Evaluation of an Educational Intervention for Clinicians on Self-Harm in Older Adults

Nonsuicidal self-injury in a cross-sectional community survey of New Zealand adults: Associations with demographic and psychological characteristics

OBJECTIVE

Understanding of nonsuicidal self-injury relies almost exclusively on adolescent and emerging adult samples. We investigated the prevalence of lifetime and past-year nonsuicidal self-injury among New Zealanders aged 16-75 years and above, before evaluating if established associations between nonsuicidal self-injury, and demographic and psychological characteristics generalise to adults.

METHOD

New Zealand adults (n = 4906; median age 55-59 years; 55.5% female) completed a cross-sectional survey assessing lifetime and past-year nonsuicidal self-injury, psychological distress, self-esteem, emotion dysregulation, and social desirability susceptibility.

RESULTS

Nonsuicidal self-injury was common among adults; 25.6% participants reported ever self-injuring and 10.7% had done so at least once in the past year. Women and younger participants were more likely to report lifetime self-injury. Although younger participants were also more likely to report past-year self-injury than older participants, this age effect was attenuated for men (b = -0.09) compared to women (b = -0.18). Self-esteem (odds ratios 0.74, 0.74), psychological distress (odds ratios 1.09, 1.16), emotion dysregulation (odds ratios 2.05, 1.88), and desire to manage others' impressions of oneself (odds ratios 0.88, 0.85) were uniquely associated with both lifetime and past-year nonsuicidal self-injury, respectively, and these effects were not moderated by age.

CONCLUSION

Although self-injury was most common among emerging adults, adults of all ages reported self-injuring. Individuals with a greater desire to manage how others perceive them appeared to underreport their nonsuicidal self-injury. While men were less likely than women to self-injure, they may also be more likely to continue self-injuring over adulthood, suggesting that the developmental factors which drive self-injury cessation among adults differ for men and women.

Conceptualizing Self-Harm through the Experiences of Psychogeriatric Experts

INTRODUCTION

Fewer studies thus far have focused on self-harm and its specific forms among older adults. Moreover, the limited available literature applies varying terminology. The categorization of self-harm used in younger populations may not be as appropriate for this population. This means that less is known about this phenomenon in older adults. The current study aimed to reduce this gap.

METHODS

Nine Flemish psychogeriatric experts participated in a semi-structured interview. Transcripts were thematically analyzed.

RESULTS

Themes emerging from the interviews suggest that self-harm in older adults may also include distinct elements, such as the omission of certain behaviours and engagement in indirect self-harm to cause bodily harm. According to the experts, self-harm may be engaged in to cope with emotions, express life fatigue, hasten death, and communicate a cry for help.

DISCUSSION

Self-harm is prevalent in older adults, and some characteristics may be specific to self-harm in an older age group. These findings may enable clinicians to be more alert to self-harm in older adults and consequently prevent serious suicidal behaviour. More research is needed to further uncover this phenomenon.

A qualitative study of multiple voices to inform aftercare services for older persons following self-harm

OBJECTIVES

Self-harm and suicide are closely related in older adults, highlighting the opportunity for Aftercare interventions in targeted suicide prevention. The study aims were to explore strengths and shortfalls of current Aftercare services for older adults from the perspective of key stakeholders and researchers; and inform a set of guiding principles for older persons' Aftercare.

METHODS

Semi-structured interviews were undertaken with a convenience sample of older people with lived experience of self-harm, clinicians and suicide researchers (n = 22). Interviews were focussed on current practice (strengths and limitations), potential improvements, and identifying the core components of an acceptable Aftercare model. Interviews were audio-recorded, transcribed and subjected to a reflexive thematic analysis grounded in interpretive description.

RESULTS

Current practice strengths included validation, a person-centred approach and optimising aftercare delivery. Limitations included ageism, practical limitations (lack of service awareness, fragmented service provision, barriers to access, and traumatising approaches), and limited services, funding and training. Overarching themes included anti-ageism; anti-stigma; empowerment and agency; conveying hope; patience and pace; accessible; and finding purpose: connections and meaningful activity.

CONCLUSIONS

Older people who have self-harmed have complex, individualised needs. They sit within intersecting systems traversing healthcare, support services, family, and the social environment. Systemic, coordinated Aftercare founded upon core principles of anti-ageism, anti-stigma, partnership, empowerment, accessibility and provision of connections and meaning are needed.

Educating Crisis Supporters About Self-Harm and Suicide in Older Adults

OBJECTIVES

This study aimed to describe existing knowledge of crisis supporters (volunteers responding to crisis calls/texts/messages) regarding self-harm and suicide in older adults and investigate knowledge translation through use of a novel online adaptive learning tool.

METHODS

The online educational tool was tested in an Australian national sample of crisis supporters (trained volunteers) aged 18+. Knowledge Transfer was evaluated utilizing a pre/post intervention methodology for data collection. The collaboratively developed online educational tool comprised a pre-test (10 questions), middle learning module (individualised for participant's incorrect pre-test responses) and post-test (10 questions) on suicidal behaviours in older adults. Data analysed included the demographic characteristics of the participants, individual question scores, and summed pre- and post-tests scores. Group differences in change scores were assessed with either one-way between subjects ANOVA or independent samples t-test, depending on the number of groups within each variable. Pre-post education comparisons on individual change in scores were made using a paired samples t-test. Statistical significance was defined as p <0.05.

RESULTS

104 crisis supporters completed the tool (pre-test, middle lesson and post-test). There was significant improvement in knowledge of crisis supporters after the intervention (pre-test scores Mean (M) = 4.56, SD = 1.62 and post-test scores M = 7.61, SD = 1.60; t (103) = 17.242, p <0.001.).

CONCLUSION

Dedicated training about suicidal behaviors in older adults is needed given their high rates of suicide and differing underlying reasons and needs compared to younger adults.

Predictive factors of nonfatal self-harm among community-dwelling older adults assessed for support services

BACKGROUND

Older adults receiving support services are a population at risk for self-harm due to physical illness and functional impairment, which are known risk factors. This study aims to investigate the relative importance of predictive factors of nonfatal self-harm among older adults assessed for support services in New Zealand.

METHODS

interRAI-Home Care (HC) national data of older adults (aged ≥ 60) were linked to mortality and hospital discharge data between January 1, 2012 and December 31, 2016. We calculated the crude incidence of self-harm per 100,000 person-years, and gender and age-adjusted standardized incidence ratios (SIRs). The Fine and Gray competing risk regression model was fitted to estimate the hazard ratio (HR; 95% CIs) of self-harm associated with various demographic, psychosocial, clinical factors, and summary scales.

RESULTS

A total of 93,501 older adults were included. At the end of the follow-up period, 251 (0.27%) people had at least one episode of nonfatal self-harm and 36,333 (38.86%) people died. The overall incidence of nonfatal self-harm was 160.39 (95% CI, 141.36-181.06) per 100,000 person-years and SIR was 5.12 (95% CI, 4.51-5.78), with the highest incidence in the first year of follow-up. Depression diagnosis (HR, 3.02, 2.26-4.03), at-risk alcohol use (2.38, 1.30-4.35), and bipolar disorder (2.18, 1.25-3.80) were the most significant risk factors. Protective effects were found with cancer (0.57, 0.36-0.89) and severe level of functional impairment measured by Activities of Daily Living (ADL) Hierarchy Scale (0.56, 0.35-0.89).

CONCLUSION

Psychiatric factors are the most significant predictors for nonfatal self-harm among older adults receiving support services. Our results can be used to inform healthcare professionals for timely identification of people at high risk of self-harm and the development of more efficient and targeted prevention strategies, with specific attention to individuals with depression or depressive symptoms, particularly in the first year of follow-up.

Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults

OBJECTIVE

The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework.

CONCLUSION

TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

Homicide and Dementia: A Systematic Review

BACKGROUND

Homicide by older offenders is rare and devastating. It likely occurs due to a complex interaction of personal, social, and environmental factors. Dementia is a progressive neurological condition which may amplify behavioural disturbances such as aggression. This systematic review aims to evaluate the factors associated with homicide committed by people with dementia in order to inform clinical practice.

SUMMARY

MEDLINE, PsychINFO, Embase, and PubMed databases were searched in accordance with PRISMA guidelines for empirical studies examining the characteristics and circumstances of people with dementia who committed homicides. Data on factors associated with the homicide were extracted and the quality of each study rated using standardized criteria. A total of 499 papers were screened and thirteen studies met the inclusion criteria. Study design included case reports (seven studies), case series (four studies), and two retrospective cohort studies, indicative of low levels of evidence. Sample sizes were 1-70. Study findings were predominantly descriptive. Quality ratings ranged from 50 to 100%. Factors associated with disinhibition such as dysexecutive syndrome, alcohol use, and delirium may predispose to severe impulsive aggression. Psychosis and personality pathology appeared to influence targeted assaults resulting in homicide by people with dementia. Victim vulnerability was also a key element.

KEY MESSAGES

The current evidence examining risk factors for homicide committed by people with dementia is limited. However, there are common characteristics reported in these descriptive studies including psychiatric factors and cognitive states causing disinhibition. Recommendations for clinical practice include early assessment of older people with dementia and changed behaviours to allow management of comorbidities and reversible risk factors, alongside education, and advice to carers (who may be targets of aggression). Specialized geriatric forensic psychiatry services and care settings should be developed.

The Development of an Online Training Tool for Crisis Supporters on Late Life Suicide: Improving Knowledge While Promoting Empowerment

Telephone crisis services have an increasing role in suicide prevention yet existing interventions have not empowered crisis supporters with adequate education targeting the needs of older people in crisis. An existing educational intervention was adapted for crisis supporters through collaboration between a crisis support service, clinician researchers, and an eLearning technology company. Empowering crisis supporters, through improving knowledge and highlighting their strengths and expertise, was emphasized. The adaptive learning technology featured a pretest, middle learning module (educational content), and post-test individualized to the participant's incorrect pretest answers. The online training tool on suicidal behaviors in late-life combined clinician researcher expertise and evidence, insights from crisis supporters, and adaptive learning technology to create a purpose-built educational tool addressing an unmet need.