A Common Casualty of Old Age: The Will to Live

By JANE E. BRODY
Suicide is more common among older Americans than any other age group. The statistics are daunting. While people 65 and older account for 12 percent of the population, they represent 16 percent to 25 percent of the suicides. Four out of five suicides in older adults are men. And among white men over 85, the suicide rate — 50 per 100,000 men — is six times that of the general population.
Yet, says Dr. Gary J. Kennedy, director of geriatric psychiatry at Montefiore Medical Center in the Bronx, “If you consider only major depression as the antecedent of elder suicide, you’ll miss 20 to 40 percent of cases in which there is no sign of mental illness.”
Dr. Kennedy, who is also affiliated with Albert Einstein College of Medicine, recently directed a symposium in New York on preventing suicide in older adults, designed to alert both mental health and primary care practitioners to the often subtle signs that an older person may try to end it all.
The Warning Signs
In interviews, he and other symposium presenters noted that detecting suicidal impulses in older people often depended on the ability of family members and friends to recognize warning signs and act on them. According to Gregory K. Brown, a suicide specialist at the University of Pennsylvania, in studies of what preceded elder suicides, “suicide ideation” — the wish to die or thoughts of killing themselves — appears not to have been taken seriously. In 75 percent of cases, the suicide victims “had told family members or acquaintances of their intention to kill themselves,” Dr. Brown said.
Dr. Kennedy put it this way: “This is not simply a doctor’s problem. We need to think of elder suicide more as a social problem and look out for individuals at risk.”
Primary care practitioners are also crucial to suicide prevention among the elderly because older people, and especially older men, are unlikely to seek out and accept mental health services but are often seen by family doctors and nurses within days or weeks of a suicide. Among suicide victims 55 and older, 58 percent visited a general physician in the month before the suicide. In fact, 20 percent see a general physician on the same day and 40 percent within one week of the suicide.
While major depression is the main precipitant of suicide at all ages, social isolation is an important risk factor for suicide among the elderly. And older men, more so than older women, often become socially isolated.
Widowers are especially at risk because older men in the current generation tend to depend on their wives to maintain social contacts. When wives die, their husbands’ social interactions often cease.
“Older males who live alone are an endangered species,” Dr. Kennedy said — particularly “in states like Wyoming, Montana and Nevada, where the social distance is great and firearms are a part of the culture.”
Many men are poorly prepared for retirement, and don’t know how to fill in the hours and maintain a sense of usefulness when they stop working. “They often sit around watching TV,” said Martha L. Bruce, a professor of sociology and psychiatry at the Weill Medical College of Cornell University in White Plains said.
And Dr. Kennedy said, “After retirement a lot of older men start drinking heavily, a sign of increased aggression turned inward.” He called heavy drinking or binge drinking a risk factor for suicide among the elderly.
A particularly vulnerable time may be after the diagnosis of a life-threatening disease like cancer. Older men who were recently discharged from the hospital are also at high risk, Dr. Kennedy said. They need to be periodically screened for depressed mood, loss of interest in life and thoughts of killing themselves.
Serious personal neglect is another warning sign; people can commit a kind of passive suicide by failing to eat, letting themselves become dangerously sedentary or not taking needed medication.
Dealing With Depression
Contrary to what many people think, depression is not a normal part of growing older. Nor is it harder to treat in older people. But it is often harder to recognize and harder to get patients to accept and continue with treatment.
“Most people think sadness is a hallmark of depression,” Dr. Bruce said. “But more often in older people it’s anhedonia — they’re not enjoying life. They’re irritable and cranky.”
She added: “Many older people despair over the quality of their lives at the end of life. If they have a functional disability or serious medical illness, it may make it harder to notice depression in older people.”
Family members, friends and medical personnel must take it seriously when an older person says “life is not worth living,” “I don’t see any point in living,” “I’d be better off dead” or “My family would be better off if I died,” the experts emphasized. “Listen carefully, empathize and help the person get evaluated for treatment or into treatment,” Dr. Brown urged. He warned that “depressed older adults tend to have fewer symptoms” than younger adults who are depressed.
The ideal approach, of course, is to prevent depression in the first place. Dr. Brown recommended that older adults structure their days by maintaining a regular cycle and planning activities that “give them pleasure, purpose and a reason for living.”
He suggested “social activities of any type — joining a book club or bowling league, going to a senior center or gym, taking courses at a local college, hanging out at the coffee shop.”
Dr. Bruce suggests taking up a new interest like painting or needlework or volunteering at a place of worship, school or museum.
Dr. Brown notes that any activity the person is capable of doing can help to ward off depression and suicidal ideation. And he urges older people to talk to others about their problems.