Helen’s story illustrates that depression is NOT a normal part of aging. While older adults may face grief related to the serial loss of friends, family, function or independence, persistent bereavement or serious depression are not “normal” and should be treated aggressively.[1] Unfortunately, mental health disorders among older adults are all too often overlooked in our society due to a multitude of factors including stigma, misinformation, and ageism (defined as age-based prejudice or discrimination).[2]
Stigma, or the shame of having mental illness, creates self-doubt and fear which prevent many individuals from seeking treatment. The social disgrace many experience causes isolation, erodes self-esteem and worsens depression – all factors which can increase risk of suicide.
Lack of information perpetuates stigma. In the example above, Helen may have thought her feelings of depression were typical or “just part of getting older.” She may have internalized pervasive messages that older adults are less valued and no longer productive members of society. With better information and less stigma, Helen may have reached out for help before she reached the point of considering suicide.
[1] U.S. Surgeon General, 1999: Older adults and mental health. In: Mental Health: a report of the surgeon general, 1999. Retrieved from www.surgeongeneral.gov/library/mentalhealth/chapter5/sec1.html
[2] World Health Organization, n.d. Ageing and life-course: Ageism. Retrieved from www.who.int/ageing/ageism/en/
Reliable data and statistics on population aging are critical for understanding the impact on societies changing older adult demographics and to inform policies and program planning. [1] The publication, Future Directions for the Demography of Aging, examines recent demographic shifts from the perspective of two dozen National Institute on Aging (NIA) researchers who identify eight disquieting demographic trends with potential negative impacts on the emotional well-being of older adults.[2] Alarmingly, the NIA data indicates that individuals 65 and older currently have the highest rate of suicide deaths. One out of four older adults who attempt suicide die, compared to 1 out of 200 in younger age groups. This is thought to be due to a number of critical factors:
- Suicide attempts among older adults are less often impulsive acts.
- Older adults are more often isolated, more likely to have a plan, and more determined than younger adults.
- Older adults tend to have access to and use more deadly methods and are then less likely to be discovered and rescued.
- Even when discovered, older adults are less likely to recover from suicide attempts due to complex health conditions and physical frailty.[3]
Additionally, though women are three times more likely to attempt suicide, men are about four times more likely than women to die by suicide. In fact, white males, particularly white men aged 85 and over, have the highest rate of suicide completion compared to other age groups. Of note, suicide is also more common in rural areas and guns are the most common method utilized.[4]
Locally, Alameda County is currently home to 270,507 adults aged 60 and over. Mirroring national trends, Alameda County census projections predict a substantial increase in the number of older adults 65+ in the coming decades.[5]
Unfortunately, it is difficult to determine how Alameda County older adult suicide rates compare to California or to the nation as a whole. There are no consensus measures for tracking or reporting of suicide statistics. Alameda County does not differentiate between age groups over 65. It also does not explore differences in method or consistently identify suicide attempts vs. completion.
To learn more about older adults and suicide statistics go to: Suicide Prevention Resource Center (Older Adults) and Healthy Alameda County.
[1] United States Census Bureau. Older Adults and Aging. Retrieved from https://www.census.gov/topics/population/older-aging.html
[2] Scommengna, P., Mather, M., & Kilduff, L. (2018, November 12). Eight Demographic Trends Transforming America’s Older Population. Retrieved from www.prb.org/eight-demographic-trends-transforming-americas-older-population/
[3] Friedman, M.B., Nestadt, P.S., Furst, L., Williams, K.A. (2018, March/April, Vol. 11 No. 2 P. 22). How Physicians Can Help Prevent Elder Suicide. Retrieved from http://www.todaysgeriatricmedicine.com/archive/MA18p22.shtml
[4] Gurnon, E. (2018, June 8). Older adults at greatest risk for suicide. Next Avenue Where Grown-ups Keep Growing. Retrieved from http://www.nextavenue.org/older-adults-at-greatest-risk-for-suicide/
[5] Alameda County. (Fiscal Year 2016-17). Alameda County Plan for Older Adults: Alameda County, Where Aging Is All About Living. https://www.alamedasocialservices.org/public/services/elders_and_disabled_adults/docs/planning_committee/Alameda_County_Area_Plan_Final.pdf
There are many challenges that can interfere with the early diagnosis and treatment of depression and prevention of suicidality in older adults. Older adults are far less likely to seek out a mental health professional when experiencing depression. They are more likely to visit a primary care provider reporting physical symptoms like fatigue, malaise, weight loss, or disrupted sleep.
Rather than experiencing classic dysphoria in the form of sadness, depression, or thoughts of suicide, older adults may simply report vague, nonspecific complaints of low motivation or lack of energy. Unfortunately, too many healthcare professionals harbor the misconception that these physical manifestations of depression are a normal part of aging. Unless a primary care provider is knowledgeable and alert to this “atypical” presentation, diagnosis can be missed and opportunities for early treatment delayed. In fact, research indicates that fully half of older adults who die by suicide had contact with their primary care provider within one month prior to the suicide.[1]
It is critically important that healthcare professionals, service providers, and the general public are educated to recognize suicide risk factors. In addition to the demographic factors summarized above, risk factors include[2]:
- Untreated depression and feelings of hopelessness and helplessness
- Recent loss of a spouse, loved one, or pet
- Debilitating or life-threatening illness
- Pain, especially if severe, chronic, and/or inescapable
- Loss of employment and/or financial difficulties
- Alcohol abuse and/or dependence
- Polypharmacy: administration of multiple medications leading to potential for interaction and adverse effects
- Membership in a marginalized population, such as non-English speakers, transgender, veterans, and/or living in poverty
Older adults experience many of these risk factors at a higher rate than younger populations simply due to life circumstances. As we age, older adults often experience accumulated losses, which may at times overwhelm a person’s resilience and capacity to “bounce back.” Moreover, older adults may experience chronic medical conditions that impair function or are life-threatening. They are more often prescribed multiple medications to manage these conditions, giving them access and means to act on suicidal ideation. Other unique factors that place older adults at high risk for suicide, include:
- Loss of independence
- Loss or decrease of meaningful activities (e.g., due to retirement, loss of mobility)
- Role transitions that affect stature in family and community
- Increased physical, social, and emotional isolation
- Fear of becoming a burden
Even when older adults maintain their independence, fear and anxiety related to future dependence and of becoming a burden to their families and communities can be powerful factors that lead to severe depression and ultimately thoughts of suicide.
In addition to identifying suicide risk factors, detection of early and late warning signs is critical to effective intervention, to prevention of suicide attempts, and to treatment of underlying causes. Warning signs include:
- Statements about death and suicide (ultimately including overt suicide threats)
- Reading material about death and suicide
- Statements of hopelessness or helplessness (e.g., “I don't know if I can go on.”)
- Disruption of sleep patterns
- Loss of interest in many of the activities and interests previously enjoyed
- Increased alcohol or prescription drug use
- Failure to take care of oneself or adhere to medical treatment plan
- Obtaining a means to commit suicide, such as hoarding medications or possessing a firearm
- Social withdrawal or elaborate good-byes
- Rush to complete or revise a will
- Giving away possessions
- Arranging care for pets or euthanizing pets unnecessarily
[1] Friedman, M.B., Nestadt, P.S., Furst, L., Williams, K.A. (2018, March/April, Vol. 11 No. 2 P. 22). How Physicians Can Help Prevent Elder Suicide. Retrieved from http://www.todaysgeriatricmedicine.com/archive/MA18p22.shtml
[2] Substance Abuse and Mental Health Services Administration. (2012) Older Americans Behavioral Health Issue Brief 4: Preventing Suicide in Older Adults; Administration on Aging, Retrieved from https://acl.gov/sites/default/files/programs/2016-11/Issue%20Brief%204%20Preventing%20Suicide.pdf
