Elderly and Suicide Prevention
By
Anushree Baheti
Fakhera Mamawala
Pratiksha Kulkarni
Srushti Kulkarni
Vaishnavi Wagh
CONTENTS
• Introduction
• Causes and symptoms and factors
of suicide.
• Theories and models of suicide.
• Researches related to suicide
among elderly.
• Assessment / risk assessment
• Preventive measures.
Introduction
“Suicide is defined as a fatal Suicide affects all age groups in the
self-injurious act with some evidence population, but worldwide, rates clearly
of intent to die.’’(Turecki and Brent , rise with increasing age. In almost all
2016). regions in the world, the highest rates
According to WHO, Every year close to are found among the oldest people
800 000 people take their own life and aged 80+.
there are many more people who Suicidal thoughts, or suicide ideation,
attempt suicide. Every suicide is a refers to thinking about or planning
tragedy that affects families, suicide. Thoughts can range from
communities and entire countries and creating a detailed plan to having a
has long-lasting effects on the people fleeting consideration. It does not
left behind. Suicide does not just include the final act of suicide. On
occur in high-income countries, but is a suicide risk scales, the range of
global phenomenon in all regions of the suicidal ideation varies from fleeting
world. In fact, over 79% of global thoughts to detailed planning. Passive
suicides occurred in low- and suicidal ideation means not wanting to
middle-income countries in 2016. be alive or imagining being dead. Active
Suicide is a serious public health suicidal ideation is thinking about
concern that cannot be ignored. different ways to die or forming a plan
Suicide occurs throughout the lifespan to die. Most people who have suicidal
and was the second leading cause of thoughts do not go on to make suicide
death among 15-29 year-olds globally in attempts, but suicidal thoughts are
2016. considered a risk factor.
CAUSES AND SYMPTOMS
● Loss of interest in things or activities
that are usually found enjoyable
● Cutting back social interaction,
self-care, and
● Grooming
● Breaking medical regimens (such as
going off diets, prescriptions)
● Experiencing or expecting a significant
personal loss (spouse or other)
● Feeling hopeless and/or worthless
● Putting affairs in order, giving things
away, or making changes in wills
● Stockpiling medication or obtaining
other lethal means
● Other clues are a preoccupation with
death or a lack of concern about
personal safety. Remarks such as "This
is the last time that you'll see me" or
"I won't be needing anymore
appointments" should raise concern.
● The most significant indicator is an
expression of suicidal intent.
FACTORS RELATED TO
SUICIDE
• Psychiatric disorders
• Physical illness
• Life events
• Family History
• Interpersonal relationship
• Substance use disorder
• childhood abuse or trauma
• Social loss, such as the loss of a
significant relationship access to lethal
means, including firearms and drugs
• Difficulty seeking help or support lack
of access to mental health or substance
use treatment
• Breakdown in the ability to deal with life
stresses, such as financial problems,
relationship break-up or chronic pain and
illness.
THEORIES AND MODELS OF
SUICIDE
Innovative view of suicide as a result of psychological distress or disorder set the ground for all
investigations. Some ideas of these grand theories have remained influential. interpersonal models of
suicide seems to share common elements with object relations theories linking suicidal wish to feeling of
guilt. Psychodynamic theory was the first to emphasize the role of object-relations in the suicidal process.
Early psychoanalytical approaches formed to understanding the suicidal mind were intuitively inclusive and
meaningful. They created a historical change of how suicide was perceived, from moral, legal, philosophical
or spiritual problem to a clinical concern (Ellis, 2001).
PSYCHOLOGICAL PAIN THEORIES
Shneidman Theory of Psychache
Shneidman (1993) defined ten common factors (“communalities”) of suicide: seeking a solution, cessation of
consciousness, intolerable psychological pain, frustrated psychological needs, hopelessness and
helplessness, ambivalence towards life and death, constriction of viable alternatives, flight from life itself,
communication of intent, and dysfunctional lifelong coping patterns. According to shneidman, suicide is
caused by psychache an intense and intolerable emotional pain that is different from depression and
hopelessness. He postulated two types of needs:
1. Primary or biological.
2. Secondary or psychological.
The psychological needs that are essential for life include, among others, love and belonging, sense of
control, positive self-image, and meaningful relationships. It is the frustration of these needs by failures,
rejections, and loss that leads to the development of psychache. The view of the suicidal act as being
instrumental in fulfilling a specific need is rooted in psychodynamic formulations. Initial support for
psychache as a factor in suicide is strong. Psychache has been shown to be a significant predictor of
suicide ideation and attempts (Flynn & Holden, 2007;et al)
Limitation:
1. understanding and clear definition of what is constituted by psychological pain does not exist.
There are extremely strong correlations between psychache, depression and hopelessness.
3. Psychache as a causal factor of suicidal outcomes, there is a need for research with larger sample
sizes, high-risk suicidal groups and longitudinal designs.
4. Psychache interacts with other risk factors to bring about suicide and what pathways lead from
psychache to suicide.
Suicide As An Escape From The Self Baumeister (1990) argued that the most common motive reported by
people for engaging in suicidal behavior is to escape from an aversive situation and to obtain respite from
an unbearable state of mind. He described six steps leading to suicidality.
1 There is a discrepancy between expected standards and perceived reality. Too-high
expectations or setbacks frustrate goals and lead to personal failure.
2 Individual interprets the failure as a function of his own characteristics, qualities, or skills,
leading to self-blame.
3 An aversive state of distorted self-awareness leads to unforgiving comparison of the self with
unachieved standards.
4 This self-awareness evokes painful negative emotions.
5 Individual attempts to escape into a relatively numb state of cognitive deconstruction,
characterized by his/her focusing on concrete sensations and movements and targeting only
immediate goals.
6 Cognitive deconstruction results in reduced behavioral inhibition with emergence of suicide
and other life-threatening behaviors.
Arrested Flight Model (Cry of Pain)
Williams (1997) posited that suicide is a product of feelings of defeat in response to humiliation or
rejection which trigger perceptions of entrapment, combined with a failure to find alternative ways to
solve the problem.
This model draws upon the concept of arrested flight reported in the animal behavior literature and which
has been suggested to account for depression in humans (Gilbert and Allan, 1998). Williams and Pollock
(2000, 2001) suggested that when individuals perceive their attempts at solving problems to be
unsuccessful, they feel powerless to escape from the situation. The sense that the future holds little
opportunity for reprieve leads to hopelessness. The model is important because it integrates
psychobiological and evolutionary factors, it emphasizes the potential interactions between emotions and
cognitions in the road to suicide and highlights the role of entrapment and hopelessness in the development
of suicidal ideation and behavior.
Limitations:
1)There is difficulty in separating the constructs of hopelessness, depression, defeat, entrapment, and
suicidal ideation.
2) Strong relationship between suicidal behavior, hopelessness, and lack of social support or rescue, it is
not clear how they relate to each other, and no single pathway can be inferred from the model.
COGNITIVE THEORIES
The Comprehensive Cognitive Model (Beck et al,1990) –
Beck et al. (1990) emphasized the cognitive aspect of suicidality. They suggested that hopelessness plays a
major role in suicide by disrupting all components of the classic cognitive triad of beliefs about self,
others, and the future. Suicide-relevant attention biases result in selective processing of suicide-relevant
stimuli. Memory biases impair the ability of the suicidal individual to recall reasons for living or being
hopeful about his/her life. Wenzel and Beck (2008) formulated a comprehensive model of suicide wherein
the interaction between three main constructs lead to suicidal act dispositional vulnerability factors,
cognitive processes associated with psychiatric disturbance, and cognitive processes associated with
suicidal acts.
Cognitive theory suggested that vulnerability factors interact with life stressors and increases the
likelihood of schemas associated with psychiatric disturbance. These schemas facilitate biased information
processing that underlies suicide. In this cognitive model there are two types of suicide schemas.
1) Non-impulsive attempts are those characterized by chronic hopelessness
2) Impulsive attempts are those characterized by perceptions of unbearability.
suicide-specific attention bias accelerates the likelihood of suicide attempt.
Limitations:
Need to test other aspects of this theory and to empirically support the mechanisms in which the factors
are interacted and mediated to increase suicidal risk.
Fluid Vulnerability Theory (Rudd, 2006)
To explain the process of suicide risk, Rudd (2006) proposed the fluid vulnerability. Modes are structural
networks of cognitive, affective, motivational, physiological, and behavioral schemas that are activated
simultaneously by relevant internal and external events. Repeated activation of a specific mode lowers
the threshold for its subsequent activation, causing a unique vulnerability. Drawing on Beck's work, Rudd
et al. (2001) suggested a suicidal mode, defined as combination of a suicidal belief system,
physiological-affective symptoms, and associated behaviors and motivations.The fluid vulnerability theory
is based on the assumption that suicidal episodes are time limited and the factors that trigger the
episode and contribute to its severity and duration are fluid in nature.
Rudd believed that every individual has a baseline vulnerability to suicide, which is determined by a
combination of cognitive susceptibilit, biological susceptibility and behavioral susceptibility. Cognitive
vulnerabilities such as rumination and cognitive inflexibility were found to predict suicidal ideation. Other
characteristics have distinguished multiple attempters from single attempters. It was suggested that
this model is very helpful in the assessment of suicidal patients by taking into account not only acute risk
factors.
Limitations:
1) Potential precipitants of suicide are unclear, as is the manner in which personality and genetic
factors interact to determine baseline levels of vulnerability.
2) No direct examination of the theory including specific assumptions for the cognitive vulnerabilities
that increase suicidal risk.
DIATHESIS-STRESS THEORIES (Schotte and Clum 1982, 1987)
The diathesis-stress models postulate that suicidal behavior occurs as a consequence of the interaction
between predisposing vulnerability factors and a triggering stress factor.
Social Problem-Solving Vulnerability Schotte and Clum (1982, 1987) proposed that cognitive rigidity in problem
solving causes a vulnerability to emergent hopelessness and suicidal ideation under naturally occurring
conditions of high life stress. Individuals with a low capacity for flexible divergent thinking are unable to
identify alternative solutions to their problems or tend to anticipate negative consequences for any proposed
solutions. suggesting potential intervention strategies focused on interpersonal problem solving. Empirical
research found that relative to non-suicidal individuals, suicidal individuals generate fewer solutions to
problems (Pollock & Williams, 2004), are less likely to use the alternatives they generate (Schotte & Clum,
1987). However, the problem-solving deficits observed in suicidal individuals might be state-dependent rather
than a trait; that is, they may be a consequence of negative life stress or depression.
Limitations:
1) There is no one clear definition to "problem solving" it is important to specify the precise type of problem
solving deficit under examination.
2) Focus on suicide ideation as an outcome, rather than suicide attempts, and use of non-clinical samples.
Overall, empirical research has not confirmed the mediational role of problem solving deficits.
Clinical-Biological Models Of Suicidal Behavior (Mann et al.1999, 2005)
The clinical model of Mann et al. (1999, 2005) suggests that psychiatric illness serves as a stressor but leads
to suicide only when combined with vulnerability. The theory is based on the notion of impulsive aggression, or
the tendency to respond to provocation or frustration with hostility or aggression, as a trait factor and
common correlate of suicidal behavior. Impulsive aggression is increased by low serotonergic activity and/or
substance abuse, potentiating the relationship between psychopathology and suicidal actions.
Brent and Mann (2006) proposed that the vulnerability to suicidal behavior is often familial with a likely
genetic component, and impulsive aggression is a key to understanding familial transmission.
The main contribution of this model is its elaboration of background causal pathways to the development of
stress-activated susceptibility to suicidal behavior. It is well delineated and supported by empirical
findings. This model has been supported by much empirical evidence (Mann et al., 2009; Melhem et al.,
2007). Many studies reported a link between impulsivity and suicide.
Limitations:
1) It is possible that impulsivity in and of itself is a peripheral construct in understanding suicidal behavior.
2)There is need to identify more refined mechanism with more explanatory power to account for suicidal
behavior.
Two-Stage Model Of Outward And Inward Directed Aggression (Apter et al., 1993; Plutchik,1995; Plutchik
et al.,1989)
This model is based on the assumption that suicide and violence are expressions of the same underlying
aggressive impulse, and it is the presence or absence of other variables that determine what the direction
the aggression will take.
Plutchik et al.(1989) listed possible triggers (stressors) that generate aggressive impulses, including
threats, challenges, insults, loss of control, and perceived threat to one's social rank. In the first stage, the
cutoff level of impulsive aggression that will be expressed in overt behavior or action is determined.
Impulsive aggression may be amplified or attenuated by other factors, such as social support, attitudes
toward violence, and access to a weapon. In the second stage, the object toward which the aggression is
directed is identified.
Model attempts to explain the impulsive-aggressive type of suicidal behavior which seems to occur more in
younger people and has received the most attention.
Interpersonal Theory Of Suicide (IPTS) (Joiner, 2005)
The interpersonal theory of suicide suggests that individuals will engage in serious suicidal behavior if they
have both the desire to die and the capability to act on that desire to die results from two distinct
interpersonal psychological states, namely perceived burdensomeness, or a feeling of being a burden to
others, and thwarted belongingness, or a feeling of alienation.
These feelings lead to the belief that one's death is worthwhile to others. When the two states
converge suicidal ideation is enhanced.
The interpersonal theory offers a possible explanation for suicide attempts by people with a history
of self-harm and other risk behavior. An important advantage of the IPTS is that it is the first to
distinguish individuals who think about suicide without acting on those thoughts from individuals who
translate suicidal ideation into action.
Studies have found a significant effect of thwarted belongingness and perceived burdensomeness on
suicidal ideation.
Limitations:
Therefore, although IPTS has received increased support in recent years, there are some theoretical
and empirical limitations.
1) It remains unclear why acquired capabilities do not always translate into completed suicide.
2) Range of experiences that contribute to self-injury habituation is unclear as well as their relative
power.
3) The theory also fails to account for the central role of psychopathologies, such as depression, in
completed suicide.
4) Research has also been limited by cross-sectional study designs and in testing the simultaneous
effect of all three factors of the IPTS and the interrelations between them.
RESEARCHES
Gruhle (1941) often gives little importance to psychoses in the genesis of suicidal acts in
the age group and emphasizes, as motives, morbid reactions to physical illness and mental
incapacity, idleness, boredom, loneliness, and inadaptability in changed circumstances.
Swinscow (1951) in an interesting statistical investigation has come to the conclusion
that “suicide in the last 50 years has increasingly become a disorder of elderly people,”
and has suggested that, “as the present century has advanced, the old may have found
their environment more hostile than the young.”
Roth and Morrissey (1952), from a study of 150 patients over the age of 60 admitted to
a mental hospital and a review of the literature, suggest a special association between
old age and depressive illness, and support their opinion of the importance of the
affective psychoses in this age group by reference to suicide rates. They report that
only 12 of their 150 patients had made attempts at suicide, and that each of these was
suffering from an endogenous depression. They are critical of Gruble's opinions, and
state that "it is not argued that social factors play no part, but that it is through their
role in the precipitation of depressive psychoses that they contribute to the causation
of suicide in the old."
Although suicide is only the 13th most common cause of death in those 65 years of age
and older, it accounted for 5,788 deaths in 1985 compared with 5,121 for 15 to 24 year
olds nationwide. As older persons constitute the fastest growing segment of the
population, the absolute number of their suicides will continue to rise. Haas and Hendin
(1983) project that the number of suicides committed by older people will double by the
year 2030 as a function of this demographic shift alone.
RISK ASSESSMENT
Risk assessment tools should never take the place of clinical judgment
since no tool can accurately predict suicide. Further, complete reliance
on a single risk score as determined by a particular risk assessment tool
may remove the holistic nature of clinical risk assessment. Instead, tools
can be used for initial screening of suicide risk or to gather auxiliary
information to further inform the clinical interview. The risk assessment
tools should be used within a recovery framework where clinicians
recognize the person’s central role in preventing suicide.
Within this framework, the value of suicide risk assessment tools is to
enable clinicians to:
• elicit and incorporate the person’s perspectives on self-harm or
suicide;
• gather additional information that can shed light on the person’s
degree of risk of suicide;
• corroborate findings from clinical interviews;
• identify discrepancy in risk, if any;
• In some instances a person may not disclose indicators of risk in a
clinical interview but may report indicators on a self-report tool.
• improve the overall quality of the suicide risk assessment process
(e.g., to assist persons with less experience in risk assessment).
RISK ASSESSMENT
A wide range of risk assessment tools have been developed to help identify risk of
suicide and self-harm or to guide the process of understanding risk. These tools
range from self-report to interview based scales that vary from simple symptom
checklists to complex scoring approaches. In addition to the use of tools
specifically for assessment of self-harm and suicide risk, suicide risk assessment
should also incorporate a complete mental status examination. This examination is
important for getting a global understanding of the person’s mental distress and
functional deficits in order to be able to design a plan of care. This
examination includes monitoring for affect, cognitive status, non-verbal behaviour,
and other factors that may indicate acute agitation or the development of warning
signs for suicide.
Identification of risk -
In a robust suicide prevention strategy, identification of risk for suicide and
self-harm –both intrinsic and extrinsic – is the first step. As discussed previously,
the process for identifying person-level factors contributing to risk should be
carried out as part of a detailed clinical interview with the person using
standardized instruments to assist as necessary. In addition to person-level risk
factors, environmental risks should also be continually evaluated and improved.
Structured checklists may help to identify environmental issues and develop a
safety improvement strategy. All members of the care team should be empowered
to alert the appropriate department or personnel about suicide or self-harm risks
that they identify.
RISK ASSESSMENT
Personnel -
The initial risk assessment is typically carried out by a psychiatrist or
physician as part of the clinical interview with the person. However,
other clinical team members including psychologists, nurses, social
workers, occupational therapists, and recreation therapists also take
part in screening and ongoing monitoring of risk. Persons involved in
the suicide and self-harm risk assessment should have specific training
in:
• risk factors and warning signs for suicide;
• establishing a therapeutic relationship with the person;
• strategies for communicating with the person, family, and other care
providers;
• proper standards for documentation of risk;
• strategies for mitigation of risk; and
• ongoing monitoring.
Training should also address stigma and staff attitudes toward suicide
and self-harm.
Finally, training should include information on how the care team can
support each other
and provide self-care.
PREVENTIVE MEASURES
Prevention of suicide and self-harm is an interdisciplinary effort to reduce individual,
environmental, and system factors that contribute to risk of suicide or self-harm. As such, the use of
suicide prevention contracts or “no harm contracts” as a sole prevention
strategy should not be considered.
Identification of risk
Identification of risk for suicide among the elderly population– both intrinsic and extrinsic –
is the first step. It is an important process for identifying person-level factors contributing to risk
should be carried out through a detailed clinical interview with the person using standardized
instruments to assist as necessary. In addition to person-level risk factors, environmental risks should
be evaluated and improved. Structured checklists may help to identify environmental issues and develop
a safety improvement strategy. All members of the care team should be empowered to alert the
appropriate department or personnel about suicide risks that they identify.
Mitigation of Risk
Reducing or mitigating the risks known through a risk assessment is the next important step in any
suicide hindrance strategy. Methods that integrate information on risk into a plan of care is the simplest
ways in which to mitigate risk. This method ought to take place with the person and, once acceptable,
relations or alternative informal supports. During this stage of prevention, careful information concerning
the extent of risk, specific risk, protective factors are known and plans to assist mitigate the chance
ought to be documented and communicated. Operating with the person, establishing crisis support and
safety plans is useful so the person will establish methods for recognizing warning signs, interact in brick,
and get in touch with crisis support once required.
Education
Targeted education is another facet of any suicide prevention program. There should be a
specific focus on those delivering direct patient care. Educational efforts may include in-services,
one-on-one instruction by a more experienced clinician, mock exercises, and resource materials available
in care environments. In-depth training resources on suicide are available including the Applied Suicide
Intervention Skills Training (ASIST). SafeTalk is also an excellent training program that is used in
conjunction with ASIST.
Primary care intervention
In primary care interventions, two primary care collaborative treatment strategies the
IMPACT (Unützer et al., 2006) and PROSPECT studies (Alexopoulos et al., 2009; Bruce et al., 2004) are
identified. Participants in the intervention groups of both studies received support from depression
care managers (nurses, psychologists, or social workers) who offered education about treatment
options, brief psychotherapy (interpersonal or behavioral), and provided close monitoring of depressive
symptoms and medication side effects as well as follow-up of patients.
The IMPACT program stands for Improving Mood – Promoting Access to Collaborative
Treatment for depression in primary care. In the PROSPECT study Prevention of Suicide in Primary
Care Elderly: Collaborative Trial, primary care practices were randomly assigned to provide either the
care management intervention or usual care (Alexopoulos et al., 2009). In both the studies, benefits
were limited to patients with major depression who had a significantly lower level of active suicidal
desire at 4, 8, and 24 months, compared to the usual-care group.
Community-Based Outreach
This can be another intervention for the elderly population. Various Japanese cohort studies
have implemented community-based outreach programs in rural areas of the country, where the suicide
rate was elevated (over 150/100,000) for both men and women aged 65 years and older (Chiu,
Takahashi, & Suh, 2003; Oyama et al., 2004, 2005; Oyama, Fujita, et al., 2006; Oyama, Goto et al.,
2006; Oyama, Ono et al., 2006). These programs typically included mental-health workshops for the
elderly, conducted by municipal public health nurses which promote awareness of depression and suicide
risk. The programs also included annual depression screenings of all residents aged 65 years and over,
followed by a clinical interview with a psychiatrist or a general practitioner (GP) with follow-up meetings
with mental health nurses. In another cohort study (Oyama et al., 2005), the program was different:
group activities (social, recreational, physical, volunteering) to reinforce social support and no
systematic depression screenings but a recommendation to participants to self-assess depression with a
short questionnaire. The results of the meta-analysis (Oyama et al., 2008) showed significant
reductions in the rate ratio of suicide, compared to baseline, but mostly among women whose risk was
reduced by around 70%.
On the community level, mental health services are available through community mental health centers
that often serve as safety nets in rural communities (Hartley, Bird, Lambert, & Coffin, 2002). Senior
outreach programs may exist in communities to serve those in need of social support, such as day
programs for the elderly. Religious communities serving seniors help to meet social needs if elders can
attend services or program activities. When elders are homebound or living in residential facilities, it is
more difficult to reach them; however, many residential facilities have programs for residents that
address social needs.
Incident review
Many elderly try attempt to suicide but they fail to do so. A near miss is an incident when a
person survived an attempt to die by suicide. These events can occur in the care environment (e.g., during
a hospital admission), among persons under the care of a healthcare team (e.g., a client receiving care in
the community), or following discharge from care. For learning and improvement purposes, reviewing near
misses can be equally as instructive as reviewing incidents of the completed acts.
An incident review aims to discover the events and system issues that may have contributed to
an incident of self-harm, a near miss or a death by suicide that occurred while the person was under the
care of the organization (either as an inpatient or community client).
The review process can use a variety of methods, including root cause analysis, to determine
factors that contributed to the incident for purposes of quality improvement. This process enables an
exploration of what happened, why it occurred, and what can be done to prevent it from happening again.
The review team may consult other clinical staff members, the person, when appropriate, the person’s
family. Review teams and review participants must understand the context within which the review
occurs.
Post-incident support
When the incident under review is one where a person has died by suicide, the organization
should have a standard policy and procedure for contacting survivors of persons. Many survivors of
suicide experience four stages of emotions and reactions following suicide: shock, recoil, post-trauma,
and recovery. For each stage, the appropriate kind of support will be different.
1. For instance, during the initial shock that follows suicide, crisis intervention strategies are
appropriate.
2. During recoil, the survivor may experience guilt, anger, shame, depression, anger, and self-doubt
that will need to be addressed through either group meetings such as a suicide review conference or
informal peer support.
3. During the post-trauma phase, specific interventions to help families or other victims of suicide
experience stigma. Specific interventions to help them overcome stigmatization might be required.
For care teams, it is important to have resources and training for supporting each other. Health
care organizations need to have structured support networks where clinicians can listen to each other, be
non-judgmental, and allow each other to openly vent or mourn an event.
Telephone Counseling
Four studies implemented telephone counseling outreach programs (De Leo, Carollo, & Dello Buono,
1995; De Leo, Dello Buono, & Dwyer, 2002; Fiske & Arbore, 2000; Morrow-Howell, Becker-Kemppainen, &
Judy, 1998). De Leo’s team evaluated the long-term impact on suicide rates of a telephone service that
included (1) Tele-Help, a 24 h emergency service for elders to call for help, and (2) Tele-Check,
twice-weekly telephone support. After 11 years (priority was given to the publication presenting the longest
follow-up period), the number of observed suicide of elderly service users living in the intervention area
was statistically significantly lower than the expected number calculated from the prevailing rate in the
region (De Leo et al., 2002). Thus telephonic counseling can also be used as a preventive measure for suicide
among the elderly population.
Preventing social isolation
Decreasing the social isolation of the elderly through family and community support is important.
Activity theory suggests that the elderly are more satisfied with life the more active they remain.
Prevention strategies aimed at improving the social lives of the elderly should be designed according to
individual needs, weighing the need to maintain independence against the increased risk of death by suicide
due to living in isolation
Quality improvement
The quality improvement process for suicide and self-harm should begin by establishing policies
that support skills among all staff. These skills include-
1. An understanding of a systems approach to patient safety
2. An understanding of risks associated with suicide and self-harm, a standardized approach to
risk assessment and monitoring
3. A focused strategy for prevention.
Data on the success of improvement efforts should be posted in common areas, both to educate
staff about various suicide and self-harm risks and successful interventions, and to trigger further
ideas for improvement. Because of the complexity of suicide and self-harm, care must be taken to avoid
reallocating resources from one high-risk area to another, thereby causing an increased risk
Making a positive impact on the suicide crisis among the elderly will take a proactive and
multi-faceted approach. Strategies that influence this at-risk group must be implemented at the
individual, relational, community, and societal levels.
