Elderly individuals account for a significant proportion of death by suicide in the United States. Recent statistics from the Centers for Disease Control (CDC) indicated that 14.6 persons per 100,000 aged 65 years or older died by suicide, with the highest risk group being males aged 85 years or older. Within that group, the rate of suicide was 51 per 100,000. Although the overall suicide rate in the elderly population has slightly decreased since 1999 (15.9 per 100,000), nonetheless, death by suicide remains a significant concern.

Factors Associated with Suicide

The majority of suicides occur within the context of a mood disorder with the remainder related to some form of psychiatric disorder including substance abuse, personality pathology, or schizophrenia. In the general population, risk factors for suicide include living in a rural area, owning firearms, and unemployment. For elderly adults, the risk factors vary based on age- and health-related issues. Table 72-1 outlines the risk factors for suicide as well as protective factors that may decrease the possibility of suicidality in elderly patients. With relation to depressive episodes, there is inconclusive evidence discerning between whether late onset (after age 60 years) or early onset, or prior or current depressive episodes are associated with increased risk.

Suicide is a complex construct with both biological and psychological etiologic factors. While there is limited information regarding biological components of suicide, the serotonergic system has consistently been implicated in suicide through mechanisms separate from affective disorders. Hydroxyindoleacetic acid, a serotonin metabolite, is significantly associated with suicide. Lower concentrations of hydroxyindoleacetic acid have been found to correlate strongly with suicide lethality, that is, patients with lower concentrations of hydroxyindoleacetic acid have been found to make more lethal suicide attempts. Regarding serotonin receptors, there tends to be an abnormality in the prefrontal cortex of patients who completed suicide, as evidenced by decreased presynaptic serotonin transporter sites. Also, compared to patients with no suicidal tendencies, patients with suicidal tendencies have increased serotonergic neurons in the dorsal raphe nucleus. The noradrenergic system has also been implicated in suicide, with research showing high noradrenalin levels in the prefrontal cortex and lower levels in the brainstem. In examining the dopaminergic system, while it has been found to be abnormal in patients with depression, there is too little research to conclude its association with suicide. Thus, research is required to further elucidate the psychiatric contributions to suicide as well as understand the connectivity between psychological, biological, and social factors.

Evaluation and Assessment

Evaluating and assessing suicide may be difficult in geriatric patients, as they may be prone to not discuss those feelings and thoughts. As such, the role of the clinician is to form a strong, trusting bond with the patient in order to comprehensively assess suicidal ideation, intent, and plan of action. The evaluation is an integral part of the treatment process, as it opens up discussion between the patient and clinician, thereby allowing prevention through decreasing access to available means of suicide, building trust, facilitating a supportive therapeutic relationship, and tailoring treatment interventions.

To increase the reliability of the interview, structured suicidal assessment scales can be used. A commonly used scale is the Scale for Suicide Ideation, which is a 19-item clinician-rated measure that assesses suicidal thoughts and behaviors for the prior 7 days and for the worst points in life as determined by the patient. The Scale for Suicide Ideation thoroughly measures many components of suicide, including suicidal plan, behavior, preparation for attempt, and anticipation of attempt. Also, a recent scale developed specifically for use in an elderly population is the Geriatric Suicide Ideation Scale. The Geriatric Suicide Ideation Scale is a 66-item multidimensional measure of suicide in geriatric patients, which assesses four factors including suicide ideation, death ideation, loss of personal and social worth, and perceived meaning of life. This measure will require further study given its newness, but, thus far, it has strong psychometric properties, is easy to administer, has standardized administration and scoring procedures, and is sensitive to suicide detection.

Just as important as clarifying risk factors, within the assessment it will be of utility to identify protective factors. Protective factors (see Table 72-1) are adaptive for the patient and help to decrease the potential suicide completion. For example, research has found that having a positive future orientation, which involves constructively thinking about the future, generating positive future outcomes, identifying and nurturing goals, and identifying reasons for living, can help decrease suicide. Although Table 72-1 lists those protective factors that have been identified in elderly patients, it is essential to enquire and assess for patient-specific protective factors, which could include hobbies, prior therapeutic treatments, and high self-worth. Once identified, protective factors should be reinforced by the clinician in order to become concrete within the patient, which may aid in the treatment process.

Management and Treatment

Managing and treating geriatric patients with suicidal tendencies initially involves three steps. The first is to diagnose and treat the current psychiatric disorder. The second step is to assess the suicidal intent and lethality with an emphasis on prevention. And the third is to construct a specific treatment plan tailored to the patient. Guidelines for managing suicide in adults were provided by the American Psychiatric Association’s (APA) practice guidelines for the assessment and treatment of patients with suicidal behavior.

For elderly adults, specific guidelines for treating and managing suicide were provided from the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). The primary goal of PROSPECT, a National Institute of Mental Health-funded, randomized, controlled trial, was to assess the effectiveness of an intervention (treatment by a psychiatric specialist) in preventing and reducing suicidal ideation and behavior. The study found that the intervention, relative to treatment as usual (with additional screening), was effective in decreasing suicidal ideation and depressive symptoms. Table 72-2 shows the PROSPECT general recommendations for working with patients with suicide as well as management techniques for patients at high risk.

Many geriatric patients who are suicidal are usually seen by their primary-care physician, and, as such, it is important for their physician to be knowledgeable of suicidal signs and symptoms and treatment strategies. Many of the patients with suicidal ideation may also present with depression; thus, psychiatric treatment may commence with an antidepressant, psychotherapy, or a combination of both. Using cognitive behavior techniques to help the patient reframe his/her thoughts, constructing positive future orientations, and developing adaptive coping strategies may help to mitigate the risk of suicide. Overall, suicide is a significant risk in elderly adults, but, with proper care including comprehensive assessment, development and implementation of patient-specific treatment, and ongoing effective management, the risk of suicide may be lessened.

The most common anxiety disorders in late life are generalized anxiety disorder and phobias. Agoraphobia without panic disorder has been described as occurring late in life, but obsessive compulsive disorder and panic disorder are generally thought to persist from earlier adulthood when present. Anxiety disorders in the elderly are commonly associated with depression. Studies looking at nursing home populations have found a prevalence ranging from 9.9% to 13.2%. It has also been shown that the presence of depression and anxiety can significantly impact the well-being of nursing home patients. Posttraumatic stress disorder (PTSD) has also been described in the elderly.

Treatment Options for Anxiety

Commonly used medications for anxiety spectrum conditions include selective serotonin reuptake inhibitors, other antidepressants, and benzodiazepines. As anxiety and depression are so commonly comorbid conditions, pharmacological treatment with antidepressants is often helpful for both conditions.

Benzodiazepine use in the elderly may be associated with some unique concerns. The indication for these drugs is similar to that for the general adult population. Studies have shown that their use is often more common in the institutional setting, and the actual indication for use is often something other than an anxiety disorder. When using benzodiazepines in the elderly, it is important to remember that pharmacological properties are influenced by age, and agents with longer half-lives and active metabolites are more likely to cause adverse events. Studies have shown that the elderly are more sensitive to the sedating effects of benzodiazepines on the central nervous system. Other adverse events documented have included dependence, cognitive impairment, paradoxical agitations, and psychomotor impairment and falls.

Posttraumatic Stress Disorder

PTSD in the elderly has been discussed in the literature, often in the setting of natural disaster and veterans of war. More than 50% of male veterans are predicted to be older than 65 years by the year 2020. Symptoms of PTSD may occur shortly after the event or may not develop until many years later. There is often a history of previous trauma in individuals with PTSD, and life stressors can bring about a relapse of symptoms. Treatment involving psychotherapy and psychopharmacology is similar to the general adult population, and studies looking at differences are lacking. However, anxiety disorders may impact the treatment outcomes for patients who are depressed. One study examining older adults in an outpatient setting showed a slower response to treatment in geriatrics with comorbid PTSD. Nonetheless, treatment can be effective and will require appropriate diagnosis and management.

Psychosis is a mental disorder often marked by a law of contact with reality and may affect individuals at any age. Geriatric health-care specialists face a particular challenge in the management of psychosis in the older patient. One of the most disenfranchised groups in health care is the elderly with psychotic disorders. The impact of psychotic disorders in the elderly is significant in both financial costs and quality of life. With national health-care costs skyrocketing, the impact on families, caregivers, and the patients’ quality of life is immeasurable. Psychotic episodes increase the risk of hospitalizations and mortality. Behavioral disturbances, are common in psychotic illness and may pose a significant threat to the safety of the elderly patient and those around them.

Clinical Presentation

The psychotic older person in a distressed state is likely to present first to a primary-care physician or geriatrician, rather than seek mental health services. As the primary-care clinician sorts through the history, the clinician may detect something odd in the nature of the person’s complaints. For instance, the history may reveal a heightened suspiciousness toward family, children, or neighbors. Patients may feel that people are stealing from them or trying to control them. The patient’s paranoia may further limit access to in-home attendants, visiting nurses, and other social service professionals. Fears of loss of autonomy and loss of mental and physical capacity can culminate in a frank paranoia. In one of the more familiar clinic scenarios, persons may present to their primary-care physician with vague somatic complaints. Upon further questioning, older persons may blame their symptoms on some implausible occurrence such as a noxious gas being pumped into their home by forces or people often unknown.