In this interview, we hear from Merrie J. Kaas, PhD, APRN, PMHCNS, FAAN, author of the Suicide in Older Adults toolkit, created in partnership with the Minnesota Northstar Geriatrics Workforce Enhancement Program. The toolkit contains resources for teaching learners how to assess and prevent suicide in older adults. Dr. Kaas is professor emeritus at the University of Minnesota School of Nursing and a board certified, practicing psychiatric-mental health clinical nurse specialist. She has decades of geropsychiatric clinical experience and teaching experience in both psychiatric/mental health and gerontological nursing.
Why did you decide to create this toolkit?
I created this toolkit because there was a lack of information about how to address suicide and suicidal questions in older adults; specifically, how to listen and look for cues as to whether an older adult might be suicidal. And second, there is a lack of information on how to ask the questions about suicidal ideation.
We tend to assume that because a person is older, they're not even thinking about suicide, but they do. And how do we address those issues? I also created this module to provide resources for what to do when we find that an older adult we're working with is currently having or has had suicidal thoughts.
Within the population of older adults in the U.S., suicide is now the 10th leading cause of death. How can the toolkit help decrease incidences of death by suicide in older adults?
Cultivating awareness among the professionals. We need to increase our awareness of the older adult who might be suicidal.
Some of these thoughts are not uncommon, and the older adults who are having these thoughts need to know they are not alone. As clinicians, we can let our older adult patients know there are ways of managing some of the emotional traumas or mental illnesses that may be associated with suicide at their age. We need to tell them not to give up hope; there are ways of feeling better.
That goes for the families as well. Sometimes family members are shocked to learn that an older family member is even thinking about suicide. Older adults don't usually talk about it. They act on those thoughts—often in a very deliberate fashion. They think about suicide, and they act on it without telling anybody because they don't want anyone to know due to feelings of shame or because they don't want to be stopped. The toolkit contains resources for families too because there's a heavy emotional burden placed on the family members after a suicidal attempt and death by suicide.
Why is this toolkit needed?
If we look at the statistics of suicidal thoughts, attempts, and completions among older adults, those incidences are going up. Right now, one suicide occurs for every estimated four suicide attempts in older adults, compared to one suicide for every estimated 25 suicide attempts in the general population. At the same time, our elderly population is rising. So naturally, we are likely to see more older people experiencing thoughts of suicide, which makes this toolkit relevant and necessary.
It's not just in our country; we’re seeing the same trend in many countries. As I looked at the statistics worldwide and through the World Health Organization, the highest rate of deaths by suicide in older adults is in Mediterranean and Sub-Saharan countries. From what I've read, it has to do with the lack of resources as one grows older: the lack of food security and housing security, relatives who aren't around as much to help take care of older family members. So there's this overwhelming sense of hopelessness—and death looks like a good option.
Clearly there's a need for this information to be provided here in the US as well as outside of English-speaking countries.
What is your hope for how this toolkit will affect the health care of older adults?
I want healthcare providers to ask the questions about suicidality and not assume that the 65- or 95-year-old person that's sitting in front of them is doing just fine. Even when they say they're doing just fine, providers need to ask the question.
I had a 92-year-old woman who I really enjoyed working with. I’ll call her Carol. She talked about her long-term depression and some anxiety. Her husband had died, and she had moved into an assisted living apartment about a year prior. Carol was feeling pretty lonely, not fitting into this high-rise senior apartment living situation. She was dressed so well. She was active, she was pleasant, and she had a sense of humor. She was brought by her son, and their family was very close.
In our sessions, I focused mostly on the symptoms of depression and what had worked for her medically before and possible therapy. At first I actually didn't think to ask her about suicide—but than I did. And she said yes, she had a specific plan.
Now Carol is 97. Over the last few years, she had those suicidal thoughts because of her depression and loneliness. But she hasn’t thought more about those plans. Even though she no longer has a plan, she still feels like she doesn't want to be around anymore. She finds that death would be easier than struggling to live. Even those words are concerning because people can passively die by suicide, such as by not eating.
One of the sobering statistics in your toolkit is that 67 percent of older adults who die by suicide had a healthcare visit within one month of their death. Clearly, a lot of these healthcare practitioners aren’t asking the questions, as you say.
Yes, we have to ask these questions. Honestly, I have worked with older adults for a long time—even so, at first I didn’t think about asking Carol from my clinical practice perspective. And then I did, and it was right in front of me. I have lots of experience, but many practitioners don't. And they're probably not going to ask. So my mission is to figure out how to get people to ask the question and listen for the cues.
That's what I want the module to do: to put death by suicide in older adults in our frontal lobe. So that when we see them, even though they are smiling and joking and they have a loving family, there's still a chance that in the dark moments of their lives they're thinking about suicide.
In addition to using your toolkit, what else can clinicians, students, preceptors, and caretakers keep in mind when working with older adults?
Listen for the cues. Always ask the questions about suicidality, no matter if it's uncomfortable, because professionals are often not used to talking to older adults. Sometimes the way they talk to them is demeaning, dismissive, or disrespectful of their age.
Typically we categorize suicidality by low risk, medium risk, and high risk. In the current standard of care for low risk, we might just talk it through. For medium risk, the older adult should see a therapist or a mental health provider. That's not always easy to do. And then for high risk, they're actively suicidal and need to visit an emergency hospital or ER for urgent care. But that shifts the responsibility from us to somebody else.
It's our responsibility to provide hope to those clients. In our toolkit, Suicide in Older Adults, what we put into the module provides hope because it forces us to identify potential resources and how to use those resources. It also makes us think about how, if things change, what things might change for the worse that we as professionals—and the client or family—need to be aware of that might increase the thoughts of death by suicide.
It’s helpful to think about the positive things that might happen, too. Maybe their arthritis pain gets managed or they get to go to a wedding. These are examples of things that we can use as a way of helping older adults develop hope for the future—not just resources for how to manage depression or hopelessness.
That's why I like the model that we created because it doesn't stop with just assessing risk; it gives us more options for what to do. There is hope for possibly preventing hopelessness in older adults. See the new toolkit for clinicians and educators, Suicide in Older Adults.
Sources:
https://save.org/about-suicide/suicide-facts/
https://save.org/about-suicide/suicide-statistics/
Schumutte & Wilkinson, 2020
Ahmedani, et al., 2019