Vol. 7 Issue 25
Suicidal Threats in Long-Term Care
While at risk, older adults are not likely to attempt suicide in a nursing home
John Davis is an 86-year-old widowed resident in a nursing home. He frequently voices his feelings of unhappiness to the staff. "I wish I was dead!" "Can you give me a pill to have me not wake up?" "If I don't get out of here soon I'll kill myself" are some of the statements he has made. He suffers from chronic pain secondary to arthritis, diabetes and coronary artery disease. He is confined to a wheelchair due to his high risk for a fall. He is on an antidepressant and has no prior suicidal attempts.
Mary Jones, 75, has no diagnosis of depression and is losing weight due to a decrease in appetite. She is cognitively impaired, scores 15 of 30 on the Mini-Mental Status Exam (MMSE), has poor short-term memory and can be resistive to care. She attempted an overdose in her early 20s but has made no attempts since then. Her poor nutritional status and combative behavior are attributed to dementia.
There is little in the literature regarding the prevalence of suicide in long-term care (LTC) settings. This is surprising, given the wealth of information available on the suicide rate of elders in general. However, based on the data available, it seems that an older person, even though at risk, is not likely to attempt suicide in the LTC setting.
Current statistics on suicide identify older adults as a high-risk population. In 1992, older adults comprised about 13 percent of the U.S. population, yet accounted for 20 percent of its suicides; in contrast, young people age 15-24 comprised about 14 percent of the population and accounted for 15 percent of the suicides.1 Among older individuals, there are two to four suicide attempts for every successful attempt 50 percent higher than the population as a whole. This is because older adults who attempt suicide are more likely to die from the attempt than any other age group. Suicide is currently the ninth leading cause of death in the elderly.1 Someone age 65 or older completes suicide every 90 minutes 16 deaths a day.1
Looking at John Davis, we note that he is Caucasian, widowed, depressed, has chronic pain, is over 85 and has expressed a wish to die. Caucasian males over age 85 complete suicide at almost 6 times the national average.2 Caucasian males over 65 have the highest suicide rate twice the rate of the general population, and 6 times the rate in women over 65.2 Suicide is more common in the divorced and widowed. Elderly men who lose their wives lose social contacts leading to isolation.2 Studies have shown that 45-80 percent of those in nursing homes suffer chronic pain. Furthermore, both pain and aging increase the risk for suicide.1
Depression is the most common diagnosis in older adults who have attempted suicide. Sixty percent of those who do commit suicide tell others before the attempt.2 In fact, a typical suicidal person will tell at least three people about their intent before they attempt.2
Mary Jones is not considered someone who could kill herself because she cannot carry out more than one step at a time on the MMSE. It is noted that she had one suicide attempt in the past due to an acute psychotic reaction but none since. The previous suicide attempt was more than 50 years ago, yet an attempt in the past is one of the greatest risk factors for suicide. Nearly half of depressed patients who commit suicide have a history of a prior suicide attempt.3
Patients clinically diagnosed with psychosis are at a higher risk of suicide, especially if they are considered paranoid or hear voices telling them to hurt themselves.2 Up to 10 percent of patients diagnosed with schizophrenia will die from a successful suicide attempt.3 Cone describes silent suicide as the intent to kill oneself by non-violent means.2 This is often accomplished through self-starvation and resistance to care.3 Jones has these symptoms but they have been attributed to dementia by the staff since she denies being depressed.
Nursing Home Setting
Based on the above information, would the individuals meet the profile of someone likely to attempt suicide and should they receive a psychiatric consult? The answer is a strong yes. But what is their chance of attempting and completing suicide in the nursing home? Surprisingly, the risk is almost nil.
A study done in Finland looking at successful suicides from 1987-1988 (n=1,297) found that only 12 occurred in nursing homes.4 The study noted, "suicide is rare in older people and apparently very rare in nursing homes." While many older people dread loss of independence and the potential indignity of being cared for in a nursing home, and may make suicidal threats, this does not seem to translate into successful suicide attempts.4 Another study calculated the rate of completed suicide in nursing homes at approximately 15.8 per 100,000.5
A suicide in a nursing home is a sentinel event and should be reported. Yet since nursing home patients suffer from chronic debilitating conditions, their cause of death is often unquestioned and the majority of states do not demand an autopsy or investigation into nursing home deaths.6 Therefore, could the suicide rate in long-term care facilities be higher? What is more relevant to look for in assessing suicidal tendencies in nursing home patients and what can we surmise from suicides that have occurred?
According to Roy, "Nursing home populations have high rates of medical illness, functional disability, depression and depressive symptoms, but little is known about the relative contribution of these problems in older residents thinking about suicide: Few empirical studies have examined self-destructive ideation in nursing home residents."1
Self-neglect in activities of daily living and higher levels of functional disability have been associated with suicidal behavior and ideation1 yet the lower the functional ability the less likely the person would have the ability to plan or carry out a successful suicide.
In the Finnish study, "eight of the 12 died by hanging, three of 12 by drowning and one of the 12 died by shooting." It would appear that successful suicides in nursing homes are violent. Additional risk factors noted in the study include a psychiatric diagnosis, previous attempt, depression and alcohol abuse.
Given this study is 17 years old, is it relevant today? Current nursing home patients face increased medical challenges, are more compromised and cognitively impaired than patients in the past. A recent government study found that less than one in 10 nursing homes employs the optimal number of nurses and aides so assessment and supervision are major concerns.7
An Uncapher et al. study of hospitalized veterans makes an important point in assessing suicidal risk in nursing home patients. The study demonstrates that "Medical illness and functional disability did not predict suicidal thoughts when depression was factored out." When depression was not factored out, medical problems but not functional disability predicted suicidal ideation.
This study concluded, "Suicidal ideation in nursing home residents is primarily explained by the presence of depression rather than by medical illness or functional disability. These findings highlight the importance of assessing and treating depression in medically ill men. "Depression is especially prevalent in physically ill, institutionalized, elderly patients. The likelihood of depression increases with increased severity of illness in the medically ill elderly, and geriatric suicidal ideation, attempts and completions are uncommon outside the context of depressive illness or symptoms."5 In summary, suicide in nursing homes appears to be a rare event in occurrence and actuality.
1. Roy, R. (2003). Depression and suicide in older adults. Retrieved May 7, 2005 from the World Wide Web at www.personalityresearch.org/papers/roy.html
2. Cone, W. (2004). Aging, mental health and long-term care. Retrieved May 7, 2005 from the World Wide Web at www.continuingedcourses.net/active/courses/course011.php
3. Lantie, J., & Averbuch, R. Death and Suicide: What you need to know and why you need to know it. Retrieved May 8, 2005 from the World Wide Web at http://184.108.40.206/search?q=cache:PZG3zTGwikIJ:medinfo.ufl.edu/year1/humbehav/powerpoint2005/Death_Suicide.ppt+suicide+risks+factors+prior+attempts+elderly&hl=en
4. Suominen, K, et al. (2004). Nursing home suicides: A psychological autopsy study. International Journal of Geriatric Psychiatry 18(12), 1095-1101. Retrieved May 5, 2005 from the World Wide Web at www.cnsforum.com/commenteditem/6b6795dd-9b62-4e4d-abde-48cd79d7cd03
5. Uncapher, H., et al. (1998). Suicidal thoughts in male nursing home residents. Annals of Long-Term Care, 6(9). Retrieved May 5, 2005 from the World Wide Web at www.mmhc.com/altc/displayArticle.cfm?articleID=altcac107
6. Null, G. Gary Null's action file: Nursing homes. Retrieved May 5, 2005 from the World Wide Web at http://www.garynull.com/Issues/Nursing%20Homes/Index.htm
7. Rotstein, G. (2002, Sept. 22). No place like home: Nursing homes struggle with too few nurses, aides for growing elderly population. Pittsburgh Post-Gazette. Retrieved May 9, 2005 from the World Wide Web at http://www.post-gazette.com/healthscience/20020922nursinghomes0922p1.asp
Michael C. LaFerney is employed by Arbour SeniorCare, Rockland, MA.