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TO LIVE OR DIE: A LOOK ATELDERLY SUICIDEJ. Conrad Glass Jr. a & Susan E. Reed aa North Carolina State University , RaleighPublished online: 03 Aug 2006.

To cite this article: J. Conrad Glass Jr. & Susan E. Reed (1993) TO LIVE OR DIE:A LOOK AT ELDERLY SUICIDE, Educational Gerontology, 19:8, 767-778, DOI:10.1080/0360127930190807

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TO LIVE OR DIE: A LOOK AT ELDERLY SUICIDE

J. Conrad Glass, Jr.Susan E. Reed

North Carolina State University, Raleigh

The elderly are at higher risk for suicide than any other age group. Characteristicsof this high-risk population are examined, along with a number of factors thatappear to be related to suicide among older persons. Strategies for intervention andlowering the suicide rate are discussed.

Not too long ago, the body of an 86-year-old man was found in a re-tirement home in Silver Spring, Maryland. A plastic bag was over hishead, and evidence of sleeping pills was found in his system. In tryingto explain this man's self-inflicted death, friends pointed to a series ofrecent losses in his life: the death of his wife, a stroke that limited hiswork, a move across the country, and a change from independent livingto life in a retirement center (Goodman, 1990; Hines, 1990).

Compared with heart diseases and cancer, suicides represent asmall proportion of the deaths among older people. However, suicidesamong the elderly are not uncommon. In 1988, 6,363 Americans overthe age of 65 were officially listed as suicide victims (National Centerfor Health Statistics, 1990). But the death of the man just describedattracted national media attention. The man was Bruno Bettelheim, arenowned psychologist whose life work had focused on the meaning oflife. He had "wrested meaning out of his experience in a concentrationcamp and resurrected it out of the minds of the autistic children heworked with" (Goodman, 1990, p. M7). That such a man should chooseto end his life in old age raises profound questions about the causes ofelderly suicide and rekindles debate about whether such suicide is everjustified.

SCOPE OF THE PROBLEM

Although teenage suicides attract considerably more media attention,elderly persons are at higher risk for suicide than any other age group.

Address correspondence to J. Conrad Glass, Jr., Department of Adult and Commu-nity College Education, 310 Poe Hall, Box 7801, North Carolina State University,Raleigh, NC 27695-7801.

Educational Gerontology, 19:767-778, 1993 767Copyright © 1993 Taylor & Francis

0360-1277/93 $10.00 + .00

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In the United States and most other Western industrialized countries,the rate of suicide increases with advancing age (Atchley, 1991; Osgood& Mclntosh, 1986; Praeger, 1988). Persons over the age of 65 consti-tute about 12.5% of the American population (American Association ofRetired Persons, 1990), yet they account for almost 20% of the reportedsuicides (National Center for Health Statistics, 1990). Suicide rates forthose 65 and older are more than 50% higher than for the populationas a whole (Mclntosh, 1989; Osgood, Brant, & Lipman, 1991).

From the 1950s until the early 1980s, researchers had documenteda steady decrease in the suicide rates among elderly persons (Mcln-tosh, 1989; Osgood et al., 1991; Osgood & Mclntosh, 1986; Seiden &Freitas, 1980); however, between 1981 and 1986, there was a 25%increase in the rate of elderly suicides ("Elderly Suicides Rise," 1989).This increase occurred mainly among white men and at the older ages.Many researchers (Lesnoff-Caravaglia, 1987; Mclntosh, 1989; Miller,1978, 1979a; Osgood et al., 1991; Samuels, 1979) agree that elderlysuicide is significantly underreported. According to Miller (1978), thenumber of suicides wrongly certified as accidents or natural deathsprobably equals the number of reported suicides.

A variety of reasons account for the underreporting of elderly sui-cides. Suicide statistics are compiled from death certificates listingsuicide as the official cause of death ("Elderly Suicides Rise," 1989;Mclntosh, 1989; National Center for Health Statistics, 1990). As maybe the case with any age group, some physicians may be reluctant toreport the death of an older person as a suicide. If there is any doubtas to the cause of death, the physicians may try to save the familymembers from the embarrassment, shame, or guilt that accompanies asuicidal death (Goodman, 1990; Miller, 1979a; Wass & Myers, 1982).Nursing homes may be reluctant to report suicides because of negativepublicity and the possibility of "governmental intervention" (Samuels,1979, p. 7). In addition, few autopsies are performed on elderly per-sons, and there is often little curiosity about their deaths (Lesnoff-Caravaglia, 1987; Miller, 1979a). Finally, unknown numbers of elderlypersons engage in behaviors that do not immediately end their livesbut do tend to hasten their deaths. Such behaviors can be found amongelderly persons in long-term care facilities (Atchley, 1991; Kahana &Kahana, 1982). Patients may refuse food or medicine, fail to followprescribed medical regimens, and deliberately place themselves indangerous situations. These passive suicidal behaviors often result inphysical conditions that increase the risk of pneumonia, cardiac arrest,respiratory failure, and other physical disease conditions. Deaths re-sulting from these behaviors are rarely recognized or reported as sui-

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cides (Osgood et al., 1991; Nelson & Farberow, 1980; Praeger, 1988;Samuels, 1979).

CHARACTERISTICS OF THE HIGH-RISK POPULATION

Determining the characteristics and causes of late-life suicides is dif-ficult. The bits and pieces of information available do not add up to aclear picture. And there is not likely to be dramatic improvement inthis situation any time soon, because suicide is difficult to study. It isgenerally easier to describe the characteristics of those who are at highrisk than it is to determine the causes of suicide. We can determine therisk factors through a psychological look back at those who committedsuicide, but the causes of suicide reside only in the mind of the one whois dead. Given that few elders leave suicide notes, not very much isknown about what causes their suicides. To complicate the matter evenfurther, many people experience these same conditions without com-mitting suicide. To directly link a particular factor to a particularsuicide is difficult. Given this dilemma, we shall examine the bits andpieces of information from the literature to see what clues are sug-gested regarding individuals who may be at high risk for suicide. At-tention is given to factors that seem to be related to suicides amongolder adults.

Researchers seem to agree that elderly persons who attempt suicidegenuinely want to die (Achte, 1988; Atchley, 1991; Kahana & Kahana,1982; Lesnoff-Caravaglia, 1988). Unlike younger persons who attemptsuicide, elderly persons are not calling for help (Miller, 1979b) or at-tempting to manipulate family or friends ("Suicide Increases," 1988).They are rarely motivated by anger or revenge (Miller, 1979b); theysimply want the release offered by death (Atchley, 1991). Elderly per-sons commit suicide "with a determination and singlemindedness ofpurpose not encountered among younger age groups" (Seiden, 1981, p.265). Often they have thought about and carefully planned their deathfor a long time (Achte, 1988; Lesnoff-Caravaglia, 1987).

Elderly people are more successful at suicide than any other agegroups (Achte, 1988; Butler & Lewis, 1973; Kahana & Kahana, 1982;Lesnoff-Caravaglia, 1988; Saul & Saul, 1988; Seiden, 1981). Elderlypersons "commit suicide the most while attempting it the least" (Sei-den, p. 265). Researchers' estimates of the ratios of successful elderlysuicides to unsuccessful attempts range from 1:1 (Kahana & Kahana,1982) to 4:1 (Mclntosh, 1985) to 8:1 (Lesnoff-Caravaglia, 1988; Send-buehler & Goldstein, 1977).

Because they truly want to die, elderly persons use more lethal

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methods than younger persons. Shooting and hanging are commonsuicide methods, although older women are likely to choose less dis-figuring methods, such as an overdose of sleeping pills (Achte, 1988;Lesnoff-Caravaglia, 1987; "Suicide Increases," 1988). Elderly personsgenerally have poorer physical health than younger persons and aretherefore more likely than younger persons to die from injuries ordamage caused by a suicide attempt (Mclntosh, 1985). For elderlypersons living alone in the community, suicide attempts often succeedbecause there is little chance of discovery or rescue ("Suicide In-creases," 1988). Elderly persons who are contemplating suicide aremuch less likely than younger persons to turn to suicide preventioncenters, crisis telephone lines, or any kind of mental health services.Older age cohorts seem unwilling to admit the need for any kind ofpsychological or psychiatric help (Dickinson, 1987; Lesnoff-Caravaglia,1987). But many elderly persons do see their physicians shortly beforeattempting suicide. In one study, 77% of the elderly persons who com-mitted suicide had seen a physician within a month of their suicidesand 29% had seen a physician within a week of their deaths. Elderlypersons in these circumstances usually report depression or physicalcomplaints, but they do not volunteer their suicidal thoughts unlessdirectly questioned by the physician (Miller, 1979b).

Elderly white men are the group at highest risk for suicide (Atchley,1991; Mclntosh, 1989; Osgood, 1985). Why is this so? Is it our culture?Is there something about the values of American white men that causethem to be more likely to define their situations as intolerable andunchangeable and thus see suicide as an appealing alternative? Is itthat more aging white males in American society, as compared withwomen and ethnic minorities, perceive the losses of social status, power,and money that often accompany old age to be severe enough to suggestsuicide as a welcome outlet? We really do not know for sure, but sucha possibility may be one factor that accounts for their drastically higherrate of suicide (Osgood et al., 1991). Atchley (1991) expanded on this byidentifying older men who have recently been widowed, diagnosed witha terminal illness, or who have undergone sudden physical deteriora-tion as being particularly susceptible to suicide. For men, the risk ofsuicide increases with age and peaks when they are in their 80s (Butler& Lewis, 1973; Kahana & Kahana, 1982; Miller, 1979b). Suicide ratesfor women seem to be fairly consistent for all age groups, with no realpeak period (National Center of Health Statistics, 1990).

Suicide rates for nonwhites are at lower levels than those for whitesin old age (Mclntosh & Santos, 1981; Seiden, 1981). Mclntosh andSantos (1981), however, documented much diversity among specificracial and ethnic minorities included in the nonwhite category. Among

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Chinese-, Japanese-, and Filipino-Americans, suicide rates peak in oldage. Among African-Americans and Native Americans, suicides amongthe elderly are extremely rare. The lower suicide rates among olderblacks as compared with older whites may be attributed to the greaterdegree of external constraint imposed on African-Americans and totheir more intense involvement in family, church, and community (Os-good et al., 1991; Mclntosh & Santos, 1981; Seiden, 1981).

Suicide rates are highest for the unmarried, especially for elderlywidowers. Elderly persons who are Protestants have higher rates ofsuicides than either Catholics or Jews (Miller, 1979b; Osgood, 1985).Older people in institutions, especially those who do not have visitors,and older people who are severely depressed also appear to be at highrisk for choosing suicide (Atchley, 1991). Other researchers have noteddepression as a contributing factor to elderly suicide (Butler & Lewis,1973; Miller, 1979b; Osgood, 1985; Praeger, 1988; Samuels, 1979). Ka-hana and Kahana (1982) reported that the suicide rate of depressedpersons is at least 25 times higher than that of the general population,although many depressed elderly people do not attempt suicide andother elderly people with no clinical signs of depression do attempt toend their lives.

FACTORS THAT POSSIBLY CONTRIBUTE TOELDERLY SUICIDE

Elderly persons who commit suicide rarely have histories of attemptedsuicide or self-destructive behaviors. Whereas younger persons mayattempt suicide for a single reason or a temporary problem, older peo-ple are thought to attempt suicide for a host of reasons. Elderly personsmay choose suicide after a "realistic appraisal of their life situation"(Lesnoff-Caravaglia, 1987, p. 267). Some researchers hypothesize thatthe reasons older people commit suicide are related to the cumulativeeffects of the losses and changes commonly experienced by aging per-sons (Achte, 1988; Butler & Lewis, 1973; Kahana & Kahana, 1982;Lesnoff-Caravaglia, 1987, 1988; Miller, 1979b; Osgood et al., 1991;Praeger, 1988; Wass & Myers, 1982). These losses are as follows:

1. Social roles at work, in the family, and in the community generallybecome more constricted as persons age.

2. Retirement leads to reduced income and may result in lowered sta-tus, prestige, and influence.

3. In a society that values youth and health, older persons may cometo feel devalued and useless.

4. Elderly persons often experience sensory and perceptual losses,

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such as hearing and visual impairments, that can limit their mo-bility and their ability to interact with other people.

5. As persons age, they are more likely to develop chronic illnesses.These illnesses can be painful and expensive, and they can lead toincreasing dependence and confinement and greater isolation fromothers.

6. As elderly persons lose physical strength and stamina, experiencesensory losses, and develop chronic illnesses, they may lose self-esteem and develop negative body images.

7. Elderly persons also experience loss through the deaths of theirloved ones, including spouses, parents, children, and friends.

8. If their physical and social circumstances necessitate institutional-ization, elderly persons face losses resulting from leaving familiarhomes and communities. They lose their freedom, and they mustadjust to dependence, restricted mobility, and smaller life space.

This list of factors that contribute to elderly suicide consists mainlyof untested hypotheses. Research on activities and well-being, in gen-eral, shows that reduced activities in later life do not cause a reductionin life satisfaction (Atchley, 1991; Palmore, Nowlin, & Wang, 1985). Infact, a large majority of persons who are retired have quite high lifesatisfaction. Therefore, why should we suspect this reduction in activ-ity to cause suicide? There is no evidence that retirement causes sui-cides (Atchley, 1991; Stenback, 1980). Retirement does not have a sig-nificant impact on physical and mental illness (Atchley, 1991; Crowley,1985), so why should we expect it to cause suicide? It appears that veryfew older people believe they are devalued and useless, despite themessages they may be getting from society. As indicated earlier, manyolder people experience the situational factors suggested earlier ascontributors to suicide without committing suicide. If there is sometruth that these factors "cause" suicide in some older people, why is itthat they cause it in some and not in others? Are there other factorsthat are the "causes"? Are there certain combinations of factors thatare more contributive to elderly suicide than others? If so, what arethey? We do not have the answers to these questions yet.

The changes and losses that accompany old age demand adaptationsfrom elderly people at a time when, for many, adaptive capacities arereduced. These changes and losses may cause much stress and lead toanxiety, depression, and feelings of helplessness and hopelessness insome individuals (Achte, 1988; Butler & Lewis, 1973; Kahana & Ka-hana, 1982). Most elderly persons cope with their life circumstanceswithout resorting to suicide, but others conclude that death is prefer-able to life. Why is this? More certain answers still need to be found.

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PREVENTION OF ELDERLY SUICIDESTHROUGH INTERVENTION

When elderly people attempt suicide, they usually succeed. "To stopelderly suicides, we have to prevent the attempt" (Atchley, 1991, p.270). In order to prevent suicide attempts, practitioners working withelderly persons must first recognize the clues that indicate suicidalbehavior. Second, practitioners must evaluate the lethality potential,or the degree of risk for a successful suicide attempt. Finally, theymust plan and carry out appropriate interventions (Cutter, 1983; Os-good, 1985; Praeger, 1988).

Researchers have delineated a series of clues that can warn of sui-cide. These clues can be divided into four categories: verbal, behav-ioral, situational, and syndromatic (Osgood, 1985). Situational cluesare very similar to the changes and losses of old age described in theprevious section. Syndromatic clues are the psychological syndromesmost often correlated with suicide. These include depression, anxiety,agitation, guilt, dependency, rigidity, impulsiveness, and isolation (Os-good, 1985).

Verbal clues involve such things as threatening suicide, stating thedesire to die, hinting at or joking about death, saying goodbye to sig-nificant others, and expressing feelings of helplessness or worthless-ness. Behavioral clues include previous suicide attempts, for those fewwho tried and failed; sudden interest or disinterest in religion; donat-ing one's body to science; making funeral plans; making or changing awill; taking out an insurance policy or changing beneficiaries; givingaway money or valued possessions; making arrangements for the careof pets; increased alcohol or drug use; self-destructive behaviors; buy-ing a gun or stockpiling medications; isolating oneself from family orloved ones or angering these persons so they will stay away; schedulingan appointment with the doctor with no apparent physical complaintor soon after the last visit to the doctor; changes in eating or sleepingpatterns; sudden recovery from deep depression; and visible interest inart forms with dominant death themes (Butler & Lewis, 1973; Cutter,1983; Miller, 1979b; Osgood, 1985; Praeger, 1988).

After recognizing the clues that warn of potential suicidal behaviorin an individual, practitioners should attempt to evaluate the degree ofrisk. "The most important steps in evaluation of lethality potential areascertaining first the existence of a suicide plan and then determiningthe lethality, availability, and accessibility of the method of self-de-struction specified in the plan" (Osgood, 1985, p. 84). Practitioners canevaluate lethality potential by asking direct questions of the elderlyperson at risk and by assessing the internal and external resources

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available to a person as well as that person's ability to communicatethoughts and feelings.

Practitioners who intervene with elderly individuals at risk for sui-cide must build trust and rapport with these individuals (Praeger,1988). They must understand the life situations of the elderly, be ableto empathize with their feelings, and "listen, listen, listen" (Osgood,1985, p. 112). Hatton, Valente, McBride, and Rink (1977) suggestedthe following steps in suicide intervention:

1. Focus on the present crisis.2. Reduce or eliminate any imminent danger.3. Evaluate the need for medication.4. Determine whether it is safe for the individual to stay alone.5. Mobilize the individual's internal and external resources. Help

structure activities for the individual and teach problem-solvingskills that can help the older person cope more effectively withstressful situations.

6. Implement an ongoing program of help.

An ongoing program of help can take many different forms. Contin-ued individual counseling may be necessary (Butler & Lewis, 1973).Pharmacological interventions may help manage psychiatric disordersassociated with elderly suicide (Osgood, 1985). Support groups "haveproven to be invaluable vehicles for ventilation of feelings, sharing ofideas, and mitigation of depression" (Saul & Saul, 1988, p. 240). Suchgroups can involve elderly people in their own problem solving and helpthem reach out and support each other. Reminiscence and life reviewtherapy can help at-risk elderly persons "to achieve a sense of meaningand to maintain integrity over despair, thereby decreasing the risk ofsuicide" (Osgood, 1985, p. 173). Creative therapy through music, art,dance, or drama offers opportunities for expressing feelings, buildingconfidence, and discovering new sources of pleasure and enjoyment.Finally, teaching elderly persons techniques to manage tension andstress (e.g., exercise, relaxation methods, finding someone with whomto talk, biofeedback, etc.) can enable them to cope constructively withthe changes and losses that accompany old age (Osgood, 1985).

IMPLICATIONS FOR PREVENTION

After considering the factors related to elderly suicide, many research-ers have drawn implications about the kinds of support needed byolder persons facing significant changes and losses. Some have sug-gested strategies that they believe would lower the suicide rate for

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elderly persons (Achte, 1988; Butler & Lewis, 1973; Lesnoff-Carava-glia, 1987; Miller, 1979b; Osgood, 1985):

1. Although it may be difficult to provide more financial resources forthose individuals who are living with an income that, to them, doesnot provide a life that seems worth living, attempts should bemade to ensure that the basic economic needs of the elderly aremet. Attempts should be made to connect older adults with propergovernmental agencies if families are not able to meet these needs.

2. Family doctors, geriatric specialists, and psychiatrists should betrained to recognize and respond to clues indicating that an elderlyperson is at high risk for suicide. They also should receive trainingto help them understand the problems commonly faced by elderlypersons. In addition, doctors need to be trained to recognize andtreat depression in their elderly patients. Special attention shouldbe paid to persons who have been recently widowed.

3. Elderly persons need access to low-cost psychiatric and psycholog-ical services. Efforts should be made to inform high-risk individ-uals and their families of the locations of such services within theircommunity.

4. All persons who work with the elderly (nursing home staff, seniorcenter employees, clergy, welfare workers, social workers, etc.)should receive training to help them recognize the warning signsof elderly suicide and know where to refer individuals at high risk.

5. The news media and public service programs should be encour-aged to report the problem of elderly suicide and to familiarize thegeneral public with the warning signs of elderly suicide. The mediaalso should help increase public awareness of the problems asso-ciated with aging.

6. Magazines targeted for older readers should publish articles ongeriatric suicide to increase awareness and stimulate discussionabout the problem.

7. Elderly members of religious groups and fraternal organizationsmight organize outreach programs to identify the elderly personsamong them who are isolated or at high risk for suicide. Where torefer such individuals should be a part of the training for volun-teers.

8. Suicide prevention centers and mental health centers also coulduse elderly outreach workers to identify elderly persons at risk forsuicide and to talk with elderly callers.

9. Public and private agencies that serve elderly persons should worktogether to develop programs for suicide prevention and interven-tion.

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10. More research is needed on geriatric suicide. More information isneeded on the special problems of widowed elderly persons andwhat constitutes meaningful life in old age.

CONCLUSION

According to gerontologist Marvin Miller (1979b), we need a "firm na-tional commitment" (p. 91) in order to significantly reduce the numberof suicides in our country. As a society, however, we see the suicidaldeaths of young persons as much more tragic than those of elderlypersons (Osgood, 1985; Praeger, 1988). Some media reports about thedeath of Bruno Bettelheim were sympathetic and even supportive ofhis choice. A Los Angeles Times article (Goodman, 1990) stated thatBettelheim "paid his dues. He tolerated suffering. He understood lifeand exercised his privilege to leave it" (p. m7). This raises the wholeethical question of whether society wants to prevent all elders fromdeciding for themselves when they will die. Are there situations wherelife is so intolerable and unchangeable for older persons that suicide isa welcome option? Discussion of this issue is beyond the scope of thisarticle, but it is a realistic issue that must be dealt with by society asit attempts to devise prevention and intervention efforts.

Without doubt, some older people face a series of significant andsometimes devastating losses. We must acknowledge that no matterwhat we do, some elderly persons in great physical and emotionalanguish will choose to end their lives. In spite of our best efforts, theysee no help or hope for their situations. But for others, our efforts mayoffer help and hope. We must continue to search for creative ways toensure that basic economic, physical, social, and emotional needs aremet. We must continually search for ways to help individuals copepositively with losses. We must help elders to discover ways they cancontinue to contribute to society and to each other, thereby giving themsome reasons to believe that life is still worth living.

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