Suicide in Older Adults: Management and Prevention

Approaches to Prevention
Up to three quarters of older adults who took their own lives did so within 30 days of seeing a primary care provider; 25% to 50% saw their provider in the last week of life.² Combined with the fact that older adults are underrepresented in the case loads of mental health specialists, these data underscore the importance of developing and implementing clinical management and prevention strategies in the primary care setting.

The US Preventive Services Task Force does not recommend routine screening for suicidal ideation and risk among adults in primary care.²² Nonetheless, the strong association between depressive disorders, stressful life events, social isolation, and suicide in older adults indicates a logical sequence of inquiry. For those seniors experiencing significant stressors or functional impairment, periodic screening for depression using short, simple measures, such as the 9-item Physician's Health Questionnaire23 (PHQ-9) or the 15-item Geriatric Depression Scale-Short Form²⁴ (GDS-S), is indicated.

Any older adult with clinically significant depressive symptoms should be questioned about suicidal thoughts with a high-sensitivity question, such as "Have you been feeling that life is not worth living?" A positive response should lead to more detailed inquiry about the presence of active thoughts of, plans for, and intent for suicide.

The assessment should be balanced with an evaluation of risk factors in each of the 5 axes noted above.²⁵ These data form the basis for clinical decision making, in collaboration with the patient and caregivers, about whether hospitalization is necessary or whether further assessment and treatment can be managed safely on an outpatient basis. A thorough assessment leading to a comprehensive multiaxial diagnosis, followed by treatment of the associated psychiatric, medical, and social morbidities should resolve the crisis.

Management of acute suicidality in older adults does not differ in most respects from that in younger people (see, for example, the American Psychiatric Association's Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors²⁶). However, preventive intervention takes on even greater urgency in older people. Although suicidal ideation and attempts are less common in older adults than in younger adults, rates of completed suicide are higher in the older group for several reasons.

Once a self-damaging act is initiated, older adults are more likely to die than younger people because they are more likely to live alone and escape rescue. Also, they have less physical reserve, making any injury more potentially lethal. Finally, older people with suicidal intent are more adept planners and more determined in their acts, choosing more immediately lethal means and implementing them with greater lethality of intent.²⁷

Because suicidal ideation and behavior are so often fatal in older people, prevention requires early and aggressive intervention for persons identified as being at high risk. Every effort should also be made to identify and prevent the development of more urgent or emergent states in older people who are not yet acutely symptomatic but who have characteristics that put them at risk for suicidal states.

The Institute of Medicine, in its landmark report on prevention of mental illnesses, advocated the use of the terms "indicated," "selective," and "universal" to describe distinct levels of preventive interventions.²⁸ Their application to suicide prevention is illustrated in the Table, including examples of their operationalization.

Indicated preventive strategies
Indicated preventive interventions target individuals with detectable symptoms or syndromes known to be proximal risk factors for suicide in older people (eg, depressive disorders). These interventions aim to prevent the initiation of a potentially lethal suicidal act. No studies have examined the effectiveness of an indicated preventive strategy in which completed suicide in a population of older adults was the targeted outcome.

Based on findings from the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), Bruce and colleagues²⁹ reported that the intervention—consisting of patient and provider education, a depression care specialist attached to the primary care practice, and standardized algorithm-driven care that included medications and psychotherapy as indicated—yielded a significantly greater proportional reduction in suicidal ideation than enhanced care as usual. Depression outcomes were significantly improved as well. However, because more than 70% of the sample were women, the study's relevance to completed suicide prevention in the United States must be questioned. Nonetheless, models of collaborative care for depression and other mental disorders of later life delivered in the primary care setting are likely to be important contributors to reduction of suicide rates in older people.

Selective preventive strategies
Selective preventive interventions target high-risk groups defined by the presence of relatively more distal risk factors than active symptomatic states, such as bereavement or family discord, physical illness, or functional impairment. Again, no selective strategy has been tested in a controlled trial.

The Tele-Help/Tele-Check service piloted by De Leo and colleagues³⁰ in Padua, Italy, offers an indication of potential effectiveness. This service provided telephone access by voice-activated systems placed within the homes of older adults at risk for poor physical and mental health outcomes and referred by social service agencies. Clients received telephone support twice weekly and as needed any time of the day or night. Over an 11-year period, significantly fewer suicides occurred in almost 19,000 service users than would have been expected in a matched population. But again, the effect was demonstrable only in women, an important caveat given the far higher rates of completed suicide in older men.

Universal preventive strategies
Universal approaches to prevention target the entire population irrespective of the risk status of any individual or group. One example of a universal preventive intervention that may have been effective in reducing late-life suicide was the Brady Handgun Violence Prevention Act of 1994. This "natural experiment" offered an opportunity to compare trajectories of suicide and homicide rate change in 32 states that newly instituted the law's provisions with 18 "control" states that already had such measures in place.³¹

Analyses revealed that while there was no difference between intervention and control states in patterns of change for homicide rates or for suicide rates in younger and middle-aged adults, there was a significantly greater reduction in the intervention states in firearm suicides specifically for persons aged 55 years and older. Almost 75% of older adults who take their own lives, the great majority of whom are men, do so with a firearm. Therefore, this universal intervention may be effective for the group of high-risk older men who appear not to have benefited from indicated and selective approaches to suicide prevention.

Conclusion
Because older people are the fastest growing segment of the population, we anticipate that the absolute numbers of late-life suicides will probably rise dramatically in the next 2 decades. There is an urgent need for more research, development of policy, and implementation of empirically based prevention practices if we are to reduce, or even contain, the toll that suicide-related morbidity and mortality take on older people and their families. Given our increased understanding of the factors that place older people at risk for suicide, prevention strategies can be designed and tested in a rigorous manner. Preliminary findings show that indicated, selected, and universal approaches all have a role to play. A comprehensive approach that incorporates all 3 is most likely to result in meaningful and sustained reductions in elder suicide injuries and deaths.