Forget me not: preventing suicide among the elderly

Some see the ageing population as a burden on the health system. xavi talleda/flickr

With public attention firmly focused on the increase in the suicide rate among people under the age of 35 in the last 20 years, few people are aware that those aged 75 years and over, particularly males, remain at very high risk.

The Senate Community Affairs Reference Committee reported on their inquiry into Suicide in Australia last year with a particular focus on youth and younger adults.

This continued the trend, since the 1990s, of Australian political inquiries into suicide focusing on younger age groups without regard to older people.

Yet over the century of official suicide statistics in Australia, suicides have predominantly occurred in older people.

In fact, worldwide, suicide rates are highest in this age group, being approximately three times higher than in people under 25.

Why then is so little attention paid to suicide in older age groups?

Perhaps some believe that older suicides are “rational” - akin to euthanasia in a society in which euthanasia has no legal standing.

Maybe they feel the issue is best left undisturbed rather than stirring up the inevitable ethical debates that would ensue.

Research into late-life suicide using psychological autopsies in which as much information as possible is gleaned from relatives, friends and health professionals about the suicide victim has found the majority of suicides in old age were suffering serious mental disorders, particularly depression.

These disorders were either untreated or the victim had an inadequate response to proffered treatment.

On the surface, this sounds like a similar situation to other age groups and so one might ask why anything different is required for suicide prevention in old age.

The answer is simple; the outcome might be the same across the age ranges, but the journeys individuals of different ages take to get there are quite different.

If we are to prevent suicide, we must understand the nuances of these journeys - what they mean to the individuals who are on them, what is sought as an alternative to death.

There are age-related reasons for mental disorders. In old age, common reasons include pain and discomfort associated with physical illnesses, loss of independence, social isolation and loneliness, and a diminishing circle of family and friends.

These are often issues that need to be addressed to alleviate suffering and reduce suicide risk.

Of course, only a small minority of depressed older people will become suicidal in such circumstances.

Those who are vulnerable include individuals with adverse early childhood experiences, such as abuse, neglect, and trauma, who have had life-long difficulties in establishing meaningful relationships, and are chronic abusers of drugs and alcohol.

An exemplar of this type of situation is a 75-year-old divorced man who is a heavy drinker and smoker, and has become increasingly housebound, anxious and depressed due to emphysema. Typically, such as person has few friends and no family support.

But just because the suicidal preoccupation of an older person is understandable does not mean that it is rational or immutable.

Very few late-life suicides occur in circumstances that could be interpreted as rational but most are understandable and amenable to change providing the underlying issues are adequately addressed.

But this knowledge about suicide in old age is nothing new because research worldwide has repeatedly shown this for over 20 years. So why is this message not filtering through into the broader community?

There are many myths about ageing in our society and one of them involves the belief that late-life is a period of increasing demoralization, depression and suffering.

Research, however, consistently shows that for the majority of older people, late life is the life stage of greatest contentment and happiness.

It is not normal to be depressed in old age – and yet too often family, friends and health professionals believe that it is normal and that nothing can, or indeed should, be done about it.

Psychological autopsy research has found poor communication between families and doctors can contribute to a failure to identify suicide risk.

Families either presume the doctor was aware of suicidal preoccupation or decide for whatever other reason not to disclose risk concerns to the doctor.

In other situations, health professionals either fail to inform families about their concerns of risk or fail to ask families if they have any such concerns.

At times, ageist attitudes contribute to these views. Instead of being seen to be a testimony to improvements in lifestyle and health care, our ageing population is perceived as a burden on our health and welfare systems.

So when a depressed older person states they want to end their life because they no longer want to be a burden, it may appear natural to agree.

It is not known how often suicides are under-reported in late life with doctors recording deaths in frail elderly as due to natural causes to avoid stigma for families and possibly - in some circumstances - to cover up assisted suicides.

An overall strategy to prevent suicide in late life needs to be embedded in a ‘Healthy Ageing’ strategy for the whole population.

Any approach that will improve the health of people in old age will be consistent with reducing late life suicide.

Other strategies could focus on those at high risk, such as older people with chronic pain, socially isolated migrants and rural elders, older persons with a history of depression, older persons recently diagnosed with life-threatening illnesses such as cancer or dementia.

This could be done by training gate keepers, such as community nurses, clergy, social workers and ambulance officers, about the risk and ways of reducing it.

Finally, the detection of depression and suicide risk in older individuals requires more training of general practitioners and other health professionals in identifying potentially high-risk individuals.

Just as importantly, they need to know how better to treat depression and other types of suffering in these identified individuals. Such training should emphasize the importance of communication with family and close friends.

The challenge for clinicians, family and friends of older people who are suffering, be it from pain and discomforts, or loneliness and demoralization, or with feelings of hopelessness and uselessness, is to find a way to relieve the suffering.

Of course adequate treatment of a clinical depression is essential, but it’s just as important to give people a reason to live.

It might be a seemingly simple thing – someone to talk to, relief from physical pain, or an air conditioner to ease breathing difficulties in a hot humid summer – but this might make all the difference between wanting to live and wanting to die.

** Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or SANE Helpline on 1800 18 SANE (7263).