Death wishes in the very elderly: data from a 3-year follow-up study

Neurocognitive markers of passive suicidal ideation in late-life depression

OBJECTIVES

(1) To delineate whether cognitive flexibility and inhibitory ability are neurocognitive markers of passive suicidal ideation (PSI), an early stage of suicide risk in depression and (2) to determine whether PSI is associated with volumetric differences in regions of the prefrontal cortex (PFC) in middle-aged and older adults with depression.

DESIGN

Cross-sectional study.

SETTING

University medical school.

PARTICIPANTS

Forty community-dwelling middle-aged and older adults with depression from a larger study of depression and anxiety (NIMH R01 MH091342-05 PI: O'Hara).

MEASUREMENTS

Psychiatric measures were assessed for the presence of a DSM-5 depressive disorder and PSI. A neurocognitive battery assessed cognitive flexibility, inhibitory ability, as well as other neurocognitive domains.

RESULTS

The PSI group (n = 18) performed significantly worse on cognitive flexibility and inhibitory ability, but not on other neurocognitive tasks, compared to the group without PSI (n = 22). The group with PSI had larger left mid-frontal gyri (MFG) than the no-PSI group. There was no association between cognitive flexibility/inhibitory ability and left MFG volume.

CONCLUSIONS

Findings implicate a neurocognitive signature of PSI: poorer cognitive flexibility and poor inhibitory ability not better accounted for by other domains of cognitive dysfunction and not associated with volumetric differences in the left MFG. This suggests that there are two specific but independent risk factors of PSI in middle- and older-aged adults.

Still ready to give up on life? A longitudinal phenomenological study into wishes to die among older adults

RATIONALE

There is a paucity of empirical studies exploring wishes to die (WTD) in older adults without a life-threatening disease or psychiatric disorder, especially on how these WTD evolve over time.

OBJECTIVE

This study aims to deepen our understanding of living with a WTD by elucidating multifaceted trajectories of death wishes in older adults without a life-threatening disease or psychiatric disorder.

METHODS

Interviews were conducted between 2013 and 2019 with Dutch men and women aged 70 and older who expressed a WTD (preferably at a self-chosen moment). Using a phenomenological, longitudinal analysis approach, 35 serial interviews were analyzed.

RESULTS

This resulted in four thematic meanings following four trajectories, namely: 1) a realized WTD, facing the ultimate decision with both freedom and a sense of fate; 2) an intensifying WTD, reaching a deadlock; 3) a diminishing WTD, experiencing tentative space for new possibilities; and 4) a vanishing WTD, being surprised by an unexpected turn. In the cases examined, the individuals' WTD was characterized by ambivalence and subject to change over time. Fluctuating, often asynchronous patterns of physical, social, psychological, and existential distress were lived intertwined. The WTD should thus be understood as dynamic and unpredictable, often impacted by external circumstances.

CONCLUSIONS

An important clinically relevant finding is that even persons with a pronounced WTD can experience openness to new possibilities, leading to a diminished or vanished WTD and/or desire to act on their WTD. Often such changes were related to (re-)establishment of connections with other people and/or society or with themselves. Since most research in this area is cross-sectional, the current longitudinal findings of this study are unique in providing insight into changes over time, thus contributing to the fields of death and suicide studies.

'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA

BACKGROUND

There is an established bidirectional relationship between mental and heart health in later life but the link between wish to die (WTD) and cardiovascular mortality is less well-defined.

METHODS

This is a longitudinal study examining the association between WTD and mortality over 9-year follow-up in a large population-representative sample of older adults. Individual-level survey data was linked to official death registration data, divided into cardiovascular and noncardiovascular causes. WTD was defined as answering affirmatively when asked 'In the last month, have you felt that you would rather be dead?' Regression models were used to obtain hazard ratios for the association between WTD at Wave 1 and mortality. Kaplan-Meier plots were used to compare survival across groups.

RESULTS

Just over 3% (275/8124) of participants reported WTD. Mortality data was available for 9% of participants (755/8124). WTD was significantly associated with all-cause mortality, with a hazard ratio of 1.41 (95% confidence interval [CI]: 1.00-1.99). Findings were attenuated and no longer significant after excluding participants with heart disease or depression/anxiety/other psychiatric illness. WTD was significantly associated with cardiovascular mortality (hazard ratio: 2.14 [95% CI: 1.21-3.78]), even after excluding participants with depression/anxiety/other illnesses but not heart disease. WTD was not associated with an increased risk of death due to non-cardiovascular causes.

CONCLUSIONS

Older people who report a wish to die have double the risk of death from cardiovascular disease in the following 9 years, even when those with depression, anxiety or other mental health problems are excluded.

Social Interactions among Older Adults Who Wish for Death

Objectives: When the need for relatedness is frustrated, some older adults feel that life is not worth living and wish for death (WD). The aim of this study was to look at the perception of social interactions among older adults who express the WD.Methods: A probabilistic sample of 2787 French-speaking community-dwelling older adults aged 65 to 96 years (M = 73.8) took part in the Seniors Health Survey, a study on the prevalence of mental disorders which also collected information on various demographic and social variables.Results: Results showed that 5% of participants expressed WD. Participants who WD felt significantly more isolated and in conflict with their children than participants without WD. When sociodemographic variables, self-rated physical health, and depression were controlled, three social variables predicted WD in a logistic regression: being distant toward others, dissatisfaction with social life, and a lack of participation in organizations.Conclusions: Results of the present study support the interpersonal theory of suicide, which suggests that self-reported thwarted belongingness can foster WD.Clinical implications: Clinicians should consider social dissatisfaction and withdrawal as risk factors for WD and design interventions that foster social skills or meaningful connections.

Functional disability and suicidal behavior in middle-aged and older adults: A systematic critical review

BACKGROUND

Middle-aged and older adults have elevated rates of suicide around the globe, but there is a paucity of knowledge about risk factors for suicide in these age groups. One possible risk factor may be functional disability, which is more common at later ages.

METHODS

The current systematic critical review examined findings regarding the associations between functional disability and suicidal behavior (suicidal ideation, suicide attempts, and death by suicide) in middle-aged and older adults (i.e. age 50 and older).

RESULTS

Forty-five studies were found that examined these associations. The majority of studies supported a significant association between functional disability and suicidal ideation. In addition, findings to date strongly suggest that depression serves as a mediator of the association between functional disability and suicidal ideation, though most studies did not directly test for mediation.

LIMITATIONS

Firm conclusions regarding suicide attempts and death by suicide, as well as mediation, cannot be drawn due to a relative lack of research in these areas.

CONCLUSIONS

The association between functional disability and suicidal behavior suggests an important area for prevention and intervention among middle-aged and older adults, but additional research is necessary to clarify the specifics of these associations and examine appropriate intervention strategies. Important future directions for research in this area include the direct comparison of associations of risk factors with different types of suicidal behavior, greater use of longitudinal data with multiple time points, and further examination of potential mediators and moderators of the association between functional disability and suicidal behavior.

Death wishes among older people assessed for home support and long-term aged residential care

OBJECTIVE

Death wishes in older people are common and may progress to suicidal ideation and attempts. This study used routinely collected data from the interRAI Home Care assessment to examine the prevalence and clinical predictors of death wishes in older New Zealanders assessed for home support and long-term aged residential care.

METHODS

Data were collected from 35 734 people aged over 65 during 2012-2014. Chi-squared analyses were used to determine significant relationships between the presence of death wishes and demographic factors, health and functional status, and emotional and psychosocial well-being. A three-step hierarchical logistic regression model was used to determine the predictive variables of death wishes, and odds ratios were calculated.

RESULTS

Death wishes were present in 9.5% of the sample. The following factors were significantly associated with death wishes: physical health (poor self-reported health, recurrent falls, severe fatigue and inadequate pain control), psychological factors (depression, major stressors and anxiety), social factors (loneliness and decline in social activities) and impaired cognition. Depression (odds ratio = 2.54, 95% confidence interval = 2.29-2.81), loneliness (odds ratio = 2.40, 95% confidence interval = 2.20-2.63) and poor self-reported health (odds ratio = 2.34, 95% confidence interval = 1.78-3.07) had the greatest odds ratios in the full model.

CONCLUSIONS

Clinically significant depression alone cannot fully account for the development of death wishes in the elderly, and several factors are independently associated with death wishes. This knowledge can help clinicians caring for older persons to identify people who are most at risk of developing death wishes. Copyright © 2016 John Wiley & Sons, Ltd.

Passive Suicide Ideation Among Older Adults in Europe: A Multilevel Regression Analysis of Individual and Societal Determinants in 12 Countries (SHARE)

OBJECTIVES

Passive suicide ideation (PSI) is common among older adults, but prevalences have been reported to vary considerably across European countries. The goal of this study was to assess the role of individual-level risk factors and societal contextual factors associated with PSI in old age.

METHOD

We analyzed longitudinal data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) on 6,791 community-dwelling respondents (75+) from 12 countries. Bayesian logistic multilevel regression models were used to assess variance components, individual-level and country-level risk factors.

RESULTS

About 4% of the total variance of PSI was located at the country level, a third of which was attributable to compositional effects of individual-level predictors. Predictors for the development of PSI at the individual level were female gender, depression, older age, poor health, smaller social network size, loneliness, nonreligiosity, and low perceived control (R (2) = 25.8%). At the country level, cultural acceptance of suicide, religiosity, and intergenerational cohabitation were associated with the rates of PSI.

DISCUSSION

Cross-national variation in old-age PSI is mostly attributable to individual-level determinants and compositional differences, but there is also evidence for contextual effects of country-level characteristics. Suicide prevention programs should be intensified in high-risk countries and attitudes toward suicide should be addressed in information campaigns.

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

OBJECTIVES

To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older.

METHOD

Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review.

RESULTS

Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed.

CONCLUSION

Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.

Active and Passive Suicidal Ideation in Older Prisoners

BACKGROUND

Older prisoners are the fastest growing incarcerated population with high suicide rates, yet limited information is available to inform best practices for their early risk detection and suicide prevention.

AIMS

The present study sought to determine the current prevalence of and factors associated with active suicidal ideation (ASI) and passive suicidal ideation (PSI) in older prisoners, and to determine if ASI and PSI were similarly associated with depression and lifetime suicide attempt - markers of subsequent suicide.

METHOD

ASI, PSI, current major depressive episode (MDE), lifetime suicide attempt, and participant characteristics were assessed during interviews with 124 prisoners aged 50 years and older. Participants were assigned to one of three mutually exclusive groups: no SI, PSI only, and ASI.

RESULTS

Past alcohol dependence and fair/poor self-rated health were associated with SI. Compared with those with no SI, older prisoners with PSI (10%) and ASI (11%) were more likely to have a lifetime suicide attempt and/or MDE. However, the likelihood of experiencing either MDE or a suicide attempt did not differ between those with ASI or PSI.

CONCLUSIONS

Among older prisoners, PSI and ASI may be similarly associated with markers of subsequent suicide. PSI should not be considered inconsequential and may distinguish older prisoners with elevated suicide risk.

Suicidal ideation in elderly Korean population: a two-year longitudinal study

BACKGROUND

This study aimed to assess the prevalence, incidence, and persistence of suicidal ideation (SI), and to investigate the psychosocial factors associated with these.

METHODS

A total of 1,204 community dwelling elderly adults aged 65 years or older were evaluated at baseline, 909 (75%) of whom were followed two years later. The presence of SI was identified using the questions from the community version of the Geriatric Mental State (GMS) diagnostic schedule (GMS B3) at both baseline and follow-up interviews. Baseline measures included demographic status, years of education, rural/urban residence, accommodation, past and current occupation, monthly income, marital status, stressful life events, social support deficits, number of physical illnesses, severity of pain, physical activity, disability, depressive symptoms, anxiety, insomnia, cognitive function, alcohol consumption, and smoking.

RESULTS

Baseline SI prevalence, follow-up incidence (SI rate at follow-up of 805 elderly subjects who did not have SI at baseline), and persistence (SI rate at follow-up of 104 elderly subjects who had SI at baseline) were 11.5%, 9.6%, and 36.5%, respectively. Baseline SI was independently associated with no current employment, lower monthly income, stressful life events, more severe pain, presence of disability, depressive symptoms, and smoking. Incident SI was independently predicted by baseline unmarried status, social support deficit, severe pain, presence of depressive symptoms, and smoking. Persistent SI was independently predicted by baseline stressful life events and depressive symptoms.

CONCLUSIONS

Depressive symptoms were independently associated with prevalent, incident, and persistent SI, but other predictors varied according to incidence and persistence outcomes.

Characteristics and comorbid symptoms of older adults reporting death ideation

OBJECTIVE

To determine whether death ideation in late life is associated with markers of elevated risk for suicide, or reflects normal psychological processes in later life.

DESIGN/SETTING

Population-based cross-sectional study in Gothenburg, Sweden.

PARTICIPANTS

The sample consists of 345 men and women of age 85 years (born 1901-1902) and living in Gothenburg, Sweden.

MAIN OUTCOME MEASURES

The Paykel Scale measured the most severe level of suicidality over an individual's lifetime. Other key measures were severity of depression and anxiety and frequency of death/suicidal ideation over the previous month.

RESULTS

Latent class analysis revealed distinct groups of older adults who reported recent death ideation. Recent death ideation did not occur apart from other risk factors for suicide; instead individuals reporting recent death ideation also reported either 1) recent high levels of depression and anxiety, or 2) more distant histories of serious suicidal ideation (indicative of worst point severity of suicidal ideation)-both of which elevate risk for eventual suicide.

CONCLUSIONS

Our results indicate a heterogeneous presentation of older adults who report death ideation, with some presenting with acute distress and suicidal thoughts, and others presenting with low distress but histories of serious suicidal ideation. The presence of death ideation is associated with markers of increased risk for suicide, including "worst point" active suicidal ideation.

You've got to have friends: the predictive value of social integration and support in suicidal ideation among rural communities

PURPOSE

To explore the role of social integration and support in the longitudinal course of suicidal ideation (SI) in a rural population.

METHODS

Baseline and 12-month data were obtained from participants within the Australian Rural Mental Health Study, a longitudinal study of community residents within rural and remote New South Wales, Australia. SI was assessed using the Patient Health Questionnaire. Individual psychological factors, family and community characteristics were examined alongside personal social networks (Berkman Syme Social Network Index), availability of social support (Interview Schedule for Social Interaction) and perception of local community (Sense of Community Index).

RESULTS

Thirteen hundred and fifty-six participants were included in the analysis (39% male, mean age 56.5 years). Sixty-one participants reported recent SI at baseline, while 57 reported SI at follow-up. Baseline SI was a strong predictor of SI at 12 months [odds ratio (OR) 19.0, 95% confidence interval (CI) 8.6-42.3); significant effects were also observed for baseline values of psychological distress (OR 1.4, 95% CI 1.0-1.9) and availability of social support (OR 0.76, 95% 0.58-1.0) on 12-month SI. The emergence of SI at 12-month follow-up was predicted by higher psychological distress (OR 1.8, 95% CI 1.3-2.4); there was a marginal effect of lower availability of support (OR 0.74, 95% CI 0.55-1.0); neither of these variables predicted SI resolution.

CONCLUSIONS

This study investigated factors associated with SI over a 12-month period in a rural cohort. After controlling for known risk factors for SI, low availability of social support at baseline was associated with greater likelihood of SI at 12-month follow-up.

Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain

HYPOTHESIS

Passive, active, and historical suicidality are associated with preference for death over disability.

DESIGN

Community nonpatients without pain, community patients with pain, and patients with acute and chronic pain were compared for endorsement of disability perception and preference for death over disability. Phi correlations and chi-square analyses were calculated between preference for death over disability and six suicidality items representing passive, active, and historical suicidality. Logistic regression was used to predict preference for death over disability in patients with acute and chronic pain.

RESULTS

For patients with acute and chronic pain, endorsement of preference for death over disability correlated significantly with all six suicidality items. The logistic regression models identified the following variables as predictors for preference for death over disability in patients with acute pain: the Behavior Health Inventory (BHI 2) family dysfunction scale, history of wanting to die, and disability perception. For patients with chronic pain, predictors were the BHI 2 Borderline scale, history of wanting to die, treated fairly by family item, frequent suicide ideation, people I trust turn on me item, and disability perception. Preference for death over disability was a statistically significant predictor in patients with chronic pain for disability perception, recent suicide ideation, having a suicidal plan, and a history of wanting to die but was not a significant predictor for any suicide items in patients with acute pain.

CONCLUSION

Preference for death over disability is associated with passive and active suicide ideation and historical suicidality in patients with chronic pain.

Suicidality and suicide in older people

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

Sex- and age-related increase in prevalence rates of death wishes and suicidal ideation in the community: results from the KORA-F3 Augsburg Study with 3,154 men and women, 35 to 84 years of age

Among risk factors for suicide, suicidal ideation (SID) is of paramount importance. This study sought to determine sex- and age-related SID point prevalence rates in the general population. A population-based survey of 3154 subjects, 35 to 84 years, conducted in 2004/05 in southern Germany, identified 170 subjects (5.4%; 95% CI 4.6-6.2) suffering from SID within the last 14 days. Age-adjusted short-term period prevalence in women (6.0%, 95% CI 4.9.-7.2) was higher than in men (4.0%, 95% CI 3.1-5.1). Among 10-year age groups, sex-related differences were only significant in middle-aged subjects (55-64 years). Prevalence increased significantly with age, leading to a prevalence of >10% in the oldest age group (75-84 years). The population-based approach demonstrates a substantial proportion of subjects suffering from SID, particularly in older age groups.