Statistics, ageism issues, risk factors, resilience factors, QPR approach, safety plan, support networks, conversing with older people
Three sections follow:
1. Background Material that provides the context for the topic
2. A suggested Practice Approach
3. A list of Supporting Material / References
Feedback welcome!
Background Information
Statistics
Australian men over the age of 85 have the highest rate of suicide.
Older people are less likely to see a mental health professional compared to younger people. They will talk to their GP and aged care staff.
As a rule older people thinking about suicide are less likely than younger people to tell others about it.
Attempts in the older population have a higher likelihood of ending in death than for younger people.
When an older person presents with a physical concern there may be an underlying mental health illness (Anglicare, 2022).
Ageism
Wand, McKay and Pond (2022) suggest ageism is one of the issues that prevents people, including medical professionals, from exploring suicide ideation with older people. Examples of ageism include considering depression as ‘understandable’ or ‘justifiable’ with associated lack of action to intervene and actively manage the situation; and judgements that suicide in an older adult is ‘not such a terrible thing’. Ageism underlies some of the other issues that older people encounter with medical professionals. It should be identified and challenged. Examples include:
Ageist attitudes can result in some clinicians failing to engage with older people. As a result clinicians are unlikely to see the emerging signs of suicide ideation.
Clinicians may not look to support the unique strengths and needs of older adults and work to effectively counteract ageism.
While GPs may be able to engage with older people around mental health interventions, many other professionals have concerns, based on ageist beliefs, about providing mental health interventions to older people. Rejection by health professionals when seeking mental health assistance may contribute to suicidal behaviours and limit further attempts to engage with clinicians.
Many clinicians, in part a result of ageist beliefs, hold that psychotherapy is ineffective in older adults.
There is a problem with communication across services and transitions in care for older adults who have self-harmed (when compared to younger people).
Risk and resilience factors
The following are potentially modifiable risk factors for suicide (Anglicare, 2022; Erlangsen, et al., 2021; Wand, McKay & Pond, 2022).
Depression
Other mental illness or symptoms: anxiety (including health anxiety), bipolar disorder, schizophrenia
Alcohol misuse
Cognitive impairment (early cognitive decline)
Losing a sense of agency—the ability to make one’s own decisions
Perceiving oneself as a burden on others
Loss of independence
Living alone, limited social support, loneliness
Physical illness (e.g. chronic worsening disability, chronic pain, delirium, malignancy, neurological disorders, liver disease, male genital disorders)
Impact of life events (e.g. recent bereavement, recent diagnosis of illness, family discord; fear of placement in a residential aged care facility)
Sharing of suicide ideation with family rather than medical professionals.
The following are static risk factors (Page et al., 2021; Wand, McKay & Pond, 2022).
Previous suicide attempts or self-harm
Childhood adversity, physical and sexual abuse
History of limited coping skills in adversity
Unemployment/redundancy or transition to retirement (due to being sick, disabled, being a primary carer)
Resilience factors (Anglicare, 2022; Erlangsen, et al., 2021; Wand, McKay & Pond, 2022).
Perseverance and determination to move forward
Self-efficacy and independence: sense of control
Past successful recovery from adversity
Positive perspective / optimism
Active Spirituality
Social support
Pro-activity: forward planning based on learning from past adversity
Having purpose and a role to play
The QPR approach
The QPR approach (question, persuade, refer) is recommended for speaking with people (older and younger) when one detects changes in mood (or other concerns) that could lead to suicide ideation (Anglicare, 2022).
Question
Be bold in asking the suicide question, even though it may feel very uncomfortable
Asking someone if they’re thinking about suicide will not ‘plant the idea in their mind’
If they are suicidal, ask if they have a plan
The person may be ashamed or want to avoid the stigma. It’s important to normalise their thoughts to reduce the feelings of shame.
Most suicidal people don’t necessarily want to die; they want the emotional pain to end.
Persuade
The goal of persuasion is simple – we want the person to agree to get some help
Active listening is important
A helpful question to ask: “Can you tell me some more about that?” Listening often helps relieve some of the emotional burden
Instilling hope is a key preventative for suicide
Sometimes a listening ear is enough
To persuade, it’s important to empathise
Language is important
A safety plan may be appropriate (see the section below).
Refer
The best referrals are ‘hand-delivered’, where you can take the person to the referred help yourself.
Make sure that you follow-up, don’t ‘refer and dump’.
Hospital may not be the best solution for some.
Have referral information close at hand for when you need it (see the section below ‘Safety Plan’).
Sometimes, all someone needs is a listening ear, and you can provide that for them.
Safety Plan
Beyond Blue (2022) have an online safety plan that can be completed with the person. The following sections are completed and then the finished plan can be printed and/or emailed to the person, a health professional or a trusted supporter.
My warning signs
Make my space safe
My reasons to live
Things I can do by myself
People and places I can connect with
People I can talk or yarn to
Professional support
Where to refer (in Australia)
General practitioner
Specialist practitioner (www.beyondblue.org.au/get-support/find-a-professional)
Mental Health Line (1800 011 511)
Suicide Call Back Service (1300 659 467): A professional, national, 24/7 counselling service for anyone affected by suicide, i.e. people feeling suicidal, people concerned about someone at risk of suicide, people who have lost someone to suicide, for professionals supporting people at risk of suicide. This service offers both immediate support and ongoing support.
For men: Mensline Australia (1300 78 99 78; www.mensline.org.au)
In a crisis: Lifeline (13 11 14); Lifeline for First Nations People (13YARN, 13 92 76, www.13yarn.org.au)
Beyond Blue (1300 224 636, www.beyondblue.org.au)
Practice Approach – Conversing with Older People
Older people are often reluctant to talk because of a range of fears or past experiences. They can feel ashamed, uncomfortable about expressing feelings, fearful of being treated differently, and/or worried about the consequences of sharing worries or problems. Therefore it is important to talk to an older person if worried about them. The following approach can help (Beyond Blue, 2018).
Prepare when and what to say.
Choose a relaxed environment (e.g. on a walk) when the person is not tired or distracted
Provide examples of how the person has changed
Try to understand things from the person’s perspective.
Ask questions to fully understand the situation.
Value the person’s wisdom and experience.
Be patient and respect privacy.
Let the person know he or she is not alone.
Check the person is safe: have they had suicidal thoughts?
The QPR approach outlined in the Background Material section above is an appropriate approach to adopt if suicide ideation arises.
If plans to end one’s life have been made, act immediately: call 000, contact mental health crisis service or go with the person to the emergency department of the local hospital.
If having suicidal thoughts, encourage the person to get support. Provide options.
Be supportive and ask how to provide help; balance helping with supporting the person’s independence.
Help the person understand what support is available.
Encourage professional help if appropriate
Don’t impose ideas; listen to and support the older person in addressing the issues in a manner comfortable to her or him.
Make a plan together; this could involve a ‘formal’ safety plan – see ‘safety plan’ in the Background Material above.
When they don’t want to talk and don’t want help
Respect the person’s right not to seek help.
Keep in touch with the person; maintain the relationship.
Reassure the person that a lot of people face challenges, and they are not alone; help is available. Provide some written information.
Supporting Material / References
(available on request)
Anglicare. (2022). Suicide Prevention for Seniors. Retrieved from https://www.anglicare.org.au/what-we-offer/mental-health/suicide-prevention-for-seniors/
Beyond Blue. (2022). Create your Beyond Now safety plan. Retrieved from www.beyondblue.org.au/get-support/beyondnow-suicide-safety-planning/create-beyondnow-safety-plan
Beyond Blue. (2018). Having the conversation with older people about anxiety and depression. Retrieved from https://www.beyondblue.org.au/who-does-it-affect/older-people/have-the-conversation-with-older-people
Erlangsen, A., Banks, E., Joshy, G., Calear, A. L., Welsh, J., Batterham, P. j., & Salvador-Carulla, L. (2021). Measures of mental, physical, and social wellbeing and their association with death by suicide and self-harm in a cohort of 266,324 persons aged 45 years and over. Social Psychiatry and Psychiatric Epidemiology, 56, 295-303. https://doi.org/10.1007/s00127-020-01929-2 A summary is available at https://www.saxinstitute.org.au/news/what-is-driving-higher-suicide-rates-in-older-people/
Page, A., Sperandei, S., Spittal, M.J., Milner, A., & Pirkis, J. (2021). The impact of transitions from employment to retirement on suicidal behaviour among older aged Australians. Social Psychiatry and psychiatric Epidemiology, 56, 759-77. (2021). https://doi.org/10.1007/s00127-020-01947-0 A summary is available at https://www.saxinstitute.org.au/news/what-is-driving-higher-suicide-rates-in-older-people/
Suicide Call Back Service. (2022). Free telephone counselling. Retrieved from www.suicidecallbackservice.org.au
Wand, A., McKay, R., & Pond, D. (2022). Towards Zero Suicide: Need and opportunities to improve implementation of clinical elements for older adults. Australasian Psychiatry, 30(3), 290-293. doi: 10.1177/10398562211054034