10.2 Epidemiology and Trends
Elderly people have the highest suicide rate in almost all countries in the world where data are available, with the highest suicide rates in persons aged 85 and older (World Health Organization 2005). In many countries such as Hungary, Belarus, and Lithuania, suicide rates increase with age in both genders. However, in other countries, for example in the US and Sri Lanka, the steady increase over the life span is only true for men but not for women. The suicide rates of older men generally surpass that of women with the highest male elderly suicide rates reported in Belarus and Lithuania (approx. 91 per 100,000). In the US, suicide rates among males are highest in the 65+ age group (29.05 suicides per 100,000) and among females, highest in the 45–54 age range (9.34 suicides per 100,000). A different trend exists for Japan, where the highest suicide rate among women is in the 75+ age group (19.4 per 100,000), and the highest rate among men is in the relatively younger 55–64 age range (55.1 per 100,000).
Race and gender are suicide risk modifiers; in the US, African American elders have lower suicide rates than Caucasians, and the suicide rate of elderly men exceeds that of women by 3–1 (Centers for Disease Control and Prevention 2012). Caucasian men over the age of 85 were reported to be at the greatest risk of all age-gender-race groups at 47.3 per 100,000, which is approximately four times the US national suicide rate (11.3 per 100,000). A US study found that men 70 years and older had higher attempt lethality than men 50 years and older (Dombrovski et al. 2008), driven by higher levels of intent. The pattern among women was different, as older women (70+) had lower attempt lethality than those between the ages of 50–69. In the US, firearm suicide rates among males aged 45–64 years were greater than all other suicide methods combined (Centers for Disease Control and Prevention 2012). These trends point to an increasing need to address risk factors that make older adults vulnerable to suicide.
10.2.1 Death by Suicide
A suicide attempt in late life is approximately 25 times more likely to be fatal compared to young adulthood (De Leo et al. 2001). Similar to adolescents and young and middle-aged adults (Mann et al. 1999; Brent et al. 1999), history of suicide attempt is the strongest predictor of death by suicide in old age (Beautrais 2002; Waern et al. 2002a; Conwell et al. 2002). Research experience of recent decades suggests that studies of suicide attempters provide the only practical in vivo window into the biological vulnerability to suicide (Maris et al. 2000). There is, however, considerable skepticism as to how representative suicide attempters are of suicide victims. Indeed, among adolescents and younger adults, the ratio of attempts to completed suicides can be as high as 100:1 (Moscicki 1995). By contrast, this ratio can be as low as 1.2:1 in older men (De Leo et al. 2001), suggesting that elderly suicide attempters may be more similar to those who die of suicide than younger suicide attempters (Pearson and Brown 2000; Frierson 1991). In addition to the fact that the elderly are more likely to be physically frail and live alone than younger adults, the low attempt-to-death ratio is mostly attributed to the fact that older suicide attempters, particularly men over 70, carry out medically serious (high lethality) suicide attempts with a high intent to die (Dombrovski et al. 2008). Thus, it has been proposed that suicidal behavior in old age best approximates lethal suicidal acts. This notion is reinforced by greater clinical and demographic similarity between attempters and suicide victims in older, compared to younger adults (Friedmann and Kohn 2008; De Leo et al. 2001). In summary, attempted suicide in old age is the clinical phenomenon most closely resembling fatal suicidal behavior, thus described as “failed suicide”.
10.2.2 Reattempt, Risk Period
Older adults are more likely to die by suicide within 1 year following a suicide attempt than are younger individuals who made an attempt (Friedmann and Kohn 2008). According to a Finnish study, the first 3 months after hospital discharge represent the highest risk period for reattempts among hospitalized elders (Karvonen et al. 2008). Hawton and Harriss conducted a prospective study investigating repetition of deliberate self-harm and death by suicide in adults aged 60 and older. They followed 730 patients who presented to the hospital after a deliberate self-harm episode for a period of 23 years. Those who had previously attempted suicide were 49 times more likely to die of suicide compared to the demographically similar general population. Nearly three quarters of the sample had high intent during the index episode of self-harm (Hawton and Harriss 2006), which is a greater proportion than found among younger patients.
10.2.3 Age-Specific Diatheses and Stressors
The importance of different vulnerability factors and certain life-events relative to suicidal behavior may change across the life span. Decision-making deficits due to cognitive decline, and in particular poor cognitive control, are more common in old age, while the pathway involving impulsive aggression is more common in young adulthood (McGirr 2008). Bereavement, disability, and pain are often cited as triggering events in old age; in contrast, financial and relationship problems are common motivations in younger age groups.
10.3 Risk Factors Associated with Suicide in the Second Half of Life
10.3.1 Physical Illness
Physical illness and associated disabilities are often cited as motivations for suicide by older suicide attempters, and sometimes mentioned by significant others as a way to rationalize or “understand” the loved ones’ suicide. Indeed, research suggests that physical illness is a frequent precipitant to suicidal behavior in older individuals (Waern et al. 2002b; Duberstein et al. 2004b; Harwood et al. 2006). In a sample of 100 suicide victims who were at least 60 years old, Harwood et al. (2006) found that physical illness was one of the three most frequent life problems associated with suicide, along with interpersonal problems and bereavement. This study also noted that pain, breathlessness, and functional limitation were the most frequent physical symptoms associated with death by suicide in late-life. Similarly, Cattell and Joley found that of the adults aged 65 and older who died by suicide, 43 % used general practitioner services before their death and 23 % had been inpatients in the year preceding their death (Cattell and Jolley 1995). From a prospective study of deliberate self-harm episodes, Hawton and Harriss (2006) identified physical illness as a significant problem in nearly half of the study sample.
Among specific diseases, cancer (Conwell et al. 1990) and diseases associated with breathlessness and pain (Harwood et al. 2006) are the ones most consistently associated with suicide in older adults. Quan et al. (2002) found that cancer, prostate disorders, and chronic pulmonary disease were associated with suicide in the elderly. Waern et al. (2002a) noted that visual impairment, neurological disorders, and malignant disease were associated with increased risk for suicide. Furthermore, using data from 1,354 completed suicides in Ontario, Canada between 1992–2000, Juurlink et al. (2004) found that while many common illnesses—such as congestive heart failure, chronic obstructive lung disease, seizure disorder, urinary incontinence, and moderate to severe pain—were independently associated with an increased risk of suicide in the elderly, the risk was greatest among patients with multiple illnesses.
In contrast to the findings discussed above, an autopsy study conducted by Préville et al. (2005) found no significant difference between health problems reported by suicide victims and controls. However, controls had more functional autonomy than suicide victims had shortly before their deaths.
Physical illness in itself has low predictive value in determining suicide risk, and one should consider other potential vulnerabilities that mediate or accentuate the effect of physical illness on suicidal behavior.
Some studies suggest that gender may play an important role in the extent to which physical illness burden is related to suicidal behavior. Heikkinen and Lonnqvist (1995) found that among victims of suicide aged 60 and older, men had encountered recent somatic illness more often than women. Physical illness may be a stronger risk factor for suicide in men than in women, though it is unclear whether this observation has occurred because studies were underpowered to observe increased suicide risk in women, or because women respond and cope differently to physical illness burden than their male counterparts (Waern et al. 2002b). A psychological autopsy study of late-life suicide victims in which a diagnosis of cancer had played a major role in victims’ decisions to end their lives found that all victims were men with a rigid, self-sufficient personality style who had had prior experience with cancer or other debilitating disease (Conwell et al. 1990). Prior to their deaths, victims had expressed fears about cancer-related physical decline, loss of autonomy, stigma of terminal illness, and a fear of becoming a burden to others. They also had diagnosable affective disorders, but had not received mental health care.
Of additional significance in assessing suicide risk is an individual’s appraisal of his or her disease burden, including the perceived effect it will have on others and the perceived change on the individual’s quality of life. Physical illness could create additional stress for caregivers, reduce functionality, and increase financial strain. Joiner (2002) at al observed that perceived burdensomeness was correlated with suicide attempter status and with the use of more lethal means of suicide, even after controlling for other relevant dimensions such as a desire to control one’s own feelings, a desire to control others, emotional pain, and hopelessness. Suicide risk may be particularly amplified among those who perceive their illness to be progressively worsening or terminal, those who previously witnessed loved ones succumb to the disease, and those who put high value on their independence. Receiving the diagnoses of cancer (Conwell et al. 1990) or AIDS increases the risk of suicide. Two time periods appear to be particularly critical to suicide risk in AIDS patients: when the HIV positive diagnosis is communicated and when cognitive complications first appear (McKegney and O’Dowd 1992).
Duberstein’s case-control study reported that suicidal elderly were more likely to perceive their illness as incurable and were also more likely to require in-home assistance, according to proxy respondents (victims’ next-of-kin). The effect of physical illness remained even after controlling for current psychiatric disorders (Duberstein et al. 2004). Loebel et al. (1991) noted that anticipation of nursing home placement was cited as a precipitating factor in 44 % of persons within their sample who had given reasons for their completed suicides. Research on the hot-cold empathy gap (Loewenstein 2005) suggests that this may be the case because patients are unable to imagine that they will adapt to changing life circumstances and their acute state of fear, anxiety, or pain immediately following an unfavorable diagnosis will not persist. As such, the decision to end one’s life may be state-dependent.
10.3.2 Cognition and Decision-Making
Over the last decade there has been an accumulation of evidence that understanding cognitive deficits and decision processes associated with suicidal behavior and their relationship to other risk factors may help to identify people at risk of suicide, and help to develop individualized treatment strategies. This could be particularly true for older suicidal adults, as accelerated age-related cognitive changes may contribute to the inability to solve problems, and to the ultimate decision to take one’s life.
Suicide is a heterogeneous behavior resulting from a convergence of individual vulnerability, state, and environmental pressures. Although there is strong evidence for developmental factors, in most countries, suicide rates peak in late adulthood. Although most elderly suicide attempters and those who die by suicide suffer from depression, only a minority of depressed elders attempt suicide, and clinicians still cannot confidently identify depressed elderly who are most likely to attempt or die by suicide. In addition, loss, illness, and disability typical of aging contribute only modestly to suicide risk, leaving an open question of what other factors may account for this pattern.
10.3.2.1 Cognitive Aging, Decision Processes, and Suicidal Behavior
It remains unclear to what extent accelerated cognitive aging explains higher suicide rates in older adults (Haw et al. 2009). There may be a certain phase of cognitive decline or a particular cognitive profile that predisposes one to suicidal behavior. For example, a Danish population study found a marked increase in suicide rates in dementia patients after an inpatient admission (Erlangsen et al. 2008). It is likely that age-related neurodegenerative and vascular changes (Alexopoulos et al. 1997; Chan et al. 2007) modify older adults’ vulnerability to suicide. The ability to make cognitively demanding decisions declines in old age even in non-demented elderly (Denburg et al. 2007). Older adults are more likely to be the victims of misleading advertising or other scams, and also make less advantageous decisions in the laboratory than younger individuals (Fein et al. 2007; Brown and Ridderinkhof 2009). This is partly explained by an age-related decline in cognitive control (MacPherson et al. 2002), related to the disproportionate effect of aging on the prefrontal cortex (Raz et al. 2005).
Originally described by Mann (2003), the stress-diathesis model differentiates temporary stressors such as psychosocial strain and mood states from a stable diathesis encompassing heritable impulsive-aggressive traits and hopelessness. An emerging literature suggests that the tendency to make disadvantageous decisions is the link between some aspects of the diathesis and suicidal behavior. Early studies described suicide attempters as poor problem solvers and the suicidal crisis as a state with low-level, concrete thinking, increased impulsivity, and a focus on immediate goals, where consequences of the attempt are not considered. There is increasing evidence to support the view that the suicide diathesis involves cognitive deficits and maladaptive decision-making. Extending the stress-diathesis model, we propose that the trait-like diatheses—impaired cognitive control, deficits in social processing, and impulsivity—are expressed in poor decisions.
10.3.2.2 Decision-Making Biases as a Link Between the Stable Diathesis and the Suicidal Crisis
Providing initial evidence, Jollant and colleagues found impaired decision-making on the Iowa Gambling Task in euthymic younger suicide attempters with mood disorders: suicide attempters failed to switch from high-initial payoff, high-loss options to low-initial payoff, long-term winning options (Jollant et al. 2005). Studies replicated these findings in younger (Bridge et al. 2006) and bipolar (Malloy-Diniz et al. 2009) patients; however, there was a negative report as well (Oldershaw et al. 2009). A similar decision-making task without working memory demands (Cambridge Gambling Task), (Clark et al. 2011) showed decision-making impairment in older suicide attempters compared to depressed non-suicidal and healthy controls. While these findings support the notion of altered decision-making in suicide attempters, the mechanisms of impairment on such a complex task remain unclear.
10.3.2.3 Cognitive Control Deficits and High-Lethality Suicide Attempts
Population studies have linked poor cognitive abilities (Andersson et al. 2008; Gunnell et al. 2011) to suicidal behavior. Deficits in cognitive control represent the most consistent finding in both middle-aged (Keilp et al. 2008, 2001; Marzuk et al. 2005; Raust et al. 2007; Nock et al. 2010) and older (Gujral et al. 2012; McGirr et al. 2012a; Richard-Devantoy et al. 2012) suicide attempters, as well as in euthymic first-degree relatives of suicide victims (McGirr et al. 2012a). Cognitive control is the active maintenance of patterns of activity that represent goals and the means to achieve them (Miller and Cohen 2001). This construct is related to the older term executive function. In the domain of decision-making, cognitive control is required to represent goals and to organize information about rewards, punishments, and available actions. Interference control, measured by the Stroop, appears to be a particularly sensitive index (Richard-Devantoy 2011; Keilp et al. 2013), related to higher lethality of suicide attempts (Keilp et al. 2001, 2013, 2008). One study found a relationship between high-lethality suicide attempts and poor cognitive control, as assessed by the Wisconsin Card Sort (McGirr et al. 2012; Dombrovski et al. 2011, 2013), independent of medication exposure, substance use disorders, and possible brain injury from suicide attempts. It is unclear, however, if these deficits are selective, and whether attention and working memory are also affected (Dougherty et al. 2004; Keilp et al. 2008). Our studies show that a basic deficit in cognitive control, which undermines decision-making in complex environments, is linked to high-lethality suicide attempts. Poor decision-making can result from several distinct decision-making biases, suggesting the existence of different pathways or subgroups en route to suicidal decisions. One of the pathways has been linked to impulsivity.
10.3.2.4 Decision-Making Deficits Related to Impulsivity in Late-Life Suicide
Impulsivity is a complex, multidimensional construct (Klonsky and May 2010; Kirby and Finch 2010; Dougherty et al. 2004). Dougherty and colleagues proposed that impulsivity includes at least three testable components: response initiation prior to complete processing, response inhibition, and myopic choice (Dougherty et al. 2009, 2010). Risk-taking impulsivity is also often considered as a separate component. It is possible that the importance of these components vary across the life-cycle in suicidal individuals, given the larger cooccurrence of substance abuse and conduct disorder in younger compared to older suicide attempters. Using Kirby’s Monetary Choice Questionnaire (Kirby 1997), Dombrovski and colleagues (Dombrovski et al. 2011) found that the preference for immediate reward over larger delayed reward, i.e., myopic choice, differentiated between low lethality (mostly impulsive) and high lethality (mostly premeditated) suicidal acts. The same group also reported that older suicide attempters neglected key information when making decisions (Dombrovski et al. 2013), linking specific decision-making patterns to low-medical lethality, poorly planned attempts (Dombrovski et al. 2011, 2013).
10.3.2.5 Social Cognition and Social Decision-Making
Lack of feeling connected (Duberstein et al. 2004b) and poor social problem solving (Gibbs et al. 2009) have been described in older suicide attempters. However, cognitive substrates of this apparent social impairment in suicide attempters remain unknown. Social cognition (i.e., the encoding, storage, retrieval, and application of social information) is a prerequisite of social understanding and empathy. One possible deficit, the inability to recognize others’ complex emotional states has been observed not only in disorders characterized by prominent social deficits (autism-spectrum disorders and frontotemporal dementia), but also in depression, alcohol dependence, and in normal aging. Szanto and colleagues reported that older suicide attempters committed significantly more errors in social emotion recognition and showed poorer global cognitive performance than elders with no psychiatric history (Szanto et al. 2012). Attempters had restricted social networks: they were less likely to talk to their children, had fewer close friends, and did not engage in volunteer activities, compared to nonsuicidal depressed elders and those with no psychiatric history.
Related posts:
Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD) as Risk Factors for Suicidal Thoughts and Behaviors
Genetic Risk Factors for Suicidal Behavior
Experimental Pharmacologic Approaches for the Reduction of Suicidal Ideation and Behavior
Psychotherapeutic Treatment Approaches for Suicidal Individuals
Animal Models of Risk Factors for Suicidal Ideation and Behaviour
Treatment Emergent Suicidal Ideation and Behavior
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
