ORLANDO – Transition to an assisted-living facility or nursing home is a period of high risk for suicide among the elderly – as well as an opportunity for preventive intervention.
That was the key message of a study, which earned its presenter, Briana Mezuk, Ph.D., the Best Early Investigator Award for the top research study presented at the annual meeting of the American Association for Geriatric Psychiatry.
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Older adults have the nation's highest suicide rate, but little research has been done on the epidemiology of suicide risk in these senior residential communities.
Dr. Mezuk, an epidemiologist in the department of family medicine and population health at Virginia Commonwealth University, Richmond, presented an analysis of suicide among seniors in nursing homes and assisted-living facilities in Virginia during 2003-2011. The data came from the Virginia Violent Death Reporting System, which includes detailed case narratives describing the circumstances of all violent deaths in the state.
Dr. Mezuk’s study was unusual in that it provided both quantitative data addressing the study hypothesis that nursing homes and assisted-living facilities where suicides occurred would have lower quality of care ratings than facilities without suicides – the opposite proved to be true – as well as common narrative themes gleaned from the case files that could provide clinicians with practical warning signs of impending suicidality.
"Common themes of verbalized anticipatory distress, substance abuse, caregiver burden, past suicide attempts, and history of mental illness highlight potential risk factors for suicide in later life," she reported.
Older adults have the nation’s highest suicide rate. Yet even though there are roughly 16,000 Medicare/Medicaid–certified nursing homes and 31,000 assisted-living facilities in the United States, little research has been done on the epidemiology of suicide risk in these senior residential communities, Dr. Mezuk noted.
In scrutinizing all 3,451 suicides among persons aged 50 years or older recorded in the Virginia reporting system during the 9-year study period, she was able to identify 109 suicides related to life in a senior community. Fifty-two decedents lived in an assisted-living facility or nursing home at the time of their death. Another 38 were getting ready to move into a long-term facility – and were demonstrably unhappy about it. And 19 Virginians over age 50 who committed suicide had a family member who had recently entered long-term care, most often a spouse.
Contrary to Dr. Mezuk’s expectations, nursing homes where a suicide took place had significantly better overall rating scores on the widely used
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Center for Medicare & Medicaid Services Nursing Home Compare metrics than facilities without a suicide, by a margin of 3.92 versus 3.11 out of a possible 5. Nursing homes with a death by suicide were less likely to be for-profit and more likely to be part of a continuing care retirement community. Their average staff rating score of 3.92 out of 5 was significantly better than the 2.97 for nursing homes without a suicide.
Assisted-living facilities where a suicide occurred had an average bed size twice that of other assisted-living facilities.
The average age of individuals who committed suicide in a nursing home or assisted-living facility was 77.8 years. Of all suicides, 22% were accomplished using firearms, 20% by hanging, 17% by falls, and 15% by cutting, among other means.
Among seniors who were living in a long-term care facility at the time of suicide, common themes that emerged from the narrative reports were a history of treatment for depression, one or more prior suicide attempts while in long-term care, and complaints of chronic pain.
Recurring themes among those who committed suicide while anticipating entry into a nursing home or assisted-living facility included explicit resistance to the move, threatened self-harm to avoid the transition, a poor family support network, and despondence over the prospect of the loss of home, friends, and mobility.
Among suicides who were caregivers of a relative who had recently entered long-term care, the common themes were marked despondence over the relative’s change of living status, their own personal failing health, and a history of treatment for depression.
Dr. Mezuk’s study was funded by the Virginia Department of Health and the National Institute of Mental Health. She reported having no financial conflicts.