with the family when possible, especially when a new diagnosis of dementia is indicated (Duberstein & Heisel, 2006; Erlangsen, Zarit, & Conwell, 2008). Some investigators suggest the use of outside professionals for regular assessment of at-risk patients, care managers to assist in assessment and surveillance, and other professionals to mediate stressful situations such as problems with family discord and financial stress (Conwell & Thompson, 2008; Cukrowicz et al., 2008; Duberstein, Conwell, Conner, Eberly, & Caine, 2004; Fiske et al., 2009; Loebel, 2005; Podgorski, Langford, Pearson, & Conwell, 2010; Unützer et al., 2006; Wallace et al., 2011).

Detection of clinically significant symptoms when using the tools with patients should trigger a referral to a psychiatric professional for in-depth diagnostic assessment and treatment. A professional such as an advanced practice nurse or physician with expertise in geriatric psychiatry would be preferred. When identifying an individual at risk for suicide, increased surveillance or hospitalization to ensure safety may be required. Other options could include partial hospitalization and day treatment (Conwell & Thompson, 2008). Because many patients may meet criteria for depression, antidepressant medication therapy may be indicated (Barak, Olmer, & Aizenberg, 2006; Conwell & Thompson, 2008; Erlangsen, Canudas-Romo, & Conwell, 2008; Unützer et al., 2006). However, some investigators caution that initiation of selective serotonin reuptake inhibitors may increase suicidal ideation during the first month of therapy, indicating the need for continued close monitoring (Juurlink, Mamdani, Kopp, & Redelmeier, 2006). The same study showed that risk declined dramatically during the following months of therapy (Juurlink et al., 2006). Another study revealed that use of antiepileptic monotherapy for mood control increased suicide-related behavior among aging Veterans (Pugh et al., 2012). Table 4 provides a list of secondary suicide prevention interventions.

Secondary Prevention Interventions for Late-Life Suicide Risk in Older Adults

Table 4:

Secondary Prevention Interventions for Late-Life Suicide Risk in Older Adults

Promising Suicide Prevention Interventions

Identification of risk factors is the first step of suicide secondary prevention. Interventions are needed that aim to reduce suicidality specific to the unique experiences of older adults. Many of these and other innovative evidence-based interventions are described below.

Suicide prevention programs, to be effective, need to move beyond risk identification and treatment at the individual level to more universal and population-focused approaches. Many investigators indicate that suicide prevention interventions need to entail a multifaceted approach (Conwell & Thompson, 2008; Cukrowicz et al., 2009; Draper, 2014; Duberstein et al., 2004; Duberstein & Heisel, 2006; Erlangsen, Canudas-Romo, et al., 2008; Podgorski et al., 2010). Unfortunately, an international research group on suicide among older adults (Erlangsen et al., 2011) noted a lack of evidence-based studies and findings for suicide prevention programs. There is a need for developing and testing a range of multimodal suicide prevention programs that are universal (entire population), selective (populations at high risk), and indicated (those who are symptomatic). Multimodal interventions that include the involvement of local government leadership, education of the general public to reduce stigma and increase awareness, training programs for community gatekeepers, and screening are found to be effective in reducing suicidal behaviors, particularly suicide attempts in men and older adults in rural areas (Ono et al., 2013). A study of nationwide suicide prevention programs in 21 Organization for Economic Cooperation and Development countries found that suicide rates declined after government-led suicide prevention programs were introduced, and the reduction was more pronounced in youth and older adults (Matsubayashi & Ueda, 2011). The systematic review of 19 suicide prevention programs showed that when programs included population-focused depression screening, treatment, and reduction of isolation, a decrease was noted in suicidal ideation and suicide rates in participating communities (Lapierre et al., 2011). A multimodal intervention in Japan increased support for individuals at high risk and was effective in reducing suicidal deaths by 48% in older adults from implementation to post implementation, whereas the suicide rate did not change in nearby comparison regions that did not receive the intervention (Oyama & Sakashita, 2016).

Evidence also supports that persistent goal setting and continued engagement to meet goals in older adults with functional limitations reduces suicidal ideation (Fiske & O'Riley, 2016). For individuals with cognitive decline, a serious stressor increasing the risk for self-harm, problem-solving therapy, which focuses on identifying and solving one problem at a time with step-by-step guidance, was found to significantly decrease suicidal ideation in relation to a comparison group 24 weeks post-treatment (Gustavson et al., 2016). There is a need to test the effectiveness of interventions such as cognitive therapy, problem-solving therapy, interpersonal therapy, acceptance and commitment therapy, and mindfulness-based approaches in reducing suicidal ideation. These interventions can be designed to help older adults compensate and adjust to functional and emotional losses often experienced by promoting emotional regulation and socioemotional adaptions to the aging process.

Incorporating strategies that potentially enhance protective factors (i.e., factors that reduce suicidal risk) into multimodal suicide prevention programs can be an innovative and effective approach to reducing suicide deaths. For example, intervention trials designed to increase contact and social connectedness demonstrated reduced suicide deaths. De Leo, Dello Buono, and Dwyer (2002) provided telephone-based outreach, evaluation, and support services over 11 years that led to significantly fewer suicides than would have been expected in the adult population in that region. The use of camera-based monitoring and real-time technologies, such as app-based tablets, smartphones, and smart televisions, may be tools that not only enhance social connectedness and reduce social isolation among older adults, but also can be used as a means for health care providers to evaluate suicidal risk and provide a wide range of support services. At the service system level, offering volunteer opportunities or one's time to help others as a source of enhancing meaning and purpose in the lives of older adults and providing affordable congregate living options, such as naturally occurring retirement communities, are additional ways to increase social networks and supports and reduce risks for late-life suicide. Heisel and Flett (2006), in a 6- to 22-month longitudinal study of 173 community-dwelling older adults (ages 65 to 93), tested an existential model of meaning making using two measures of meaning in life. Their findings add to a growing body of literature and research indicating meaning in life plays an important role in promoting mental health and well-being and may contribute to enhancing resiliency when older adults experience thoughts of suicide. In other words, meaning in life appears to protect against the onset or exacerbation of late-life suicidal ideation (Heisel & Flett, 2006). Interventions designed to help older adults find meaning in their lives such as journaling, reminiscent therapy, and interventions that facilitate involvement in activities (Butcher et al., 2018) that are meaningful and sources of enjoyment, may be additional ways to enhance meaning and protective factors that reduce suicidal risk (Butcher & McGonigal-Kenney, 2005).

Van Orden and Deming (2018) also address the importance of firearm safety, training, and storage. In a cross-sectional study of 2,939 adults in the United States, as many as 39% of older adults had at least one gun in the household, and among these individuals, 5.1% had suicidal ideation in the past 1 year and 3.6% had attempted suicide in the past (Van Orden & Deming, 2018). Only 55% had firearm safety training and 21% stored their guns loaded and unlocked (Van Orden & Deming, 2018). Primary care providers are well positioned for firearm screening/safety and counseling, yet less than one half (30%) routinely ask about firearm access during suicide risk assessment (Slovak, Pope, & Brewer, 2016). Assessing firearm access and providing safety counseling may contribute to lowering rates of firearm suicide in later life in countries like the United States, where firearms predominate as a lethal method for suicide in older adults.

Conclusion

Growing old is an inevitable journey that many individuals will have the privilege of experiencing (Van Orden & Deming, 2018). The tragedy of suicide is often preventable. Identification of risk factors and screening for depression are effective approaches to reducing suicide deaths in older adults. Suicide prevention cannot be limited to hospital, primary care, and clinic settings, but rather must reach into communities and culture. Universal prevention strategies are needed to address the issues of stereotyping and ageism that persist and are deeply embedded in our culture. Effective approaches for addressing the negative impact of ageism exist. For example, the PEACE (Positive Education about Aging and Contact Experiences) model includes educational strategies and intergenerational contact designed to reduce age-related discrimination, stereotyping, and prejudice (Levy, 2016). The PEACE model may also promote health and well-being in older adults and give rise to changes in policies and programs such as health care and housing that affect the meaningfulness and quality of lives of older adults. In the wake of the increased media attention of suicide deaths, now is the time to make suicide prevention for older adults a global health care priority.

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Comprehensive Assessment for Late-Life Suicide Risk in Older Adults

The interview should take into account the following factors that play a role in treatment planning:
Identification of risk factors, diagnosed medical problems, medications, functional status, nutritional status, personal and family psychiatric history, alcohol or drug use, thorough physical and neurological examination
Cognitive functioning mental status examination, including changes in cognition over time; educational level
Psychological strengths and symptomatology, coping skills, spirituality, sexuality, suicidal ideation, past attempts at suicide
Quality and quantity of social support, financial status, legal history, potential for elder abuse
Time course /duration and severity of depressive symptoms to differentiate type of depression

Assessment Tools for Late-Life Suicide Risk in Older Adultsa

Assessment ToolExplanation
Comprehensive psychosocial assessment formThis form should be adapted to the older adult and cover all areas of risk and protection.
Mini Mental State Exam (MMSE)A widely used screening tool to assess cognitive functioning of older adults. It contains items that assess orientation, attention and calculation, immediate and short-term recall, and language and ability to follow simple written and verbal commands. The MMSE is designed to be administered by a clinician. It yields a maximum score of 30 and a minimum score of 0. A score of ≤23 indicates the presence of dementia. The MMSE has demonstrated high sensitivity and specificity (Folstein, Folstein, & McHugh, 1975). This tool is useful as dementia, especially newly diagnosed, is a risk factor for suicide.
Montreal Cognitive Assessment (MOCA)A widely used screening assessment for detecting cognitive impairment. It is a brief 30-question test that takes approximately 10 to 12 minutes to complete. It was published in 2005 by a group at McGill University working for several years at memory clinics in Montreal, Canada. It was validated in the setting of mild cognitive impairment and has subsequently been adopted in numerous other clinical settings (Nasreddine et al., 2005).
Patient Health Questionnaire 2 (PHQ-2)A two-item tool based on the PHQ-9 that asks two yes/no questions: During the last 2 weeks have you been bothered by: (1) having little interest in doing things? (2) feeling down, sad, or hopeless? If the client answers yes to either question, the provider should administer the full PHQ-9 (Pfizer, 2005).
Geriatric Depression Scale–Short Version (GDS-15)A 15-item tool to assess presence of depression in older adults. The advantages of the tool are that it can be self- or clinician-administered and it is brief (usually taking less than 10 minutes to complete) (Sheikh & Yesavage, 1986).
Geriatric Depression Subscale for Suicide Ideation (GDS-SI)A 5-item subscale of the GDS-15. Client scores of ≥1 on five selected items (3, 7, 11, 12, and 14) have been strongly correlated with positive suicidal ideation. All items are generally related to increased feelings or perceptions of hopelessness, worthlessness, emptiness, and reduced happiness in life (Friedman, Heisel, & Delavan, 2005; Heisel, Duberstein, Lyness, & Feldman, 2010; Heisel & Flett, 2006).
Cornell Scale for Depression in Dementia (CSDD)Commonly used to detect depression in adults with mild to severe dementia. It is a 19-item instrument that relies on interviews with clients and nursing staff and is based on behavioral observation. It can be used in hospital, outpatient, and nursing home settings, and may be useful for assessing clients with dementia for depression (Alexopoulos, Abrams, Young, & Shamoian, 1988).
Nurses' Global Assessment of Suicide Risk (NGASR)Can be used to augment the psychosocial assessment form and GDS-SI to further assess risk factors (Cutcliffe & Barker, 2004).

Factors that Reduce the Risk of Late-Life Suicide in Older Adults

Cultural pridea
Positive relationships with friends
Positive religious/spiritual beliefs
Sense of responsibility to family
Positive family relationships
Self-identity and consciousnessa
Female gender
Married or partnered
Fear of suicide
Greater numbers of children and grandchildren
Recognition of purpose and meaning in life
Social cohesion and pro-social behavior

Secondary Prevention Interventions for Late-Life Suicide Risk in Older Adults

Crisis intervention to ensure safety is the highest level of secondary prevention. The following measures may be used individually or in combination to prevent suicide attempts. The appropriate measure or combination of measures should be determined by a trained professional. Other measures that focus on longer-term secondary prevention are also listed.
Crisis InterventionsOther Interventions

Hospitalization

Increased surveillance

Partial hospitalization

Day treatment

Antidepressant medications

Communicating risk to family

Appointment of care manager

Care manager for more frequent risk assessment

Counseling

Cognitive-behavioral therapy

Decision-making support

Support groups

Assistance to resolve family discord

Assistance with financial stress

Increase social involvement

Increase activity with faith community

Authors

Dr. Butcher is Associate Professor and Dr. Ingram is Assistant Professor Emeritus, University of Iowa College of Nursing, Iowa City, Iowa. Dr. Butcher is also Associate Director, Barbara and Richard Csomay Center for Gerontological Excellence, Series Editor, Evidence-Based Practice Guidelines, and Editor, Nursing Interventions Classification, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Copyright © 2018 Csomay Center for Gerontological Excellence.

The full guideline is available at http://www.uiowacsomaygeroresources.com

Address correspondence to Howard K. Butcher, RN, PhD, Associate Professor and Associate Director, Barbara and Richard Csomay Center for Gerontological Excellence, The University of Iowa College of Nursing, 442 NB, Iowa City, IA 52242; e-mail: howard-butcher@uiowa.edu.

Posted Online: September 13, 2018

10.3928/00989134-20180907-01

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