Suicide rates in the United States increased from an age-adjusted rate of 11.3/100,000 in 2007 to 14.0/100,000 in 2017 (CDC Fatal Injury Data). During that same period, rates among adults 65 and older remained higher than the national rate, climbing from 14.3 to 17.1/100,000. Increased risk for suicide in later-life is driven in large part by the dramatically high rate of suicide among white males aged 85 and older, who experience an average annual rate of over 50 suicide deaths per 100,000. Suicide rates are also rising among middle aged adults, suggesting that suicide risk in the second half of life is a significant public health concern. This article will outline the scope of the problem, describe an important area for intervening to reduce suicide risk (namely, comorbid physical illness and depression), and offer suggestions to engage clinicians and community members in efforts to reduce suicide deaths among older adults.
Identifying individuals who are at imminent risk of suicide is a daunting task with unique challenges among older adults. Compared to younger cohorts, older adults are less likely to express intent, tend to use more lethal means, and may experience physical frailty and social isolation, thereby reducing chances of rescue and survival after an attempt (Conwell, 2001). For these reasons, although older adults attempt suicide at lower rates compared to younger adults, they are more likely to die from a suicide attempt. To reverse late-life suicide trends at a time when the median age of the United States population is advancing, suicide prevention efforts must be redoubled with a focus on public health approaches that intervene on risk factors that could have the broadest impact across the largest number of people.
Late-life suicide risk factors include psychiatric illness, physical illness, functional disability, neurocognitive disorder, and social isolation (Conwell, Van Orden & Caine, 2011). Whereas depression is frequently and strongly associated with suicide, physical illness is a precipitant in approximately 50% of late-life suicide deaths (Choi et al., 2017). Depression frequently co-occurs with physical illness, including cardiovascular conditions, diabetes, and stroke. Given their frequent comorbidity and associations with suicide, both depression and physical illness should be considered when assessing and intervening for suicide risk.
Physical illness, suicide, and depression are complexly interrelated. Multimorbidity, the presence of more than one chronic condition, is common in later life and is associated with increased risk for depression and suicide compared to individuals without multiple chronic illnesses (Read et al., 2017; Juurlink et al., 2004). Physical illness may contribute to the development of depression due to difficulty coping with disease-related functional impairments, pain, or loss of independence. Moreover, depression may develop because of decreased engagement in physical and social activities due to physical limitations or other symptoms of illness (Fiske et al., 2008). Among older adults with physical illnesses, depression may compound feelings of hopelessness regarding health outcomes and contribute to self-perceived burden on others. Depression may similarly increase risk for physical illness through multiple pathways, including for example, inactivity, weight loss, or cognitive impairment (Blazer, 2003).
Additionally, medical care transitions (e.g., hospital to skilled nursing facility to home) may be a time of heightened risk for suicide among patients with physical illness and depression. A study of Veterans found increased suicide risk during the 6 months after discharge from a skilled nursing facility (McCarthy et al, 2013). Physically ill patients are more likely to utilize inpatient medical services if they have comorbid depression (Himelhoch et al., 2004), and additional functional and mental health declines could contribute to increased suicide risk after discharge. Hospitalization is associated with physical and functional decline in the years after discharge (Ehlenbach et al., 2015), and termination of rehabilitation services is associated with increased risk of depression and anxiety in older adults (Simning et al., 2018). Enhanced care coordination, psychosocial interventions, and occupational supports to reduce activity restriction may attenuate suicide risk during medical care transitions, although more research is needed to identify effective prevention measures.
Comorbid depressive symptoms and suicide risk may be underrecognized and undertreated among older adults presenting for medical services. The reasons for this are manifold. Compared to younger adults, older adults are less likely to receive comprehensive safety assessment and safety planning, or to be referred for mental health services (Pettit et al., 2017; Simons et al., 2019). Depression may also be masked or misdiagnosed due to somatic and cognitive symptoms that overlap with medical and neurocognitive conditions. Finally, patient and provider attitudes toward mental health and aging may affect the type and focus of care provided. Older adults who hold negative attitudes about aging have poorer mental and physical health as they grow older, are more likely to endorse suicidal thoughts, and do not live as long as older adults who hold positive attitudes. Health care providers may unintentionally promote negative health behaviors and dependence through use of elderspeak (i.e., speech that is slower, louder, and simplified) or providing assistance when it is not needed (Schroyen et al., 2015).
There is a clear need to enhance suicide prevention strategies for older adults with physical illness, but what can healthcare providers and community members do today to manage and reduce suicide risk?
Older adults are more likely to be seen by a medical than a mental health provider within the month before suicide death. Because older adults may not disclose suicidal thoughts or intent, healthcare providers may wish to consider assessing for additional risk factors when patients present with comorbid depression and medical conditions. Assessment of suicide means (e.g., firearms), nutritional status, and social isolation could provide insight regarding risk level and potential intervention targets. When concerns are present, initiate safety planning and offer referral to mental health services in addition to considering medication. Collaborative care models (https://aims.uw.edu/collaborative-care) can improve mental health treatment outcomes within primary care. In areas where resources are limited, telemental health services may be an option.
Safety plans should be developed collaboratively with the patient and can be framed as “crisis plans” or “bad day plans” if the patient disagrees with the provider’s assessment of risk. Identifying methods to make the environment safe (i.e., means reduction) when risk is high is an important component of the plan. Include family or care providers when possible and provide the patient a copy of the plan. The plan should also include contact information for the National Suicide Prevention Lifeline, which provides free, confidential support available 24 hours 7 days a week by calling 1-800-273-8255 (press 1 for the Veterans Crisis Line).
Encourage and seek resources to support increased social connection and activity engagement for at risk patients to reduce loneliness and social isolation. There are several nonprofit and community service organizations that offer volunteer companionship, social activities, or support groups for patients. Local Area Agencies on Aging can offer information regarding available resources (Directory of New York State Offices for the Aging: https://www.aging.ny.gov/nysofa/LocalOffices.cfm)
Both functional impairment and pain may co-occur with physical illness and depression, increasing suicide risk. Adequate pain management and strategies to support functional independence could reduce feelings of helplessness and burden. Occupational therapists can help identify environmental adaptations or other aides to support maximum functioning. Motivational interviewing and/or cognitive-behavioral interventions may improve outcomes for patients who struggle with treatment engagement due to ambivalence or depressive thoughts.
Ageism is common and unavoidable, but not immutable. Negative messaging about aging may contribute to misperceptions that depression is a normal part of aging or that disability is always burdensome. Education and self-assessment (e.g., Project Implicit, https://implicit.harvard.edu/implicit/) can increase awareness of biases and help reduce the prevalence of ageist behaviors such as elderspeak. Engagement in intergenerational activities may also challenge misperceptions about age. Local libraries and YMCAs may have information about programs or resources.
In conclusion, older adults die by suicide in greater numbers than younger adults, and suicide risk is particularly high among white males 85 and older. Physical illness and depression are common precipitants of late-life suicide but identifying patients at imminent risk is challenging because older adults may not endorse suicidal thoughts or intent despite high risk. Current strategies for reducing late-life suicide include routine risk assessment and management within medical settings, providing opportunities for social connection to reduce loneliness and isolation, and increasing awareness of ageism within medical and social settings. Preventing late-life suicide will require coordinated effort among researchers, providers, family, and community.
Emily Bower, PhD is a postdoctoral fellow and is supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs and the VA Center of Excellence for Suicide Prevention. The contents do not represent the views of the US Department of Veterans Affairs or the United States Government. She can be reached at firstname.lastname@example.org.