Expressing suicidal thoughts
My patient is expressing suicidal thoughts…
Despite recent improvements in the detection and treatment of late-life depression, rates of suicide among older adults remain high. Approximately six thousand Americans over age 65 years die by suicide each year, nearly seven times the number of lives lost due to homicide.1 Rates of suicide are expected to rise as the baby boom cohort, a group with historically high rates of suicide, enters older adulthood.1,2 There are many biological, psychological, and socio-cultural risk factors associated with suicide. Older adults with psychiatric and substance use disorders are at highest risk of committing suicide.1,2 Cognitive deficits in later life, including dementia and impaired decision-making, have also been linked to suicide.1,2 Poor physical health and functional impairments also contribute to risk of suicide in later life. Impairment in instrumental activities of daily living (IADLs), visual impairment, malignancy, chronic pain, and neurological disorders have all been found to significantly increase risk of death by suicide among adults over age 65.1,2 Older adults with multiple acute and chronic conditions are also at increased risk, especially when these conditions threaten autonomy and personal integrity.2 Stressful life circumstances, such as loss of spouse, family discord, financial difficulties, and change in employment status also increase risk, while social connectedness and participation in religious and spiritual activities are protective against development of depression and suicidality.1,2
Interprofessional Assessment and Collaborative Interventions
All nurses and health care providers are encouraged to take a universal approach to suicide prevention by completing depression screenings with all patients in all settings and determining patient’s access to means of suicide.3 Professionals working with older adults will likely find the Geriatric Depression Scale (GDS) and Geriatric Suicide Ideation Scale (GSIS) useful in identifying and measuring the severity of suicidal considerations in this population.1 Primary care and mental health care clinicians are encouraged to ask about firearm ownership, access, and use when assessing at-risk older adults.1 Given older adults’ increased isolation and greater frailty, interventions to prevent self-injury are a priority for this population.2 Interventions delivered in the primary care setting may be especially effective, as many older adults are reluctant to seek care in mental health practices and therefore turn to their primary providers.1,2 Nearly 50% of adults over age 55 who die by suicide visit a primary-care provider in the week prior to death.1 Primary care providers are encouraged to discuss issues related to aging and becoming dependent on help from others with their patients, while stressing that depression in later life is not a normal sign of aging.1,3
Interventions should also target older adults with numerous risk factors for later-life depression and suicidal ideation. Elders with chronic, painful, and functionally-limiting conditions and those who perceive themselves to be a burden on others may especially benefit from intervention. Social workers, psychologists, and community-based agencies can be instrumental in screening and monitoring for depression and suicidal ideation among older adults in the community, especially those receiving visiting nurse or aide services at home and delivered meals.2,3 Visiting nurses and health care providers can also assess for warning signs of depression in older adults at home, including substance abuse, sleep disturbances, pain, and other physical symptoms that decrease quality of life and increase suicidal ideation in the elderly.3
For older adults with active suicidal ideation, it is imperative that nursing, medical, and psychiatric providers ensure the patient’s safety and reduce risk of self-harm. Relatives, friends, and caregivers will be instrumental in monitoring patient for suicide risk, maintaining safety, and communicating with providers as necessary.3 Clinicians in acute and primary settings should evaluate patients’ medication history and consult with geriatric psychiatrists and pharmacists to plan pharmacological treatment, which may include selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants.1 Psychiatrists and psychologists can also train patients in use of coping strategies to improve responses to life transitions and negative stressors, which will in turn reduce rates of depression and suicide.1 Suicidal ideation, intent, behavior, and access to lethal means should be assessed by nurses and providers on an ongoing basis, and hospitalization should be considered for patients expressing severe suicide ideation and intent.1 Health care institutions and organizations should provide professionals across all disciplines with training to detect, intervene, and manage depression and suicide risk in later life.1,3 Participation in community-based educational initiatives to destigmatize mental health issues will also improve efforts to identify and treat older adults with later-life depression and suicidal ideation.1
Interprofessional contacts for this topic:
Acute care providers
Primary care providers
Home health aides
Link to the following evidence-based protocols:
1Heisel, M.J., & Duberstein, P.R. (2005). Suicide prevention in older adults. Clinical Psychology: Science and Practice, 12(3), 242-259.
2Conwell, Y., Van Orden, K., & Caine, E.D. (2011). Suicide in older adults. Psychiatric Clinics of North America, 34(2), 451-468.
3Erlangsen, A., Nordentoft, M., 2, Y., Waern, M., De Leo, D., Lindner, R., ... & Lapierre, S. (2011). Key considerations for preventing suicide in older adults: Consensus opinions of an expert panel. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 32(2), 106-109.