Aging Critical Issue in Aging

Suicide Rates Among Geriatric Persons

The causes of death among the elderly are traditionally associated with the normal aging process or what would be called natural process, diseases associated with age and the debilitations it can cause. Yet, other factors also contribute to the cause of death an individual might succumb to, widowhood, retirement, forced relocation, and/or loneliness especially around the holidays. (Huyck Hoyer 1982) Still other studies are making it clear that murder and suicide rates are increasing dramatically among the elderly. (cf., Birren, Schaie, 1977) (Nussbaum, Pecchioni, Robinson & Thompson, 2000, p. 294) Suicide was the eleventh leading cause of death among persons over the age of 65 in 1982. (Riley, 1983, p. 144) Some strides have been made and between the years 1983 and 1998 suicide averaged as the fourteenth leading cause of death for persons over the age of 65, lower than the average for all ages over those same years. (Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC, 2001) When looking at this particular statistic consideration must be made for the increased incidence of disease among the over 65 population. The reality of which skews the comparison considerably.

In assessing the needs of any elderly population and community ability to assist them, on the issue of risk for suicide, the population at high risk can be seen as falling into three general categories. All of these categories increase risk of depression often a precursor to suicide. Depression and suicide risk factors are particularly evident in the geriatric population.

The first category being those persons who have had a recent loss, usually the death of a spouse or child but could also be a loss like a home or possessions:

There had been considerable research on the effects of loss of spouse in old age, especially through widowhood. Studies have found that persons without a spouse have lower morale (Gurin et al., 1960; Kutner, 1956), have lower incomes (U.S. Census), have higher rates of institutionalization (Palmore, 1976b), and higher mortality and suicide rates. (Palmore, 1981, p. 79)

This sort of depression is normal in association with the natural grief process associated with loss and only becomes problematic when prolonged to a degree that it significantly impairs the individual's quality of life. It then becomes clinically necessary to treat and treatment is especially necessary when that individual shows suicidal tendencies.

The second general category is people who have just received an unpleasant medical diagnosis, a terminal diagnosis or a debilitating chronic diagnosis. Impending issues of dependency or chronic physical discomfort or pain are significant factors in this category. The chances for the occurrence of such diagnoses naturally increase as one ages. Once again this depression linked to a life event is normal and does not become abnormal until the time that it affects the person's quality of life.

The third category is a category that includes the group who might be more closely associated with true clinical depression, regardless of other environmental factors they seem to feel a general lack of usefulness or purpose that elicits feelings of depression and could result in higher risk for suicidal thoughts or actions. "Organically-based major depression, also referred to as primary depression, results from various biological and chemical changes in the brain and nervous systems or from changes in the endocrine system." (Osgood, Brant & Lipman, 1991, p. 101)

Recent investigations of mental illness after the age of sixty have reemphasized the close link between depressive illness and old age, and recent psychiatric studies of cases of attempted suicide have also demonstrated the significance of depressive illness as the common setting of suicidal acts in this age group. At all ages, both individual and social factors contribute to the genesis of suicide. In old age, individual factors are the more important, and mental illness of a clearly recognizable kind plays a leading role. (Menninger, 1957, p. 144) person suffering form organic depression would nearly always benefit from mental health treatment but once again it becomes imperative under conditions of severer life impairment.

IR.C. Batchelor, M.B., D.P.M., F.R.C.P.Ed Physician Superintendent, Dundee Royal Mental Hospital; Lecturer in Clinical Psychiatry, University of St. Andrews, Scotland in his contributing chapter "Suicide in Old Age" of the book Clues to Suicide can answer the question of the necessity of this study. In this chapter Batchelor discusses the possible layman dismissal of the aged as a population at high risk for suicide. Conjecturing that an uninformed person might think that the elderly are less likely to commit an act of such a rash nature.

Yet the facts are that, in many countries of Western civilization, suicide is relatively more common in the higher age groups, and with the exception of extreme old age, it becomes a progressively more frequent reaction both in men and women, as they grow older. Male and female attempted suicide and suicide rates vary according to the culture in which the individual lives, but there appears to be a general tendency in old age for male rates for suicidal acts to be higher. As the proportion of old people in our communities becomes larger, suicide among them is likely to become an increasing medical and social problem. (Menninger, 1957, p. 143)

The target population in this assessment will be the residents of an assisted living facility as well as individuals who use the services of a home assistance agency. Neither population requires outside assistance for personal physical care but only requires assistance for specific activities of daily living. These needs include but are not limited to, meal planning and preparation, general house keeping duties such as a weekly maid service might provide, they also require assistance with household maintenance and general upkeep. All of these services have a twofold purpose in an assisted living environment and in a home assistance situation, they prove that the individual has made a decision to remain independent of family for these daily needs and/or that the individuals family is unwilling or unable to provide them. Additionally the combined results of these group study choices both those living at home with assistance and those living in an assisted living facility is not necessarily to compare and contrast the two environments but to eliminate the soft constraint associated with the true differences in the availability of social interaction, which has been shown to greatly increase or decrease signs and symptoms of depression in a significant way. This social contact theory has been a commonly suspected source of general unhappiness associated with some elderly persons and has recently begun to be studied in a significant way. One set of theories associated with it is:

The prevalent decremental model of aging (N. Coupland & J. Coupland, Chapter 3, this volume) that predicts decline in sensory, mobility, and cognitive thresholds of ability, with ensuing problems in interpersonal communication resulting in isolation from social interaction and increasing social distance from younger people. Written from a sociological-critical theory perspective, a theme of power and powerlessness can be traced through this chapter. (Nussbaum & Coupland, 1995, p. 2)

There are several other theories associated with this model and some theorists like Hepworth (see below) that associate the theoretical and real decline of the above mentioned factors with a feeling of powerlessness:

In relation to depictions of elderly communicative powerlessness, Hepworth makes reference to social exchange theory, which captures the belief that the older person becomes costly to interact with (see also Bourdieu, 1991). The perceived costliness of communicating with older people might lead to avoidance and marginalization, or to deindividualization (see also Harwood, Giles, & Ryan, Chapter 5, this volume). (Nussbaum & Coupland, 1995, p. 2)

Hepworth points out that the young person's assumption of cost related to interaction with the elderly person has more to do with their own perceptions of the social norms regarding elderly needs. Regardless of the theory or theories used to understand this decline and also the associated decline in general feelings of well being that might be a precursor to depression and/or suicidal behavior, there is strong evidence that these factors of social isolation do significantly effect the geriatric population.

Goals for such a study would be to determine the risk level of elderly individuals in The target population for suicide attempts, in an attempt to help similar populations obtain more timely access to mental health treatment and possibly prevent the increase in incidents of suicide among the elderly. The relative weights for such a study would be a statistical decrease in the number of suicides and suicidal thoughts among the test population and hopefully a broader result from a better understanding.

There will be a set of constraints that are inherent to the process. The first constraint lies in the assessment process. Self-assessment is inherently a weak developmental tool as individuals might misrepresent information based on known or unknown falsehoods. The type of assessment tool used would be a self-report tool that consisted of a questionnaire to be administered in the assisted living facility by an MSW and in the home setting the individual social worker or care provider who assesses the needs of the client. The questionnaire shall consist of questions regarding general welfare and general feelings of contentment vs. dissatisfaction in relation to services being provided, family involvement, independence, and general health. I will model the questionnaire on that performed by Lawton in 1984:

The most detailed attempt to differentiate aspects of subjective well being was made by Lawton (1984) who administered a large number of questionnaires for different scales to 285 U.S. subjects. Two general factors emerged, which Lawton argued represented interior well-being, including self-esteem, satisfaction with past life and positive attitudes to present health, and exterior well-being, including satisfaction with accommodation and social contacts. (Coleman, 1995, p. 56)

Additionally for the needs of this study there will be a standardized diagnostic questionnaire for depression which will include an in depth question about suicide.

1. Have you contemplated suicide in the last year, yes or no, and if so:

on how many occasions did you contemplate suicide?

A were your thoughts fleeting or concrete e.g. did you contemplate ways in which you could take your own life?

I do you feel that these thoughts are severe enough for you to need assistance from a mental health professional in this matter?

A follow up assessment will be administered to the same individuals wherever possible to determine if their general mental state has improved and if they feel they are better informed about the issues surrounding depression and suicide.

There are normal constraints associated with self-assessment tools and there is also some evidence of special consideration with elderly individuals:

Most research involves self-assessment: Self-reports are subject to certain problems including social desirability, memory distortions, and cognitive biases. There is some evidence that increasing age is associated with a tendency to give conventional or socially desirable responses to questions (Spanier & Cole, 1975). (Mares & Fitzpatrick, 1995, p. 186)

This tendency among the elderly to answer questions to please the questioner is a hard constraint and the only possible solution is careful creation and administration of the assessment tool. Patients must be informed that the answers to the questions will be anonymous and unknown to the facility or organization administering the assessment. The actual care facility and the home assistance company will receive only completed statistical findings upon publication. Patients should be informed that if they wish to follow up their assessment with questions about the process or a counseling referral that they may do so by calling a telephone number provided by the administering agency on the signed consent form provided before the assessment.

Other normative constraints would be associated with the ability to administer the assessment to a large enough test group to show a significant statistical result over a five-year period. Though the suicide is the 14th leading cause of death among the elderly the actual numbers of incidence might not be significant enough to provide a true statistical tool for evaluation. This possible constraint can be dealt with by lengthening the actual total time that the test as a whole is performed as a way to increase the number of assessments garnered from the test population or by increasing the number of locations studied with the same result.

With this information the needs of the target group will become more apparent. As the research shows the needs of this particular group are particularly strong in the areas of acceptance and communication. The recognition of a mental health problem such as depression and/or suicidal thoughts is crucial to an individual or family attaining effective treatment in time. Additionally the systems in place presently must continue to expand to provide greater access to care.

Achieving this goal is more easily said than done. Problems arising in the interaction of physical and mental symptoms, in developing mental illness in old age or growing old with mental illness, and in addressing elder depression, anxiety, and substance abuse all highlight issues associated with recognition. (Holstein & McCurdy, 1999, p. 174)

The target population of this assessment fall into a category of individuals who by some standards have better access to mental health treatment than do clients who have little to no repeated contact with the health care system and especially contact with a system that is tuned to the needs of a geriatric population.

Of the two groups addressed the individuals still residing at home would again be at greater risk for lack of access to mental health treatment or even awareness of the severity of their symptoms. Once again this is associated with the general lesser opportunity for frequent social interactions. Symptoms of depression are often long-term, causing some individuals who are suffering from organic and/or situational depression to become accustomed to the symptoms and the subsequent lifestyle change. Occasionally, in a worst-case scenario an individual and his or her family may actually believe that their suffering is a normal aspect of the aging process, unaware that there are reasonable and effective treatments for this condition. Depression is often marked by an inability to evaluate ones self in a realistic manner.

Yet as a group the target population has some advantages to access. The first as I pointed out previously is the mere exposure to a health care system tuned to their needs. Furthermore, clients of services such as an assisted living facilities or home assistance agencies are often served on a long-term basis. This length of service allows repeated points of contact for comparison and assessment of general mental health. Home assistance agencies often have contact information for family and other concerned persons who can be made aware of a possible problem and help the individual attain access to mental health treatment.

Assisted living facilities often employ trained health care professionals both nurses and social workers that assist clients with the transitions of relocation including everything from address changes to medication administration. The staff is often trained to observe and intervene when an individual has a dramatic change in the level of care required. Like home assistance agencies they are also usually in contact with family and/or other concerned persons who might assist the client with access to mental health treatment.

The one factor above all others in regards to the advantages of clients of these two types of services in the socioeconomic status they often represent. Access to either service, regardless of subsidies that are often available, especially to assisted living residents requires the economic ability to retain such services in the first place. This factor plays heavily into the ability for any person to obtain access to needed health care, be it treatment for depression or any other health care need. These clients often carry health care insurance that covers health care needs to a large degree and shelters personal assets as well as those of their family, from the average health care expenditures that sometimes grow exponentially with age. The individual may not be someone who would be considered wealthy but they are lacking nothing of their basic needs and would not be in danger of doing so if they were to have a health catastrophe. Yet, the issue of financial well-being may also be a double edged sword for the target population because:

Changes of home and removal from friends and associations are often poorly tolerated in old age. Those who have lost much in social status, financially or otherwise, particularly if the blow has been sudden and unexpected, are more likely to commit suicide than those who have always been used to little. (Menninger, 1957, p. 147)