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

After a risk determination is made, it must be documented in the medical record. The level of risk and rationale for that determination must be included [58]. Stating only the level of risk without a rationale (ie, the older adult’s responses to questions) is not adequate, and documenting only the older adult’s responses without a determination of risk is also not sufficient. Finally, it is critical to document the intervention that occurred or steps taken after the level of risk was determined.

Critically, stating only that there was no indication of suicide risk is inadequate. For example, documenting “No evidence of suicide risk” is not appropriate. This documentation does not indicate that the older adult was specifically asked about suicide ideation, death ideation, suicidal intent, or plan to die by suicide. It also does not indicate a level of suicide risk. Examples of appropriate documentation include:

Patient was asked about suicide risk. She denied current suicide ideation but reported death ideation. She denied any current suicidal intent or plan. She also denied any previous suicide attempts. Therefore, acute suicide risk was deemed to be low. Provided patient with wallet card about the National Suicide Prevention Lifeline. Also called the Friendship Line while in the room with the patient to connect her with services. Finally, provided a brief list of local mental health professionals to patient; the patient reported she would like to see Dr. Smith. Called and left a message for Dr. Smith with referral information with patient during appointment.

Patient was asked about suicide risk. He reported both death ideation and suicide ideation. He also reported a nonspecific plan (ie, causing a single-vehicle motor vehicle accident, with no specific plan for the motor vehicle accident or timeframe) and denied any intent to act on his thoughts of suicide. He reported one previous suicide attempt, at age 22, by overdose on over-the-counter medication. He reported that this attempt did not require medical attention. Therefore, acute suicide risk was determined to be moderate. Patient was introduced to the behavioral health specialist, who met with the patient during the appointment to conduct further assessment and intervention.

Specific Intervention Strategies

Despite the fact that the pace of the primary care setting often does not allow for time-intensive intervention, there are ways to address suicide risk in this setting. Importantly, no-suicide contracts should not be used at any time [59,60]. No-suicide contracts are documents that patients who are experiencing suicide ideation are required to sign that state that they will not die by suicide while under the care of the practitioner. These contracts have no evidence of effectiveness, and some researchers argue that they may in fact damage the relationship with patients and serve the practitioner’s needs more than the patient’s needs [59].

One of the best options for older adults at low acute suicide risk is to provide resources and referrals. The National Suicide Prevention Lifeline can be reached at 1-800-273-TALK (8255); trained counselors are available to speak to patients at all times. Wallet cards with information about the National Suicide Prevention Lifeline are available at no charge from the US Substance Abuse and Mental Health Services Administration online store. The Friendship Line is another service available free to adults ages 60 and older, 24 hours per day, 7 days per week; this line can be reached at 1-800-971-0016. The Friendship Line, which is managed by the Institute on Aging, also provides outreach calls to older adults who may be isolated or lonely, increasing connectedness and potentially reducing suicide risk.