Suicide Risk in Older Adults: The Role and Responsibility of Primary Care
Finally, rigid personality traits or coping styles are a risk factor for suicide among older adults [28,31]. As older adults face potential losses, health changes, and functional decline, effective positive coping strategies and flexibility are key to maintaining well-being. If older adults are unable to flexibly cope with these challenges, their risk for suicide increases [28].
In addition to risk factors, which confer suicide risk but do not necessarily suggest that an older adult is thinking about suicide, warning signs exist that indicate that suicide risk is imminent. These include suicidal communication (ie, talking or writing about suicide), seeking access to means, and making preparations for suicide (eg, ensuring a will is in place, giving away prized possessions). One important note is that discussing and preparing for death may be developmentally appropriate for older adults, particularly those with chronic illnesses; however, such appropriate preparation is critically different from talking about suicide or a desire for death.
Additionally, a lack of planning for the future may be a warning sign. For example, older adults who decline to schedule medical follow-up or do not wish to refill needed prescriptions may be exhibiting warning signs that should be addressed. Similarly, not following needed medical regimens (eg, an older adult with diabetes no longer taking insulin) is also a warning sign. Other, potentially more subtle warning signs may include significant changes in mood, sleep, or social interactions. Older adults may become agitated and sleep less when they are considering suicide, or may feel more at ease after they have made the decision to die by suicide and their sleep or mood may improve. Withdrawing from valued others may also be a warning sign. Finally, recent major changes (eg, loss of a spouse, moving to an assisted living facility) may be triggers for suicide risk and can serve as warning signs themselves.
Specific Screening Strategies
Given the numerous risk factors and warning signs for older adult suicide, as well as the time limitations that primary care practitioners face [44,45], it would be impractical to comprehensively assess each older adult who presents at a primary care practice. Therefore, more specific screening is necessary. Most importantly, every older adult should be screened for suicide ideation and death ideation at every visit. Screening at every visit is critical because suicide ideation may develop at any point. Previous research has included screening of over 29,000 older adults in 11 primary care settings for suicide ideation, risk of alcohol misuse, and mental health disorders [15], suggesting that suicide risk screening is feasible. Other studies have also successfully used widespread screening for depression and suicide ideation among older adults in primary care [46–48]. Additionally, in an emergency department setting, universal suicide risk screening has been associated with significantly improved risk detection [49], indicating that improved screening may be beneficial in identifying suicide risk. Importantly, asking about suicide does not cause thoughts of suicide [50]. Additionally, it is a myth that those who talk about suicide ideation will not act on these thoughts [51].
When primary care practitioners inquire about suicide ideation, they should also ask about death ideation; though some may believe that death ideation is not as significant in terms of suicide risk as suicide ideation, recall that research has not found differences in previous suicide attempts or current hopelessness among older adults with death ideation versus suicide ideation [14]. Therefore, screening for death ideation should be completed as part of every suicide risk screening.
Screening can take many forms. Screening may be oral; asking an older adult if he or she is having thoughts of suicide or is experiencing a desire to die is a brief, 2-question screening that may provide valuable information (eg, “Are you having thoughts about your own death or wanting to die?”, “Are you having thoughts of killing yourself or thinking about suicide?”). This screening may be conducted by medical assistants, nurses, care managers, or physicians, with the patient’s responses documented. Importantly, a standard procedure should be implemented to ensure older adults are consistently asked about suicide risk at each visit, but do not feel inundated by such questions from numerous staff.
If verbal questions are asked, they must be asked appropriately. Euphemisms or indirect language should not be used during a screening; older adults should be directly asked about thoughts of death and suicide, not simply asked questions such as, “Have you ever had thoughts of harming or hurting yourself?” A question like this does not adequately assess current suicide risk, as it does not assess current thoughts, nor does it specifically inquire about suicide ideation (ie, killing one’s self). It is also important to phrase questions in a manner that invites honest responses and conveys an openness to listening. For example, asking, “You’re not thinking about suicide, are you?” suggests that the practitioner wants the older adult to say no and is not comfortable with the older adult endorsing suicide ideation. Open questions that allow endorsement or denial (eg, “Are you having thoughts of killing yourself?”) imply that the practitioner is receptive to either an endorsement or denial of suicide ideation.
