Preventing suicide in older patients with an eagle eye and a listening ear

November brings spring and the pre-Christmas frenzy. GPs are overwhelmed with patients, trying to catch up on COVID-delayed health prevention and trying desperately to plan a holiday with no cover in sight. Universities are busy with assignments and examination preparation, and older people are gardening, watching the mokopuna, cleaning the paths from the winter moss and grunge, and, in their own way, keeping connections going for the betterment of society.

In the main, older patients are resilient, productive and a very positive influence in our world. However, at this time, the breadth of ways of living means that not all are flourishing.

Some older people are lonely, and a recent article in Australasian Psychiatry, written by our own experts from the University of Otago and University of Auckland, outlined the issue of suicide in older people. A literature review and Delphi process was used to consider and formulate recommendations (discussed later in this article).¹

Suicide is the unspoken undercurrent in our youth, less frequent in midlife and surprisingly common among older people, particularly men.² The intersection of depression, dementia and loneliness is a significant risk for older people, and men fare worst – perhaps they are not so attentive to social connections through life and rely on their female companions “for all that”.

Certainly, patterns of work and retirement are gender based in our current society, and while men benefit from marriage, women do not seem to, at least not to the same extent. So, it is perhaps not surprising that older men living alone are the at-risk group we are talking about here.

For GPs, the main risk factors for suicide to be aware of are physical illness and functional impairment, both of which are very prevalent in our waiting rooms and on our phones.

Risks for non-fatal self-harm have been identified from interRAI data and include: depression diagnosis (hazard ratio 3.02; 95 per cent confidence interval 2.26–4.03), at-risk alcohol use (HR 2.38; 95 per cent CI 1.30–4.35) and bipolar disorder (HR 2.18; 95 per cent CI 1.25–3.80). Protective factors were cancer and having a severe level of functional impairment (probably because this meant they lacked the capacity to act?).³

Suicide prevention is a tricky area. We have a large focus on young people in Aotearoa as our youth, particularly disadvantaged youth, have some of the highest suicide rates in the world. However, older men have the highest rate of death by suicide in almost all countries.

The first of the recommendations from the group mentioned above was that, as part of a national suicide prevention plan, we have a specific, separate and unique plan for older people supported by an appropriately staffed and funded taskforce.

Further recommended considerations were extracted from the current literature:

Universal prevention recommendations focus on the entire population to reduce risk and include: reducing access to lethal means; addressing suicide “hotspots”; and ensuring responsible media responses to suicide. Education of health professionals needs to be developed and delivered.

Indicated prevention is for those who are symptomatic and high risk. Here, the recommendations include: age-specific instruments for depression screening; integrated depression care management in healthcare, including use of all treatment modalities; and assertive and immediate help after suicide attempts, with mandated registration of a contact person in the electronic record.

Selective prevention for high-risk groups recognises that not all risks are visible. Systematic outreach to support older people who are at risk due to isolation and other stressful situations (eg, bereavement; functional decline; retirement; whānau and family conflict), with optimisation of management of chronic problems (eg, sleep disorders) is recommended, along with awareness of alcohol abuse as a significant risk for suicide in older people.

There is considerable evidence that most people who die by suicide have sought medical attention in the year before – for older people, sometimes quite frequently. They don’t tend to bring this as the presenting complaint, so an eagle eye is needed.

Suicidal ideation is actually quite common. Talking this through, establishing the risk of harm, preventing access to lethal means, and providing immediate support with close follow-up and management of depression (if present) is the task of the health practitioner in that context.

Trials that prove suicide prevention works are few and far between, but being aware, being in touch, and providing opportunities to allow older folk to talk through misery, admit desperation and receive a listening ear and encouragement are very likely to be helpful.

GPs and nurse practitioners do a lot that is not acknowledged nor visible, and suicide prevention is one of them – through the therapeutic relationships that continuity of care brings.

Overall, the recommendations highlight the need for organised, funded prevention to reduce the devastation that suicide brings, not just to the suicidal patient, but to family, whānau, neighbours, health providers and wider society.

I am sure we can all think about the older people we know who may be lonely in this springtime of preparation for the festive season.

Ngaire Kerse is president of the New Zealand Association of Gerontology and the Joyce Cook Chair in Ageing Well, University of Auckland