suicide prevention in senior living communities...suicide prevention in senior living communities...
TRANSCRIPT
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Suicide Prevention in Senior Living Communities
Carol Podgorski, PhD, MPH, LMFTUniversity of Rochester
CCSME ConferenceMarch 14, 2014
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Disclosure
The presenter DOES NOT have an interest in selling a technology, program, product, and/or service to CME/CE professionals.
Carol Podgorski, PhD, has nothing to disclose with regard to commercial relationships.
The content of this presentation does not relate to any product of a commercial interest.
Therefore, there are no relevant financial relationships to disclose
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Objectives• Provide an overview of the epidemiology of suicide
and suicidal behaviors in congregate living settings
• Introduce tools that providers and facilities can use to promote healthy populations while reducing risk factors that contribute to suicide
• Present a case study of a suicide attempt in a senior living community to illustrate– Individual, interpersonal and ecological factors
that contribute to suicidal behaviors– Opportunities for intervention/prevention
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“My work is done. Why wait?”
George EastmanMarch 14, 1932Age 77
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Suicide Rates by Age, Race, and GenderU.S. -- 2004
0
10
20
30
40
50
60
10--14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+Age (Years)
Sui
cide
Rat
e P
er 1
00K
White Male Black Male
White Female Black Female
Source: National Center for Health Statistics
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ATTEMPTED:COMPLETED SUICIDE
Deaths
Hospitalizations
Emergency
Dept visits
1
2
4
General population
Older adults
1
5
30
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LETHALITY OF LATE LIFE SUICIDE
• Older people are – more frail (more likely to die)– more isolated (less likely to be rescued)– more planful and determined
• Implying– interventions must be aggressive– primary and secondary prevention are key
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DOMAINS OF SUICIDE RISK IN LATER LIFE
Psychological- personality- coping
Psychiatric- depression- other
Medical - illness- treatment
Social- loss- life change
Biological- aging- environment
Adapted from Blumenthal SJ, Kupfer DJ. Ann NY Acad Sci 487:327-340, 1986
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RISK FACTORS FOR SUICIDE AMONG ELDERS
• Depression – major depression, other• Prior suicide attempts• Co-morbid general medical conditions • Often with pain and role function decline• Social dependency or isolation • Family discord, losses • Personality inflexibility, rigid coping• Access to lethal means
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Comorbidity and Suicide Risk
Juurlink et al., Arch Intern Med 2004;164:1179-1184
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Loss and Bereavement Bereavement greatly increases the risk of depressive
episodes (Bruce et al., 1990). Complicated grief and depression in bereaved older
adults increases suicidal ideation (Szanto, Prigerson, Houck, et al., 1997).
The oldest old men experience the highest increase in suicide risk immediately after the loss of a partner (15 fold) (Erlangsen, Jeune, Bille-Brahe, Vaupel, 2004).
Older adults who experience stressful losses are significantly more likely to drink excessively than those who have not (Jennison, 1992), and to use ISDB in LTC(Nelson & Farberow, 1980).
Suicide rate in elderly is highest for divorced/widowed(CDC).
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Senior Living Communities (SLCs)• For purposes of this presentation, SLCs
include:
– Independent senior living communities– Assisted living facilities– Long term care facilities– Continuing Care Retirement Communities
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Independent Living Communities• Units are designed for healthy, active seniors• Types of units include:
– Studio apartments– 1-, 2-, or 3-bedroom apartments– Cottages – Townhouses – Duplexes – Single-family homes
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Assisted Living Facilities• 267,000 to 417,000 (1992-1998)• Average age: 85• 79% female• 99% white• Require assist with average of 2.3 ADLs• 52% have some cognitive impairment• (AARP, 2000)
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Long Term Care Facilities• For those who require skilled nursing care
• Population is:– 70% female– 75% > 75 years old; median age is 83.2; – 84% white; 13% African American;
Hispanic/Latino underrepresented at 4%– Require assist with average 3.8 ADLs
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Population 65 Years and Over in Nursing Homes by Age, 1990 and 2000:Percent of U.S. population age >65 that live in nursing homes
Age
Percent of age group
20001990 2000
65 years and over 5.1% 4.5% 1,557,800
65 to 74 years 1.4 1.1 210,159
75 to 84 years 6.1 4.7 574,908
85 years and over 24.5 18.2 772,733
Source: U.S. Census Bureau, Census 2000 special tabulation;1990 Census of Population, Nursing Home Population: 1990 (CPH-L-137).
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Common Factors
• Congregate/Communal living settings
• Loss
• Homogeneity (age, SES, experience)
• TRANSITIONS!!!
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Man Fatally Shoots Wife, Self at Retirement HomeEx-Diplomat's Spouse Was Infirm, Police Say
Friday, May 16, 2008Friday, May 16, 2008
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Risk Factors for Suicide inLTC Residents
• Major Losses– Function --
ADLs/IADLs– Cognitive loss– Self-esteem– Purpose
• Situational Cues– Death of someone
close– Diagnosis of major
illness– An unwanted move
or change(Rosowsky, 1993)
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Means of Self-Harm in LTC
Old-old are more likely to employ indirect Intentional Life Threatening Behaviors (ILTBs)—refusing to eat or drink (43%) and taking medications (40%) (Rosowsky, 1993)
Wrist slashing (49%), shooting (18%), asphyxiation (13%) (Rosowsky, 1993)
• Food refusal (26.8%) (Draper et al., 2002)
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Method of suicide among NYC residents age 60+ by location: 1990 – 2005
All Long-term care Community-dwelling
p-valueN (%) N (%) N (%)
Total N 1770 47 1723
Overdose 224 (7.0) 4 (8.5) 220 (12.8) 0.387Hanging 503 (28.4) 17 (36.2) 486 (28.2) 0.231Long fall 533 (30.1) 24 (51.1) 509 (29.5) 0.002Cutting 81 (4.6) 2 (4.3) 79 (4.6) 1.000††
Firearms 286 (16.1) 0 (0.0) 286 (16.6) 0.002Other 143 (8.1) 0 (0.0) 143 (8.3) 1.000††
(Mezuk, B, Prescott, M, Tardiff, K, 2008)
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http://store.samhsa.gov/product/SMA10-4515
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Everyone in a senior living community has a role to play in promoting emotional health and
preventing suicide
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What is in the Toolkit?• Resources to help staff in SLCs promote
emotional health and prevent suicide among residents– Executive director, administrator, department
managers, supervisors– Nursing, medical, mental health, social work,
clergy, activities staff– Dietary, housekeeping, transportation,
maintenance, grounds, security• Provides resources and information to
engage residents
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Toolkit Components• Overview
• Guide to Promoting Emotional Health and Preventing Suicide in SLCs
• Trainer’s Manual
• Fact Sheets for Residents
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The Toolkit Framework• Comprised of three approaches
– Whole population
– At-risk
– Crisis response
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Improve physical, mental,emotional
and spiritualhealth or well-being of a
population
Primary Prevention:Risk Reduction
Secondary Prevention:Early Intervention Tertiary Prevention:
Postvention
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How can whole population approaches help to reduce suicide in SLCs?
Reduce risk factors
Increase protective factors
Create health-promoting environments
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AvoidingDisease
Engagement With Life
Maintaining High CognitiveAnd Physical Function
SUCCESSFUL AGING
Rowe & Kahn, Successful Aging, 1998
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Whole Population Approach:Goals
Goal 1.1:Activities
Residents have access to activities that promote emotional health and well-being
Goal 1.2:Social networks
Social networks are established among residents
Goal 1.3:Environment
Physical and social environment promotes emotional health and well-being
Goal 1.4:Lethal means
Residents’ access to methods of self-harm is limited
Goal 1.5:Staff training
Staff receive training and support for their roles in promoting emotional health of residents
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Goal 1.1:Activities
Residents have access to activities that promote their emotional health
and well-being
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Examples of Health-Promoting Activities
• Health/wellness activities• Disease and injury prevention and chronic
disease management classes• Intellectual activities• Art – creativity, imagination, self-expression• Skill-building• Coping support programs• Spiritual activities• Volunteer/mentoring
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Active Engagement with Life
Maintaining relationships with other people
– Balance between providing and receiving support
Performing activities that are productive(Rowe and Kahn, 1998)
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Function and Suicide
Lower level of functioning predicts mortality in NH residents (Draper, et al., 2003).
Functional disability together with depression predicts suicidal ideation.
Self-neglect in basic ADLs and higher levels of functional disability have been correlated with suicidal behavior/ideation. (Nelson & Farberow, 1980; Zautra, Maxwell, Reih, 1989)
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Move over, bingo!
Nursing home residents use Wii for therapy, fun
By Stacy Forster of the Journal Sentinel
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Multiple leisure activities on a regular basis
38% less risk of dementia__________________________________
Each additional leisure activity
8% less risk of dementia
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FEAR affects function
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FEAR of Alzheimer’s Disease
1/3 of well-educated older adults have this fear – “the most dreaded” (Dark-Freudeman, et al., 2006)Prevents active livingInfluences use of resources and choicesLeads to isolation
Fear of Alzheimer’s Disease is modifiable!(e.g., understanding memory; “Maintain Your Brain”)
November 11, 2002More Than Death, Fearing a Muddled Mind
By N. R. KLEINFIELD
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Fear of Falling 1 in 3 adults >65 experience a fall; 30% require
treatment (Friedland,2008) Reduces physical activity Reduces function and increases frailty Decreases pleasure and participation in
activities previously enjoyed Increases isolation
• Fear of falling is modifiable!• Environmental safety features, medications,
assistive devices, exercises, learning how to fall, tai chi
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Fear of Losing Sensory Function• Hearing loss
– 45.9%: prevalence between ages 48-92– 30% over 60; 50% over 85
• Cruickshanks KJ,Wiley TL, Tweed TS, et al. The Epidemiology of Hearing Loss Study, 1995
• Vision loss– 21% >age 65 have some visual impairment– Vision loss leads to social isolation and depression
(14-20%), higher among women– Estimates for NH population: 21%-52%
• www.lighthouse.org
• Most Americans could benefit from available services but don’t use them!
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Goal 1.2Social Networks
Social networks are established among residents
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Establishing Social Networks
• Welcoming activities, buddy systems, friendship tables
• Caring neighbor activities• Programs where staff and residents partner• Programs that involve residents in decision-
making
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What is social support? Information leading one to believe that he or she
is cared for, loved, esteemed, and a member of a network of mutual obligations (Rowe & Kahn, 1998)
Socio-emotional– Expressions of affection, respect and esteem– Assure a person that s/he is valued
Instrumental– Acts of direct assistance such as giving
physical help, helping with chores, transportation, financial assistance, meals.
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Social Connections and Health
Resistance to colds (JAMA, 1997) Prolongs life in illness (GWUMC, 2001) Breast cancer
Combats depression (Circulation, 2000) Isolation and heart disease (UC-Irvine, 2002) Delays AIDS in people HIV+ (Psychosomatics,
2000)
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Social Connections and Health
• Potential Mechanisms
– Social relationships increase motivation to take better care of oneself because these networks promote feelings of self-worth, responsibility, control and meaning in life.
– May alter our moods and cause changes in levels of hormones that regulate our immune systems
– Offers comfort and protection; serves as the litmus for one’s own pain, alienation, and invalidism
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Why Loneliness Is Hazardous to Your HealthScience 14 January 2011:
Vol. 331 no. 6014 pp. 138-140
John Cacioppo, PhD
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Social Connections and Memory
Socialization helps memory by keeping many regions of the brain stimulated.
Swedish Longitudinal Studies (1987-1996)– Studied types of activities (productive, mental,
social, physical, and recreational)– Rich social networks ½ AD risk– Avoided social contact 2X AD risk
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A Caveat …
“Silent collusion” refers to the assistance from others for the achievement of death – e.g., “not looking”.
It is more prevalent in LTC.
Understanding and accepting “rational” components of another's decision to die may make others in the context silent “colluders”
The cultural system of the institution, its goals, attitudes, values and beliefs affect risk in LTC.
(Rosowsky, 1993)
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Goal 1.3:Environment
The physical and social environment promotes emotional health and well-
being
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Key Environmental Factors
• Welcoming and inclusive• Homelike• Accessible• Aesthetically pleasing• Presence of gathering areas
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Goal 1.4:Lethal Means
Residents’ access to methods of self-harm is limited
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Strategies to Restrict Means
• Policies and procedures
• Physical barriers
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Goal 1.5:Staff Training
Staff receive training and support for their roles in promoting the
emotional health of residents
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Examples of Staff Training
• Train ALL staff on the aging process, risk and protective factors for suicide emotional health issues
• Importance of consistent, high quality care• Interpersonal skills; attitudes toward
depression, substance abuse, suicide• Value of consistent assignment to the same
residents
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At-Risk Approach: GoalsGoal 2.1Warning signs
All staff are able to identify and respond to warning signs for suicide.
Goal 2.2Risk factors
All staff are able to identify risk and protective factors for suicide.
Goal 2.3Depression
All staff are able to recognize symptoms of depression.
Goal 2.4Substance abuse
All staff are able to recognize symptoms of alcohol abuse and medication misuse
Goal 2.5Community connections
Appropriately designated staff establish effective connections in community to support emotional health of residents
Goal 2.6Help seeking
Residents are knowledgeable about and comfortable seeking help for emotional health problems (SI, depression, substance abuse)
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Goal 2.1:Warning Signs
All staff are able to identify and respond to warning signs for suicide.
Designated staff are able to screen individual residents for suicide risk
and ensure that the appropriate action is taken when a resident may
be at risk
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The Warning Signs• Hopelessness• Rage, uncontrolled
anger, seeking revenge• Acting reckless;
engaging is risky activities
• Feeling trapped• Increased alcohol or
drug use
• Withdrawing from friends, family and society
• Anxiety, agitation, unable to sleep, sleeping all the time
• Dramatic mood changes
• No reason for living; no purpose in life
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Goal 2.2:Risk Factors
All staff are able to identify risk and protective factors for suicide
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Goal 2.3:Depression
All staff are able to recognize symptoms of depression.
Appropriately designated staff are able to screen individual residents
for depression and ensure that residents who are depressed receive
treatment.
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Goal 2.4:Substance Abuse
All staff are able to recognize symptoms of alcohol abuse and
medication misuse. Appropriately designated staff are able to screen
individual residents for these conditions and ensure that residents
with substance abuse problems receive treatment.
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Goal 2.5:Community Connections
Appropriately designated staff establish effective connections in the
community to support emotional health of residents.
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Establishing Community Connections
• Compile a directory of mental health care providers
• Establish a personal connection
• Disseminate the information to appropriate professional staff
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Goal 2.6:Help Seeking
Residents are knowledgeable about and comfortable seeking help for
emotional health problems, including suicidal ideation, depression, and
substance abuse
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Promote Help Seeking Behavior
• Decrease barriers to seeking treatment• Cultural stigma• Personal embarrassment about mental illness• Normalize help-seeking• Involve family members and caregivers
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Problem Solving Skills
Difficulties with interpersonal problem solving have been associated with hopelessness and suicidal behavior(Arie, 2008; Roskar, 2007; Jeglic, 2005)
Suicide attempters were poorer, more passive problem solvers even when mood improved (Pollock & Williams, 2004)
Promising interventions– Program to Encourage Active, Rewarding Lives for
Seniors (PEARLS) (Ciechanowski, Wagner, Schmaling, et al., 2004)
– Problem solving therapy (Arean, Hegal, Vannoy, et al, 2008)
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8689Mr. Reynolds Mrs. Reynolds
M 65 yrs.
Hearing loss
Diabetes
Stroke
Early AD
Mobility
MD
Minister
Friends at SLC
Attorney/Financial Planner
SLC Amenities