Although in some countries suicide rates in young males have risen dramatically in the last decade or so, suicide in old age is important because rates in older people, especially those over 74, are still proportionately higher in most countries of the world where reasonably reliable statistics can be obtained.⁽¹⁾ For example, in 2004 in Lithuania where suicide incidence is currently the highest, the
overall rate in males per 100 000 total population was 70.1, but in men over 74 the rate was 80.2. In the United States, where suicide is neither especially common nor rare, in 2002 the overall rate for males per 100 000 total population was 17.9, but 40.7 in men over 74. Rates for older women are nearly always much lower than for their male counterparts.

A second reason for the importance of suicide in old age is that the proportion of older people in the population is rising worldwide. Indeed, the increase in developing countries is likely to be even greater than in developed countries. Although rates vary from year to year and birth cohort to cohort, it is highly likely that unless suicide prevention becomes a great deal more effective than at present, more and more older people will kill themselves in the coming years.

As with younger people, completed suicide in old age may be seen as part of a continuum from suicidal thinking through deliberate self-harm (which does not lead to death), to completed suicide. An added component within this continuum for older people is that of ‘indirect self-destructive behaviour’, such as refusal to eat and drink or ‘turning one’s face to the wall’ which is clearly intended to hasten death. Finally, although this section does not deal with euthanasia and related issues, assisted suicide in people with terminal illness such Alzheimer’s disease and cancer may also be seen as part of the suicide continuum.

A number of studies have explored this issue. Fleeting thoughts of suicide or the idea that life is not worth living occur in up to about 15 per cent of community-dwelling older people,⁽²⁾ but serious consideration of suicide is very much less.⁽³⁾ It is those older people with mental disorders, mostly depressive, who show a higher frequency of thoughts that life is not worth living and harbour ideas of committing suicide. It seems logical to suppose, therefore, that depressed elders should be the target of suicide prevention strategies.

Unlike the young, some elderly people have the possibility open to them of behaving passively in such a way as to hasten death. This may happen either by refusing medical treatment essential to maintain life, or simply by declining to eat and drink—‘turning one’s face to the wall’. As regards the latter, many people, especially non-medical, believe that this is reasonable behaviour akin to so-called ‘rational suicide’, and court rulings have sanctioned it. There is no doubt that there are several cases in which a person’s right to refuse treatment or nutrition, for example during the terminal phase of cancer, should and would be respected. However, it has been argued that many of such cases suffer from undiagnosed but treatable depressive illnesses. Some support for this point of view was provided by a questionnaire study of more than 1000 residential and nursing home administrators in the United States.⁽⁴⁾ Cognitive impairment, loss events, refusing medication, food, and drink, loneliness, feeling rejected by families are all risk factors for indirect suicidal behaviour in residential homes.⁽⁵⁾ It is wise, therefore, that no one should be permitted to turn his or her face to the wall before assessment for the presence of a treatable depressive disorder.