MANAGEMENT OF SUICIDAL BEHAVIOR IN THE ELDERLY

Abstract

Suicidal behavior is more lethal in the elderly than among younger age groups; therefore, its management must be by prevention. Data from the Epidemiologic Catchment Area study, a landmark survey of the incidence and prevalence of psychopathologic conditions in the United States, found that persons more than 65 years of age were less likely ever to have made a suicide attempt than younger adults.52 Yet rates of completed suicide are higher in late life than at any other point in the life course.53 As a result, the ratio of attempted to completed suicides decreases dramatically with age from as high as 200:1 in young adulthood to 4:1 in the elderly.57 Many factors may explain the increased lethality of self-destructive behaviors in older people. They are frailer, subject to acute and chronic diseases, and have fewer physical reserves. They may be less likely than younger, healthier people to survive self-damaging acts. Older Americans are more isolated than younger adults and adolescents, less likely to be discovered in time to minimize the morbidity and mortality rates of a suicide attempt. Finally, data suggest that older suicidal people act with greater determination to die. They give fewer warnings to others of their suicidal plans, 10 use more violent and potentially deadly methods to commit suicide than do younger people, 48 and apply those methods with greater planning and resolve.15 Once initiated, the suicidal acts of older people are likely to be deadly. Because of the greater malignancy of their self-destructive behaviors, it is that much more important that elders at risk be identified prior to development of the suicidal crisis. This article considers interventions to limit the morbidity and mortality rates of late-life suicide from a preventive medicine framework. It is a fundamental precept that the effectiveness of a prevention measure depends on the identification of risk factors for the disease, the strength of the causal relationships between the risk factors and the disease, and the “alterability” of those risk factors.30 First the existing literature on risk factors for suicide among the elderly is reviewed. The focus is on studies of completed suicide, as they are likely to represent most accurately the targeted group of elders at greatest risk for suicide morbidity and mortality. Then we consider the implications of these risk factors for primary and secondary prevention, emphasizing interventions in the community and primary care medical settings.