Dimitris N. Kiosses, PhD

Suicide in late life constitutes a major public health concern. In 2019, the Centers for Disease Control and Prevention (CDC) reported that the suicide rate for all ages in the United States was 14.5/100,000. Middle-aged and older adults have higher rates of suicide than their younger counterparts (19.41/100,000 for individuals aged 55 to 64), and the highest rate of suicide remains for older males (39.9/100,000 for males aged 75 and older).

 Despite the alarmingly high rates, psychosocial interventions for this population are understudied and urgently needed.

Mobile devices provide a unique and powerful opportunity to deliver interventions to suicidal individuals during periods of increased suicide risk.

 With the current COVID-19 pandemic, reliance on digital health technology is growing, and developing targeted interventions that can be used remotely by older adults during times of emotional crisis is of paramount importance.

To establish effective psychosocial interventions, risk factors for late-life suicide must be examined. Sociodemographic and clinical factors that are more commonly found in middle-aged and older individuals (eg, widowhood, cognitive decline, etc) play an important role in suicide risk. Understanding the complex interaction of these late-life occurrences can guide efforts in designing preventative interventions.

According to the CDC, middle-aged and older adults account for the highest number of suicides compared to younger populations. In 2018, adults aged 65 and older were reported to make up 16% of the US population, but were responsible for 18.8% of suicides.

 While there are an estimated 25 suicide attempts for every completed suicide in the general population, approximately 1 in 4 suicide attempts results in death for older adults.

 Gender, race, and ethnicity also influence suicide risk and behavior. Women consistently account for a higher number of suicide attempts than men. There are 3 female attempts for each male attempt, yet an estimated 3.6 males die by suicide for every 1 female death. This discrepancy is attributed to the difference in method, because men often use more lethal methods when attempting suicide.

 In comparison to other racial and ethnic groups, non-Hispanic American Indian/Alaska Native and non-Hispanic white people account for the highest rates of suicide at 22.3 and 17.6/100,000, respectively.

Cognitive Functioning and Physical Illness

As many as 1 in 9 older adults suffer from some form of cognitive impairment.

 Cognitive impairment is often responsible for reducing decision-making capacity and affecting emotion regulation abilities, potentially contributing to suicidal ideation and behavior.

 Discrepancies in literature regarding suicide risk and cognitive impairment suggest that dementia can either be a risk factor or a protective factor depending on the progression and severity of symptoms.

 However, a review on suicide risk and Alzheimer disease found that Alzheimer disease is associated with a moderate suicide risk in older adults, even several years after diagnosis.

Physical illness and functional disability in late life are also strongly associated with suicide. In a cohort study by Erlangsen and colleagues,

 investigators found that certain cancers and liver disease, specifically, are most closely associated with suicidal outcomes. Despite strong associations found in research, reviewers of the literature advise caution when using physical illness to determine risk, many noting that identifying physical illness does not serve as a predictor for suicide, nor does quantifying the severity of symptoms.

Psychiatric Illness and Suicidal Behavior

Psychiatric illness is noted in up to 97% of late-life suicides, with major depression cited as the most strongly associated psychiatric disorder.

 Retrospective analysis of psychiatric illness and suicide mortalities in older adults in Denmark highlight recurrent depression as contributing to the highest rate of suicides in adults aged 60 and older, followed closely by other affective disorders and reaction to stress/adjustment disorders. This risk was significantly increased for individuals who were hospitalized for any type of psychiatric disorder, with hospitalized psychiatric illness accounting for 22.3% of male suicides aged 60 and older.

One of the predictors of suicidal behavior is suicidal ideation, especially active suicidal ideation with intent or plan. However, in older adults who are seeking aging services, even passive suicidal ideation is an indicator of suicide risk.

 Despite the elevated number of late-life suicides, suicidal older adults often go undetected due to lower rates of reporting,

 especially in primary care where older adults most likely seek medical treatment. This information highlights the need for increased identification strategies, as well as enhanced efforts to prevent the onset of suicidal ideation given the high mortality rate in late-life suicide attempters.

Interpersonal losses including widowhood or death of friends and family are commonplace in advancement of age. The accompanying stress, sense of loneliness, and social disconnection in response to loss is associated with elevated suicide risk, especially within the first year after the death of a close relative.

 Passive and active suicidal thoughts are particularly common among older adults in long-term care facilities, and social isolation and loneliness are some of the most frequently reported bases for suicidal thoughts.

 The relationship between perceived social support and psychiatric illness, most notably depression, is strong even when controlling for other factors, such as negative affectivity and overreporting of experiences.

 This points toward a need for more dynamic psychosocial interventions.

Existing Psychosocial Interventions for Suicide Prevention

Current randomized, controlled trials (RCTs) that evaluate psychosocial interventions for older adults are typically developed to address depression or other affective disorders in young adults and are not specifically targeted toward suicidality.

 Of the few published RCTs that measure suicidal ideation as a primary outcome in older adults, the intervention and assessment methods are diverse. Conwell

 investigated the effect of a peer companionship program on socially disconnected older adults, but saw no significant difference in suicidal ideation outcomes between the treatment and control groups. Two studies, conducted by Ecker

 evaluated adaptations of CBT on veterans with suicidal ideation. The first study was a 4-month brief cognitive behavioral therapy (CBT), and the second was CBT for depression compared against 2 other evidence-based psychotherapies. Both authors reported a reduction in suicidal ideation in the CBT/bCBT groups compared to control groups.

 examined suicidal ideation as a primary outcome in tests of problem-solving therapy in older adult populations. These studies both saw significant reductions in suicidal ideation in the treatment groups; however, 1 study tailored the intervention toward older adults with depression and executive dysfunction, and the other targeted subjects with functional disability, making the interventions difficult to compare.

 investigated the effects of problem adaptation therapy (PATH) on suicidal ideation, an intervention that utilizes emotion-regulation techniques and compensatory strategies in older adults with depression and cognitive impairment. The authors saw a reduction in suicidality in the PATH participants, but the reduction was not significantly different from the supportive therapy control group.

The samples in the aforementioned studies represent specific populations (ie, veterans with medical illness, older adults with functional disabilities), and are not representative of the general older adult population. The heterogeneity of the interventions creates difficulty in both between-study comparisons and generalizability to the general population. Moreover, these studies often exclude those who express active suicidal ideation, leaving out those who are at greater risk of suicide. The results are promising; however, it is important that findings be replicated with larger and more representative samples to more accurately examine the effectiveness and promote generalizability of the interventions.

The onset of the COVID-19 pandemic and the associated policies have the potential to exacerbate the severity of the previously identified risk factors for suicide in older adults. Social-distancing guidelines, stress, and limited access to health care may contribute to increased feelings of isolation and loneliness, worsening of cognitive and functional abilities, and intensification of symptoms of psychiatric disorders.

 Technology offers the opportunity to alleviate logistical barriers to receiving clinical interventions for older adults who may have difficulty adhering to treatment. As the reliance on telehealth increases, more thorough investigation into remote psychosocial intervention methods targeted specifically for this population is particularly essential.

Literature on the role of technology treatment for suicide prevention in older adults is sparse. Preliminary findings available on feasibility and acceptability of technology-based mobile interventions suggest promising effects of improvement, but further testing is needed.

 In a review of mobile health technology for suicide prevention, one intervention, Virtual Hope Box (VHB), was tested in middle-aged adults. The study recruited both young and middle-aged veterans with a mean age of 46 years old and tested an augmentation of CBT using smartphone capabilities to enhance and personalize the experience with a “hope box.” The study evaluated the effect of the application on intensity of suicidal ideation and importance of reasons for living, but the results yielded no statistically significant treatment effect on these outcomes between the treatment and control groups.

Our research at the Emotion, Cognition, and Psychotherapy Lab at Weill Cornell Medicine aims to reduce suicide risk by employing a simplified, personalized, and easy-to-use mobile intervention. WellPATH is a tablet application that focuses on emotion regulation strategies (specifically, cognitive reappraisal strategies, which focus on seeing a situation from a different perspective) to reduce negative emotions associated with increased suicide risk. It is a personalized, mainly standalone, mobile intervention that incorporates patient-specific techniques that can be accessed when the patient is faced with negative emotions. The patient and WellPATH interventionist identify situations, problems, or concerns that trigger intense negative emotions that may lead to increased suicidal ideation or behavior and develop personalized cognitive reappraisal strategies to reduce the intense negative emotions.

Preliminary results indicate that patients are able to utilize the user-friendly interface with ease and are highly satisfied with the support provided by WellPATH.

 The WellPATH application takes into consideration characteristics unique to older adults and offers immediate access to an intervention that is easy to use. It addresses the need for a mobile suicide prevention intervention for middle-aged and older adults at high suicide risk, which is particularly germane, given the increased reliance on telehealth.

The topic of suicide in older adults requires greater consideration. Identification of risk factors is valuable in understanding elder suicidality; however, further attention is encouraged for the development and evaluation of effective interventions tailored to older adults. The few psychosocial interventions mentioned show overall promising results, but unfortunately, there is little available data beyond what has been described. The novel WellPATH tablet application has the opportunity to provide relief to individuals at high risk of suicide by offering an immediate intervention to patients in their actual environment. With the rapid increase in population of middle-aged and older adults, the continued exploration of adaptive preventative interventions is essential for safeguarding the well-being of this increasingly vulnerable population.

 is a research assistant in the Weill Cornell Medicine Kiosses Lab. 

is associate professor of psychology in clinical psychiatry at Weill Cornell Medical College; associate attending psychologist at New York-Presbyterian Hospital; and primary investigator in the Weill Cornell Medicine Kiosses Lab.

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Articles

Recent updates in suicide prevention interventions for older adults and how a novel tablet application may provide relief to individuals at high risk of suicide.

Suicide in Older Adults: Advances and the Role of Technology in Treatment

Depression, cognitive impairment, and disability often coexist in older adults. Therefore, to effectively treat late-life depression, clinicians need to evaluate the presence and degree of the patient’s cognitive deficits and level of disability.

This article highlights the importance of psychosocial interventions in the treatment of depressed, cogni-tively impaired, and disabled older adults; describes existing psychosocial interventions for this population; and presents a case illustration of problem adaptation therapy (PATH). PATH is a novel home-delivered intervention that aims to reduce both depression and disability in depressed older adults with significant cognitive impairment (including mild to moderate dementia) and disability.

 The clinician must conduct a thorough evaluation that includes a review of the current depressive symptoms, past history of depression, history of pharmacological and psychosocial treatments and their effectiveness, and an evaluation of suicidal ideation. For most cognitively impaired elders, the clinician needs to interview the caregiver and obtain information that may not be available with the patient self-report. Instruments that have been validated in the assessment of depression in cognitively impaired elders may help in the evaluation (

Because depressed elderly patients often do not report depressed mood but do report lack of interest or pleasure in activities, the clinician needs to use the patient’s language and experience in making an evaluation. Sometimes depressed older adults use words other than “depression,” such as feeling blue, down, discouraged, and not motivated. Because geriatric depression may be comorbid with other illnesses, symptoms that are caused by depression must be differentiated from those of another illness. Sometimes this differentiation is extremely difficult, because depression may exacerbate existing physical symptoms.

An important aspect of the evaluation is the assessment of cognitive impairment. The clinician may ask the patient and the caregiver about the effects of cognitive difficulties on the patient’s functioning and identify cognitive strengths as well as deficits. Specific questions about the patient’s ability to start and stay with a new task until it is completed, to sustain attention and concentrate while reading or speaking with others, and to remember recent events and conversations may provide important infor-mation about the patient’s everyday functioning.

Screening tools such as the Mini-Mental State Examination (MMSE) may help identify overall cognitive impairment, but they are generally not sensitive to executive deficits or mild cognitive impairment.

 A somewhat more inclusive measure is the Modified Mini-Mental State Examination-the extended version of the well-known MMSE.

 Another screening instrument that has shown increased sensitivity to milder forms of cognitive compromise is the Montreal Cognitive Assessment (MoCA).

 (The complete MoCA test, as well as normative data and instructions for use, is available online at 

.) Translations into multiple languages are also available. These cognitive screening instruments can be administered with minimal training.

? Despite the effectiveness of pharmacological treatments in the acute phase of late-life depression, symptom remission is achieved in fewer than 40% of elderly depressed patients with cognitive impairment, with or without dementia. Therefore, effective psychosocial interventions for this population are needed. However, most psychosocial interventions for the acute treatment of geriatric major depression are designed for “young-old,” cognitively intact, ambulatory patients who can follow outpatient treatment plans.

? To treat depressed older patients with comorbid cognitive impairment and disability, psychosocial interventions need to be modified to include involvement of a caregiver, home delivery of the interventions, and environmental changes to help improve everyday functioning. With these modifications, psychosocial interventions may provide relief to a large group of elderly patients with depression who may not respond to antidepressant medication treatment.

Instruments that are administered in the context of a formal neuropsychological evaluation can provide a more accurate evaluation of cognitive deficits; ie, a score of 130 on the Mattis Dementia Rating Scale has a 98% sensitivity and 97% specificity for the diagnosis of Alzheimer dementia.

 Neurocognitive assessment conducted by a neuropsychologist provides assessment of the patient’s cognitive strengths and weaknesses that is interpreted in the context of the patient’s premorbid functioning, age, ethnicity, and education, and can yield essential knowledge that contributes to treatment success.

In addition to the assessment of depression and cognitive impairment, the clinician needs to evaluate the patient’s functional, behavioral, and physical limitations (eg, hearing, visual, mobility problems). Information must be collected from both the patient and the caregiver; careful questioning may identify and evaluate discrepancies in their reports. The clinician evaluates how depression, cognitive impairment, and disability have affected the patient’s everyday functioning (ie, what activities the patient can no longer do; what the patient’s past and current pleasurable activities are; what effects, if any, the patient’s cognitive difficulties may have had on taking medication and performing activities of daily living). Available clinician-administered instruments may be helpful in providing information on the patient’s functioning (

Despite the effectiveness of pharmacological treatments in the acute phase of late-life depression, symptom remission is achieved in fewer than 40% of elderly depressed patients with cognitive impairment, with or without dementia.

 Therefore, effective psychosocial interventions for this population are needed. Despite this need, most psychosocial interventions for the acute treatment of geriatric major depression are designed for “young-old” (average age, 65 to 70 years), cognitively intact, ambulatory patients who can follow outpatient treatment plans.

 To effectively treat depressed older patients with comorbid cognitive impairment and disability, these psychosocial interventions need to be modified (eg, involvement of a caregiver; home delivery of the psychosocial intervention; environmental changes to help depressed, cognitively impaired older adults improve their everyday functioning). The following interventions have been designed for depressed older patients with varying degrees of cognitive impairment.

Problem-solving therapy for mild executive dysfunction (PST-ED).

 PST-ED is a 12-week outpatient treatment for ambulatory depressed elders with mild executive dysfunction. It consists of 7 problem-solving stages and helps the patient identify his or her problems and find the best possible solution by learning the problem-solving stages and applying them to future problems. PST-ED has been found to be effective in reducing depression and disability in this population.

Interpersonal psychotherapy for mild cognitive impairment (IPT-CI).

 IPT-CI has been modified for depressed elderly patients with mild cognitive impairment. Modifications include the systematic incorporation of concerned caregivers into the treatment process; joint patient-caregiver sessions help promote better understanding, communication, and respect.

 Finally, the IPT-IC therapist helps the dyad (patient and caregiver) adjust to their role transition as a result of the patient’s cognitive deficits and impaired functioning.

Cognitive-behavioral therapy (CBT) for mild dementia.

 Although CBT has been adapted for depressed elderly patients with mild dementia, no efficacy data are available.

 During the 16 to 20 sessions, comprehensive neuropsychological test data are used to assess the cognitive capabilities of the patient. In addition, behavioral activation interventions are used in conjunction with memory aids (eg, notepads, audio recording of sessions). These interventions are also used to examine the evidence for and against a negative thought and to try out new attitudes and cognitions in stressful situations.

Behavioral treatment for depression in moderate to severe dementia.

 In a randomized trial, a behavioral treatment that taught caregiver strategies designed to increase patients’ pleasant events or to help with problem-solving skills reduced depressive symptoms in elderly patients with major or minor depression and moderate to severe dementia.

 This treatment is the recommended psychosocial intervention for elderly patients who are depressed and have symptoms of advanced dementia.

Problem adaptation therapy. This is a new 12-week, home-delivered intervention developed to treat late-life major depression comorbid with significant cognitive impairment (including mild to moderate dementia) and disability.

 PATH focuses on the patient’s ecosystem, which involves the patient-caregiver dyad, and the patient’s home environment. Appropriate strategies are assessed and planned in the patient’s living environment, where patients experience most of their difficulties. PATH imparts problem-solving skills by using problem-solving therapy as its basic framework to promote adaptive functioning.

Pragmatic and readily available environmental adaptation tools, including calendars, checklists, notepads, signs, and timers, are integrated into the therapy. Finally, caregivers participate in the problem-solving process and the use of environmental adaptation tools, and assist in engaging and directing the patient to pleasant events. The PATH therapist must use the patient’s remaining cognitive strengths and promote independence and, at the same time, find effective ways to bypass the patient’s cognitive deficits and behavioral and functional limitations.

The case vignette describes how PATH can be helpful in the treatment of patients with depression and comorbid cognitive impairment and disability. It also illustrates the complexity of depression treatment in this population. Even though PATH is a home-delivered intervention that requires evaluation of the patient’s actual environment, in certain cases, it can be provided in outpatient settings with the help of a caregiver.

Mrs Y, an 82-year-old woman, became severely depressed following surgery for a hip fracture. Her cognitive functioning had decreased in the previous year. Her depression was characterized by depressed mood, lack of energy or interest in activities, psychomotor retardation, anhedonia, and concerns that she would never be herself again. Her MMSE score was 24 and her Dementia Rating Scale score was 128.

Her executive functioning was significantly impaired, and she had mild memory and attention deficits. Mrs Y felt lost and was unable to perform activities that she performed regularly before surgery, including shopping, cooking, paying bills, and arranging social and family activities for herself and her husband. Mrs Y’s behavioral change affected her care. She could not organize her schedule to go to the rehabilitation center and to keep her primary care appointments. When her husband arranged house calls by a physical therapist, Mrs Y was not able to follow the recommended physical therapy exercises.

A clinician familiar with PATH visited Mrs Y to discuss the nature of her depression, redefine some complaints as symptoms of her depression, and explain how PATH could help both her depression and her disability. Mrs Y, her husband, and the therapist developed a list of Mrs Y’s problems. Among them, Mrs Y decided to target her inability to perform physical therapy exercises and her lack of social activities. For the first problem, Mrs Y indicated that she was disorganized, did not set a time for her exercises, and failed to memorize their sequence. The therapist suggested that Mrs Y always perform her exercises at the same time every day (10:30 am) and created a schedule of activities that would help her get ready for her exercises. The PATH therapist asked Mrs Y’s physical therapist to give Mrs Y only 2 exercises initially and to increase the number of exercises progressively. The physical therapist also provided Mrs Y with written instructions. Within the next 4 weeks, Mrs Y was able to perform 4 exercises daily.

As Mrs Y started progressing with her physical exercises, she, her husband, and the therapist started exploring the reasons for the lack of social activities. Mrs Y had not seen her family and friends because she found it difficult to get motivated and organized. She agreed to go to her daughter’s upcoming birthday party, which would provide the opportunity to reconnect with her daughter’s family and other friends. In addition, the party could serve as a stepping-stone for a broader plan of social activities. The plan involved buying a gift for her daughter. Mrs Y was uncertain of what to buy and where to buy it. Her homework assignment, therefore, was to work with her husband and create a list of pros and cons for possible gifts and stores. Working with her husband, Mrs Y was able to overcome her lack of motivation and buy a gift. She went to her daughter’s birthday party and was happy to see her family and especially her grandchildren.

During the next session, the therapist, Mrs Y, and her husband made a plan for pleasurable activities for the following weeks. These successes facilitated her rehabilitation, enhanced her self-esteem, and reduced her hopelessness. A few weeks after the intervention, Mrs Y’s depressive symptoms subsided, and she reported a better quality of life.

Psychosocial interventions are critical for elderly patients with depression who have cognitive impairment and disability because antidepressants provide symptom remission in fewer than 40% of patients. Psychosocial interventions must evaluate and target not only depression but also cognitive impairment and disability (

. Therefore, appropriate modifications may be necessary: involvement of a caregiver, home delivery of the intervention (if possible), and environmental changes to help the patients improve their functioning. With these modifications, psychosocial interventions may provide relief to a large group of elderly patients with depression who may not respond to antidepressant medication treatment.

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Dimitris N. Kiosses, PhD

Articles

Suicide in Older Adults: Advances and the Role of Technology in Treatment

Psychosocial Interventions for Depressed Older Adults With Cognitive Impairment and Disability