“Our connections with others are what bind us to life! Together, we can make a difference. Together, we can save lives.”—Arbore (2019, p. 65)
Suicide in older adults is a cause for enormous concern from researchers, health care providers, policy makers, and society at large (Conwell, Van Orden, & Caine, 2011). More than 47,000 suicides were documented in 2017, with 8,500 in adults older than 65 (Axelrod, Balaban, & Simon, 2019). The actual number of late-life suicides is probably much higher, as the rates of suicide by older adults are thought to be under-reported by approximately 40% due to “silent suicides”—overdoses, self-starvation, self-dehydration, and “accidents” (Aging in Place, 2019). Risks for suicide actually increase with age. Men who are 65 and older face the highest risk of suicide (Axelrod et al., 2019). Individuals ages 75 to 85 have higher rates of suicide than those between ages 65 and 75, and those 85 or older have the highest risk yet (Aging in Place, 2019). Despite these alarming statistics, research on suicide in this “forgotten population” (Williams, 2007) is scant, often leaving family and professional caregivers unaware of suicide warning signs (Axelrod et al., 2019).
Adding to the seriousness of the problem is that when older adults attempt suicide, they are far more likely to die than younger individuals (Axelrod et al., 2019). Research has shown that one in four older adults who attempt suicide die, compared to one of 200 attempts for young adults. The exact reasons for this higher prevalence are not known, but older adults who attempt suicide are often frail, making them more vulnerable to self-inflicted injury. They are often more isolated, making rescues more difficult; are more likely to have a pre-determined plan; and may be more determined to die than younger individuals (Axelrod et al., 2019; Greenlee & Hyde, 2014).
Why Older Adults Are at Risk
A combination of biological, psychological, social, and cultural factors can increase an older adult's risk of suicide ideation (Axelrod et al., 2019; Worthington, 2019). Risk factors include prior suicide attempts, history of depression, lack of social support, hopelessness, prior traumatic events, and access to lethal means (Arbore, 2019). Aging can present physical and mental problems and transitions that make coping difficult. Approximately 80% of older adults live with a chronic disease, such as arthritis, diabetes, and high blood pressure, that may bring pain and disability (Axelrod et al., 2019). Physical and/or mental issues might end an older adult's ability to drive, read, or engage in activities needed to stay independent. Cognitive deficits in later life have been linked to suicide (Conwell et al., 2011), and substance use has been reported in approximately one in three suicides (Aging in Place, 2019). Many older adults live in isolation, with children miles away, and crave the human connection that family visitations bring; loneliness can add to their suicide risk (Axelrod et al., 2019). Older adults may be struggling with the death of a lifelong spouse, other family member, or friends and these losses can trigger feelings of loss of control and hopelessness that increase suicide risk (Worthington, 2019). Research also suggests that economic insecurity contributes to suicide in older adults, who often have fewer financial resources, leading to more uncertainty about their future (Greenlee & Hyde, 2014).
As older adults lose the ability to complete once routine and meaningful activities, depression can set in. In addition to physical and mental changes with aging noted above, side effects of medications commonly used by older adults, such as statins and beta-blockers, may cause depression (Greenlee & Hyde, 2014). Studies consistently show the strong relationship between suicide and depression (Worthington, 2019). This evidence is especially important when considering that depression is under-detected in older adults. Depression, coupled with social isolation, physical and/or mental illness, functional impairment, pain, and financial worries can lead to despair (Greenlee & Hyde, 2014).
More than 25% of Americans older than 65 live in rural areas and may experience unique situations that increase suicide risk (Arbore, 2019). Rural residents have a higher prevalence of chronic disease, higher disability rate, lower prevalence of healthy behaviors, and widening gap in life expectancy relative to the nation as a whole (Arbore, 2019). They also have higher rates of cigarette smoking, high blood pressure, obesity, and poverty, less access to health care, and are less likely to have health insurance. Rural areas have a “lethal triad” of easy firearms access, high rates of drug and alcohol use, and low health care access (Arbore, 2019, p. 63). Mental health facilities and/or experienced practitioners are often clustered in urban centers rather than rural settings, adding to the problem of suicide risk for older adults (Arbore, 2019).
Treatment and Prevention
It is important for family and professional caregivers to know what to watch for in prevention of suicide. Certain behaviors should be considered red flags, such as stockpiling medication, rushing to revise a will, using alcohol or drugs increasingly, altering sleep habits, sharing statements of hopelessness, and withdrawing socially. Other cautionary behaviors are saying goodbye or expressing the feeling of being a burden (Axelrod et al., 2019).
Even with knowledge of risk factors, it is difficult to predict who will actually attempt suicide; therefore, it can be helpful to understand suicide as a developmental process to which risk and protective factors define a trajectory over time (Conwell et al., 2011). Use of this developmental perspective can help identify opportunities to intervene for older adults to alter their suicidal trajectories (Conwell et al., 2011). A medical model or high-risk approach to suicide prevention would focus on the terminal point of the developmental process, when older adults are at greatest risk. A public health approach, however, calls for preventive intervention across the entire continuum. This approach is especially important for older adults because, unlike suicide among young people, older adult suicide is not an impulsive act; it may have been contemplated for years (Worthington, 2019).
The Institute of Medicine has advocated use of terminology describing preventive interventions at three levels: indicated, selective, and universal (Conwell et al., 2011). Conwell et al. (2011) suggest that the most effective prevention program for suicide in later life would be one that incorporates elements of each.
Indicated preventive interventions are those that target individuals who demonstrate symptoms and risk factors for suicide. The objective is to diagnose and treat psychiatric disorders to prevent the suicidal behavior. Diagnosis and treatment of depression is often cited as an example of indicated preventive intervention because of the close association of depression with suicide risk (Conwell et al., 2011).
Selective preventive interventions target asymptomatic or pre-symptomatic individuals or groups, such as older adults with chronic, painful, functionally limiting conditions; those who have become socially isolated; or those who perceive themselves to be a burden to others. The sites for selective preventive interventions are often broader than for indicated interventions, such as homes of older people receiving visiting nurse services or home-delivered meals or agencies that provide community-based social services.
Universal preventive interventions target an entire population irrespective of the risk status of any individual or group within it. Sites for universal prevention are ones that allow broad dissemination of public health or legislative messages to effect change across the population. One example of a universal preventive intervention is the passage of the Brady Handgun Violence Prevention Act in 1994; in the years following implementation of the legislation, there was a significantly greater reduction in suicides with a handgun by people older than 55 in states that newly implemented background checks and waiting periods for gun purchase (Conwell et al., 2011).
What Can Be Done to Help?
Renn (2019) noted that although a variety of philanthropic and nonprofit organizations focus on prevention of suicide in youth and young adults, suicide in older adults has not received the same level of attention. Greenlee and Hyde (2014) warned that it has never been more critical to raise public awareness of the signs and risk factors for suicide in older adults and to learn how to help. There is a need for more nurses and other health professionals trained to recognize these signs and risk factors and intervene at key points along the suicide trajectory. But older adult suicide prevention cannot be conceptualized solely as the responsibility of health care professionals (Arbore, 2019). Many rural areas have few, if any, psychiatrists, psychologists, social workers, nurse practitioners, and/or counselors, and even in rural communities that may have these health care professionals, there is no guarantee that they have been trained to work with and treat older adults. Paraprofessionals in rural areas can be trained as critical links to mental health providers, building connections between local resources and health care providers (Arbore, 2019).
The National Institute of Mental Health (NIMH; access https://www.nimh.nih.gov) is the lead federal agency for research on mental disorders and is an important resource for learning about programs focused on suicide prevention. One program, Safety Planning, pairs patients with caregivers to develop a plan to limit access to lethal means such as firearms, pills, or poisons. The plan also describes coping strategies and resources for help in a crisis. This plan has been shown to reduce suicidal thoughts and actions (NIMH, 2019).
The Suicide Prevention Resource Center (access https://www.sprc.org) provides valuable information about community resources focused on the problem of suicide in older adults. Noting that suicide prevention efforts can have greater power when they move beyond a single organization to reach a whole community, the Center provides contact information and details about suicide prevention plans in individual states. Its website also features a variety of training programs to build knowledge and skills in suicide prevention.
The Zero Suicide Institute (access http://zerosuicideinstitute.com) guides organizations toward safer suicide care by providing a range of consultation and training to the organizations. The Zero Suicide Framework offers tools and strategies to promote organization-wide transformations for safer suicide care in health care systems. Noting that the process of making system-wide improvements and culture change can be complex and challenging, the Institute helps organizations launch evidence-based practices for suicide prevention and map a path to success.
Currently, few interventions for suicide prevention are supported by research and most of that research has not been extended to suicide prevention for older adults (Renn, 2019). Renn (2019) noted, however, that these interventions may provide templates for successful interventions for older adults. For example, the Caring Contacts program for military personnel demonstrated that its text message–based intervention could reduce the odds of having suicidal ideation and making a suicide attempt among active duty military personnel (Comtois et al., 2019). Simple, scalable interventions such as this may also be effective in reducing the occurrence of suicide ideation and attempts in older adults.
Despite lack of randomized clinical trials to provide evidence-based interventions for late-life suicide prevention, there are general guidelines that can be helpful (Aging in Place, 2019):
- Take the time to have caring, nonjudgmental conversations with an older adult who may be considering suicide.
- Help older adults find support groups so they can connect with others who are struggling with life issues.
- Limit access to drugs and alcohol to potentially keep older adults from taking their own life while under the influence.
- Remove any lethal means, such as firearms and medications, that would make it easier for an older adult to attempt suicide.
There is a critical need to identify evidence-based interventions to help prevent suicides in older adults. It is also urgent to equip more nurses and other health professionals with knowledge and skills to recognize risks of late-life suicide and intervene appropriately. The importance of depression as a factor in suicide makes its detection and effective treatment for older adults vital. Because many older adults in need of mental health care do not receive adequate treatment, it is particularly important to target nontraditional linkages to care in the community, such as aging social services that help maintain connectedness to families, friends, and communities. Finally, consideration must be given to universal preventive approaches for changing attitudes and biases that inhibit older adults from accessing effective and affordable mental health care.
- Aging in Place. (2019, December). Elderly suicide: The risks, detection and how to help. Retrieved from https://www.aginginplace.org/elderly-suicide-risks-detection-how-to-help
- Arbore, P. (2019). Suicide prevention among rural older adults. Generations – Journal of the American Society on Aging, 43(2), 62–65.
- Axelrod, J., Balaban, S. & Simon, S. (2019, July27). Isolated and struggling, many seniors are turning to suicide. Retrieved from https://www.wnpr.org/post/isolated-and-struggling-many-seniors-are-turning-suicide
- Comtois, K. A., Kerbrat, A. H., DeCou, C. R., Atkins, D. C., Majeres, J. J., Baker, J. C. & Ries, R. K. (2019). Effect of augmenting standard care for military personnel with brief caring text messages for suicide prevention: A randomized clinical trial. JAMA Psychiatry, 76(5), 474–483. https://doi.org/10.1001/jamapsychiatry.2018.4530 PMID: doi:10.1001/jamapsychiatry.2018.4530 [CrossRef]30758491
- Conwell, Y., Van Orden, K. & Caine, E. D. (2011). Suicide in older adults. The Psychiatric Clinics of North America, 34(2), 451–468, ix. https://doi.org/10.1016/j.psc.2011.02.002 PMID: doi:10.1016/j.psc.2011.02.002 [CrossRef]21536168
- Greenlee, K. & Hyde, P. S. (2014). Suicide and depression in older adults: Greater awareness can prevent tragedy. Generations – Journal of the American Society on Aging, 38(3), 23–26.
- National Institute of Mental Health. (2019). Suicide prevention. Retrieved from https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml#part_153179
- Renn, B. N. (2019, October15). Suicide in older adults: A quiet epidemic. Retrieved from https://www.gih.org/views-from-the-field/suicide-in-older-adults-a-quiet-epidemic/
- Williams, M. M. (2007). Invisible, unequal, and forgotten: Health disparities in the elderly. Retrieved from https://scholarship.law.nd.edu/ndjlepp/vol21/iss2/6/?utm_source=scholarship.law.nd.edu%2Fndjlepp%2Fvol21%2Fiss2%2F6&utm_medium=PDF&utm_campaign=PDFCoverPages
- Worthington, B. (2019). Elder suicide: A needless tragedy. Retrieved from https://www.todaysgeriatricmedicine.com/news/exclusive_03.shtml