In almost all industrialized countries, men 75 years and older have the highest suicide rate among all age groups. Of the countries that provide suicide data, Hungary has the highest suicide rates for both elderly men and women: in 1991-1992, the suicide rate for men 75 years and older was as high as 100,000. The lowest rates for both elderly men and women were in Northern Ireland, and England/Wales, with rates for men 20/100,000 and 18/100,000 respectively in 1987. In the U.S. in 1996 (the most current rates available), white males 85 and older have the highest suicide rates, 65 per 100,000. This rate is over five times the rate of all age-adjusted suicides. Over the last two decades, in the US, men accounted for about 4 out of 5 of completed suicides in the 65 years and older age group. This is partly explained by the fact that men are more likely to use higher lethality methods. Seventy-four percent of men and 31% of women aged 65 and above who competed suicide used firearms, while 3% of men and 33% of women who completed suicide used overdose on medications in the U.S.
Suicide rates vary with age, ethnicity, and marital status. In the U.S., the suicide rate of Caucasian, Chinese, Japanese, and Filipino American men increases with age, while in African-American, Hispanic, Native American, and Alaska Native men the highest suicide rate is in the middle-aged.
The incidence of murder suicide for persons age 55 and older is increasing. It has been estimated to equal 0.4-0.9 per 100,000. In most cases an elderly husband who is the caretaker kills his wife and then himself. In addition to physical illness, marital discord plays an important role in elderly murder-suicide cases.
Special Considerations Specific to Suicide in the Elderly
Elderly are most likely to die in or following a suicide attempt
In every suicide, even in the apparently most determined ones, there is a degree of ambivalence. While in younger age groups suicide attempts are often impulsive and communicative acts (“a cry for help”), in late-life most attempts can be considered "failed suicides." Older individuals make fewer suicide attempts per completed suicide. The ratio of suicide attempts to subsequent suicide completions is lower for older adults than for younger groups. The ratio of attempts to suicide completion is estimated to be approximately 4:1 among the elderly whereas, for the population as a whole, estimates for the ratio range between 8:1 and 20:1. The reason for this low attempt to completion ratio is complex. The elderly have more health problems and frequently live alone, which increases the probability of a fatal outcome. Suicides in older people are often long-planned and involve highly lethal methods. In addition, although most people who kill themselves give direct or indirect warnings, older people are less likely to directly communicate their intent to die.
As the elderly are often preoccupied with death and dying, their environment is more likely to miss the indirect warnings that they give, e.g., statements such as, “nothing is in front of me anymore.” However, contrary to common belief, lack of hope is not part of normal aging, not even in the terminally ill elderly. Reported age differences in suicidal intent have been found using the psychological autopsy method. These findings suggest that older suicide victims had higher intent on the Suicide Intent Scale. That is, older adults were more likely to have avoided intervention, taken precautions against discovery, and were less likely to communicate their intent to others. They may therefore be more difficult to identify as at risk for suicide than younger individuals. Moreover, older men, in particular, were less likely to have had a history of previous attempts, while older women who committed suicide were more likely to have attempted suicide in the past than younger female suicide victims. Thus, older men at risk for suicide may be more difficult to detect than at-risk older women.
Identification of indirect self-destructive behavior in the elderly
In addition to overt suicide attempts, there are subtle behaviors especially in the elderly, with conscious or unconscious intent to die, such as refusal to eat or drink, noncompliance with treatment, or extreme self-neglect. This has been termed “sub-intentional suicide” and refers to indirect self-destructive behaviors (ISDB) in which noncompliance was not part of cognitive impairment. These self-destructive behaviors, which often lead to premature death, may be particularly common in certain settings like nursing homes, where more immediate means to commit suicide are limited, and among people whose religion deems suicide to be a sin. Especially with elderly residing in long-term care facilities, depression and hopelessness should be warning signs of suicidal behavior. In addition, food refusal and other self-harming behavior should be signs that the resident should be evaluated for psychological distress and provided appropriate treatment. The Scale of Suicidal Ideation (SSI) can help clinicians to identify patients with ISDB. The SSI asks whether the patient would avoid steps necessary to save or maintain life, would deliberately ignore taking care of his/her health, and feels like trying to die by eating too little or by not taking needed medications. Using the SSI and the Beck Depression Inventory, it has been found that elderly depressed patients with ISDB had similarly high levels of hopelessness and were similar to patients who reported that they were thinking about killing themselves by suicide.
Adapted from IDENTIFICATION OF SUICIDAL IDEATION AND PREVENTION OF SUICIDAL BEHAVIOR IN THE ELDERLY by Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Drugs and Aging. In press |
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