Mohammed T. Abou-Saleh

470 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYThe symptom profile of elderly suicides prior to the event hasbeen described in earlier studies. Barraclough 4 , in examining 30elderly suicides, reported complaints of insomnia (90%), weightloss (75%), guilt feelings (50%) and hypochondriasis (50%) in themonth prior to death. The existence of suicidal ideation oftenlacks spontaneous expression and it is important that such ideasare explored. Suicidal intent may be less evident, particularlywhere physical ill-health complaints are prominent. For example,in a recent study from Finland 7 of over 200 elderly suicides,suicidal intent was communicated to attending healthcare professionalsin only 18%. The lesson to be learnt is that the presence ofsomatic symptoms should not detract from a close examination ofthe mental state with particular regard to a depressive illness andcoexistent suicidal thoughts.Primary substance misuse disorders account for a smallerproportion of suicides than in younger age groups, withprevalence estimates of 5–40%. Similarly, non-affective psychosesare uncommonly reported compared to younger suicides. Theassociation between suicide and dementing illnesses has receivedlimited attention. Although advanced dementia is likely to be aprotective factor, the significance of an early dementia as a riskfactor for suicide is largely speculative. Individual case studies,however, indicate that in some people the fear of progressivedependency and ‘‘institutionalization’’ is an important dynamic,irrespective of the presence of evident cognitive deficits. There aresimilarly few reports on the association between personality andsuicide in the elderly. Earlier studies described a personalityprofile of inflexibility, ‘‘failure to adjust’’ and poor adaptation tochange. More recently, Duberstein 9 reported a lower openness toexperience (OTE) score in elderly compared to younger suicides.This profile may be summarized as a cognitive propensity toperceive problems in dichotomous, black-and-white terms, arigidly defined self-concept and a diminished behaviouralrepertoire, thus decreasing the capacity to adapt to loss andchange.BIOLOGICAL FACTORSSuicide as a distinct neurobiological entity has been investigatedin the search to identify potential biological markers, althoughthis research has been almost exclusively undertaken on a youngerpopulation. This may be partly attributable to the inherent andoften contradictory data on the effect of ageing on central nervoussystem neurotransmitter systems. Jones et al. 10 , however, in astudy of the suicidal elderly, found significant lower concentrationsof cerebrospinal fluid 5-hydroxyindoleacetic acid andhomovanillic acid, compared to non-suicidal and normal controls,which is in keeping with other studies in younger suicides.PHYSICAL ILLNESSThe importance of physical illness as a major antecedent to suicideand attempted suicide in the elderly has long been emphasized.Not only does the older suicide have a higher prevalence of illnesscompared to his younger counterpart, but the incidence ofphysical illness greatly exceeds that found in the non-suicidalelderly. Several early studies reported medical illness directlycontributing to suicide in around 60–70% of cases, with evidenceof higher rates of physical illness among elderly males comparedto females. In a recent Scandinavian study 5 , the importance ofphysical ill-health as a life event in the 3 months before death wasdemonstrated, with elderly men displaying an excess of serioussomatic illness compared to elderly females (55% vs. 31%),suggesting gender differences in coping with such age-normativestressors.Several central nervous system and systemic disorders havebeen linked with increased risk of suicide. These include epilepsy,multiple sclerosis, Huntington’s chorea, head injury, peptic ulcerand rheumatoid arthritis. The association of suicide with cancer isinconsistent with some studies supporting such an association,while others refute the risk, especially among hospitalizedpatients. In a study from Canada 11 involving 543 elderly suicides,with information obtained from coroners’ inquests, those withmedical illnesses were significantly less likely to be referred topsychiatric services than those without a medical illness, andthose with a terminal illness, comprising almost 9% of the total,were least likely of all to receive a psychiatric assessment. Anumber of studies have drawn attention to the importance ofsubjective complaints of pain prior to suicide in the elderly 12,13 ,with nearly 20% of the samples indicating it to be a majorconcern prior to death. The point to be reiterated is that thepresence of physical illness or presentation with somatic orhypochondriacal concerns may mask the underlying depression,and this type of presentation may be of importance in elderlymen, who may be less likely to verbalize their depressed mood oradmit to suicidal thoughts.These findings for completed suicide have their parallel inattempted suicide in the elderly. In a study of 100 elderly suicideattempts, 53% were considered to be suffering from significantphysical illness at index assessment following the attempt 14 . Thecohort demonstrated an increased mortality from natural causescompared to an age- and gender-matched population and, afteran average of 3.5 years, 42% of the original subjects had died.PREVENTIONAny strategy designed to prevent suicidal behaviour needs to takeaccount of the following factors. Which individuals are likely tobe at risk, how are they to be identified, and by whom? To whatextent may training and education influence detection andmanagement of vulnerable elderly individuals? How may servicesbe improved to effect a reduction in rates of suicidal behaviour?Risk AssessmentThe act of suicide is a complex phenomenon, involving multiplepsychological, physical and social factors operating at a crucialmoment in the life of a vulnerable individual, and any riskassessment procedure needs to reflect these varied antecedents. Atypical high-risk individual, for example, may be described as anelderly male, living alone following recent bereavement, who mayhave painful, chronic health problems, who is currently depressedand who has made previous suicide attempts. The problem withapplying risk factors lies in the generation of high false-positivepredictions associated with the relatively low base rate ofcompleted suicide, and as yet no instruments exist with sufficientsensitivity or specificity to be clinically useful as a risk assessmentscale in the elderly. It is the clinical interview that remains thecornerstone of such assessment and needs to clarify key variables.These considerations should not, however, detract the assessorfrom the real increased susceptibility of the elderly to eventualsuicide. This can be seen particularly in elderly attempters, wheresuicidal intent, as measured by the Beck intent scale, is at itshighest for any age group 15 . Attempts in the elderly are also amuch stronger predictor of subsequent completed suicide,compared with attempts in younger people, with a ratio ofattempts to completion estimated to be around 4:1 compared withbetween 8:1 and 200:1 for younger attempters. All attemptsshould be taken seriously.