Role of Alcohol in Late-Life Suicide

Behavioral Health Status after Globe Removal in U.S. Service Members

OBJECTIVES

To describe the incidence of new behavioral health (BH) diagnoses in patients who underwent globe removal (GR) in the Military Health System (MHS).

DESIGN

Retrospective cohort study.

SUBJECTS

Active duty service members (SM) who underwent GR and/or were diagnosed with a BH diagnosis between 2017 to 2022 in the MHS system.

METHODS

This retrospective study queried the MHS Mart (M2) database for patients who underwent GR secondary to trauma between 2017 and 2022. A multivariate Poisson regression model, adjusted for age and sex, was used to calculate the relative risk (RR) of new BH diagnoses in patients who underwent GR compared to those who did not. Patients with a BH diagnosis prior to GR were excluded from this analysis.

MAIN OUTCOME MEASURES

Probability of developing a new BH condition after GR compared to non-GR individuals.

RESULTS

There were 901,595 SM patients with a BH diagnosis between 2017 to 2022, and 103 patients had a history of GR secondary to globe trauma. Among the GR group, 29 had a prior BH diagnosis and 27 had a new BH diagnosis post-GR. Compared to the population who have not undergone GR, the estimated RR (95% CI) for patients with a new BH diagnoses post-GR were as follows: suicide or suicidal ideation 47.2 (7.9-145.8), alcohol use disorder 17.3 (7.5-33.5), anxiety 12.8 (6.86-21.5), adjustment disorder 10.5 (5.9-17.0), substance use disorder 5.29 (1.64-12.3), and depression 8.0 (3.2-16.1). The number of lag days was shorter for patients who were diagnosed with a new BH condition after GR (median = 49 days) compared to those who were diagnosed with a BH condition before GR (median = 351 days). Due to the rare events of GR, there were substantial limitations in the calculation of estimated RR. However, this study suggests that patients undergoing GR are at an increased risk for developing a new BH diagnosis, with higher rates of suicide and/or suicidal ideation, substance disorders, and other mental health conditions compared to the non-GR population. Early BH screening is crucial for these patients.

[The influence of an age-specific treatment setting on the success of inpatient detoxification treatment in older patients with substance-related disorders]

In this study, the success of inpatient qualified withdrawal treatment in an age-specific setting was compared with that in a mixed-age setting.175 patients (137 male, average age 59.4 years) with different substance-related disorders were examined. Treatment success was defined as the regular termination of treatment.During the observation period significantly more elderly patients were admitted to the age-specific setting than to the mixed-age setting. Regardless of the treatment setting, more than 80% of patients completed withdrawal treatment regularly. For the overall group as well as for the subgroup of opioid dependent persons in maintenance treatment, withdrawal treatment was significantly more successful in an age-specific setting.The demographic development and these results speak in favor of the implementation of age-specific services for older patients with substance-related disorders.

Alcohol use and the gender-specific risk of suicidal behavior: a systematic review and meta-analysis protocol

BACKGROUND

Alcohol use is an important risk factor for suicidal behavior, with a heightened risk found among women. The objective of this study is to determine the gender-specific risk of suicidal behaviors (suicide attempt and death by suicide) for different levels and dimensions of alcohol use-i.e., for (1) average alcohol volume consumed, (2) binge drinking, and (3) individuals with an alcohol use disorder.

METHODS

We will systematically search the available literature for primary studies on the risk relationships specified above. Using a predetermined set of keywords, a comprehensive systematic literature search will be conducted in the following electronic databases: Embase, PsycINFO, PubMed, and Web of Science. The basic inclusion criteria will be (1) an original, quantitative (cohort, case-control or cross-sectional) study; with (2) a measure of risk of at least one dimension of our alcohol exposures in relation to at least one of our outcomes of interest (suicide attempt or death by suicide), and its corresponding measure of variability is reported (or sufficient data to calculate these); and (3) estimates of risk stratified by gender. Studies (1) that use only qualitative labels of alcohol use, and (2) where suicide attempt and non-suicidal self-harm cannot be disaggregated will be excluded. There will be no restrictions on language, geographical region, or year of publication. Two reviewers will independently perform the search and systematic assessment of each identified study and subsequent extraction of data. Categorical random-effects meta-analyses will be conducted to obtain gender-specific pooled risk estimates. Risk of bias will be assessed using the Risk of Bias In Non-randomised Studies-of Interventions tool and the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of evidence.

DISCUSSION

This study will synthesize all available data on the gender-specific relationship between various dimensions of alcohol use and suicidal behavior simultaneously in a coherent framework. We will provide risk estimates with the detail needed to better understand the respective risk relationships and appreciate the burden of alcohol-attributable suicide.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022320918.

Substance Use Disorders in the Elderly

The population of elderly in the United States with substance use disorders (SUDs) is growing appreciably. SUDs among the elderly are often associated with poor outcomes and are frequently underdiagnosed. The current diagnostic criteria are less sensitive in identifying SUDs among the elderly. Routine screening with validated screening tools may improve the diagnosis of SUDs among the elderly. There is a dearth of data from controlled studies on SUDs among the elderly and the use of pharmacologic agents for treatment, although data indicate that older adults with SUDs respond well to treatments that are specifically designed for this age group.

Completed Suicide by Firearm in an Individual With the Agrammatic Variant of Primary Progressive Aphasia: Case Report

The agrammatic or nonfluent variant of Primary Progressive Aphasia (nfvPPA) is a form of Frontotemporal Dementia (FTD) that is characterized by progressive language dysfunction, poor sentence construction, and low verbal fluency. Individuals with nfvPPA have intact insight into their decline, which may manifest as frustration and hopelessness, and show signs of impulsivity and disinhibition. Little is known about suicide risk in this patient population. Here we describe a case of an 84 year-old male with nfvPPA who, over the course of his care, experienced a decline in language and motoric functioning which coincided with increasing irritability and impulsivity. Despite this significant decline, he denied depressive symptoms or showed any suicidal tendencies, and he seemed to be looking forward to future events. His suicide, committed with a handgun during what appeared to be a rather innocuous trip to the garage, came as a significant shock to his spouse, family, and his clinical care team. To our knowledge, this is the first reported case of completed suicide in a patient with the nfvPPA subtype of FTD. Though this patient demonstrated demographic risk factors for suicide (advanced age, retired military veteran with easy access to firearms) there is a lack of data regarding how FTD may have contributed. Retained insight especially seems to be a risk factor for suicide across all forms of dementia. Impulsivity may be key when considering suicidality amongst FTD patients. Additionally, this case demonstrates the importance of addressing gun safety as there are few guidelines around gun ownership in this patient population.

[Management of suicidal crisis in general practice: evaluation of care practices according to patient age]

Nearly 800,000 people die by suicide each year worldwide. Up to 75% of suicidal patients consulted their general practitioner in the months preceding their attempt. A study, conducted among 167 practitioners in Champagne-Ardenne in 2016-2017, aims to evaluate the practices of general practitioners in the management of suicidal crisis, particularly according to the age of the patient. It provides elements for reflection on their role in suicide prevention.

Utilization of psychiatric services prior to suicide- a retrospective comparison of users with and without previous suicide attempts

INTRODUCTION

The aim was to investigate psychiatric health care utilization two years before death by suicide among individuals with previous suicide attempts (PSA) compared with those without (NSA).

METHOD

A retrospective population-based cohort study was conducted including 484 individuals who died by suicide in Sweden in 2015 and were in contact with psychiatric services within the two years preceding death, identified through the Cause of Death register. Data on psychiatric health care two years before death, including suicide attempts according to notes in the medical record was used. Associations between having at least one PSA vs. NSA and health care utilization were estimated as odds ratios (OR) with 95% confidence intervals (CI) by logistic regression analyses.

RESULTS

Of the 484 individuals included, 51% had PSA. Those with PSA were more likely than NSA to have received a psychiatric diagnosis [OR 1.96 (CI 95% 1.17-3.30)], to have ongoing psychotropic medication [OR 1.96 (CI 95% 1.15-3.36)] and to have been absent from appointments during the last three months [1.97 (1.25-3.13)]. In addition, elevated suicide risk was more often noted in the psychiatric case records of those with a PSA than those without [OR 2.17 (CI 95% 1.24-3.79)].

CONCLUSION

The results underline the importance of improved suicide risk assessment as well as thorough diagnostic assessment and when indicated, psychiatric treatment as suicide preventive interventions regardless of PSA. Furthermore, the larger proportion of absence from appointments in individuals with PSA may indicate a need of improved alliance between psychiatric care providers and individuals with PSA.HIGHLIGHTSBeing assessed with elevated suicide risk was more common among those with previous attempt/s (PSA).One-fifth of all with no previous attempt (NSA) had no psychiatric diagnosis, compared to one in ten in those with PSA.Receiving psychotropic medication was more common among those with PSA.

Sleep disturbances are associated with cortical and subcortical atrophy in alcohol use disorder

Sleep disturbances are prominent in patients with alcohol use disorder (AUD) and predict relapse. So far, the mechanisms underlying sleep disruptions in AUD are poorly understood. Because sleep-related regions vastly overlap with regions, where patients with AUD showed pronounced grey matter (GM) reduction; we hypothesized that GM structure could contribute to sleep disturbances associated with chronic alcohol use. We combined sleep EEG recording and high-resolution structural brain imaging to examine the GM-sleep associations in 36 AUD vs. 26 healthy controls (HC). The patterns of GM-sleep associations differed for N3 vs. REM sleep and for AUD vs. HC. For cortical thickness (CT), CT-sleep associations were significant in AUD but not in HC and were lateralized such that lower CT in right hemisphere was associated with shorter N3, whereas in left hemisphere was associated with shorter REM sleep. For the GM density (GMD), we observed a more extensive positive GMD-N3 association in AUD (right orbitofrontal cortex, cerebellum, dorsal cingulate and occipital cortex) than in HC (right orbitofrontal cortex), and the GMD-REM association was positive in AUD (midline, motor and paralimbic regions) whereas negative in HC (the left supramarginal gyrus). GM structure mediated the effect of chronic alcohol use on the duration of N3 and the age by alcohol effect on REM sleep. Our findings provide evidence that sleep disturbances in AUD were associated with GM reductions. Targeting sleep-related regions might improve sleep in AUD and enhance sleep-induced benefits in cognition and emotional regulation for recovery.

Suicidal Behavior and Club Drugs in Young Adults

Psychoactive drugs play a significant role in suicidality when used for intentional overdose or, more frequently, when the intoxication leads to disinhibition and alterations in judgment, thereby making suicide more likely. In this study, we investigated suicidality prevalence among drug users and evaluated the differences in suicide ideation, taking into account the substance categories and the association of suicide ideation intensity with other psychiatric symptoms. Subjects admitted to the Can Misses Hospital's psychiatry ward in Ibiza were recruited during summer openings of local nightclubs for four consecutive years starting in 2015. The main inclusion criterium was an intake of psychoactive substances during the previous 24 h. The Columbia Suicide Severity Rating Scale (C-SSRS) was used to assess the suicide risk. Suicidality was present in 39% of the study cohort. Suicide Ideation Intensity overall and in the previous month was higher in users of opioids and in general of psychodepressors compared to psychostimulants or psychodysleptics. Suicidality was not correlated with alterations in any of the major psychopathological scales employed to assess the psychiatric background of the study subjects. The presence of high levels of suicidality did not specifically correlate with any major symptom indicative of previous or ongoing psychopathological alterations. These findings suggest that impulsivity and loss of self-control may be determinants of the increased suicidality irrespectively of any major ongoing psychiatric background.

Promoting Healthy Aging During COVID-19

Older adults have been markedly impacted by the coronavirus disease 19 (COVID‐19) pandemic. The American Geriatrics Society previously published a White Paper on Healthy Aging in 2018 that focused on a number of domains that are core to healthy aging in older adults: health promotion, injury prevention, and managing chronic conditions; cognitive health; physical health; mental health; and social health. The potentially devastating consequences of COVID‐19 on health promotion are recognized. The purpose of this article is multifold. First, members of the Healthy Aging Special Interest Group will present the significant difficulties and obstacles faced by older adults during this unprecedented time. Second, we provide guidance to practicing geriatrics healthcare professionals overseeing the care of older adults. We provide a framework for clinical evaluation and screening related to the five aforementioned domains that uniquely impact older adults. Last, we provide strategies that could enhance healthy aging in the era of COVID‐19.

Characteristics of persons who die on their first suicide attempt: results from the National Violent Death Reporting System

BACKGROUND

Much of suicide research focuses on suicide attempt (SA) survivors. Given that more than half of the suicide decedent population dies on their first attempt, this means a significant proportion of the population that dies by suicide is overlooked in research. Little is known about persons who die by suicide on their first attempt-and characterizing this understudied population may improve efforts to identify more individuals at risk for suicide.

METHODS

Data were derived from the National Violent Death Reporting System, from 2005 to 2013. Suicide cases were included if they were 18-89 years old, with a known circumstance leading to their death based on law enforcement and/or medical examiner reports. Decedents with and without a history of SA were compared on demographic, clinical, and suicide characteristics, and circumstances that contributed to their suicide.

RESULTS

A total of 73 490 cases met criteria, and 57 920 (79%) died on their first SA. First attempt decedents were more likely to be male, married, African-American, and over 64. Demographic-adjusted models showed that first attempt decedents were more likely to use highly lethal methods, less likely to have a known mental health problem or to have disclosed their intent to others, and more likely to die in the context of physical health or criminal/legal problem.

CONCLUSIONS

First attempt suicide decedents are demographically different from decedents with a history of SA, are more likely to use lethal methods and are more likely to die in the context of specific stressful life circumstances.

Self-reported sleep disturbance in ambulance attendances for suicidal ideation and attempted suicide between 2012 and 2017

BACKGROUND

Sleep disturbances are among the top-ten warning signs for suicide, however there has been limited investigation of the relationship between these variables in acute presentations, particularly community settings. We examined ambulance attendances for suicide ideation and attempt to explore the role of sleep and co-morbid factors (mental health symptoms, attendance time, and alcohol and benzodiazepine use).

METHODS

Coded clinical records from Ambulance Victoria for the period 1 January 2012 to 30 June 2017 were analysed.

RESULTS

Paramedics attended 97,198 cases of suicidal ideation or suicide attempt during the study period. Just over half (56.4%) of these were for suicidal ideation, and 43.6% were for attempted suicide. Depression symptomology-related attendances were more common than those for anxiety and despite a lower proportion of both sleep and current anxiety-related symptoms, benzodiazepine use was significantly more common in attendances for suicide attempts (25.9%) than for ideation (2.2%). Co-morbid benzodiazepine use was associated with attempted suicide (OR: 10.37 (10.04-10.72), in a hierarchical regression model.

LIMITATIONS

Data represent self-report/paramedic observation only, and do include validated measures of sleep or drug use. Sleep disturbance is likely under recorded in ambulance attendances given the primary role of paramedics is to stabilise patients, and minimise risk of harm during transport.

CONCLUSION

This study reports internationally unique data, and provides the first examination of ambulance coded clinical records for suicide ideation and attempt. Sleep disturbances had a unique role in these attendances, over and above common co-occurring factors including drug use and mental health diagnoses.

Influencing and protective factors of suicidal ideation among older adults

Suicide is a global issue, but few studies have explored the triggers and psychological feelings of suicidal ideation in older adults. A qualitative design with face-to-face semistructured interviews examined the experience of suicidal ideation in adults aged 65 years and older. A purposive sampling of 32 outpatients with suicidal ideation from a medical centre in northern Taiwan participated. Interview data identified three themes: triggers for suicidal ideation, contributing psychological changes, and factors of adaptive response. The triggers for suicidal ideation included physical discomfort, loss of respect and/or support from family, impulsive emotions due to conflicts with others, and painful memories. Psychological changes contributed to suicidal ideation: feelings of loneliness, a sense of helplessness, or lack of self-worth. Participants described adaptive responses that acted as protective factors of suicidal ideation: support from family and friends, control of emotions, establishing a support network, comfort from religion, medication, and focussing on the family. Mental health nurses and clinicians should incorporate evaluations of stressful life events and psychological changes into a screening scale for older adults to improve detection of those at risk for suicide. Teaching coping strategies could provide timely interventions to secure the safety of this older population of adults.

Neurobiology of Elderly Suicide

Suicide in the elderly is an underestimated and complex issue that has mainly been explored in sociological, clinical and psychological perspectives. Suicide in non-elderly adults has been associated with diverse neurobiological alterations that may shed light on future predictive markers and more efficient preventative interventions. The aim of this paper was to review studies specifically investigating the neurobiology of elderly suicidal behaviour. We performed a systematic English and French Medline and EMBASE search until 2013. Contrary to literature about the non-elderly, we found a paucity of studies investigating the biomarkers of suicidal risk in elderly adults. Main findings were found in the neurocognitive domain. Studies generally supported the existence of cognitive deficits, notably decision-making impairment and reduced cognitive inhibition, in patients with a history of suicidal act compared to patients without such history. However, replications are needed to confirm findings. Due to several limitations including the small number of available studies, frequent lack of replication and small sample size, no firm conclusions can be drawn. The authors encourage further investigations in this field as insight in the neurobiology of these complex behaviors may limit clichés about end of life and aging, as well as improve future prevention of suicide in the elderly.

Alcohol-Related Diagnoses in Hospital Admissions for All Causes Among Middle-Aged and Older Adults: Trends and Cohort Differences From 1993 to 2010

OBJECTIVE

This aim of this study was to characterize trends in alcohol-related hospital admissions among middle-aged and older adults from 1993 to 2010 in relation to age, gender, race, and cohort membership.

METHOD

This study utilized repeated cross-sectional data from the Nationwide Inpatient Sample. Using alcohol-related classified admissions, yearly rates and longitudinal trends of alcohol-related inpatient hospitalizations based on age, period, birth cohort, gender, and race were estimated.

RESULTS

Among those aged 45 and older, admissions rose from an estimated 610,634 to more than 1,134,876, and rates of any alcohol-related diagnosis also increased from 1993 to 2010. Rates for men were consistently higher than women, and rates for Blacks were higher than Whites. Age was associated with decreasing rates, but post-World War II cohorts displayed higher rates over time.

DISCUSSION

Rates of alcohol-related admissions are increasing among adults above age 45, which may be a function of cohort effects. Training the health care workforce is crucial to respond to this trend.

Associations of Mental Health and Substance Use Disorders With Presenting Problems and Outcomes in Older Adults' Emergency Department Visits

OBJECTIVES

The increasing prevalence of mental health and/or substance use disorders in older adults is a significant public health issue affecting their health, health care use, and health care outcomes. These disorders are especially prevalent in emergency department (ED) visits. This study examined the effect of mental health and substance use disorders on older adults' ED presenting problems and outcomes.

METHODS

Data were from the publicly available 2012 Nationwide Emergency Department Sample data set (unweighted n = 5,344,743 visits by the 65+ years age group). We used binary logistic regression analysis to test relationships between mental health and substance use disorders and suicide attempts, falls, and other injuries and multinomial logistic regression analysis to test relationships between the disorders and ED outcomes of death, hospital admission, transfer to institutional care, home health care, leaving against medical advice (AMA), or other or unknown destinations, as opposed to routine care.

RESULTS

Of ED visits by older adults, 5.1% involved anxiety disorders, 7.1% involved mood disorders, 10.45% involved delirium/dementia, 1.4% involved alcohol use disorders, and 0.6% involved drug use disorders; 0.2% were suicide-related, 12.0% involved falls, and 10.2% involved other injuries. Mental health and substance use disorders had large-to-medium effects on suicide attempts. Both dementia and delirium and alcohol use disorders had a small effect on falls. Drug use disorders had a small effect on other injuries. Anxiety disorder had a small effect on the risk of death in the ED or in the hospital, relative to routine care. Suicide attempts and drug use disorders had a medium effect on hospital admission. Suicide attempts had a large effect, delirium and dementia and other mental disorders had medium effects, and mood disorder had a small effect on the risk of transfer to another facility. Delirium and dementia, suicide attempts, and drug use disorders had small effects on the risk of discharge with home health care. Alcohol use disorders and drug use disorders had a small effect on the risk of leaving AMA. Finally, suicide attempts had a medium effect on the risk of other outcomes and unknown destinations.

CONCLUSIONS

Late-life mental health and substance use disorders are significant risk factors for both intentional self-harm and unintentional injuries that bring older adults to the ED and contribute to ED dispositions and outcomes that involve more intensive and longer-term health care services. The findings underscore the importance of detection and treatment of these disorders among older adults before they end up in the ED.

Associations of lifetime abstention and past and current alcohol use with late-life mental health: a propensity score analysis

BACKGROUND

Compared to the extensive research on the effects of alcohol intake on physical health, little research has been done on the effects of alcohol use/nonuse patterns on mental disorders in late life. This study examined associations between mental disorders and alcohol use/nonuse patterns among individuals aged 65+ years.

METHODS

Data came from the public use files of the 2008 to 2012 National Survey on Drug Use and Health. Alcohol use/nonuse groups were lifetime abstainers, ex-drinkers, bingers, and nonbingers. Mental health problems were lifetime major depressive episode (MDE) and anxiety disorder, past-year MDE and anxiety disorder, and past-year serious suicidal ideation. To minimize selection biases resulting from a complex array of covariates, we implemented a generalized boosted model to generate propensity score weights on covariates. Then we employed logistic regression models with mental health outcomes as the dependent variables.

RESULTS

The four alcohol use/nonuse groups did not differ in past-year MDE. However, odds ratios show that, relative to non-binge drinking, lifetime abstention decreased the odds of lifetime MDE by more than 60% (OR = 0.39, 95% CI = 0.23-0.68, p = .001) and the odds of lifetime anxiety disorder by almost half (OR = 0.55, 95% CI = 0.38-0.79, p = .002). Ex-drinkers were more likely than nonbingers to report past-year serious suicidal thoughts (OR = 2.29, 95% CI = 1.45-3.62, p < .001).

CONCLUSIONS

While lifetime abstainers had significantly better lifetime mental health histories than nonbingers, ex-drinkers had worse past-year mental health status. Since lifetime abstainers and ex-drinkers have significantly different characteristics, researchers should distinguish between these groups.

Middle-aged and older adults who had serious suicidal thoughts: who made suicide plans and nonfatal suicide attempts?

BACKGROUND

High suicide rates in late middle-aged and older adults are significant public health problems. Although suicide risk and protective factors are well established, more research is needed about suicide planners and attempters. Using multi-year, national epidemiologic survey data, this study identified correlates of making suicide plans and nonfatal suicide attempts among U.S. adults aged 50+ years.

METHODS

Data are from the 2008 to 2012 U.S. National Survey on Drug Use and Health (NSDUH). Descriptive statistics were used to examine sample characteristics by past-year serious suicidal thoughts, suicide plans, and suicide attempts. Binary logistic regression analyses were used to examine potential correlates (sociodemographic factors, health status, religiosity, psychiatric and substance use disorders (SUDs), and mental health and substance abuse treatment use) of suicide plans and suicide attempts among those who reported serious suicidal thoughts.

RESULTS

Of the 2.5% of the study population that had serious suicidal thoughts (n = 804), 28% made suicide plans and 11.5% attempted suicide. Although 42% of those with serious suicidal thoughts had major depressive episode (MDE), MDE was not significantly associated with suicide plans or attempts in multivariate models. Being employed decreased the odds of making suicide plans, while mental health service use was associated with increased odds of suicide plans. SUDs increased the odds of suicide attempts.

CONCLUSIONS

It is important to screen middle-aged and older adults for severe mental and SUDs and suicidal thoughts and to target interventions for likely planners and attempters.

Psychiatric care of the older adult: an overview for primary care

As the population ages, primary care providers will be frequently called on to manage psychiatric disorders suffered by their older patients. This overview of delirium, dementia, depression, and alcohol and substance misuse highlights the common presentations and suggests initial approaches to treatment. The challenges facing caregivers are also discussed.

Understanding older adults' attitudes and beliefs about drinking: perspectives of residents in congregate living

Drinking motives may change as adults age, yet few studies in the United States of America have examined older adults' perspectives about their own drinking habits. The current study explored beliefs and attitudes of alcohol use of retired adults residing in a congregate care setting in the Baltimore/Washington DC metro area. Individual interviews were conducted with a sub-sample of 11 individuals who participated in a daily diary study on alcohol use among older adults. All participants in the study were identified as regular drinkers, meaning they had an alcoholic beverage on at least six of the eight days prior to screening. The participants' mean age was 81.5 years with a majority being women (54.5%). Older adults reported alcohol use as a long-term habit or routine. Participants also recognised that their alcohol use was influenced by peer drinking and by the availability of alcohol at the congregate care setting. Participants normalised their drinking as a form of routine socialisation carried from earlier life stages. Participants did not report reactive drinking, suggesting that older drinkers do not see their alcohol use as driven by specific reactions to life stresses or losses associated with ageing. The study also indicates that drinking may provide older adults in congregate care with a sense of continuity from before retirement and preserve their identity and autonomy.

Secular changes in at-risk drinking in Sweden: birth cohort comparisons in 75-year-old men and women 1976-2006

Background: little is known about the prevalence of at-risk drinking in older adults.

Objective: to compare rates of at-risk drinking in 75-year-olds examined in 1976–77 and in 2005–06.

Design: cross-sectional survey.

Setting: two samples representative of the general population in Gothenburg, Sweden.

Participants: 75-year-olds born in 1901–02 (n = 303) and in 1930 (n = 753).

Methods: participants took part in a multidisciplinary study on health and ageing. Protocols regarding alcohol consumption were identical for both cohorts. Total weekly alcohol intake was estimated and at-risk drinking was defined as ≥100 g alcohol/week.

Results: the proportion abstaining differed significantly between birth cohorts (18% in 1976–77 versus 9% in 2005, P < 0.001). Frequencies of drinking beer and liquor were similar in the two cohorts for men, but were lower for women in the later-born cohort. Proportions drinking wine were higher in the later-born cohort for both sexes. Total weekly alcohol intake was higher for both men and women. At-risk drinking was observed in 19.3% of the men in the earlier-born cohort, and in 27.4% in the later-born cohort (P = 0.117). Corresponding figures for women were 0.6 and 10.4% (P < 0.001). At-risk drinking was significantly associated with birth cohort in women (OR: 13.77, CI: 1.82–104.0, P = 0.011) and the occupational group in men (OR: 1.60, CI: 1.13–2.26, P = 0.008).

Conclusions: alcohol consumption in 75-year-olds has changed markedly, especially in women. Studies need to be carried out in varied settings in order to evaluate the clinical and public health implications of changing trends in alcohol consumption.

Substance Use and Associated Health Conditions throughout the Lifespan

A life stage perspective is necessary for development of age-appropriate strategies to address substance use disorders (SUDs) and related health conditions in order to produce better overall health and well-being. The current review evaluated the literature across three major life stages: adolescence, adulthood, and older adulthood.

FINDINGS

1) Substance use is often initiated in adolescence, but it is during adulthood that prevalence rates for SUDs peak; and while substance involvement is less common among older adults, the risk for health complications associated with use increases. 2) Alcohol, tobacco, marijuana, and, increasingly, prescription medications, are the most commonly misused substances across age groups; however, the use pattern of these and other drugs and the salient impact vary depending on life stage. 3) In terms of health outcomes, all ages are at risk for overdose, accidental injury, and attempted suicide. Adolescents are more likely to be in vehicular accidents while older adults are at greater risk for damaging falls. Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder).

CONCLUSION

Prolonged heavy use of drugs and/or alcohol results in an array of serious health conditions. Addressing SUDs from a life stage perspective with assessment and treatment approaches incorporating co-occurring disorders are necessary to successfully impact overall health.

[Suicide in the elderly: age-related specificities?]

Suicide in the elderly raises the question of our relationship with aging and death. Suicide rate is relatively high in this group and is significantly related to depression widely under-diagnosed in the elderly. Suicidal behaviour in the elderly has clinical specificities including high intentionality and lethality, usually little personal history of suicidal behaviour and low levels of impulsivity-aggression. Suicidal vulnerability could rely on etiopathogenic mechanisms both common and different according to age; for example, a preponderance of early developmental factors and impulsivity-aggression in adolescents and young adults vs. pathological aging in older adults, but partly similar neurocognitive deficits leading individuals not to respond adequately to their environment (itself different with age). Direct comparisons between elderly and younger subjects would be required. The article concludes with a summary of the principles of recognition and management of suicide risk.

Validation of the Drinking Motives Questionnaire (DMQ) in older adults

Drinking motives have been established as an important construct in the prediction of alcohol use and drinking problems among younger adults, but there is little understanding about the drinking motivations of older adults. Although emerging evidence shows the importance of studying older adults' own reasoning for their alcohol consumption, measures that have been used to assess such reasons lack psychometric assessment. This study aims to validate the three-dimensional structure of the Drinking Motives Questionnaire (DMQ) in older adults and to investigate the relationships between drinking motives and alcohol use. A sample of community dwelling older adults (N=370) completed self-report measures assessing drinking behavior and motives for drinking. Using confirmatory factor analysis, the results supported a three-factor model of drinking motives. Multi-group analysis of invariance showed support for configural and metric invariance, and partial support was met for scalar invariance. Social motivations for drinking were the most frequently endorsed, followed by enhancement, and coping motives. Males reported more frequent drinking for each of the three motives. Social motives were consistently related to drinking behaviors and coping had a direct relationship to drinking problems. Overall, the study shows that the DMQ has promise as a measure for use with older adults.

Examining a brief suicide screening tool in older adults engaging in risky alcohol use

Alcohol misuse increases risk of suicidal behavior in older adults. The Depressive Symptom Inventory-Suicidality Subscale (DSI-SS; Metalsky & Joiner, 1997) and its relation to suicide attempt history was examined to see if it differed for older adults as a function of their alcohol use. Structural equation modeling was used in a sample (N=1,061) of older adult outpatients to examine the scale's measurement invariance and population heterogeneity and its relation to suicide attempt history. Analyses supported the equivalence of the DSI-SS in risky and nonrisky drinkers. The DSI-SS significantly predicted past suicide attempts. Findings support the viability of the DSI-SS as suicide screening tool for older adults.

Suicidal behaviours in affective disorders: a deficit of cognitive inhibition?

OBJECTIVE

Suicide has been related to affective disorders. We hypothesized that suicide could be associated with cognitive inhibition deficit. Our study aimed to systematically review all published articles that examined the relation between cognitive inhibition deficit and suicidal behaviours (that is, suicide attempt or suicidal ideation) in patients with affective disorders.

METHOD

We performed an English and French MEDLINE and EMBASE search, ranging from 1970 to 2010, indexed under the MeSH terms of suicide, neuropsychology, neuropsychological tests, and executive function, combined with the following title and abstract terms: neuropsychological functions, executive functioning, and executive performance.

RESULTS

Among the 164 selected studies, 9 observational studies met the selection criteria and were included in the final analysis. The number of participants ranged from 57 to 244 (28% to 66%, respectively, were men). Executive dysfunction was more frequently found among patients with suicidal behaviours. In particular, higher cognitive inhibition deficit was observed in depressed subjects with suicide behaviours, compared with depressed subjects without any suicidal behaviour. The results of the meta-analysis showed a higher impairment in inhibition score, according to the number of perseverations in the Wisconsin Card Sorting Test (Cohen d = 0.68) than in inhibition according to the time needed to perform the Trail-Making Test part B (d = 0.01) among patients with suicidal behaviour, compared with patients with no suicidal behaviour.

CONCLUSION

This systematic review and meta-analysis showed a positive association between cognitive inhibition deficit and suicide attempts in patients with affective disorders. Future research should examine whether cognitive inhibition deficit precedes the suicidal behaviour.

Patterns of alcohol and drug use among depressed older adults seeking outpatient psychiatric services

OBJECTIVE

Alcohol and drug use and related problems may compromise depression treatment, and older adults may be especially at risk for poor outcomes. However, alcohol and drug use among older adults have not been studied in settings in which depression treatment is provided. This study examined the prevalence and clinical and demographic correlates of alcohol and drug use and misuse of prescription drugs among adults with depression seeking outpatient psychiatric care (excluding chemical dependency treatment).

METHODS

The sample included 154 older adults (age 60 years and older who scored ≥10 on the Beck Depression Inventory-II [BDI-II] at intake). Participants also completed alcohol and drug use questions and the Short Michigan Alcohol Screening Test.

RESULTS

Recent alcohol and drug use, heavy episodic drinking, and history of alcohol-related problems were common. Alcohol use in the prior 30 days was reported by 53% of men and 50% of women. Cannabis use in the prior 30 days was reported by 12% of men and 4% of women; and misuse of sedatives in the prior 30 days was reported by 16% of men and 9% of women. In exact logistic regression, higher BDI-II score was associated with cannabis use (odds ratio = 15.8, 95% confidence interval = 2.0-734.0, exactp = 0.003).

CONCLUSIONS

Older adults with depression are likely to present for treatment with a range of concurrent alcohol and drug use patterns, including cannabis use and misuse of prescription medication. Clinicians should evaluate depressed patients for substance use and related problems and consider appropriate interventions.

The association between personality disorder and an act of deliberate self harm in the older person

BACKGROUND

Suicide rates are higher in the over 65s than in younger adults and there is a strong link between deliberate self harm (DSH) and suicide in older people. The association between personality disorder (PD) and DSH in older adults remains uncertain. Our objective was to describe this association.

METHODS

A case control study was conducted in which participants were: (i) those who had undertaken an act of DSH and (ii) a hospital-based control group drawn from a geographical contiguous population. PD was assessed using the Standardised Assessment of Personality (SAP).

RESULTS

Seventy-seven cases of DSH were identified; 61 (79.2%) of these participants were interviewed. There were 171 potential controls identified of whom 140 (81.9%) were included. An SAP was completed in 45/61 (73.8%) of cases and 100/140 (71.4%) of controls. The mean age was 79.8 years (SD = 9, range 65-103). The crude odds ratio for the association between PD and DSH was 5.91 [(95% CI 2.3, 14.9) p<0.0001]. There was a strong interaction with age stratified at 80 years. There was no association between PD and DSH after age 80. The adjusted odds ratio for PD in the group <80 years was 20.5 [(95% CI 3, 141) p = 0.002]. Borderline and impulsive PD traits tended to be associated with an episode of DSH more than other personality types.

CONCLUSIONS

PD appears to be a strong and independent risk for an act of DSH in people aged between 65 and 80 years and should be looked for as part of any risk assessment in this population. Access to specialist services may be required to optimally manage this problem and reduce the subsequent risk of suicide.

Alcohol use disorders in geriatrics

Alcohol use disorders cause significant morbidity and mortality in the geriatric population. This review article begins with a hypothetical case for illustration, asking what the primary care physician could do for a geriatric patient with alcohol abuse over a course of four office visits. Various aspects of alcohol use disorders in the geriatric population are reviewed, such as range of alcohol use, epidemiology, medical/psychiatric impact, detection, comprehensive treatment planning, modalities of psychotherapy, medication management, and resources for clinicians/patients.

Older adults' inpatient and emergency department utilization for ambulatory-care-sensitive conditions: relationship with alcohol consumption

OBJECTIVE

This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries.

METHOD

This secondary data analysis used the 2001-2006 Medicare Current Beneficiary Survey (unweighted n = 5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission.

RESULTS

Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio = 1.91, 95% CI: 1.11-3.30; p < .05). Drinking pattern was not significant for other ACSC measures.

DISCUSSION

Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower quality outpatient care.

Case-control study of suicide attempts in the elderly

BACKGROUND

Prior studies have inadequately explored the relationship between late-life suicidal behavior and subclinical/clinical symptoms. This study aimed to assess the risk associated with subclinical symptoms, mild cognitive impairment and clinical factors among late-life suicide attempters.

METHOD

Forty-three elderly patients aged 60 years and older who sought emergency services in a university-affiliated general hospital for attempting suicide and 43 comparison subjects participated in this study between March 2005 and December 2006. The comparison group was recruited by advertising in the community around the hospital. DSM-IV based diagnostic interview and screening instruments including the GDS, MMSE, BSRS-5 and APGAR were applied. Adjusted odds ratios were measured in the final multiple logistic regression model.

RESULTS

Suicide attempters were more likely to meet a diagnosis of depressive disorder, after adjustments for BSRS-5 score and drinking habit. The adjusted odds of suicide among people with a BSRS-5 score of more than 5 points was 17.8 times higher than those with the BSRS score less than or equal to 5 points.

CONCLUSIONS

Our findings support the significant impact on late-life suicidal behavior from the assessment of subclinical symptoms, including anxiety, depression, hostility, sleep condition and interpersonal symptoms. The assessment of subclinical symptoms by the BSRS-5 may help in the future prevention of late-life suicidal behavior in primary care settings.

Alcohol-drinking history and fatal injury in older adults

Although most clinical guidelines for older adults allow for one drink a day in persons without a history of alcoholism, diabetes, or cardiovascular disease, alcohol may contribute to fatal injury in the elderly. Using two national surveys, this case-control study determined the associations between drinking history and fatal injuries from falls, motor vehicle crashes and suicides. We performed a case-control study using 1,735 cases who died of falls, motor vehicle crashes, or suicides selected from the 1993 National Mortality Follow-Back Survey; controls (n=13,381) were a representative sample of the U.S. population from the 1992 National Longitudinal Alcohol Epidemiologic Survey. Cases and controls were restricted to ages 55 years and older. Having 12 or more drinks in the year before death or interview for the controls was used to assess alcohol-drinking history. The unadjusted relative odds for drinkers versus nondrinkers for falls, motor vehicle crashes, and suicides were 1.7, 1.7, and 1.6, respectively. Adjustment for age, gender, marital status, education, and working in the last year did not change these effect estimates, which all excluded the null value. Drinking increased the risk of suicide more for women than for men. Drinking history in older adults is associated about equally with an increased risk of fatal injury from falls, motor vehicle crashes, and suicides.

Longitudinal Study of Suicide After Traumatic Injury

BACKGROUND

Suicide risk after discharge among trauma patients could be influenced by multiple factors. The aim of this study is to establish whether patients discharged from a trauma center experience an increased suicide rate and whether this can be explained by defined demographic, injury, or alcohol abuse risk factors.

METHODS

Patients admitted between July 1, 1983, and June 30, 1995, and discharged alive from a Level I trauma center (n = 27,399) were followed for 1.5 to 14.5 years to determine whether they had died. Death determination was made by an epidemiologic support service, which had created a repository of death certificates. Variables used in the analyses included age, gender, race, Injury Severity Score, discharge disposition, mechanism of injury, and alcohol toxicology. General and trauma populations were compared using standard mortality rates. Risk factors for suicide within the trauma population were explored using Pearson's chi2, Mantel-Haenszel chi2, Cox proportional hazards, and Mantel-Cox log-rank methodology.

RESULTS

Suicide was more common in the trauma than in the general population (standard mortality rate = 1.71). This difference may be attributed primarily to alcohol use problems. Suicide risk in the trauma population increased with age from 25 to 44 years, male gender, Caucasian race, and positive alcohol toxicology. Disability (as measured by discharge disposition), but not injury severity, also seemed to have an influence on suicide rates.

CONCLUSION

Interventions that address modifiable risk factors for suicide (substance abuse, psychiatric disorders, hopelessness, and social isolation) could benefit trauma patients known to be at higher risk for suicide, particularly those abusing alcohol.

Psychiatric Emergencies in the Elderly Population

This article reviews the most common behavioral emergencies in the geriatric population. Psychiatric emergencies are seen frequently by emergency physicians who face the challenge of assessing and managing patients presenting with psychosis, severe depression, agitation, suicidal intent, and substance abuse in the emergency department. The evaluation is frequently complicated by the necessity to investigate numerous domains such as underlying medical conditions, prior psychiatric disorders and substance abuse, as well as psychosocial factors. It is crucial to rule out organic causes for what appears to be psychiatric disease in the elderly. The assessment might be further complicated by the patient's limited ability to recall pertinent aspects of the history due to either cognitive impairment or acute distress. Emergency department personnel might have inadequate expertise in assessing emergencies in elderly persons, further impeding the ability to appropriately manage behavioral complications in geriatric patients. Availability of high-quality emergency care and tight collaboration with primary care providers, psychiatric consultants, and social services is crucial to optimal outcomes from acute psychiatric decompensations in the elderly.

Geriatric alcoholism

BACKGROUND

The authors reviewed the clinical features, epidemiology, diagnosis, medical treatment, orofacial findings and dental treatment of geriatric patients with alcoholism.

TYPES OF STUDIES REVIEWED

The authors conducted MEDLINE searches for the period 1995 through 2004 using the terms "alcoholism," "geriatric," "pathophysiology," "treatment" and "dentistry." They selected reports published in English in peer-reviewed journals for further review.

RESULTS

Physiological changes associated with aging permit the harmful effects of drinking alcohol to arise at lower levels of consumption than in younger people. Excessive use of alcohol exacerbates the medical and emotional problems associated with aging and predisposes the person to adverse drug reactions with medications controlling these illnesses.

CLINICAL IMPLICATIONS

The incidence of dental disease in this population is extensive because of diminished salivary flow and a disinterest in performing appropriate oral hygiene techniques. Concurrent abuse of tobacco products worsens dental disease and heightens the risk of developing oral cancer. Identification of patients who abuse alcohol, a cancer-screening examination, preventive dental education, and use of saliva substitutes and anticaries agents are indicated. Clinicians must take precautions when performing surgery and when prescribing or administering analgesics, antibiotics or sedative agents that are likely to have an adverse interaction with alcohol.