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Dwivedi Y, editor. The Neurobiological Basis of Suicide. Boca Raton (FL): CRC Press/Taylor & Francis; 2012.
17.1. INTRODUCTION
Suicide in late life merits special attention for many reasons. Epidemiologically, one of the groups most at-risk for suicide is older adults. It has long been recognized that in the United States, elderly white males have the highest suicide rates. In a review published by Hawton and van Heeringen, it was noted that suicide rates are also highest in the elderly in most countries around the world [1]. The elderly are not only a vulnerable population, but suicide has a more severe impact in this demographic group. For example, one study showed that suicide in late life tends to be associated with less warning and more lethality compared to attempts in younger populations [2]. This has also been shown in a study demonstrating that elderly suicide victims are more likely to have more serious intent with less warning [3]. These epidemiological studies highlight the importance of understanding suicide in late life. Thus, a small but prolific number of researchers have examined why the prevalence of suicide is higher in the elderly. Crucial to this understanding of suicidality in the elderly is the identification of risk factors for proper evaluation and intervention.
17.2. RISK FACTORS
The identification of suicide risk factors in late life has been greatly enhanced by the use of psychological autopsy. These studies attempt to identify differences between populations that have committed suicide or present with suicidality compared to control groups. Additionally, these studies comparing demographic and clinical features of suicide attempters versus age-matched controls have shown great utility in identifying factors that increase the risk of suicide in the elderly. In a Swedish study by Wiktorsson et al., suicide attempters 70 years of age or older tended to be unmarried, have a low education level, live alone, have a history of psychiatric illness, and have a history of a previous attempt [4]. This study highlights both the sociodemographic and clinical risk factors that have identified in a number of studies.
17.2.1. Sociodemographic Factors
Age and gender differences in suicidal ideation, attempts, and attempt lethality have all been identified in the elderly. It has been shown that even among men 50 years of age and older, men 70 years of age and older have higher attempt lethality than those younger than 70 years, while women older than 69 years had lower attempt lethality compared to younger women. The increase in lethality appeared to be driven by increased levels of intent [5]. In a British survey by Harwood et al., the authors reviewed suicides by individuals 60 years of age and older. In their study, men represented 67.7% of cases and the most common means for men was hanging, while it was overdose in women [6]. These studies reflect that males have higher and more lethal means of suicide compared to their female counter parts.
As would be expected, socioeconomic status is an important variable influencing suicidality in the elderly. It has been shown that lower socioeconomic status has been a risk factor for suicide in the elderly [7].
Other sociodemographic factors such as marital status are important risk factors for suicide. Loss of a spouse has been shown to be a risk factor [8]. However, there are particular features of bereavement that correspond to increased suicidality. For example, elderly subjects who rate high on scales of complicated bereavement are more likely to have suicidal ideation compared to lower scoring subjects [9]. The effect of losing a spouse demonstrates the important buffering effect of social relationships. This is also highlighted in a study showing that lower levels of perceived social support are also associated with suicidal ideation [10,11].
17.2.2. Clinical Risk Factors
There has been extensive work looking at mood disorders as a risk factor for suicide in the elderly. A study of completed suicides of patients who had visited a primary care practice within 30 days of suicide compared to control subjects demonstrated that suicide victims had higher levels of depressive illness, physical illness, and functional limitations [12]. In a survey of home health-care utilizers, suicide victims were more likely to have depressed mood, alcohol dependence, chronic pain, lack of social supports, and financial difficulties compared to controls [13]. There is also evidence that even subclinical depressive symptoms can increase the risk of suicide. In a Taiwanese study by Liu and Chiu, elderly patients who attempted suicide had significantly higher scores on the Brief Symptom Rating Scale compared to control subjects [14]. Suicidality also impacts how well mood disorders are treated. In a study by Szanto et al., elderly depressed subjects with suicidality were harder to treat, evidenced by higher relapse rates [15]. In addition to mood disorders, schizophrenia has been associated with increased suicidality in older patients. According to a study by Cohen et al., schizophrenic patients had higher prevalence of suicidal thinking and suicidal attempts compared to control subjects [16].
The presence of Axis II disorders is also a risk factor for suicide. In a study by Heisel et al., narcissistic personality disorder or trait was associated with increased risk of suicidality in later life [17]. Other personality characteristics such as neuroticism have also been associated with increased suicidal ideation [18]. While personality traits associated with suicidality offer limited opportunities for intervention, they are key to identifying at-risk patients.
In addition to the expected association of psychiatric illness and suicidality in the elderly, a number of studies have shown that medical illnesses are key risk factors. In a Finnish study identifying psychosocial stressors as antecedents to suicide in the elderly compared to younger suicide victims, the authors found that elderly suicide victims were more likely to have somatic illness as a stressor compared to loss, financial difficulties, and occupational issues [19]. One of the first studies to examine the impact of medical comorbidities found that a diagnosis of cancer played a large role in the decision to commit suicide [20]. Stroke risk measured by Cerebrovascular Risk Factor (CVRF) is higher in suicides compared to controls [21]. In conjunction with medical comorbidities, polypharmacy and medications can serve as additional risk factors. This was demonstrated by one study that showed the use of sedatives and hypnotics was associated with an increased suicide risk in the elderly [22]. Thus, medical illnesses and its associated complications can be very important factors in suicidality, particularly in the elderly.
17.2.3. Neurobiological Factors
While postmortem studies have been used extensively to understand neuropathological correlates of suicide in younger populations, there has not been extensive study focused on elderly samples. However, there have been attempts to understand the neuroendocrine and neurocognitive correlates of suicidality in the elderly. For example, HPA axis dysregulation has been associated with increased suicide risk. In a longitudinal study by Jokinen and Nordstrom, elderly depressed patients who went on to commit suicide all failed the dexamethasone suppression test [23]. Cognitive impairment has been associated with increased passive and active suicidal ideation in the elderly [24]. More specifically, impairment in executive function, memory, and attention was associated with suicidal ideation [25]. The cognitive impairments have also been linked to poor decision making seen in suicidality. In a paper by Dombrovski et al., elderly suicide attempters had impaired reward/punishment learning characterized by inability to learn from past experience [26].
17.3. EVALUATION
Proper evaluation for suicidality in the elderly depends on effective identification of the aforementioned risk factors. To assess these risk factors, several screening tools have been discussed in the literature. Typically, these screening instruments have been used for the assessment of mood disorders, particularly major depressive disorder. The Hamilton Rating Scale for Depression has a suicidality question with answers ranging from feeling like life is not worth living to previous suicide attempts [27]. Another screening tool that addresses suicidality is the Beck Depression Inventory, a self-administered questionnaire that asks specifically about suicidal thoughts [28]. For the geriatric population, the Geriatric Depression Scale (GDS) has been developed. While it is thought to be limited in that there are no specific questions to address suicidality, a study by Cheng et al. found that the GDS could accurately detect suicidal ideation, particularly in the “old–old,” aged 75 and older [29]. Also, it has been demonstrated that the GDS can detect degree of suicidality as well [30].
There have been efforts to develop more specific suicide assessments that can be used in the primary care setting. For example, the “SLAP” interview protocol involves follow-up questions after a patient expresses suicidal ideation. SLAP is an acronym for specificity of the suicide plan, lethality of the means, availability of the means, and proximity of rescuers [31].
17.4. INTERVENTION/PREVENTION
The identification of risk factors facilitates the development of prevention measures to mitigate the likelihood of suicide attempts in the elderly. A number of these measures have been studied extensively in the literature. An important aspect of these intervention/prevention measures is the setting in which they take place. There are many different settings where prevention efforts for suicide should and can occur. Mental health settings are common locations for suicide assessment. Patients are typically assessed for suicidality as part of a standard evaluation. Unfortunately, large number of elderly patients in need of a psychiatric assessment will not utilize these facilities [32]. Instead, primary care settings are an important focal point of contact for a suicidal elderly patient. According to a number of studies cited by Conwell and Duberstein, within 30 days of committing suicide, up to 76% of patients had contact with a primary care provider [33]. In addition, some of the risk factors for suicidality are ideally detected in this setting, such as chronic medical illnesses or functional impairment. This has been highlighted in several studies. One of the ways to prevent late-life suicides that has been best characterized in the literature is effective treatment of late-life depression. The PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study showed significant reductions in suicidal ideation when tailored treatment guidelines were used in a primary care setting compared to treatment as usual [34]. In another trial in a primary care setting called the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) study, Unutzer et al. lowered suicidal ideation as early as 6 months and as late as 24 months after an intervention involving Problem Solving Treatment [35].
Another important setting is residential communities, which include independent living facilities, assisted living facilities, and long-term care facilities. In a paper by Podgorski et al., the authors describe approaches to suicide prevention in these communities focusing on at-risk groups and whole populations [36]. “At-risk” approaches focus on targeting individuals who possess risk factors such as mood disorders, functional impairment, and medical illness with programs that include referral for treatment, assessments for suicidality, and reducing stigma. Whole population approaches address issues such as coping, promoting social networks, decreasing access to lethal means, and promoting engagement in positive activities. An example of this last approach was demonstrated in a study by Oyama et al. who used an intervention involving group activities to lower suicide rates in elderly women from a community-based sample [37]. These studies suggest that targeted interventions that address specific risk factors in a variety of settings provide the best outcomes in reducing suicidal ideation and suicide attempts.
17.5. CONCLUSION
Given the changing demographics across the globe, suicide in the elderly is a major public health issue. Suicide in the elderly is characterized by particular challenges in identifying risk factors, evaluating suicidality in the context of these risk factors, and developing targeting interventions designed to meet the specific issues dealt with in late life. In addition to the detecting risk factors and formulating interventions, there is much more work to be done in identifying specific neurobiological substrates of suicidality in the elderly. In particular, there is a dearth of research using postmortem analyses with a focus on elderly samples either from autopsy or from subjects followed prospectively. This is particularly important since the profile of molecular targets identified as altered in suicidal patients may be different in the elderly subjects.
In this chapter, we have also discussed studies using cognitive neuroscience to understand impaired decision making in suicidal elderly subjects. This fascinating work in neurocognitive assessments demonstrates specific cognitive dysfunction associated with suicidal ideation and provides the foundation for future work in neuroimaging and neuropathology.
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