'Alarming' Rate of Suicidal Behavior in Long-term Care Residents

Suicidal behaviors are common in older adults — and especially older women, new research suggests.

In a meta-analysis that included 20 studies and more than 3 million total individuals living in long-term care (LTC), the prevalence rate for suicidal behavior was more than 6%. In addition, the most common of these behaviors was suicidal ideation.

In addition, the prevalence was much higher in women than in men.

These high rates underline the need for clinicians to exercise "extra caution" when assessing elderly people living in a long-term care facility, co-investigator Syeda Beenish Bareeqa, MBBS, clinical researcher, Jinnah Medical and Dental College, Karachi, Pakistan, and research observer, University of Texas Southwestern Medical Center, Dallas, told Medscape Medical News.

"Missed diagnoses or undertreatment in this population can lead to deleterious health outcomes," Bareeqa said.

The findings were presented at the American Association for Geriatric Psychiatry (AAGP) 2022 Annual Meeting.

Underdiagnosed, Undertreated

In the United States, about 42% of adults 70 years and older will live in LTC, either in an assisted care facility or a nursing home, Bareeqa noted.

Although many long-term care residents have a mood disorder, previous research shows that fewer than 25% of cases are diagnosed and treated, she said.

Bareeqa added that suicide — and its association with factors such as the COVID-19 pandemic, depression, and cyber bullying — is a topic of increasing interest to researchers. She and her colleagues wanted to investigate suicide behaviors in the setting of long-term care.

The researchers conducted a literature search for studies of suicidal behavior among LTC residents over aged 60 years. They examined general suicide behavior and the most common subtypes: suicide ideation, suicide attempts, completed suicide, self-destructive behavior and nonsuicidal self-injury.

The analysis included 20 studies and 3 million individuals living in LTC. The majority of the studies were conducted in the US (n = 5) and Australia (n = 4).

Results showed an estimated suicidal behavior prevalence rate of 6.4% (.064; 95% CI, .057 - .070), or 64 per 100,000 persons.

A rate this high is "alarming and unexpected," said Bareeqa. She noted most of the studies included in the analysis were conducted in developed countries with advanced healthcare systems.

The World Health Organization reports the suicide rate per 100,000 older adults (aged 75 years and older) is 50 for men and 16 for women, but this is not stratified by living settings, Bareeqa noted.

Higher Rates in Women

In the current analysis, 5 of the 20 studies had low risk of bias, 14 had moderate risk, and 1 had high risk, Bareeqa reported.

In subgroup analyses, the researchers found much of the suicidal behavior was driven by studies out of Australia, where the prevalence of suicidal behaviors was 36.9% (95% CI, 9.2 - 64.7) vs 1.4% in the US (95% CI, 1.0 - 1.8).

Another surprising finding was the prevalence of suicidal behaviors among women (15.8%), which was much higher than among men (7.9%). "Male gender is a well-established risk factor for suicide in the medical literature but this is not the case in our study," said Bareeqa.

In addition, the analysis showed suicidal ideation was the most common type of suicidal behavior. In a pooled population of around 2 million people in eight studies, the prevalence of suicidal ideation was 12%.

For psychiatric illnesses accompanying suicidal behavior, the prevalence of depression alone was 14.4%, which was much higher than the rate of 5.1% for multiple comorbidities — including depression, anxiety, obsessive-compulsive disorder, psychotic disorder, history of previous suicide attempt, delusion, delirium, and hallucination.

Although depression and other psychiatric conditions may help explain suicidal behavior in older adults, Bareeqa believes physical illness also plays a major role.

"Illnesses like cancer or end-stage organ failure, which are quite common with advancing age, are debilitating and in some instances incurable. These medical problems create a breeding ground for mental health problems and can eventually lead to devastating outcomes such as suicide," she said.

She noted the importance of a "multi-pronged approach" to prevent suicide among older people in long-term care facilities.

In addition, her research team aims to assess the quality of care provided by long-term care facilities. "Maybe we can get to the root of this problem and devise strategies to improve it," said Bareeqa.

"Not Uncommon"

Commenting for Medscape Medical News, Rajesh R. Tampi, MBBS, professor and chairman, Department of Psychiatry, Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services, Omaha, Nebraska, said the results suggest that, despite the risk for bias among the included studies, "suicidal behaviors are not uncommon among older adults in LTC."

However, Tampi, who is also a past president of the AAGP and was not involved with the research, noted the analysis only describes associations "but does not indicate causality."

In addition, additional subgroup analyses should yield information on possible risk factors for suicidal behaviors in LTC, such as depression, anxiety, and chronic pain, he added.

American Association for Geriatric Psychiatry (AAGP) 2022 Annual Meeting: Session "Oral Presentations 3." Presented March 21, 2022.

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