Suicide in Long-Term Suicide in Long-Term CareCare

Thomas Magnuson, M.D.Thomas Magnuson, M.D.

Division of Geriatric Division of Geriatric Psychiatry UNMCPsychiatry UNMC

To Get Your Nursing CEUsTo Get Your Nursing CEUs After this program go to After this program go to www.unmc.edu/nursing/mk.. Your program ID number for the May 10Your program ID number for the May 10thth program is program is

10CE026.10CE026. Instructions are on the website.Instructions are on the website. **All questions about continuing education credit and **All questions about continuing education credit and

payment can be directed towards the College of Nursing at payment can be directed towards the College of Nursing at UNMC.**UNMC.**

Heidi KaschkeHeidi KaschkeProgram Associate, Continuing Nursing EducationProgram Associate, Continuing Nursing Education402-559-7487402-559-7487hkaschke@unmc.edu

Objectives Objectives

Discuss the demographics of suicide in the Discuss the demographics of suicide in the elderly in the community and in the nursing elderly in the community and in the nursing homehome

Look at risks for self-harm in the nursing Look at risks for self-harm in the nursing homehome

Discuss how to evaluate opportunity for Discuss how to evaluate opportunity for suicide in the nursing homesuicide in the nursing home

Identify interventions facilities can use to Identify interventions facilities can use to prevent suicide in the nursing homeprevent suicide in the nursing home

Propose a means of conveying all information Propose a means of conveying all information to providers to assess a suicidal residentto providers to assess a suicidal resident

CaseCase

Mrs. QMrs. Q81 year old with moderate dementia81 year old with moderate dementia

Placed two months ago after a hospital stayPlaced two months ago after a hospital stayHad been at home before that hospitalizationHad been at home before that hospitalization

Very angry, especially at her family, for Very angry, especially at her family, for being in the NHbeing in the NH““What’s the use…they dumped me here!”What’s the use…they dumped me here!”Noncompliant at times.Noncompliant at times.Seen weeping at times, usually after family Seen weeping at times, usually after family

visitsvisits

Demographics Demographics

On the rise in the USA since 1950sOn the rise in the USA since 1950s More people die by suicide than homicideMore people die by suicide than homicide

88thth leading cause of death in the USA leading cause of death in the USA 33rdrd leading cause of death among those 15-24 leading cause of death among those 15-24

years of ageyears of age 30,000 suicides a year in the USA30,000 suicides a year in the USA

5800 suicides in those 65 every year in the USA5800 suicides in those 65 every year in the USA 86 suicides/day86 suicides/day 1500 attempted suicides/day1500 attempted suicides/day

Roughly 1 in 20 attempts succeeds Roughly 1 in 20 attempts succeeds

Demographics Demographics

Suicide in the elderlySuicide in the elderly Highest completed suicide rateHighest completed suicide rate

19% of all suicides19% of all suicides 13% of the general population13% of the general population

Greatest is for those over 85Greatest is for those over 85 21/100,00021/100,000

Means Means Firearms 71%Firearms 71%

Most widely used means among men (78%) and women Most widely used means among men (78%) and women (35%)(35%)

Overdose 11%Overdose 11%Suffocation 11%Suffocation 11%Falls 1.6%Falls 1.6%Drowning1.4%Drowning1.4%Fire 0.4%Fire 0.4%

Demographics Demographics

RaceRace Over 65 years of age (2006)Over 65 years of age (2006)

White 15/100,000White 15/100,000African-American 4/100,000African-American 4/100,000Native American 5/100,000Native American 5/100,000Asian-American 8/100,000Asian-American 8/100,000

GeographyGeography Massachusetts 5.9/100,000Massachusetts 5.9/100,000

Men 9.0Men 9.0 Wyoming 31.9/100,000Wyoming 31.9/100,000

Men 53.0Men 53.0 Nebraska 11.1/100,000Nebraska 11.1/100,000

Men 23.9Men 23.9

Characteristics Characteristics

Fewer warnings of intentFewer warnings of intent More planning, more determinedMore planning, more determined 2/3 had a high intent score2/3 had a high intent score

Less likely to surviveLess likely to survive More violent means, more immediateMore violent means, more immediate

Ideation less common than in younger peopleIdeation less common than in younger people 1-36%1-36%

Smaller ratio of attempts to completed Smaller ratio of attempts to completed suicidessuicides 4:1 in men over 65 years of age4:1 in men over 65 years of age 200:1 in young women200:1 in young women

Risks for SuicideRisks for Suicide

Depression and other mental disordersDepression and other mental disorders Substance abuseSubstance abuse Previous suicide attemptPrevious suicide attempt Family history of mental health problemsFamily history of mental health problems Family history of suicideFamily history of suicide Firearms in the homeFirearms in the home Exposure to others who have committed Exposure to others who have committed

suicide suicide Male Male

Risk Factors for Suicide in the Risk Factors for Suicide in the ElderlyElderly

Mood disordersMood disorders Especially Major DepressionEspecially Major Depression Higher prevalence of depressive disorders than in young Higher prevalence of depressive disorders than in young

peoplepeople Previous suicide attemptsPrevious suicide attempts Substance useSubstance use

Alcohol disinhibits and depressesAlcohol disinhibits and depresses Male Male

85% of the suicides over 65 years of age85% of the suicides over 65 years of age Physical illness or decline in self or spousePhysical illness or decline in self or spouse

56% had serious illnesses56% had serious illnesses Loss of social supportLoss of social support

More isolated sociallyMore isolated socially

CaseCase

She reports she wants to kill herselfShe reports she wants to kill herself Endorses her family “doesn’t care”Endorses her family “doesn’t care”

Risks Risks No history of depression, suicide attemptsNo history of depression, suicide attempts

No history of such commentsNo history of such comments No substance abuseNo substance abuse FemaleFemale Recent worsened physical and cognitive healthRecent worsened physical and cognitive health

Led to admission to the NHLed to admission to the NH Perceived lack of social supportPerceived lack of social support

Family emotionally involvedFamily emotionally involved

Evaluation Evaluation

UnfortunatelyUnfortunately20% had visited their MD within 24 20% had visited their MD within 24

hourshours41% had visited their MD within a week41% had visited their MD within a week75% had visited their MD within a month75% had visited their MD within a month11% had seen a mental health provider 11% had seen a mental health provider

within the monthwithin the month7% had seen a mental health provider 7% had seen a mental health provider

within the yearwithin the year

Suicide in the Nursing HomeSuicide in the Nursing Home

New York City (2008)New York City (2008)1,724 suicides in those over 60 in one 1,724 suicides in those over 60 in one

yearyear47 occurred in the NH47 occurred in the NH

Main risk factor was ageMain risk factor was ageFewer died by gunshot wound Fewer died by gunshot wound Increase in death by falls 2.5x if in the NHIncrease in death by falls 2.5x if in the NH

Over 15 years there was a decline in Over 15 years there was a decline in suicide in NYC in those over 65suicide in NYC in those over 65But the rate in NH stayed stableBut the rate in NH stayed stable

Suicide in the Nursing HomeSuicide in the Nursing Home

Northeast Italy (2006)Northeast Italy (2006)5 completed, 8 attempted but not 5 completed, 8 attempted but not

completedcompleted18.6/100,000 and 29.7/100,00018.6/100,000 and 29.7/100,000

All but one suicide and one attempted All but one suicide and one attempted suicide had a history of psychiatric suicide had a history of psychiatric problemsproblems7/13 lived in the facility <1 year7/13 lived in the facility <1 year

No differences in those seeing or not No differences in those seeing or not seeing a mental health providerseeing a mental health provider

Suicide in the Nursing HomeSuicide in the Nursing Home

USA (1999)USA (1999)Aged 60 and aboveAged 60 and above

Community 19.2/100,000Community 19.2/100,000Nursing home 15.8/100,000Nursing home 15.8/100,000

Indirect self-destructive behaviorsIndirect self-destructive behaviorsUsually related to dementiaUsually related to dementiaLeads to death 79.9/100,000Leads to death 79.9/100,000

Case Case

Is there opportunity for suicide?Is there opportunity for suicide?She uses a walker, but is frailShe uses a walker, but is frail

Readily fatigued by short walks to the dining Readily fatigued by short walks to the dining roomroom

All available means removedAll available means removedCords tied up high, finger foods, no pills in Cords tied up high, finger foods, no pills in

roomroomNo elopement riskNo elopement risk

She scores 14/30 on the MoCAShe scores 14/30 on the MoCACannot plan any daily activity at all Cannot plan any daily activity at all

What to do?What to do?

Assess riskAssess risk

Assess opportunityAssess opportunity

Convey information to providerConvey information to provider

Interventions Interventions

Assess RiskAssess Risk

Do they have a previous suicide attempt?Do they have a previous suicide attempt? How serious was this attempt?How serious was this attempt? How long ago?How long ago?

Do they have a family history of suicide?Do they have a family history of suicide? Ask family or friendsAsk family or friends

Do they have repeated suicidal ideations?Do they have repeated suicidal ideations? Ask all shifts if this has occurredAsk all shifts if this has occurred

Is the resident male?Is the resident male? Is the resident white?Is the resident white?

Assess RiskAssess Risk

Is the resident less cognitively impaired Is the resident less cognitively impaired than most residents?than most residents?

Has their physical health worsened Has their physical health worsened recently?recently?

Do increased social stressors now exist?Do increased social stressors now exist?Have they suffered the onset of, or the Have they suffered the onset of, or the

worsening of, disability?worsening of, disability? Is there a family member or friend Is there a family member or friend

overly sympathetic to their suicidal overly sympathetic to their suicidal wishes?wishes?

Assess OpportunityAssess Opportunity

Are they ambulatory?Are they ambulatory?More physically robustMore physically robust

Can they readily leave the facility?Can they readily leave the facility?Elopement riskElopement risk

Is a method of suicide available to Is a method of suicide available to them?them?OverdoseOverdoseHanging/suffocationHanging/suffocationFallFallCut wristsCut wrists

Assess OpportunityAssess Opportunity

Have you eliminated available Have you eliminated available methods?methods?CordsCordsBeltsBeltsShoestringsShoestringsPlastic utensilsPlastic utensilsPlastic bagsPlastic bagsRazorsRazorsChecked for pill hoardingChecked for pill hoarding

Assess OpportunityAssess Opportunity

Cognitive evaluationCognitive evaluationDo they have the cognitive capacity to Do they have the cognitive capacity to

formulate a plan?formulate a plan?Are they too demented to even employ an Are they too demented to even employ an

available means?available means?Do they rapidly change emotions when Do they rapidly change emotions when

redirected?redirected?Would they forget the suicidal ideation Would they forget the suicidal ideation

within an hour?within an hour?

Case Case All her comments, behaviors documented All her comments, behaviors documented

No matter how serious it appearsNo matter how serious it appears Said this repeatedly for 20 minutes, then redirection Said this repeatedly for 20 minutes, then redirection

helpfulhelpful Reviewers always like a clear paper trailReviewers always like a clear paper trail

All risks documented for herAll risks documented for her May be helpful to have an existing formMay be helpful to have an existing form

Evaluation of her opportunity documentedEvaluation of her opportunity documented Helps assess how realistic the threatHelps assess how realistic the threat

There appears to be little opportunity in this caseThere appears to be little opportunity in this case All information conveyed to the primary All information conveyed to the primary

providerprovider Patient has no history of psychiatric illness, Patient has no history of psychiatric illness,

therefore no mental health providertherefore no mental health provider

Convey the InformationConvey the Information

When the suicidal ideation begin?When the suicidal ideation begin? Early in the morningEarly in the morning

Anxiety, mood often worse in the AMAnxiety, mood often worse in the AM Afternoon Afternoon

Sundowning, fatiguedSundowning, fatigued Nighttime Nighttime

Frustrated by efforts to get then to return to bedFrustrated by efforts to get then to return to bed YesterdayYesterday

Why did you wait?Why did you wait? Five minutes agoFive minutes ago

May require a bit more observationMay require a bit more observation

Convey the InformationConvey the Information

What were the circumstances when this What were the circumstances when this began?began? Out of the blueOut of the blue

May quickly go away May quickly go away After a family visit or phone callAfter a family visit or phone call

Cued into thinking about going homeCued into thinking about going home After an altercation with a staff or peerAfter an altercation with a staff or peer

Heightened anxiety, angerHeightened anxiety, anger Asking the resident to do something they did not Asking the resident to do something they did not

want to dowant to do Fight about a bathFight about a bath

New onset physical symptomsNew onset physical symptoms ““I feel so bad I could…”I feel so bad I could…”

Convey the InformationConvey the Information

What did they actually say?What did they actually say? ““I could just kill myself.”I could just kill myself.”

Frustration?Frustration?Figure of speech?Figure of speech?Real intent?Real intent?

““Why am I alive?”Why am I alive?”Not all references are pathologicNot all references are pathologic

I’ll show you…I will end my life and you’ll be in I’ll show you…I will end my life and you’ll be in trouble.”trouble.”

Anger towards someone who gets in their wayAnger towards someone who gets in their way NothingNothing

This may be the most concerning This may be the most concerning

Convey the InformationConvey the Information

What did actually do?What did actually do? Tried to push through staff to get out the doorTried to push through staff to get out the door

Not suicidal, want to go to workNot suicidal, want to go to work Wrapped a cord around their neckWrapped a cord around their neck

Trying to move the radioTrying to move the radio Found hiding pillsFound hiding pills

But not hoardingBut not hoarding Cutting on their wrists with a plastic knifeCutting on their wrists with a plastic knife

Impulsive or history of anxious cuttingImpulsive or history of anxious cutting Refuse to eat, take medicationsRefuse to eat, take medications

Real wishes to die versus manipulationReal wishes to die versus manipulation Nothing Nothing

Just said they want to kill themselvesJust said they want to kill themselves

Convey the InformationConvey the Information

How long did the talk or behavior last?How long did the talk or behavior last? SecondsSeconds

Possibly a figure of speechPossibly a figure of speech MinutesMinutes

Then readily redirectedThen readily redirected Several hoursSeveral hours

May be the real thing…May be the real thing… Until they took a napUntil they took a nap

Frustrated but redirectedFrustrated but redirected Stopped after the offending party leftStopped after the offending party left

Angry at someone, e.g. daughterAngry at someone, e.g. daughter

Convey the InformationConvey the Information

Are they angry or frustrated about Are they angry or frustrated about something?something?Certain individualsCertain individualsBeing in the nursing homeBeing in the nursing homeBeing illBeing illRecognizing their cognition is decliningRecognizing their cognition is decliningPainPainFeeling abandonedFeeling abandoned

Convey the InformationConvey the Information

Have they made such claims before in the Have they made such claims before in the facility?facility? Came and went quicklyCame and went quickly

Appears less seriousAppears less seriousCry wolfCry wolf

Led to an ER visitLed to an ER visitWhat happened there?What happened there?$5,000 car ride and snack$5,000 car ride and snack

Led to an inpatient stayLed to an inpatient stayMade an attemptMade an attemptMade a serious attemptMade a serious attempt

Case Case

Physician calledPhysician called Relay all the information collected on Mrs. Q Relay all the information collected on Mrs. Q

Does she have other symptoms of depression?Does she have other symptoms of depression? Convey facility interventionsConvey facility interventions

Will follow 1:1 for the next hourWill follow 1:1 for the next hourMrs. Q without serious risk or opportunityMrs. Q without serious risk or opportunity

No further talk, behavior after 20 mins.No further talk, behavior after 20 mins. Then every 15 minutes for the rest of the dayThen every 15 minutes for the rest of the day

Repeat question every hour or soRepeat question every hour or so Document she denied after that for the rest of the dayDocument she denied after that for the rest of the day

Reevaluated the next morningReevaluated the next morning No suicidal thoughts endorsedNo suicidal thoughts endorsed Physician discontinued every 15 minute checksPhysician discontinued every 15 minute checks

InterventionsInterventions Gain assessment from the providerGain assessment from the provider

Use their psychiatrist firstUse their psychiatrist first The primary provider will thank youThe primary provider will thank you

Convey all the informationConvey all the information Especially about opportunity and riskEspecially about opportunity and risk Convey any concerns about depressionConvey any concerns about depression

May require treatment interventionMay require treatment intervention Facility interventionsFacility interventions

One to oneOne to one Next hour until done or gone to ERNext hour until done or gone to ER

Every 15 minute checks if no further ideation or low riskEvery 15 minute checks if no further ideation or low risk Discontinue the next dayDiscontinue the next day

Continue to question the resident about suicide, thoughts of Continue to question the resident about suicide, thoughts of deathdeath

Remove all meansRemove all means Persistent symptoms, numerous risksPersistent symptoms, numerous risks

Now transfer to the ER may be appropriate Now transfer to the ER may be appropriate

Objectives Objectives

Discuss the demographics of suicide in the Discuss the demographics of suicide in the elderly in the community and the nursing elderly in the community and the nursing homehome

Look at the risks for self-harm in the nursing Look at the risks for self-harm in the nursing homehome

Discuss how to evaluate opportunity for Discuss how to evaluate opportunity for suicide in the nursing homesuicide in the nursing home

Identify interventions facilities can use to Identify interventions facilities can use to prevent suicide in the nursing homeprevent suicide in the nursing home

Propose a means to conveying all information Propose a means to conveying all information to providers to assess a suicidal residentto providers to assess a suicidal resident