BY JENNIFER GAZDA, LCSW, CMC, CDP
Many of us have been personally impacted in some way by suicide over the course of our lives. The Centers for Disease Control and Prevention (2022) reports that one person commits suicide every 11 minutes. That is 49,000 individuals in one year. While the importance of self-care and mental health has been highlighted over the past several years, especially evident following the COVID-19 pandemic when we were all expected to isolate ourselves to prevent the spread of disease, people continue to struggle and have thoughts of ending their lives.
Many of the stories I have heard or experienced over my lifetime occur in young adults, individuals who are trying to find themselves and what they want to do with their lives and have not fully developed good coping strategies. Perhaps they experienced some type of trauma and could not find the resilience to push through any longer. I have had family members and friends lose their children to suicide without seeing any type of sign or clue that their child was struggling. One day, I received a call about a relative in her 80s who was hospitalized for slitting her wrists. I was shocked – this person was experiencing a sudden loss and grief and wanted to end that pain. I found myself having a deeper emotional reaction to this elderly person aiming to end their life because I had fallen into ageist views that if someone reached a certain age, they have developed their coping skills and strategies and had proper support in place. I could not have been more wrong.
Of the approximate 49,000 individuals who committed suicide in 2022, about 20% of those were individuals over the age of 65, and people aged 85 and older had the highest rates of suicide of all age groups (CDC, 2022). While depression and various life factors contribute to thoughts of suicidal ideation in all ages, what is shocking is that older adults are more likely to be successful in their suicide attempts. A quick Google search highlights several murder-suicide tragedies throughout the United States between older adult couples. What causes this to occur? What risk factors are there that contribute to older adults and suicide? Are there resilience factors that ameliorate the risks? What can we do as case managers to help this particular population of people to maintain their lives, and hopefully a good quality of life? These are the questions I am hoping to help answer and share with you to assist in your daily practice.
Risk Factors of Suicidal Ideation in Older Adults
As part of general education, at least in the social work field, there is training and education provided on identifying signs of depression, and we learn about different scales and questionnaires that can be used to measure severity of depression. Generally speaking, experiencing depressive episodes can lead to suicidal ideation in any age group. However, for older adults there are additional factors to consider that contribute to suicidal thoughts. While depression is one, consider the amount of loss someone may experience as they age. Death can eventually surround someone as they experience the loss of their spouse, siblings, friends and extended family. I remember sitting at my kitchen table with my uncle when he was in his 80s and he shared that he thought aging and retirement would be “the golden years,” but what is so golden about being the only one left?
Another factor that can contribute to suicidal ideation is mild cognitive impairment (Rymo et al, 2022). Many of us that work with older adults or at one time or another have treated or supported someone with some form of cognitive impairment or dementia. Dementia has many stages and progresses in symptom severity over time, with people affected eventually losing the ability to maintain their independence in daily task completion. Have you ever heard or used the phrase “pleasantly confused” when meeting a patient? This phrase has been used typically for individuals with more advanced cognitive impairment. For those individuals with mild cognitive impairment, they still have much of their executive functioning and understand what is happening to them. They may become frustrated or depressed as they realize they are experiencing the loss of things they have been able to do throughout their lives. Rymo et al. (2022) note that individuals with mild cognitive impairment are at a higher risk for suicide as they maintain the ability to execute a plan to follow through on their intrusive thoughts.
Physical impairments and conditions have been found to contribute to a higher risk of suicidal ideation in older adults (Jing et al, 2021). Imagine that arthritis impacts your knees, but you enjoyed going for runs three times a week. Now, it may hurt to simply walk, let alone run. Imagine you enjoyed reading to escape the stress of life, but you have lost your vision to macular degeneration or some other eye disease. While there are audio books or other options available, this is still an impact to your daily habits and practice and impacts the ability for someone to function independently. Jing et al. (2021) found that having two or more physical conditions was associated with suicidal thoughts and plans in their sample studied.
Changes in living environment or situation is another contributing factor to suicidal ideation in older adults. I cannot count the number of times I have met with a patient over the age of 65 and heard a similar message: “I do not want to go to a nursing home.” People have a strong desire to maintain their independence and age in place, and having to leave their comfortable chosen setting is arguably one of the most difficult transitions during this life stage. However, sometimes it is necessary for rehabilitation or for an individual’s safety due to the risks that may not be able to be ameliorated in the home. Vale et al. (2023) found that older adults staying in an institutionalized setting for over one year had higher rates of depressive symptoms and suicidal thoughts. People who move to alternative living arrangements are often faced with the loss of autonomy and experience difficulties with completing their activities of daily living. Upon admission to nursing homes, patients are required to have a screening using the Minimum Data Set (MDS) 3.0, which includes asking about thoughts of suicide but only in one question (Salvatore, 2023). One question can easily be answered not truthfully, and additional measures should be taken to ensure patient safety, especially if someone entering a nursing home experiences any of the other risk factors in this article.
Social isolation can coincide with moving to an alternative living environment as individuals may not know anyone else living there. Upon moving, individuals lose their former community and networks that they have grown accustomed to. Further, family members may visit less often because now their loved one is believed to be cared for better by professionals. Even with activities or other opportunities provided in assisted living facilities or nursing homes, individuals may not be comfortable participating or may feel disconnected from the other residents. For example, this past week I was visiting someone in a continuing care retirement community, and she told me, “I’d like it better if I was not surrounded by old people.” I have had other clients in the past share with me that they are more high-functioning than the other people they live with, so it is hard to have a conversation or connect with people who cannot respond in the same manner. Further, social isolation can occur if someone loses the ability to drive safely, which limits their ability to go anywhere independently.
Protective Factors
While the risk factors presented here are not comprehensive, they do highlight the importance of looking a little closer at the individual experiences of older adults when evaluating suicide risk. It is equally important to fully examine the supports and protective factors that patients have to help them overcome adversity and maintain a level of resilience. While pharmacological treatment is always an option for patients experiencing signs of depression or suicidal ideation, there are other factors that can be considered as contributing to lower risk. The presence of a supportive family, maintaining social interaction in the community, continuing to participate in physical activity and preferred hobbies are examples of protective factors that can decrease the risk of depressive symptoms. Vale et al. (2023) further identify protective factors of having religious beliefs and having a generally optimistic viewpoint of life. When meeting with older adults as patients, providers should explore protective factors available in addition to risk factors to help with building support strategies and interventions.
Insights for Case Managers
With this information at hand, what can we do as case managers and medical providers to ensure that older adults receive comprehensive evaluations and effective support plans to meet their needs? It may depend on the setting in which you are employed or interacting with the individual, but there are some options and strategies of which you should consider and be aware. According to Shah et al (2022), “[V]arious studies have shown that interventions such as diet improvements, cognitive training, psychosocial programs and depression medication could reduce the severity of frailty and suicidality, with physical exercise being the most effective intervention” (p. 571).
Further, there are suicide prevention intervention programs used in primary care offices or in patient homes through various programs that are aimed at addressing suicide, such as IMPACT or PROSPECT (Shah et al., 2022). Case managers and providers should aim to provide regular suicidal ideation screening to older adults, especially those in rural communities who may have chronic conditions (Jing et al., 2021). When completing screenings and questionnaires, be observant of your behavior and attention. Have you ever been in a doctor’s office and had the nurse or social worker run through the list of questions to ask without looking up once from their computer? I hardly would disclose any information to this person if I were struggling with thoughts of suicide and the person is not even looking at me.
Looking ahead, we need to shift our thinking on how we evaluate and treat older adults. There are times when ageism and ageist thinking may be a barrier to fully examining and treating our patients. While getting older brings many of us closer to thinking of our death, it is not a routine part of the aging process to have a wish to die and want to end our lives. No matter our age, we bring value to the world and deserve respect and full consideration of our unique experiences when receiving services. Consider this the next time you complete an assessment on an older adult.
References
https://www.cdc.gov/suicide/facts/data.html
Jing, Z., Li, J., Fu, P.P., Wang, Y., Yuan, Y., Zhao, D., Hao, W., Yu, C., and Zhou, C. (2021). Physical multimorbidity and lifetime suicidal ideation and plans among rural older adults: the mediating role of psychological distress. BMC Psychiatry, 21:78. https://doi.org/10.1186/s12888-021-03087-4
Rymo, I., Fassberg, M. M., Kern, S., Zetterberg, H., Skoog, I., Waern, M. and Sacuiu, S. (2022). Mild cognitive impairment is associated with passive suicidal ideation in older adults: A population-based study. Acta Psychiatrica Scandianavica, 148, 91-101.
Salvatore, T. (2023). Dying by Suicide in Nursing Homes: A Preventable End of Life Outcome for Older Residents. Journal of Death and Dying, 88(1), 20-37.
Shah, J., Kandi, O.A., Mortagy, M., Abdelhameed, A., Shah, A., Kuron, M., and Abdellatif, Y.O. (2022). Frailty and Suicidality in Older Adults: A Mini-Review and Synthesis. Gerontology, 68, 571-577.
Vale, B.A., de Araujo, H.T., de Sena, R.C.F., Costa, P.B., and de Miranda, F.A.N. (2023). Suicidal Ideation and Risk of Depression Among Older Adults Residing in Long-Stay Insititutions. Revista Baiana de Enfermagem, doi: 10.18471/rbe.v37.47289.
Jennifer Gazda, LCSW, CMC, CDP, holds a doctorate of social work from Aurora University and has dedicated the majority of her career to helping the geriatric population and their families. Jennifer has held the role of case manager in a variety of settings including child welfare, skilled nursing and hospitals. Jennifer currently serves as regional director-Midwest for Arosa, provider of private care management and home care services across the country.
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