Suicide in old age is a serious public health problem worldwide. Older adults’ population is at particular risk of suicidal behavior due to a combination of factors, including physical illness, social isolation, loneliness, bereavement, and depression. Indeed, older people are more likely to die by suicide than any other age group in most countries (World Health Organization, 2021). In this regard, data from the Global Burden of Disease study show that, although age-standardized suicide mortality rates decreased globally by 32.7% from 1990 to 2016 (Naghavi, Reference Naghavi2019), with a more marked decrease among older adults, suicide rates among individuals aged 65 years and over are still the highest among men and women in nearly all regions of the world (Naghavi, Reference Naghavi2019; WHO, 2021) and tend to increase further with age, continuing this trend even among centenarians (Shah et al., Reference Shah, Bhat, Zarate-Escudero, De Leo and Erlangsen2016).
Globally, suicide in old age affects 27.45 individuals per 100,000 population in the over 70 years of age group and 16.17 individuals per 100,000 population in the 50 to 69 years of age group (IHME, 2018). In Australia, the age-adjusted suicide rate among men aged 85 years and over (36.2/100,000 person-years) was three times higher than that observed in the general population (12.1/100,000 person-years) (Australian Institute of Health and Welfare, 2022). An Australian study also found that, while suicide rates in women tend to remain stable throughout the course of old age, men appear as increasingly more vulnerable to suicide in the more advanced age groups (85 years of age and older) (Koo et al., Reference Koo, Kolves and De Leo2017). These gender differences could perhaps be explained by women’s greater propensity to seek help, obtain health care, and use less violent methods of suicide (Schriivers et al., Reference Schriivers, Bollen and Sabbe2012).
Aged care recipients and suicide: new data from Australia
Approximately 36% of Australians over the age of 65 years access aged care services each year (Australian Government Department of Health, 2021). Over the course of their lives, two-thirds of older adults use either temporary, permanent, or home-based care services (Chomik and Townley, Reference Chomik and Townley2019). Data on suicide mortality in old people requiring assistance are very limited or virtually absent. To fill this gap, Cations et al. (Reference Cations2023) wanted to propose an exploratory study, through the analysis of a cohort of older adults who died by suicide in Australia during access or while waiting to receive assistance services, permanent residential or home care, between 2008 and 2017. The data they obtained and presented in International Psychogeriatrics provide insight into the sociodemographic and clinical characteristics of those who have died by suicide and help identify psychosocial risk factors associated with suicide at contexts of care for older individuals, as well as investigating the prevalence of their access to mental health services and the use of psychotropic drugs in the year preceding death.
The study by Cations et al. (Reference Cations2023) was conducted using the National Historical Cohort of the Registry of Senior Australians (ROSA) (Inacio et al., Reference Inacio2019), that is, a platform made up of anonymous data of older adults users receiving assistance services in Australia, which contains data in liaison with the National Aged Care Data Clearinghouse and the Australian Institute of Health and Welfare (AIHW) National Death Index (NDI), the Australian Government Medicare Benefits Schedule (MBS) and PBS (Pharmaceutical Benefits Scheme), as well as state hospital data collections (New South Wales, Victoria, South Australia and Queensland only). The study included all people aged 65 years and over who were assessed as eligible for formal aged care, home-based, or permanent residential services. The multi-professional assessments aimed at the person’s functional and cognitive impairments in order to determine as accurately as possible the level of support required by older individuals and to offer personalized services capable of guaranteeing the person’s safety and well-being. The analyses of the data used for the study were carried out considering the type of service received by the older adults at the time of death. Indeed, existing evidence suggests that suicide rates and factors influencing death by suicide differ between those living in settings where lifelong residential care is offered and those living in the community (Murphy et al., Reference Murphy, Bugeja, Pilgrim and Ibrahim2018).
Overall, Cations et al’ study found that the suicide death rate among home care and continuing residential care recipients is lower than that of the general population of older Australians (Australian Institute of Health and Welfare, 2022). This could suggest that care services for older adults have a protective function able of modulating the risk of suicide, perhaps because they are capable of providing continuous monitoring and greater safety of the person, as well as reducing access to means of suicide. In their study, Cations et al. (Reference Cations2023) positively emphasize the protective role of care services for older adults, attributing them the ability to promote the psychological well-being of the frail person and to reduce social isolation by promoting, where possible, greater autonomy of the person (Royal Commission into Aged Care Quality and Safety, 2019). Those authors have also highlighted that the growing frailty of individuals with cognitive impairment or dementia is associated with a lower probability of death by suicide among those who live in residential facilities or are waiting to receive assistance, a fact probably explained by the fact that the person’s functional and cognitive limitations may also reduce the ability to perform a suicidal act (Murphy et al., Reference Murphy, Bugeja, Pilgrim and Ibrahim2018). Another interesting result concerns the fact that within the analyzed cohort, people waiting to receive assistance died by suicide more frequently than those who were receiving it (Cations et al., Reference Cations2023). This finding confirms the results of a previous study, which highlighted that a prolonged transition to residential care was a risk factor for suicide in older adults (Mezuk et al., Reference Mezuk, Ko, Kalesnikava and Jurgens2019).
Additionally, older men were more likely to die by suicide than women. This is consistent with general population-based data that older men have the highest age-adjusted suicide rate of any group both in Australia (Australian Institute of Health and Welfare, 2022) and internationally (WHO, 2021). The research by Cations et al. (Reference Cations2023) also showed that older adults who died by suicide had greater access to mental health services in the year prior to their death than those who died from other causes. The authors take the opportunity to point out that also in Australia, government-subsidised mental health services tend to be underutilized by both healthy older adults and older care recipients, a problem that should certainly attract the attention of public health planners (Cations et al., Reference Cations2022).
Conclusions
The study by Cations et al. (Reference Cations2023) highlights the importance of effectively preventing suicide in individuals institutionalized or benefiting from home care through multicomponent interventions that aim to reduce social isolation, clinical symptoms, and access to lethal methods, while capable to increase awareness of the person’s needs and access to support and treatment services. In fact, important barriers to accessing mental health services seem to characterize older adults, including a low propensity to ask for help (Polacsek et al., Reference Polacsek, Boardman and McCann2019).
Prevention of suicide in old age should considerably expand its range of interventions and pay more attention to the numerous socio-environmental conditions that can have a particularly impact in late life. The fight against ageism and stereotyped thinking, which is pervasive in society, including among health care professionals, must be pursued with great vigor (de Mendonça Lima et al., Reference de Mendonça Lima, De Leo, Ivbijaro and Svab2021). Research should promote the investigation of individual and contextual factors (e.g. how is life in a large nursing home?) associated with suicide and include personal or environmental details in the analysis about the person’s experience with care services, in such a way as to add depth to the data and stimulate more qualitative research on older adults with suicidal ideation. This would favor a better understanding of the phenomenology and the experience lived by this particular population and permit the implementation of intervention programs adapted to the need of the person.
To date, studies have indicated that implementing gatekeeper interventions appear as effective strategies for suicide prevention; probably, those programs could be applied in aged care settings too (Krysinska et al., Reference Krysinska2016; de Mendonça Lima et al., Reference de Mendonça Lima, De Leo, Ivbijaro and Svab2021). Theoretically, interventions aimed at reducing social isolation and loneliness could also contribute to preventing suicide in late life; however, the impact of such programs is still unproven (De Leo, Reference De Leo2022). In addition, the implementation of these programs in aged care settings could be particularly challenging, given the limited availability of mental health skills in the actual workforce of those settings (Jones et al., Reference Jones, Matias, Powell, Jones, Fishburn and Looi2007). Thus, any policy initiative to promote mental health skills in personnel and access to mental health care by users in those contexts would be particularly important.
Suicide in old age is a serious public health problem worldwide. Older adults’ population is at particular risk of suicidal behavior due to a combination of factors, including physical illness, social isolation, loneliness, bereavement, and depression. Indeed, older people are more likely to die by suicide than any other age group in most countries (World Health Organization, 2021). In this regard, data from the Global Burden of Disease study show that, although age-standardized suicide mortality rates decreased globally by 32.7% from 1990 to 2016 (Naghavi, Reference Naghavi2019), with a more marked decrease among older adults, suicide rates among individuals aged 65 years and over are still the highest among men and women in nearly all regions of the world (Naghavi, Reference Naghavi2019; WHO, 2021) and tend to increase further with age, continuing this trend even among centenarians (Shah et al., Reference Shah, Bhat, Zarate-Escudero, De Leo and Erlangsen2016).
Globally, suicide in old age affects 27.45 individuals per 100,000 population in the over 70 years of age group and 16.17 individuals per 100,000 population in the 50 to 69 years of age group (IHME, 2018). In Australia, the age-adjusted suicide rate among men aged 85 years and over (36.2/100,000 person-years) was three times higher than that observed in the general population (12.1/100,000 person-years) (Australian Institute of Health and Welfare, 2022). An Australian study also found that, while suicide rates in women tend to remain stable throughout the course of old age, men appear as increasingly more vulnerable to suicide in the more advanced age groups (85 years of age and older) (Koo et al., Reference Koo, Kolves and De Leo2017). These gender differences could perhaps be explained by women’s greater propensity to seek help, obtain health care, and use less violent methods of suicide (Schriivers et al., Reference Schriivers, Bollen and Sabbe2012).
Aged care recipients and suicide: new data from Australia
Approximately 36% of Australians over the age of 65 years access aged care services each year (Australian Government Department of Health, 2021). Over the course of their lives, two-thirds of older adults use either temporary, permanent, or home-based care services (Chomik and Townley, Reference Chomik and Townley2019). Data on suicide mortality in old people requiring assistance are very limited or virtually absent. To fill this gap, Cations et al. (Reference Cations2023) wanted to propose an exploratory study, through the analysis of a cohort of older adults who died by suicide in Australia during access or while waiting to receive assistance services, permanent residential or home care, between 2008 and 2017. The data they obtained and presented in International Psychogeriatrics provide insight into the sociodemographic and clinical characteristics of those who have died by suicide and help identify psychosocial risk factors associated with suicide at contexts of care for older individuals, as well as investigating the prevalence of their access to mental health services and the use of psychotropic drugs in the year preceding death.
The study by Cations et al. (Reference Cations2023) was conducted using the National Historical Cohort of the Registry of Senior Australians (ROSA) (Inacio et al., Reference Inacio2019), that is, a platform made up of anonymous data of older adults users receiving assistance services in Australia, which contains data in liaison with the National Aged Care Data Clearinghouse and the Australian Institute of Health and Welfare (AIHW) National Death Index (NDI), the Australian Government Medicare Benefits Schedule (MBS) and PBS (Pharmaceutical Benefits Scheme), as well as state hospital data collections (New South Wales, Victoria, South Australia and Queensland only). The study included all people aged 65 years and over who were assessed as eligible for formal aged care, home-based, or permanent residential services. The multi-professional assessments aimed at the person’s functional and cognitive impairments in order to determine as accurately as possible the level of support required by older individuals and to offer personalized services capable of guaranteeing the person’s safety and well-being. The analyses of the data used for the study were carried out considering the type of service received by the older adults at the time of death. Indeed, existing evidence suggests that suicide rates and factors influencing death by suicide differ between those living in settings where lifelong residential care is offered and those living in the community (Murphy et al., Reference Murphy, Bugeja, Pilgrim and Ibrahim2018).
Overall, Cations et al’ study found that the suicide death rate among home care and continuing residential care recipients is lower than that of the general population of older Australians (Australian Institute of Health and Welfare, 2022). This could suggest that care services for older adults have a protective function able of modulating the risk of suicide, perhaps because they are capable of providing continuous monitoring and greater safety of the person, as well as reducing access to means of suicide. In their study, Cations et al. (Reference Cations2023) positively emphasize the protective role of care services for older adults, attributing them the ability to promote the psychological well-being of the frail person and to reduce social isolation by promoting, where possible, greater autonomy of the person (Royal Commission into Aged Care Quality and Safety, 2019). Those authors have also highlighted that the growing frailty of individuals with cognitive impairment or dementia is associated with a lower probability of death by suicide among those who live in residential facilities or are waiting to receive assistance, a fact probably explained by the fact that the person’s functional and cognitive limitations may also reduce the ability to perform a suicidal act (Murphy et al., Reference Murphy, Bugeja, Pilgrim and Ibrahim2018). Another interesting result concerns the fact that within the analyzed cohort, people waiting to receive assistance died by suicide more frequently than those who were receiving it (Cations et al., Reference Cations2023). This finding confirms the results of a previous study, which highlighted that a prolonged transition to residential care was a risk factor for suicide in older adults (Mezuk et al., Reference Mezuk, Ko, Kalesnikava and Jurgens2019).
Additionally, older men were more likely to die by suicide than women. This is consistent with general population-based data that older men have the highest age-adjusted suicide rate of any group both in Australia (Australian Institute of Health and Welfare, 2022) and internationally (WHO, 2021). The research by Cations et al. (Reference Cations2023) also showed that older adults who died by suicide had greater access to mental health services in the year prior to their death than those who died from other causes. The authors take the opportunity to point out that also in Australia, government-subsidised mental health services tend to be underutilized by both healthy older adults and older care recipients, a problem that should certainly attract the attention of public health planners (Cations et al., Reference Cations2022).
Conclusions
The study by Cations et al. (Reference Cations2023) highlights the importance of effectively preventing suicide in individuals institutionalized or benefiting from home care through multicomponent interventions that aim to reduce social isolation, clinical symptoms, and access to lethal methods, while capable to increase awareness of the person’s needs and access to support and treatment services. In fact, important barriers to accessing mental health services seem to characterize older adults, including a low propensity to ask for help (Polacsek et al., Reference Polacsek, Boardman and McCann2019).
Prevention of suicide in old age should considerably expand its range of interventions and pay more attention to the numerous socio-environmental conditions that can have a particularly impact in late life. The fight against ageism and stereotyped thinking, which is pervasive in society, including among health care professionals, must be pursued with great vigor (de Mendonça Lima et al., Reference de Mendonça Lima, De Leo, Ivbijaro and Svab2021). Research should promote the investigation of individual and contextual factors (e.g. how is life in a large nursing home?) associated with suicide and include personal or environmental details in the analysis about the person’s experience with care services, in such a way as to add depth to the data and stimulate more qualitative research on older adults with suicidal ideation. This would favor a better understanding of the phenomenology and the experience lived by this particular population and permit the implementation of intervention programs adapted to the need of the person.
To date, studies have indicated that implementing gatekeeper interventions appear as effective strategies for suicide prevention; probably, those programs could be applied in aged care settings too (Krysinska et al., Reference Krysinska2016; de Mendonça Lima et al., Reference de Mendonça Lima, De Leo, Ivbijaro and Svab2021). Theoretically, interventions aimed at reducing social isolation and loneliness could also contribute to preventing suicide in late life; however, the impact of such programs is still unproven (De Leo, Reference De Leo2022). In addition, the implementation of these programs in aged care settings could be particularly challenging, given the limited availability of mental health skills in the actual workforce of those settings (Jones et al., Reference Jones, Matias, Powell, Jones, Fishburn and Looi2007). Thus, any policy initiative to promote mental health skills in personnel and access to mental health care by users in those contexts would be particularly important.
Conflict of interest
None.
Description of author(s)’ roles
Authors have equally contributed to the preparation of this manuscript.