Suicide Risk in Older Adults: The Role and Responsibility of Primary Care

Additionally, as noted previously, the interaction between perceived burdensomeness and thwarted belongingness may identify older adults who are potentially experiencing, but not reporting, suicide ideation [41]. The Interpersonal Needs Questionnaire [56] is the validated assessment for both perceived burdensomeness and thwarted belongingness. Perceived burdensomeness is assessed via 6 self-report items, and thwarted belongingness is assessed via 9 self-report items on this measure [56]. There are not specific cutoffs that determine high versus low perceived burdensomeness or thwarted belongingness, but older adults’ responses can provide information about their experiences of these constructs. Administration of the Interpersonal Needs Questionnaire can provide information about potential risk for suicide among older adults who may otherwise deny thoughts of suicide or death.

If the screening for suicide ideation or death ideation is positive (ie, the older adult endorses thoughts of suicide or death), the treating primary care practitioner must then follow up with additional questions to determine current level of suicide risk. To make this determination, at a minimum, follow-up questions should focus on whether the older adult has any intent to die by suicide (eg, “Do you have any intent to act on your thoughts of suicide?”), as well as whether he or she has a plan to die by suicide (eg, “Have you begun formulating a plan to die by suicide?”). When asking about a plan, it is important to determine how specific the plan is. For example, an older adult with a specific method identified and date selected to implement the plan is at much higher risk than an older adult with a relatively vague idea. It is also critical to assess for the older adult’s access to means for suicide. If an older adult has a specific plan and has the capability to carry out the plan (eg, plans to overdose on prescription medication and has large quantities of medication or high-lethality medication at home), he or she is more likely to die by suicide than an older adult who does not have access to means (eg, only has small quantities of low-lethality medication available). A general assessment of risk factors and previous suicidal behavior (ie, any previous suicide attempts) also informs decisions about level of risk and interventions.

After a screening or assessment is completed, a risk determination must be made and documented. Acute suicide risk can be categorized as low, moderate, or high. It is not appropriate to say that there is “no” suicide risk present. Low risk occurs when there is no current suicide ideation, no plan to die by suicide, and no intent to act on suicidal thoughts, especially when the patient has no history of suicidal behavior and few risk factors [57]. Moderate risk is evident when there is current suicide ideation, but no specific plan to die by suicide or intent to act on suicidal thoughts. There are likely warning signs or risk factors, which may include previous suicidal behaviors, present in moderate suicide risk [57]. High risk is indicated by current suicide ideation with plan to die by suicide and suicidal intent. There are significant warning signs and risk factors present; there may also be a recent suicide attempt, though this is not a requirement for a high risk determination [57]. Undetermined suicide risk occurs when a practitioner cannot accurately assess risk, but concern regarding suicide is present; this is primarily used when a patient refuses to answer questions about suicide. Undetermined risk should be treated as at least moderate risk. Because research shows that death ideation has similar outcomes to suicide ideation in older adults [14], death ideation should also be factored into determinations of suicide risk; reports of death ideation may indicate low or moderate risk in older adults, dependent upon other risk factors, suicidal intent, and plan.