IPA Bulletin
Research and Practice

SUICIDE IN ELDERLY PEOPLE

HENRY O’CONNELL, MERCER’S INSTITUTE FOR RESEARCH ON AGEING, ST. JAMES’ HOSPITAL · Ireland

It may be that the gods are merciful when they make our lives more unpleasant as we grow old. In the end, death seems less intolerable than the many burdens we have to bear.” –Sigmund Freud

Introduction: The extent of the problem
Pooled international data from the World Health Organization show that older people have a higher risk of completed suicide than any other age group worldwide (WHO, 2002). The male/female ratio is 3-4 to 1, similar to other age groups, with men over the age of 75 having the highest risk of all. Furthermore, older people are more likely to use lethal means of suicide. Despite these facts, older people are frequently sidelined in discussions on suicide for a number of reasons. These reasons include a higher absolute number and higher economic burden associated with suicide in younger people, and ageist assumptions in society, whereby suicidal and hopeless feelings are perceived as being natural and understandable consequences of ageing. Such ageist assumptions also manifest in clinical practice, where it has been demonstrated that older people are less likely than younger people to be asked about suicidal feelings, and are less likely to be offered appropriate treatment (O’Connell et al, 2004).

Risk factors and associations
Suicide in elderly people is a complex and multifactorial phenomenon, and risk factors and associations can be broadly described as being psychological, physical/medical and social. Such factors frequently overlap and have an additive effect.

Psychological factors
Depression is the most important risk factor of all for suicidal ideation and behaviour in older people. However, older people may be less likely to volunteer depressive symptoms and suicidal feelings (Conwell et al 2002). Furthermore, depressive symptoms in older people may present atypically, with prominent anxiety symptoms, physical complaints and reduced ability and motivation to look after everyday affairs and self-care. Other important psychological factors include alcohol use disorders (especially in men) and certain personality traits (e.g. rigidity and neuroticism) that may be accentuated by the effects of brain ageing. Older people with a previous suicide attempt have a particularly high risk of subsequently completing suicide (Hepple and Quinton, 1997).

Physical/Medical factors
The effects of physical health factors on suicidal ideation and behaviour are generally mediated by psychological factors such as depression. Such physical health factors include chronic pain, neurological disorders, malignancy, visual impairment and total physical illness burden (Waern et al, 2002).

Social factors
Divorced, widowed and single status are risk factors for suicide in older people, although recent research suggests that the protective effect of marriage may not be significant  over the age of 80 (Erlangsen et al, 2003). Other risk factors include loneliness, low social interaction, recent stressful life events, interpersonal discord and bereavement. Protective factors include higher life satisfaction and religiosity (Cook et al, 2002).

Detection and Management
Screening for suicidal feelings in older people should be opportunistic, with high-risk subgroups defined and targeted. These high-risk subgroups include those with de-pressive illnesses, previous suicide attempts, alcohol use disorders, physical illness and those who are socially isolated. Any mention of hopelessness or suicidal feelings in older people should be taken seriously and war-rants thorough evaluation and treatment. Treatment should be multidisciplinary and coordinated, and involve family members and carers if possible. Depression is likely to be present and should be treated aggressively. Along with pharmacotherapy, the physical and social condition of the older person should be assessed and any remediable problems should be tackled.

Conclusions
Suicide in older people is a common and tragic phenomenon, and is often associated with potentially treatable health factors. Old Age Psychiatrists have a vital role in the clinical detection and management of suicidal feelings in older people. Old Age Psychiatrists also have a role in advocating for older people and bringing the topic of suicide in older people to the forefront at a national level.

References
1. O’Connell H, Chin AV, Cunningham C, Lawlor BA. Recent developments: suicide in older people. BMJ. 2004 Oct 16;329(7471):895-9.
2. World Health Organization, 2002. www.who.int/mental_health/prevention/suicide
3. Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry 2002;52: 193-204.
4. Hepple J, Quinton C. One hundred cases of attempted suicide in the elderly. Br J Psychiatry 1997;171: 42-6.
5. Waern M, Runeson B, Allebeck P, Beskow J, Rubenowitz E, Skoog I, et al. Mental disorder in elderly suicides: a case-control study. Am J Psychiatry 2002;159:450-5.
6. Chiu HF, Yip PS, Chi I, Chan S, Tsoh J, Kwan CW, et al. Elderly suicide in Hong Kong—a case-controlled psychological autopsy study. Acta Psychiatr Scand 2004;109: 299-305.
7. Erlangsen A, Bille-Brahe U, Jeune B. Differences in suicide between the old and the oldest old. J Gerontol B Psychol Sci Soc Sci 2003;58:S314-22.
8. Cook JM, Pearson JL, Thompson R, Black BS, Rabins PV. Suicidality in older African Ameri-cans: findings from the EPOCH study. Am J Geriatr Psychiatry 2002;10:437-46

Henry O’Connell
Mercer’s Institute for Research on Ageing, St. James’ Hospital, Dublin, Ireland

Reprinted from IPA Bulletin Volume 2 Number 2