You receive a dispatch call to check the welfare of an 86 year old Caucasian male. The reporting party is one of the man’s daughters, Judy, who lives out of state. She has been unable to contact her father Thomas Clark; he has not returned calls or sent her his weekly letters. Judy informs you that Clark’s wife died in hospice five months ago. Clark has congestive heart failure and diabetes. Judy has already contacted his physician and learned that he did not keep a medical appointment scheduled for two days ago. She also reports that her father has not shown signs of dementia, but in the past he has stated “I am no good to anyone any more, everyone would be better off if I was dead”. Judy also informs you that Clark was in the military and has several firearms that he keeps locked in a gun safe.
You request a second unit. When you arrive at the upscale residence you see that the yard is in total disarray. There is at least a week’s worth of newspapers in the driveway. It doesn’t appear that Clark has driven his ’05 Cadillac in a very long time. The mailbox is overflowing. It is dusk but there are no lights on in the residence. Clark comes to the door, still wearing his pajamas. His hygiene is poor, he is malodorous, and he hasn’t shaved in sometime. Clark takes note that you are appraising him, and tells you he was just headed to the shower. You ask him if you can come in, he reluctantly lets you. The home is certainly not tidy, but it is reasonably clean. Clark asks you why you are there, you explain, and he tells you that “Judy is a worry wart”. He admits to being down after the loss of his wife, but insists he is not suicidal. You notice a pistol on the coffee table and ask him about it. He tells you it is for protection; that there has been a rash of home robberies in the neighborhood. You know that is not true. He does have prescription bottles, financial folders and a glucometer on the table. He shows you his kitchen. He does have electricity and the water runs. There are dishes in the sink; there is food and insulin in the refrigerator. There a number of empty beer cans in a recyclable bin. He warms up to you a little and states it would be fine if someone followed-up with him. He agrees to go back to his physician and to call Judy. He also agrees to put his firearm back in the safe. You have one of those “hinky” feelings, but there is nothing else you can do for Clark now. You call Judy and describe the situation; you encourage her to involve the family. You make the appropriate referrals when you get back to the station.
You learn that Clark died of a self-inflicted gunshot wound to the head two days later. You take that a little hard; no suicide is easy to deal with but you had gotten to know the victim. You did everything right, or did you?
The Problem
Someone age 65 or over completes suicide every 90 minutes; an average of sixteen deaths a day. Elders account for 20% of all suicides; but they comprise only 12% of the population. White males over age 85 are at the highest risk; they complete suicide at approximately six times the national average. The rates are probably much higher than that, it is estimated that elderly suicide may be under reported by at least 40%. These so called “silent suicides” include deaths by medical noncompliance/overdoses, self-starvation or dehydration, and supposed accidents.
The elderly complete suicide one out of every four attempts; compared to one out of sixteen in younger adults. The reason for this discrepancy is that the elderly use more deadly means when attempting suicide using guns and hanging.
More Staggering Statistics:
- Elderly white men were at the highest risk with a rate of approximately 31.1 suicides per 100,000 each year
- White men over the age of 85 “who are labeled as old-old”, are at the greatest risk of all age, gender, and ethnicity groups. In 2007, the suicide rate for these men was 45.42 per 100,000. That was 2.5 times the current rate for men of all ages (18.3 per 100,000).
- 84.4% of elderly suicides are male
- The elderly have the highest rate of completed suicides compared to any other age group
- Among the elderly there is 1 completed suicide for every 4 attempts. Whereas, 15-24 year olds complete suicide at a rate of 1 for every 100-200 attempts
- Firearms are the most common means of suicide among the elderly, accounting for 73% of all completed attempts.
- Suicides among the elderly are rarely impulsive. The elderly have thought about their suicide for months, or even years
Additionally, older adults have homicide-suicide rates that are twice as high as younger adults. Each year more than 500 homicide-suicides or 1,000 deaths occur in persons 55 years and older. Homicide-suicides in older people were previously considered to be suicide pacts, mercy killings or altruistic homicide-suicides, where both partners were old and sick. This has been proven to be untrue. Homicide-suicide acts are a result of depression and desperation. Almost all homicide-suicides in older persons involve a husband who kills his wife before killing himself.
The Causes
The leading cause of suicide among all individuals is untreated depression. About 1/3 of individuals who are 65 or older will experience depression. It is important to remember that depression is not a normal process of aging. Depression is related to chemical imbalances in the brain. Many different factors in the elderly can lead to an increased prevalence of depression: severe chronic/intractable pain, debilitating and/or terminal illness, the loss of a loved one, financial stress, increased social isolation, serious physical and/or cognitive impairments, decreasing independence, major changes in social roles (retirement), and alcohol or narcotic dependence. Any elderly person showing the signs and symptoms of depression needs mental health treatment.
Additionally, any elderly person who exhibits symptoms of depression needs to have a thorough physical exam from a medical doctor to determine if there is a physical basis for the depression. Certain diseases/conditions may cause symptoms of depression: thyroid disorders, diabetes, Parkinson's disease, multiple sclerosis, strokes, tumors, and viral infections. Additionally certain medications can cause symptoms of depression: antihypertensives, hormones, steroids, and arthritis medication.
Ten Warning Signs
1. Loss of interest in things/activities that are usually found enjoyable
2. Feeling hopeless and/or worthless
3. Decreasing social interaction
4. Not attending to personal self care, grooming or dressing
5. Not following prescribed medical regimens: medications, medical treatments, exercise or diets
6. Loss of a significant other (especially a spouse)
7. Making final plans: giving away possessions, or making changes in finances and/or wills
8. Buying firearms or stock piling prescriptions
9. Saying good-bye to others that sound permanent
10. Any verbalization of suicidal ideation needs to be taken seriously
Law Enforcement Checklist for Assessing Suicidality in the Elderly
It is important to remember that many elderly people will hide their depression because they do not want to be seen as weak, crazy, or suffering from dementia. They are afraid that they will be placed in assisted living or nursing home facilities.
- Look for aforementioned warning signs
- If you suspect that the individual is depressed ask them directly if he or she is thinking of suicide or self-harm. If they acknowledge suicide ideation initiate a petition for a 72 hour psychiatric evaluation as a “danger to self”. Arrange transportation to the closest emergency room.
- Attempt to get collaborative information: family, friends, senior volunteers, medical providers, neighbors, etc. Third party information can be used to substantiate a psychiatric petition.
- Assess the living situation; can the individual maintain at their current location or are they unable to care for themselves
- Get help from in-house resources if you have any: a mental health team or elder team/detective
- Get help from outside resources: make a report to Adult Protective Services
- Encourage disposal of firearms in the home and promote safe storage of all firearms
- Train other officers, EMTs, and emergency workers to recognize possible suicide attempts that may be mistaken for accidents.
- Get the word out to elders and their families that late life depression is readily treatable condition that may lead to suicide if not addressed.
- Follow-up with the any depressed individual if time permits
Suicide is society’s most preventable form of death. No matter what a person’s age maybe, suicide affects others. It is estimated that every suicide intimately affects at least 6 other people. Survivors of suicide have a significantly higher rate of suicide themselves. Law enforcement officers are often survivors of suicide. Debrief with other officers following all completed suicide calls.
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About The Author:
Pamela Kulbarsh, RN, BSW has been a psychiatric nurse for over 25 years. She has worked with law enforcement in crisis intervention for the past ten years. She has worked in patrol with officers and deputies as a member of San Diego's Psychiatric Emergency Response Team (PERT) and at the Pima County Detention Center in Tucson. Pam has been a frequent guest speaker related to psychiatric emergencies and has published articles in both law enforcement and nursing magazines.
