Older Adult Suicide: Recognition, Prevention and Support

A presentation by:

Ted M. Natt, Jr. Community Benefit and Communications Coordinator St. Joseph of the Pines Southern Pines, NC [email protected] (910) 246-3125 office (910) 585-4058 cell

SUICIDE OVERVIEW

Older adults made up 14.9 percent of the U.S. population in 2015, but accounted for 17.9 percent of the 44,193 suicides nationwide that year, according to data from the Centers for Disease Control. The higher rates are attributed to:  Greater levels of intent to die  Premeditation of suicidal acts  Lethality of suicide means (more firearm use)  Social isolation that reduces chances for rescue after suicidal acts  Physical frailty that makes any suicide act more lethal Further, older adult suicide may be under-reported by 40 percent or more. Not counted are "silent suicides," like deaths from overdoses, self-starvation or dehydration, and "accidents." Experts call these statistics "alarming" because the elderly are the fastest growing segment of the population. As a result, the issue of later-life suicide should be a major priority for us as the baby boomer generation moves through retirement and starts considering our communities. Why? Because the "baby boom" cohort – those born between 1946 and 1964 – has had relatively higher suicide rates at any given age than earlier or subsequent birth cohorts. Experts say that this group of society seems to struggle with depression more significantly than previous generations. That is important to note because depression is the psychiatric diagnosis most commonly associated with suicide, and depression is present in at least 50 percent of all suicides. However, depression among older adults is under-detected. In addition, physical ill health and functional impairments contribute to risk for suicide in later life. As the number of an individual's acute and chronic conditions increases, so does the cumulative risk. Experts say it is likely that the perceived meaning of those illnesses, their impact on function, pain, and threats to autonomy and personal integrity play pivotal roles as well. Perceived health status may ultimately prove to have greater salience to late life suicide and its prevention than objective measures. Other contributing factors can include losses through bereavement as well as rupture of relationships with family members and other sources of support. The bottom line is that stressful life events are predisposing factors. Older adults "cry for help" in markedly different ways than teens, because depression looks different when we age. When young people talk about suicide or say, "I want to die," older adults are more likely to say, "There's no place for me," or "I don't want to be a burden." Suicide among older adults is often the result of several factors working in combination. Rarely, if ever, would a single factor produce a suicide. Unlike suicides among young people, older adult suicide is not an impulsive act. Elderly suicide is contemplated for a long time. Caregivers need to be alert to any change in behavior because suicidal older adults often:  Believe there are no solutions to their problems.  Perceive themselves as powerless to change their life circumstances.  Feel that they are a burden to others.  Find that life has no meaning. Older men are at higher risk of committing suicide than older women. White males aged 85 and older are at the highest risk among all older adults. Conversely, the rate of suicide tends to decrease in women as they age. SUICIDE RISK FACTORS AND WARNING SIGNS

A person who may be thinking about suicide likely does not want to die, but is in search of some way to make pain or suffering go away. Older adults who attempt suicide are often more isolated, more likely to have pain, and more determined than younger adults. Although older adults attempt suicide less often than those in other age groups do, they have a higher completion rate. Adults over the age of 65 "succeed" in one of every four attempts, while all ages combined "only" succeed one in every 100-200 attempts. At the threshold of older adulthood, thoughts often turn to satisfaction in the past and confidence – emotionally, financially and socially – in the events yet to unfold. Unfortunately, for some older adults, such satisfaction and confidence are elusive or nonexistent. In addition, in the face of hopelessness in the prospects of a satisfying future, some older adults choose to end their lives prematurely. Suicidal thoughts in older adults may be linked to several important risk factors and warning signs, including:  Depression  Prior suicide attempts  Marked feelings of hopelessness; lack of interest in future plans  Feelings of loss of independence or sense of purpose  Medical conditions that significantly limit functioning or life expectancy  Breaking medical regimens (such as going off diets, prescriptions)  Impulsivity due to cognitive impairment  Cutting back on social interaction, self-care and grooming  Loss of interest in things or activities that are usually found enjoyable  Family discord or losses (such as the recent death of a loved one)  Either sleeping too little or too much  Eating problems  Inflexible personality or marked difficulty adapting to change  Stock-piling medication or obtaining lethal means (such as firearms)  Daring or risk-taking behavior  Sudden personality changes  Alcohol or medication misuse or abuse  Negative thoughts  Verbal suicide threats such as, "You'd be better off without me," "Maybe I won't be around," This is the last time that you'll see me," or "I won't be needing anymore appointments."  Giving away prized possessions  Getting wills or finances in order It is important to note that experts say suicide cannot be predicted on an individual basis. Suicide in later life is complex and multidetermined; depression almost never leads to suicide by itself. There is little research on suicide intent disclosure among older adults. In addition, 75 percent of older adults who die by suicide have had no prior attempts. Detection is a critical first step in preventing older adult suicide, because suicide is 100 percent preventable. PREVENTING SUICIDE

Policy makers say efforts to prevent suicide across the country are spotty. The issue is exacerbated by the fact that most people view youth suicide as a greater tragedy than later-life suicide. This way of thinking works against effective outreach to older adults and efforts to understand and treat their conditions. An obstacle faced by mental health professionals and others in reaching this group is that older adults do not usually seek treatment for mental health problems, mainly due to embarrassment, fear and stigma. In addition, the primary care system – the average doctor's visit lasts 15 minutes – is simply not set up for detecting, assessing and treating mental health issues. Evidence shows that most elderly suicide victims visit their physician shortly before dying. In fact, 77 percent of older patients who die by suicide visit their primary care physician within a year of their death and 58 percent do so within their last month. Most of these clients are not diagnosed with a psychiatric disorder and do not seek mental health services. The question of suicide is seldom raised. Until more provider training is implemented, it will likely fall on family, friends and caregivers to play a key role in prevention. A timely and appropriate intervention can prevent suicide, and addressing issues sooner rather than later often results in better treatment outcomes. Take any mention of suicide seriously. If someone is threatening suicide, get help right away. There are toolkits available that provide a framework for your whole population (universal prevention), a protocol for trying to help at-risk individuals (selective prevention), and a crisis response should there be a suicide attempt or death at your community (indicated prevention). A typical first step is training your staff and volunteers to identify warning signs, developing a list of mental health providers in your area, conducting depression and suicide screening, and providing counseling to at-risk individuals. The goal of assessing suicide risk in an older person is to help determine the most appropriate actions to keep that that person safe. One must determine the sense of urgency and take the next steps for further assessment and intervention. Older adults who have thoughts about killing themselves with a plan and intent to act should not be left alone but should be supervised for their safety until emergency services are in place. If your community does not have a relationship with a local mental health professional, it is important to find someone to whom residents with mental health issues can be referred when the need arises. At the very least, residents and staff should know the telephone number for the National Suicide Prevention Lifeline: 1-800-273-TALK (8255). Social risk factors are significant with respect to late life suicide, so promoting family and social support and connectedness is extremely important. The Centers for Disease Control has identified as a key strategy for preventing suicidal behavior at all ages "the promotion and strengthening of connectedness at personal, family, and community levels." Our communities can foster the emotional well-being of all residents by creating an environment that promotes communication, respect, engagement, and a sense of belonging and connectedness. Partnerships, coordination of care, and integration across service settings can help meet the needs of older adults who are at-risk for suicide. Financing outreach, case identification, and appropriate treatment can be a challenge. Reducing suicide among older adults requires actions at multiple levels to increase recognition and treatment. Your community can do its part in learning to recognize and address the specific – and often unique – factors that increase vulnerability and risk in the later years of life. POST-SUICIDE SUPPORT

The Survivors of Suicide Loss Task Force notes in its April 2015 report that "there is a profound lack of awareness – among the public, certainly, but also among many who provide care to the bereaved – about the damage that suicide can cause people who experience the finality and pain of its impact. "The severity and duration of suicide's damage for many of our friends and neighbors is far worse that is recognized, and our society is not even close to responding adequately or effectively to lessen the damage or to help people recover from the tragedy that has befallen them." The task force established National Guidelines that reinvent postvention in a way that focuses our compassion on answering the call to meet the needs of EVERYONE exposed to a suicide. It is estimated that about 115 people may be exposed to each suicide in the United States. So, in any given year, about 7 percent of the U.S. population is exposed to the suicide of someone else. Research has shown that exposure to suicidal behavior (ideation and attempts) or a fatality raises the risk of subsequent suicide in people who have been exposed. Additionally, exposure markedly increases the risk of numerous other deleterious mental health, relational, and social consequences. The guidelines call for communities and organizations to provide everyone who is exposed to a suicide access to effective services and support immediately – and for as long as necessary – to decrease their risk of suicide, to strengthen their mental health, and to help them cope with grief. Postvention refers to an organized response in the aftermath of a suicide to accomplish any one or more of the following:  To facilitate the healing of individuals from the grief and distress of a suicide loss  To mitigate other negative effects of exposure to suicide  To prevent suicide among people who are at high risk after exposure to suicide The task force believes that postvention responses ought to be considered on behalf of ANY person who has been exposed to the death by suicide of another. The response of a given individual to suicide can vary substantially based on a number of factors, including a person's role and relationship with the circumstances of the death and the deceased. In addition, people's needs related to the death will likely change over time as they move through the healing process – even years later. Suicide is often the concluding event of an ongoing crisis for the deceased and, simultaneously, the initiation of an altogether new crisis for the bereaved. It is important, however, to recognize that the suicide bereaved are not a uniform population. Different people will need different resources at different times during their healing process. Unfortunately, suicide has long been stigmatized. In contemporary times, there is probably less outright condemnation of suicide, but harsh, institutionalized judgments from the past have left a lingering discomfort in many people about how to respond in a supportive way to the suicide bereaved. Even more distressing, perhaps, is the fact that hardly any research has investigated treatments specifically tailored to suicide loss survivors. It is important to remember that survivors of suicide loss are also people who are bereaved by the death of a loved one, irrespective of the fact that their loved one died by suicide. Supporting suicide loss survivors in ways that all bereaved people need to be supported is an excellent guideline for building a foundation upon which their long-term healing can be built. Perhaps the task force put it best when it noted that "a great deal of work lies ahead." SUICIDE RESOURCES

 National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

 SAMHSA (Substance Abuse and Mental Health Services Administration) National Helpline : 1-800-662 HELP (4357)

 HopeLine Crisis line: 1-877-235-4525. HopeLine volunteers make daily calls to older adults and people with disabilities who are home-bound and living independently with little or no daily contact with others. These daily calls provide a reminder that someone cares and is willing to listen.

 Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/ files/NationalGuidelines.pdf

 North Carolina Suicide Prevention Plan http://www.sprc.org/sites/default/files/2015-NC-SuicidePreventionPlan-2015-0505- FINAL.pdf

 Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities https://store.samhsa.gov/shin/content/SMA10-4515/SMA10-4515.ToolkitOverview.pdf

 Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Centers https://store.samhsa.gov/shin/content//SMA15-4416/SMA15-4416.pdf

 The Role of Senior Living Community Professionals in Preventing Suicide http://www.sprc.org/sites/default/files/resource- program/SrLivingCommunity_providers.pdf

 Suicide: North Carolina 2017 Facts & Figures https://afsp.org/about-suicide/state-fact-sheets/#North-Carolina

 Older Americans Behavioral Health Issue Brief 4: Preventing Suicide in Older Adults https://www.ncoa.org/wp-content/uploads/Older-Americans-Issue-Brief-4_Preventing- Suicide_508.pdf

 Suicide Among Older Adults: Prevalence, Risk Factors, and Prevention https://www.ncoa.org/wp-content/uploads/Sept-29-Slides-Suicide-Prevention-Among- Older-Adults-1.pdf

 American Foundation for Suicide Prevention: Suicide Statistics https://afsp.org/about-suicide/suicide-statistics/

 American Association for Marriage and Family Therapy: Suicide in the Elderly https://www.aamft.org/AAMFT/Consumer_Updates/Suicide_in_the_Elderly.aspx

 Suicide Later in Life: Challenges and Priorities for Prevention https://ac.els-cdn.com/S0749379714002608/1-s2.0-S0749379714002608- main.pdf?_tid=e07cd7ff-1ad1-428b-9d88- 1a0441d2fbd4&acdnat=1525801437_6f63325489f2259f87de68851a73b4a7

 American Association of Suicidology http://www.suicidology.org/

 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action https://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full- report.pdf