Suicide Risk in Older Adults: The Role and Responsibility of Primary Care
Journal of Clinical Outcomes Management. 2017 April;24(4)
References
It is also essential to discuss other suicide-related outcomes among older adults, including suicide attempts and suicide ideation. This is critical particularly because the ratio of suicide attempts to deaths by suicide in this age-group is 4 to 1 [1]. This is in contrast to the ratio of attempts to deaths across all ages, which is 25 suicide attempts per death by suicide [1]. This means that suicide prevention must occur before a first suicide attempt is made; suicide attempts cannot be used a marker of elevated suicide risk in older adults or an indication that intervention is needed. Intervention is required prior to suicide risk becoming elevated to the point of a suicide attempt.
Older adults are more likely to die on a first or early attempt for 4 primary reasons [6]. First, older adults tend to be more medically frail, making them less likely to survive a suicide attempt. Second, older adults are often more isolated, meaning that they are less likely to be found quickly after a suicide attempt or to have someone intervene when they attempt suicide. Third, older adults may be more planful about suicide attempts; for example, an older adult may take steps to ensure he or she is not found after a suicide attempt or to gain access to more lethal means. Finally, older adults are more likely to use highly lethal means (eg, firearms) [6]. Approximately 70% of all death by suicide among older adults is by firearm ( Figure 2 ), substantially higher than the percentage among other age-groups [2].
It is also critical to recognize that despite the fact that suicide rates rise with age, reports of suicide ideation decrease with age [7,8]. Across all ages, 3.9% of Americans report past-year suicide ideation; however, only 2.7% of older adults report thoughts of suicide [9]. The discrepancy with the increasing rates of death by suicide with age suggest that suicide risk, and thereby opportunities for intervention, may be missed in this age-group [10].
However, older adults may be more willing to report death ideation, as research has found that over 15% of older adults endorse death ideation [11–13]. Death ideation is a desire for death without a specific desire to end one’s own life, and is an important suicide-related outcome, as older adults with death ideation appear the same as those with suicide ideation in terms of depression, hopelessness, and history of suicidal behavior [14]. Additionally, older adults with death ideation had more hospitalizations, more outpatient visits, and more medical issues than older adults with suicide ideation [15]. Therefore, death ideation should be taken as seriously as suicide ideation in older adults [14]. In sum, the high rates of death by suicide, the likelihood of death on a first or early suicide attempt, and the discrepancy between decreasing reports of suicide ideation and increasing rates of death by suicide among older adults indicate that older adult suicide is an important public health problem.
Suicide Prevention Strategies
Many suicide prevention strategies to date have focused on indicated prevention, which concentrates on individuals already identified at high risk (eg, those with suicide ideation or who have made a suicide attempt) [16]. However, because older adults may not report suicide ideation or survive a first suicide attempt, indicated prevention is likely not enough to be effective in older adult suicide prevention. A multilevel suicide prevention strategy [17] is required to prevent older adult suicide [18]. Older adult suicide prevention must include indicated prevention but must also include selective and universal prevention [16]. Selective prevention focuses on groups who may be at risk for suicide (eg, individuals with depression, older adults) and universal prevention focuses on the entire population (eg, interventions to reduce mental health stigma) [16]. To prevent older adult suicide, crisis intervention is critical, but suicide prevention efforts upstream of the development of a suicidal crisis are also essential.
