Practical Geriatrics: Completed Suicide in Late Life

In addition to age, gender and ethnicity are influential variables. The rate of suicide for women plateaus or decreases slightly after peaking around age 60 (3). A possible reason for the lower suicide rate among elderly women is their wider social network compared with men's, and their lower rate of suicide may also reflect their less frequent use of lethal means, especially firearms (9), although this may be changing (10).

Race is also associated with the incidence and prevalence of completed suicides. The rate of suicide in the Caucasian group markedly outweighs rates in other groups, although a rise in the rate of suicide by black males has begun to appear (4). In 1998 4,655 Caucasian men aged 65 years or older died by suicide (33.1 per 100,000), and 132 African-American men did so (11.7 per 100,000). A closer analysis of rates by age, gender, and ethnicity delivers small enough numbers that the results are considered unreliable.

How aging is experienced varies from person to person, with individuals reacting differently to the impact of loss and bereavement, physical illness, changes in psychosocial roles, diminution of income, and other factors.

The increasing social isolation believed to be an inevitable concomitant of advancing age has been thought to be a contributing factor to the rising rate of suicide as age increases, although this is still not established (11). Widowhood among men, but not among women, appears to carry particular risks, and the corollary also appears to be the case—marriage confers a protective effect against suicide. Loss or separation in early life could be a mediating influence on suicide by bereaved persons after the death of a spouse (12). Social support as perceived by the individual does not always correspond with objectively measured support, with depression and hopelessness being determinants of how such support is experienced (13).

Murder of a spouse or partner followed by the perpetrator's suicide has recently received research attention (14). On the basis of a series of cases, the incidence is estimated at 1,000 to 1,500 cases per year (14). The authors suggested a relationship typology in which most perpetrators are of the dependent-protective type and the others are divided among aggressive and mutually dependent, symbiotic types.

Age is accompanied by an increase in the degree of suicidal intent and, consequently, mortality. This observation is based on the fact that the ratio of completed to attempted suicide is higher for persons aged 65 years or older than for any other age group and especially so for elderly men. The methods employed contribute to the relationship of age with the dangerousness of the suicidal act, with men more prone to using firearms (9).

The association between physical illness and suicide is especially marked among the elderly (15). One study found a specific association between visual impairment, neurologic disease, and malignant illness with suicide, and the association was especially marked in men (16). However, the role that terminal illness plays in suicide is controversial. Although it is commonly believed that terminal illness, especially when accompanied by pain and the loss of independence and hope, provides grounds for suicidality, several investigators have not found this to be the case. Conwell and Caine (17) found that only one person among 85 persons of all ages who completed suicide had a terminal illness. There is evidence that the link between physical illness and suicide is mediated by depression and hopelessness (18). Because much illness during old age is of a chronic nature, expectations of admission to long-term care may arise, and this anticipation appears to be a factor associated with completed suicide among the elderly (19). However, admission to a long-term care facility is no guarantee that the risk of suicide has passed (20).

An extensive array of investigations has established that it is depression, usually unipolar, and to a much lesser extent alcohol abuse that are the most common axis I diagnoses associated with completed suicide among the elderly (21).

Also, a body of evidence is growing concerning the contribution of personality to completed suicide among the elderly. Efforts to apply the available axis II framework have not been very fruitful. Recently, however, the construct of "openness to experience" has been found useful in typifying the personality of elderly persons who commit suicide (22). This personality is characterized by such terms as "constricted," "shut in," and "[showing] diminished affective intensity, preference for the familiar (that is, find change very stressful)" (22). Pearson and Brown (23) suggested that "the personality characteristics of the majority of elderly male suicides include the appearance of being overly strong and self-sufficient, having difficulty with being dependent and accepting help, and [having] a rigid, inflexible coping style, similar to a lack of openness to new experience."

Numerous investigations have found that suicidal elderly people have frequently consulted medical services, usually a primary care physician, shortly before the suicidal act, sometimes in the last few days or hours before the suicidal act (5). Also, the diagnosis of depression and suicidal intent is infrequently made among the elderly (24,25). One investigation found that 41 percent of 1,397 persons who committed suicide had contact with a health care professional within 28 days of death, 47 percent within one week, and 18 percent on the day of death. Suicidal intent was discussed in only 22 percent of these meetings (26).

Several initiatives have been started in order to improve the situation pertaining to primary care (27,28). The Prevention of Suicide in Primary Care Elderly: Collaborative Trial provided depression screening of randomly selected patients aged over 60 years who were being seen in 20 primary care practices in three cities. In certain cases intervention consisting of psychopharmacologic treatment and psychotherapy was more rapidly successful in reducing the Hamilton Depression Rating Scale score and suicidal ideation than in the control group, which received customary care.