Abstract
Although suicide in other demographic groups may receive more public attention, suicide among older adults has long been an intense target of concern for suicide prevention. In fact, in most populations and regions of the world, suicide rates are highest in older or middle age adults. Older adult suicide is also an area where the suicide prevention field has learned a lot about successful prevention programs that utilize a combination of clinical and social/community programs.
A Introduction
Although suicide in other demographic groups may receive more public attention, suicide among older adults has long been an intense target of concern for suicide prevention. In fact, in most populations and regions of the world, suicide rates are highest in older or middle age adults. Older adult suicide is also an area where the suicide prevention field has learned a lot about successful prevention programs that utilize a combination of clinical and social/community programs.
B Principles
a. Older adult suicide is a longstanding public health crisis.
b. Suicide rates in older age adults are often the highest of any age group, especially among developed nations.
c. Older adult suicide is complex with converging risk factors including unaddressed mental health conditions, disability from both mental and physical health problems, social isolation, losses of peers, autonomy, and sense of identity, youth-idolizing culture that devalues older age members of families and society, economic changes, and even potential cohort effects in some instances.
d. It is important for clinicians to guard against erroneous “common sense” assumptions, for example, if I were in their shoes (e.g., loss of autonomy or chronic pain) I’d also be depressed or suicidal. Clinical depression and suicide risk are not normal responses at any age.
e. It is critically important to identify and address the most potent risk factors for suicide among older adults, “The 4 D’s”: Depression, Disease/Disability, Disconnectedness, and Deadly means.
f. A multi-prong suicide prevention strategy for older adults includes community, family, policy, and clinical interventions.
C Scope of the Problem and Trends
In most parts of the world, older adults have the highest rates of suicide. Suicide in both middle and later life are critical targets for prevention, given the highest rates in almost all countries occur among middle or older adults. Although suicide attempts are more frequent among adolescents and young adults, middle and older age men and women show the highest suicide rates in most developed countries.1, 2 In contrast, in many low- and middle-income countries, suicide rates peak in young adulthood.3
Figure 15.1 Suicides globally by age, showing high and low country-level incomeIn most high-income nations, middle and older age adults have the highest suicide rates. In low- and middle-income countries, suicide rates peak in young adulthood.2
Older adults have historically had the highest rates of suicide in developed nations, including in the UK, USA, Australia, Denmark, and other European countries. However, middle age suicide rates are also notably high and in Canada and the USA have surpassed older demographic age groups. Older Canadian and American adults’ rates remain high however, and the lethality of attempt behavior rises over the course of the life cycle. In the older years, attempts tend to be more lethal with the attempt to death ratio approximately 4:1 (versus in youth where the attempts to death ratio is approximately 100:1).1
In other countries, the relationship of aging with suicide risk varies. In China older adults’ suicide rates have increased in recent years even while the overall national suicide rate has declined; the past three decades have witnessed a remarkable drop in overall suicide rates in China from 17.6 per 100,000 in 1987 to 7.46 in 2014. This decline is thought to be driven by sharp decreases in the rate of younger Chinese people during recent years of urbanization and new opportunities, while older Chinese rates continue to rise.4
A number of factors influence suicide risk among middle and older age adults, including physical and mental health-related disability, stressors common to this life stage, economic trends, societal views and roles of older adults, unmet expectations, isolation, and losses.
Cohort effects may also play a role. In the USA, throughout their entire life cycle over many decades, the Baby Boomer generation (born 1946–1964) has had higher suicide rates (and other psychosocial problems) than any other previous generation. As Boomers make up an increasingly large part of the older population, this means that the rate among older Americans could unfortunately rise if this cohort effect continues.5
The suicide method for older adults varies around the world. In the USA, older adults have significantly higher rates of firearm suicide than younger Americans, highlighting the rate of fatality of attempts by older adults generally being much higher than for younger populations.6
In older age Americans, the gender gap widens especially for older White men, whose rates are 6 to 8 times higher than older age White women. For African American men, suicide rates peak in the young adult years. African American females are the demographic group with the lowest rates of suicide in the USA.
Figure 15.2 Suicide rates by age, with gender and race, in the USA
Suicide rates tend to be higher among older adults, although in some groups such as Black males and both Black and White females in the USA, rates are lower in older adults.
D Risk Factors for Older Age Adults: The 4 D’s
Recommendations for Addressing the 4 D’s
1. Aggressively screen and treat depression in older adults.
2. Address the concerns of patients concerning their illnesses including the illnesses’ psychological impacts on autonomy, identity, suffering, and anxiety. Optimize patients’ functioning to every extent possible in order to minimize the disabling impact of illnesses. Treating depression and anxiety is critical to this when they are present.
3. Involve family and “prescribe” various social activities and services.
4. Counsel patients on lethal means. Ensure any lethal methods including firearms, dangerous medications, and substances, are secured or stored outside the patient’s home. Involve family in this discussion when possible.7–9
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