Euthanasia, suicide among elderly, Oregon, & UK

	Oregon ranks near top in suicides among elderly
	Hospitals in euthanasia row "Elderly people are very easy to coerce"
	Hospital tries to end (elderly) patient's life support

Recent developments: Suicide in older people

 

Oregon ranks near top in suicides among elderly

By Tim Christie
The Register-Guard  March 7, 2005

Much ink has been spilled over the suicide last month of gonzo journalist Hunter Thompson. At age 67, in the kitchen of his Colorado compound, he stuck a .45-caliber gun in his mouth and pulled the trigger.

Those who knew the hard-living, gun-loving Thompson, including his family, have said his violent, self-inflicted death came as no surprise, nor was it the result of chronic pain or depression.

"This is a triumph of his, not a desperate, tragic failure," his wife, Anita Thompson, told the Rocky Mountain News.

While Thompson was a true American iconoclast, his means of death exemplifies what public health and mental health officials say is a troubling, preventable trend in Oregon and across the country: Elder suicide.

The elderly - particularly older white men - have the highest suicide rates of any age group, by far. And Oregon has some of the highest elder suicide rates in the country.

Between 1999 and 2002, the rate of suicide among Oregonians 65 and older was 24 per 100,000 population, ranking sixth in the nation and 56 percent higher than the national average of 15.4 per 100,000.

In 2003, the suicide rate among Oregon men 65 and older was 38 per 100,000. By age 85, the rate jumped to 109 per 100,000.

Dr. Cliff Singer, a geriatric psychiatrist at Oregon Health & Science University, said it's not clear why older white men are more likely to succumb to suicide.

But the chronic illnesses that come with age often impair their ability to function in life, and that can lead to depression, he said.

"They become demoralized because they can't be as active and independent as they'd like to be," he said. "Demoralization can lead to depression and depression is a major risk factor for suicide."

Disability may hit older white males harder than other demographics, he said.

"This is a group that is more used to feeling like they had leadership roles in society and within their families," he said. "Now they feel emasculated and highly shamed by their physical frailty and functional decline. They cope with it less well than others."

Most of these men who kill themselves had recently visited a physician, Singer said.

"That tells you they are asking questions about their health and their prognosis," he said. "When they're told they have a chronic disabling condition for which perhaps only palliative care is available, they decide to end it."

Older white men are also more likely to succeed at suicide, Singer said. One of four attempts result in death, compared with one in 20 attempts among the general population.

"They tend to be nonambivalent and choose highly lethal means," he said.

Guns, in particular, are the means of choice. Among elderly Oregonians, guns are used in 80 percent of suicide deaths, according to state statistics.

State public health officials are developing a plan to prevent elder suicides, said Lisa Millet, who manages the injury and violence prevention program for the Department of Human Services.

Doctors, she said, should screen their patients for depression, and not view depression as a normal reaction to declining health and diminishing independence.

One strategy is training lay persons in intervention skills, just as many people get CPR training, Millet said. To date, nearly 3,000 Oregonians have been taught how to intervene when a friend or family member is facing a mental or emotional crisis.

Singer said it's important for doctors and family members to get seniors to talk about their feelings of hopelessness or demoralization. Talking about it can lead to treatments, such as better pain control or antidepressants.

"Just the psychological relief of the unburdening that comes through talking about a person's hopelessness, that sometimes relieves tension and buys time," he said.

At PeaceHealth Medical Group's Senior Health and Wellness Center, doctors routinely screen new patients for depression, said Sandy Sanders, a licensed clinical social worker.

Sanders counsels seniors who are feeling depressed, anxious or struggling to adjust to a major life change, such as the death of a spouse or the inability to live independently.

"It's pretty much all about loss," she said.

Singer said he sees no connection between Oregon's high elder suicide rates and the fact that it's the only state that permits doctor-assisted suicide.

"I think they're independent aspects of the same social psychology of Oregon," he said. "We are a state of independent-minded people who want to control their own destiny."

The fact that Oregon is a very secular state - our churchgoing rates are among the lowest in the country - may play a role in higher suicide rates, he said.

"Religious beliefs and spiritual practices ... have some measure of reducing suicide risk," he said.

As for Thompson, a notorious hell-raiser with a prodigious appetite for drugs and alcohol, family members insist that his suicide was the result of his desire to go out on his terms - not because of depression or chronic pain resulting from a hip replacement, broken leg and back surgery.

"Hunter did not do this in a moment of fear, desperation or despair," his son, Juan Thompson, told the Rocky Mountain News.

"I don't know why he chose this moment. But he was quite clear about what he was doing and he was going to go out on his own terms on his own time."

Tim Christie can be reached at 338-2572 or tchristie@guardnet.com.

Source http://www.registerguard.com/news/2005/03/07/b1.cr.healthfiles.0307.html

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Hospitals in euthanasia row By Lech Mintowt-czyz, Evening Standard 13 December 2004

Factors associated with suicide in elderly people: re-examining the files of usual suspects

Top Introduction Sources and selection criteria Dispelling the myths (Greek... Epidemiology of suicidal... Factors associated with suicide... Detection Management References

 
A wide variety of factors have been implicated in suicidal behaviour in elderly people. These can be described broadly as psychological, physical, and social factors. Such factors are either modifiable, such as physical and psychiatric illness, or non-modifiable, such as sex and social class. A description of modifiable and non-modifiable factors may provide insights into factors associated with suicidal behaviour in elderly people.

The case-control study, using psychological autopsies (information gathered after death from relatives, healthcare professionals, and medical records), is the most commonly used method for examining risk factors and associations for suicide in older people. Recent research has also focused on differences in risk factors for suicide between "young old" (under 75 years) and "old old" populations.^{6 w8} The importance of such research is reflected in the epidemiology of suicide in elderly people, in view of the increased risk for those aged over 75 years.¹

Psychological factors
According to psychological autopsy studies of suicides in elderly people, 71-95% of the people had a major psychiatric disorder at the time of death.⁴ Depressive illnesses are by far the most common and important diagnoses. In the only prospective, non-clinical cohort study of older people to date in which completed suicide was the outcome, self rated severity of depressive symptoms was the strongest predictor of suicide.⁷ Those people in the poorest summary score category were 23 times more likely to die as a result of suicide than those with the least depressive symptoms. Other important psychological factors included drinking more than three units of alcohol a day and sleeping nine or more hours at night. The generalisability of these results is limited, however, because the people were living in a retirement community. A recently published retrospective case-control study found that alcohol use disorders predicted suicide in older people.⁸ A history of alcohol dependence or misuse was found in 35% of elderly men and 18% of elderly women who had died as a result of suicide, with corresponding rates in controls of only 2% and 1%.

A review summarised the findings of four psychological autopsy studies that examined the effect of psychiatric illness on completed suicide.⁴ Any axis I psychiatric disorder was associated with a substantially increased risk of completed suicide, with odds ratios ranging from 27.4 to 113.1. One of the studies found an odds ratio of 162.4 for recurrent major depressive disorder, with single episode major depression, dysthymia, and minor depression being important but less powerful predictors of completed suicide.⁹ Older people with psychotic depression may have a still further increased risk of completed suicide, although a recent study found no difference in the numbers of suicide attempts between psychotic and non-psychotic depressed elderly inpatients.^w9

Other psychiatric illnesses, such as anxiety disorders, psychotic disorders, and substance use disorders, have also been implicated as risk factors for suicide in elderly people, but seem to be significantly less important than depressive illnesses.⁴

Although three of the four studies that examined dementia diagnoses found no significant difference between people who died as a result of suicide and controls, more detailed examination of the nature and anatomical location of cerebrovascular disease is likely to provide clinically useful information in the future.⁴ Traditionally, an increased risk of suicide in patients after stroke was thought to be secondary to depression and functional impairment.^w10 However, strategic infarcts specifically affecting frontal and subcortical circuitry have been associated with both depression and impulsivity, and the importance of cerebrovascular disease in suicidal thoughts and behaviour in older people has been argued.^w11 In addition, a case-control study found that Alzheimer's disease was over-represented at autopsy in elderly people who had died as a result of suicide.^w12

In keeping with findings in younger populations, significantly lower concentrations of 5-hydroxyindoleacetic acid and homovanillic acid have been found in the cerebrospinal fluid of elderly people who died as a result of suicide compared with non-suicidal and normal controls.^w13

The roles of personality type and traits have been studied in elderly people who died as a result of suicide. Clinical experience suggests that the effects of ageing on the brain, physical health problems, and life events such as bereavement may coarsen or accentuate pre-existing maladaptive personality traits in certain elderly people and make them more likely to engage in suicidal thinking or behaviour.

Elderly people who die as a result of suicide have been shown to have higher levels of neuroticism and lower scores for openness to experience, having a restricted range of interests and a comfort with the familiar.¹⁰ Interestingly, the only controlled study assessing personality disorder diagnosis, found that it was not over-represented in elderly people who died as a result of suicide.^w14

A follow up study of 100 elderly people who had attempted suicide two to five years after the index attempt found that 42 had died, 12 being suspected suicides and five dying as a delayed result of the index attempt.¹¹ Twelve women had attempted a further non-lethal attempt and five men had completed suicide after a further attempt. Recent case-control studies identified a history of a suicide attempt as a risk factor for suicide in older people.^{12 w15} These studies highlight the importance of secondary prevention strategies targeted at those who have attempted suicide.

Physical factors
Although problems with physical health and level of functioning are important in the cause of suicidal behaviours, controlled studies suggest that their effects are generally mediated by mental health factors, most notably depression. A recent psychological autopsy study of completed suicide in nursing home residents highlighted the complex interplay between physical and psychological factors.¹³

Having more than three physical illnesses and a history of peptic ulcer disease in a population sample of community dwelling residents aged over 85 years were predictive of increased suicidal feelings.^w3 Physical health and disability seem to be associated independently of depression with the "wish to die."^w16 This death wish was also found to be associated with the highest comorbidity in a large sample of older patients attending their general practitioner for depression, anxiety, and at risk alcohol use.^w17

Based on a review of 235 prospective studies, physical disorders were associated with an increased risk of suicide, including HIV/AIDS, Huntington's disease, multiple sclerosis, peptic ulcer, renal disease, spinal cord injury, and systemic lupus erythematosus.^w18 A retrospective case-control study, however, found that neither current serious physical illness nor a visit by a general practitioner in the previous month was significantly associated with completed suicide.^w15 Two other retrospective case-control studies found the burden of physical illness and current serious physical illness to be significantly associated with completed suicide in elderly people.^{14 15} Depression was not accounted for in the first of these studies, however, and when included in the analysis in the second study, the effects of physical illness became non-significant.⁴ A retrospective case-control study did find that serious physical illnesses (visual impairment, neurological disorders, and malignant disease) were independent risk factors for suicide.⁹ The authors concluded that serious physical illness may be a stronger risk factor for suicide in men than in women, implying that elderly males may be more vulnerable to the effects of physical health problems. These findings have important implications for the detection and management of suicide in elderly people, highlighting the importance of psychiatric evaluation in people with physical disorders.

There are also important ethical implications; the fact that there is a high prevalence of potentially treatable psychiatric illness in those elderly people who have both physical illness and suicidal ideation should be central in any discussion on physician assisted suicide.

Social factors
As with other age groups, elderly people seem to have an excess of stressful life events in the weeks before suicide. The nature of these may differ in older people, with more emphasis on physical illness and losses, such as bereavement, and less emphasis on interpersonal discord, financial and job problems, and legal difficulties; these last four factors are more typically associated with suicide in younger populations.¹⁶ Some recent studies have, however, found an association between interpersonal discord and suicide, even in later life.^{17 w19}

Decreased social support and social isolation are generally associated with increased suicidal feelings in elderly people.^{w17 w20} An influential study suggested that elderly people who had died as a result of suicide were more likely to have lived alone.¹⁸ More recent studies do not agree with these findings, but they did report that loneliness and low social interaction were predictive of suicide.^{12 17 w15}

Religiosity and life satisfaction were found to be independent protective factors against suicidal ideation in elderly African-Americans.^w21 Similar findings have been reported in terminally ill elderly people, where higher spiritual wellbeing and life satisfaction independently predicted lower suicidal feelings.¹⁹

In general, widowed, single, and divorced elderly people have a higher risk of suicide, with marriage seeming to be protective. Bereavement is also associated with attempted and completed suicide in elderly people—men seem especially vulnerable after the loss of a spouse, with a relative risk three times that of married men. In contrast, widowed and married elderly women seem to have a similar risk.¹⁶ A recent study concluded that the protective effect of marriage was not apparent in those aged over 80 years, showing how risk factors for suicide may differ between young old and old old.^w8

Although several social factors associated with suicide in elderly people are non-modifiable, they may give clues as to the underlying biological processes involved in suicidal ideation and behaviour. For example, the increased vulnerability of elderly men to bereavement and physical illness may be mediated by relatively higher levels of cerebrovascular disease and alcohol use disorders compared with elderly women.