A wake up call about suicide in old people

This reflection comes from psychiatrists and epidemiologists aiming to assess the high incidence of suicide in elderly compared to the rest of the population.

Late September 2023 the National School of Health, and the Foundation on Psychiatry and Mental Health organized a meeting within the “Summer Program of the Public Health School of Menorca”, it counted on epidemiologists and representatives from the Spanish Society of Psychiatry and Mental Health. In mental health, it is non-common to find clinicians and epidemiologists working together, but luckily, this practice has already yearly and fruitful tradition.

In Spain, suicide deaths have maintained an increasing trend from 1980¹, although with up and down periods. Latest data available revealed a new increase trend initiated in 2018, just before the COVID-19 pandemic, reaching in 2021 rates of 12.53/100.000 for men and 3.93 for women.

Despite the fact that suicide rates for those 65 years and older were decreasing from 1990 on, by 2021 the age adjusted rate/100.000 was 12.28, much higher in men (21.7/100.000 versus 5.7/100.000 in women).

Suicide in old people concentrates the highest adjusted rates in most developed world². In 2021, suicide remains high among people 75–84 years, and alarming in men 85 years and older. Among women, the highest rates were found in 75–84 years with 7.01/100.000. To date, suicide in men maintain the highest rates compared to women and increase by age groups, reaching 14.24/100.000 for those 65–74 years and 42.6/100.000 for 85 years and older.

Among old people, suicide methods are usually definitive, meaning they are really seeking certain death³. Spain has not specific interventions to address old people, but other countries have started facing it like UK or France.

Suicide in elderly becomes complex due to different health conditions, socio-cultural and demographic changes in all developed world. In Spain life expectancy, constant decreases in natality, new social ways of living (disperse families) and heterogeneous social and economic situations, have built a new scenario for the elderly. Years ago, the elderly had a social role and remained living with family, mostly in rural areas. Today, competitiveness, cult of youth and urban patterns, have displaced much old people to keep alone in the traditional family's house, after the children leave. Others have to deal with new habitats and relatives or they are sent to nursing homes, always depending on the financial issues. Whatever the case may be, in Spain old people living alone has been increasing overtime specially among women, but recently also men (the most affected by suicide)⁴.

Suicide burden in the elderly depends more on sex and living profiles than on extended population risks⁵. In fact, the ratio man/women in 2021 goes from 2.7 in 65–74 years, to 7.6 among 85 years and older.

Risk factors for committing suicide affects all ages, but for the elderly a wide melting pot of possibilities defined by personal and environmental conditions are key players. This scenario strongly complicates the ways to identify who is at higher risk, when should be addressed and how to face it.

After 65 years, the risk of chronic and disabling diseases increase. This reality put people in less advantageous conditions to face life problems, including the path to the end of life.

The loss of pre-retirement habits like go to work, have an active cellular phone, an executive activity, or the fact of no longer being a reference for the family, are new scenarios to face. All these factors individually or together, drive old people to the anomie. They get loss and need to rebuild their life with less and fewer personal resources. Most of them have to identify new goals in life and new daily activities to pursuit them, others with less capacity or worse conditions do not make it. In sum, risk factors seem to act depending on their individual feelings and environmental influences. These scenarios provide different profiles depending on sex, age, having or not a partner, cultural, professional and socio-economic conditions. Men have more difficulties to face retirement, ageing's challenges and loneliness, but women seem to be more successful in undertaking this stage of life.

In this context, experts have discussed suicide risks and protective factors for committing suicide:

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  Some risk factors have been clearly described in the literature^6,7 with the highest odds ratios for suicide. Among them, having a mental or neurocognitive disease, previous suicide attempts, somatic disease, loss of functional capacity, pain or substance addictions.

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  Loneliness is also a strong risk and shows different scenarios like, social exclusion, living alone, or having lost a partner recently. The fact of “feeling alone” independently of the real circumstances is a robust determinant for suicide ideation and needs to be explored. For old men, loneliness is a high risk, acting alone or enhancing others.⁸ Loneliness has become a major social problem for old people during and after COVID pandemic and will likely continue to grow.

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  Fragile socioeconomic scenarios can provide bad living conditions and sometime reasons to look for death. Poverty or financial fragility can be addressed by a strong social support for old people. However, it is not always available and much social problems are not identified “on time”. The social support for elderly in Spain is poorly developed; which makes usually families being the only providers.

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  The retirement experience has recently been identified as a risk factor for suicide among old people⁹. The mandatory retirement at 65 years or before in some companies, and the heterogeneity of health conditions among the elderly would need to be assess and adapted to the functional capacities at the age of retirement. Life expectancy in Spain has increased prevalence of old people with excellent functional capacities.

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  Among social risk factors, much evidence appears related to the adverse effects of “ageism”. It refers to the way we think, feel and act towards people according to their age. Among old people, discriminatory attitudes, or social beliefs based on their abilities, can develop negative consequences on mental health. Frequently ageism is expressed by relatively common ideas like; “elderly already had their time” or “now it is time for youth”. The WHO's report on ageism assesses attitudes of healthcare workers, undervaluing elderly “intrinsic capacities”, or restricting their access to treatments required. In fact, health care workers are not different from the general population. Ageism seems to be a good framework for addressing efficient strategies to reduce suicide among the elderly.

Fortunately, positive assets with potential action against suicide have also been identified. In fact, among old people there is no correlation between ideation and suicide¹⁰.

Good cognitive functions and physical health seem to be the highest protective factors among older people. Additionally strong protective scenarios are linked to individual and social conditions like, feeling satisfaction with their own life and experiencing gratification from their social life. Elderly people at risk of suicide are very consistent users of self-help technology. This opens an opportunity for secondary prevention programs.

Based on risks and protective factors, fighting ageism starts from the health system. Within primary care, the exercise of hearing elderly and improve their intrinsic capacity could be a good start to reduce suicide. Additionally, adequate resources to socialize and reduce feelings of loneliness are urgent needs. Finally, an extended campaign against ageism could help to reach wider social integration for the elderly.

Ethics in publishing

We did not use personal data or identifiers. Thus, Ethics approval, consent to participate and consent for publication were not requested.

Authors' contributions

IN was the major contributor in writing the manuscript. All authors have provided views and contributions and have read and approved the final manuscript.

Declaration of generative AI and AI assisted technologies in the writing process

During the preparation of this work, the authors only used Pub-Med and other national web's of knowledge, in order to write this paper and assess findings. After using those tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.