Death wishes among older people assessed for home support and long-term aged residential care

A systematic review of psychosocial protective factors against suicide and suicidality among older adults

BACKGROUND

Research on suicide rarely focuses on protective factors. The goal of this systematic review was to assess the evidence of the associations between protective factors and reduced suicidality among older adults.

METHOD

First, a scoping review was conducted to identify pertinent terms that refer to various protective factors against suicidality. A systematic review, following the PRISMA guidelines, was then conducted on a selection of 15 protective factors (e.g., perceived control, well-being and quality of life, life satisfaction, purpose-in-life, resilience, coping, religiosity, hope, self-regulation, sense of belonging, mattering, positive relationship, social support, social connectedness, and social participation), with separate searches performed on each factor in five databases. Empirical studies were eligible if participants were adults aged 60 years and over, and if the studies reported predictive statistical analysis.

RESULTS

A total of 70 studies were retained for the review. Suicidal ideation was the main outcome measure (91%). Significant associations were consistently observed between all protective factors and reduced suicidal ideations or behaviors, particularly for purpose-in-life, resilience, and positive relationships, indicating that these are solid components for suicide prevention. Using scales, instead of a single item, to measure protective factors (e.g. life satisfaction) was more efficient to capture the associations. On the other hand, results were similar whether studies used subjective (e.g., sense of belonging) or objective (e.g., social connectedness) measures.

CONCLUSION

Protective factors were inversely associated with suicidal ideation. Improving protective factors is essential for the development of late-life suicide prevention and interventions, instead of merely focusing on risk factors.

Predictive factors of nonfatal self-harm among community-dwelling older adults assessed for support services

BACKGROUND

Older adults receiving support services are a population at risk for self-harm due to physical illness and functional impairment, which are known risk factors. This study aims to investigate the relative importance of predictive factors of nonfatal self-harm among older adults assessed for support services in New Zealand.

METHODS

interRAI-Home Care (HC) national data of older adults (aged ≥ 60) were linked to mortality and hospital discharge data between January 1, 2012 and December 31, 2016. We calculated the crude incidence of self-harm per 100,000 person-years, and gender and age-adjusted standardized incidence ratios (SIRs). The Fine and Gray competing risk regression model was fitted to estimate the hazard ratio (HR; 95% CIs) of self-harm associated with various demographic, psychosocial, clinical factors, and summary scales.

RESULTS

A total of 93,501 older adults were included. At the end of the follow-up period, 251 (0.27%) people had at least one episode of nonfatal self-harm and 36,333 (38.86%) people died. The overall incidence of nonfatal self-harm was 160.39 (95% CI, 141.36-181.06) per 100,000 person-years and SIR was 5.12 (95% CI, 4.51-5.78), with the highest incidence in the first year of follow-up. Depression diagnosis (HR, 3.02, 2.26-4.03), at-risk alcohol use (2.38, 1.30-4.35), and bipolar disorder (2.18, 1.25-3.80) were the most significant risk factors. Protective effects were found with cancer (0.57, 0.36-0.89) and severe level of functional impairment measured by Activities of Daily Living (ADL) Hierarchy Scale (0.56, 0.35-0.89).

CONCLUSION

Psychiatric factors are the most significant predictors for nonfatal self-harm among older adults receiving support services. Our results can be used to inform healthcare professionals for timely identification of people at high risk of self-harm and the development of more efficient and targeted prevention strategies, with specific attention to individuals with depression or depressive symptoms, particularly in the first year of follow-up.

A scoping review exploring the ‘grey area’ of suicide-related expression in later life: Developing a conceptual framework for professional engagement

As the body of research on suicide in later life has developed, so has its vocabulary. This has generated a high level of overlap in concepts and terminology used to articulate suicide and how it might present, as well as ‘grey area’ behavioural terms that are both specific to older adults and less well-defined (e.g. ‘hastening of death’ or ‘completed life’). A better understanding of individual experiences and pathways to suicide can help to inform assessment and interventions, and increase the potential to relate any theoretical concepts to the implementation of such. Here, we adopted a scoping review to search systematically literature on specific presentation, features, circumstances and outcomes of these grey areas of suicide in later life. Fifty-three articles (quantitative, qualitative and theoretical) were reviewed. A narrative approach was used to merge and translate this body of knowledge into a new conceptual framework based on four key themes: (a) a sense of completed life or existential loneliness; (b) death thoughts, wishes and ideation; (c) death-hastening behaviour and advanced directives; and (d) self-destructive or self-injurious behaviour. We discuss the importance of integrating this understanding into current knowledge and suicide prevention strategies for older adults. Recommendations are made for unifying research with policy themes on healthy ageing, person-centredness within service provision and citizen participation.

Effects of a Reminiscence Program on Meaning of Life, Sense of Coherence and Coping in Older Women Living in Nursing Homes during COVID-19

Aging is a dynamic process that can bring well-being but also physical and cognitive decline. Older adults can draw on their personal resources to help them cope and thrive through the aging process. Having personal resources to cope and ensure older adults’ well-being is important. Psychological strengths such as a sense of coherence, resilience, and coping are protective against the adversity associated with health problems such as those stemming from the COVID-19 pandemic. Our study’s purpose was to investigate the usefulness of reminiscence therapy for older women living in nursing homes during the COVID-19 pandemic. A sample composed of 29 older women was evaluated with the Purpose-in-Life Test (PIL), Sense of Coherence (SOC-13) and Brief Cope Inventory (COPE-28). Our reminiscence program consisted of 10 sessions lasting 60 min each. Reminiscence therapy is a psychological intervention for older adults to assist in remembering and interpreting the life events, feelings, and thoughts that define and give meaning to the person’s life. Reminiscence can lead to positive mental health and other elements of particular relevance to older adults. In each session, we worked on a different theme that promoted the memory of positive emotions: optimal experience, decisive moment, stresses, tensions, problems and solutions, memories of childhood, adolescence, maturity, significant people in life, sense of life, and future script. We compared an intervention group (n = 12) with a control group (n = 17) using a pre-post, single-blind design. Significant results were obtained and showed that reminiscence therapy was effective in increasing meaning of life, sense of coherence, and coping in older women. The reminiscence therapy applied yielded positive effects in older female participants living in a nursing home during COVID-19 pandemic.

Role of resilience and social support in the relationship between loneliness and suicidal ideation among Chinese nursing home residents

OBJECTIVES

Loneliness is a risk factor of suicidal ideation, while resilience and social support are protective factors; however, the complex mechanisms behind these factors have not been examined among nursing home residents. This study evaluated the mediating effect of resilience on the association between loneliness and suicidal ideation and whether this mediating effect was moderated by social support.

METHODS

Residents (N = 538; Aged ≥60years; 321 female, 217 male) from 37 nursing homes in China completed this cross-sectional study. Their loneliness, resilience, social support, and suicidal ideation were measured. Regression analyses using bootstrapping methods were conducted to explore the mediating and moderating effects.

RESULTS

Some residents (14.9%, 80/538) reported current suicidal ideation. The correlation between loneliness and suicidal ideation was partially mediated by resilience (indirect effect = 0.067, 95% CI = 0.011-0.122). Overall social support moderated the resilience on suicidal ideation, indirectly impacting loneliness on suicidal ideation (moderating effect = 0.086 [95% CI = 0.005-0.167]). Support from family and nursing home staff moderated the direct (path c') and indirect path (path b) of the mediation model, respectively.

CONCLUSIONS

Our findings underscore the vital role of resilience and social support to buffer against suicidal ideation, which is common among nursing home residents in China.HighlightsWe evaluated suicidal ideation in mainland Chinese nursing home residentsLoneliness and suicidal ideation were partially mediated by resilienceSocial support moderated the effect of loneliness and resilience on suicidal ideationThe results were self-reported and are not generalizable to all of ChinaResilience and social support can buffer against suicidal ideation among residents.

Performance of the Cognitive Performance Scale of the Resident Assessment Instrument (interRAI) for Detecting Dementia amongst Older Adults in the Community

The Cognitive Performance Scale (CPS) in the widely used interRAI suite of instruments is of interest to clinicians and policy makers as a potential screening mechanism for detecting dementia. However, there has been little evaluation of the CPS in home care settings. This retrospective diagnostic study included 134 older adults (age ≥ 65) who were discharged from two acute psychogeriatric inpatient units or assessed in two memory clinics. The reference test was a diagnosis of clinical dementia, and the index test was interRAI CPS measured within 90 days of discharge. The overall accuracy of the CPS was good, with an area under the Receiver Operating Characteristic curve of 0.82 (95% CI = 0.75–0.89). The optimal cut point was 1/2, coinciding with the recommended cut point, with good sensitivity (0.90, 95% CI = 0.81–0.96) but poor specificity (0.60, 95% CI = 0.46–0.72). Positive predictive value improved from 0.72 (95% CI = 0.66–0.78) to 0.89 (95% CI = 0.75–0.96) when using a cut point of 2/3 instead of 1/2. If the results of the present study are replicated with more generalisable interRAI samples, older adults with a CPS of 3 or above, but without a formal diagnosis of dementia, should be referred for further cognitive assessment.

Current wishes to die; characteristics of middle-aged and older Dutch adults who are ready to give up on life: a cross-sectional study

BACKGROUND

Literature shows that middle-aged and older adults sometimes experience a wish to die. Reasons for these wishes may be complex and involve multiple factors. One important question is to what extent people with a wish to die have medically classifiable conditions.

AIM

(1) Estimate the prevalence of a current wish to die among middle-aged and older adults in The Netherlands; (2) explore which factors within domains of vulnerability (physical, cognitive, social and psychological) are associated with a current wish to die; (3) assess how many middle-aged and older adults with a current wish to die do not have a medically classifiable condition and/or an accumulation of age-related health problems.

METHODS

Data of 2015/16 from the Longitudinal Aging Study Amsterdam were used for this cross-sectional study (1563 Dutch middle-aged and older adults aged between 57 and 99 years), obtained through structured medical interviews and self-reported questionnaires. Three experienced physicians assessed whether the participants with a current wish to die could be classified as having a medically classifiable condition and/or an accumulation of age-related health problems.

RESULTS

N = 62 participants (4.0%) had a current wish to die. Having a current wish to die was associated with multiple characteristics across four domains of vulnerability, among which: self-perceived health, problems with memory, self-perceived quality of life and meaningfulness of life. Fifty-four participants with a current wish to die were assessed with having a medically classifiable condition, of which one was also assessed with having an accumulation of age-related health problems. Six people were assessed to have neither, and for two people it was unclear.

CONCLUSION

A small minority of middle-aged and older adults in the Netherlands have a current wish to die. Most of them can be classified with a medical condition and one person with an accumulation of age-related health problems. Furthermore, the findings show that having a current wish to die is multi-faceted. There is still a need for more knowledge, such as insight in to what extent suffering stemming from the medical classifiable disease contributes to the development of the wish to die.

Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes

Importance

The Dutch Regional Euthanasia Review Committees (RTEs) reviewed and reported an increasing number of cases of euthanasia and physician-assisted suicide (EAS) requested by older people with multiple geriatric syndromes (MGS). Knowledge of the characteristics of cases of EAS for MGS is important to facilitate societal debate and to monitor EAS practice.

Objective

To examine the accumulation of patient characteristics, geriatric syndromes, and other circumstances as reported in the case summaries of the RTEs that led to unbearable suffering associated with a request for EAS and to analyze the RTEs' assessments of these cases of EAS.

Design, Setting, and Participants

A qualitative content analysis was conducted of all case summaries filed from January 1, 2013, to December 31, 2019, under the category MGS and published in a national open access database. These case summaries were selected by the RTEs from the total of 1605 reported cases of EAS in the category MGS.

Results

The RTEs published 53 cases (41 [77%] female) under the category MGS. A total of 28 patients (53%) had always perceived themselves as independent, active, and socially involved. None of the patients suffered from life-threatening conditions. Multiple geriatric syndromes, such as visual impairment (34 cases [64%]), hearing loss (28 cases [53%]), pain (25 cases [47%]), and chronic tiredness (22 cases [42%]), were common. The request for EAS was often preceded by a sequence of events, especially recurrent falls (33 cases [62%]). Although physical suffering could be determined in all cases, the case descriptions found that suffering occurred on multiple dimensions, such as the loss of mobility (44 [83%]), fears (21 [40%]), dependence (23 [43%]), and social isolation (19 [36%]).

Conclusions and Relevance

This qualitative study suggests that an accumulation of geriatric syndromes leading to a request for EAS is often intertwined with the social and existential dimension of suffering. This leads to a complex interplay of physical, psychological, and existential suffering that changes over time.

Factors Associated With Hospital Presentation of Self-Harm Among Older Canadians in Long-Term Care: A 12-Year Cohort Study

OBJECTIVES

This study aimed to examine the incidence of, and factors associated with, hospital presentation for self-harm among older Canadians in long-term care (LTC).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The LTC data were collected using Resident Assessment Instrument-Minimum Data Set (RAI-MDS) and Resident Assessment Instrument-Home Care (RAI-HC), and linked to the Discharge Abstract Database (DAD) with hospital records of self-harm diagnosis. Adults aged 60+ at first assessment between April 1, 2003, and March 31, 2015, were included.

METHODS

Adjusted hazard ratios (HRs) of self-harm for potentially relevant factors, including demographic, clinical, and psychosocial characteristics, were calculated using Fine & Gray competing risk models.

RESULTS

Records were collated of 465,870 people in long-term care facilities (LTCF), and 773,855 people receiving home care (HC). Self-harm incidence per 100,000 person-years was 20.76 [95% confidence interval (CI) 20.31-25.40] for LTCF and 46.64 (44.24-49.12) for HC. In LTCF, the strongest risks were younger age (60-74 years vs 90+: HR, 6.00; 95% CI, 3.24-11.12), psychiatric disorders (bipolar disorder: 3.46; 2.32-5.16; schizophrenia: 2.31; 1.47-3.62; depression: 2.29; 1.80-2.92), daily severe pain (2.01; 1.30-3.11), and daily tobacco consumption (1.78; 1.29-2.45). For those receiving HC, the strongest risk factors were younger age (60-74 years vs 90+: 2.54; 1.97-3.28), psychiatric disorders (2.20; 1.93-2.50), daily tobacco consumption (2.08; 1.81-2.39), and frequent falls (1.98; 1.46-2.68). All model interactions between setting and factors were significant.

CONCLUSIONS AND IMPLICATIONS

There was lower incidence of hospital presentation for self-harm for LTCF residents than HC recipients. We found sizable risks of self-harm associated with several modifiable risk factors, some of which can be directly addressed by better treatment and care (psychiatric disorders and pain), whereas others require through more complex interventions that target underlying factors and causes (tobacco and falls). The findings highlight a need for setting- and risk-specific prevention strategies to address self-harm in the older populations.

Impact of COVID-19 on the health and psychosocial status of vulnerable older adults: study protocol for an observational study

BACKGROUND

Many countries around the world have adopted social distancing as one of the public health measures to reduce COVID-19 transmissions in the community. Such measures could have negative effects on the mental health of the population. The aims of this study are to (1) track the impact of COVID-19 on self-reported mood, self-rated health, other health and psychosocial indicators, and health services utilization of people who have an interRAI assessment during the first year of COVID-19; (2) compare these indicators with the same indicators in people who had an interRAI assessment in the year before COVID-19; and (3) report these indicators publicly as soon as data analysis is completed every 3 months.

METHODS

interRAI COVID-19 Study (iCoS) is an observational study on routinely collected national data using the interRAI Home Care and Contact Assessment, which are standardized geriatric assessment tools mandated for all people assessed for publicly funded home support services and aged residential care in New Zealand. Based on the 2018/19 figures, we estimated there are 36,000 interRAI assessments per annum. We will compare the four post-lockdown quarters (from 25th March 2020) with the respective pre-lockdown quarters. The primary outcomes are self-reported mood (feeling sad, depressed or hopeless: 0 = no, 1 = yes) and self-rated health (0 = excellent, 1 = good, 2 = fair, 3 = poor). We will also analyze sociodemographics, other secondary health and psychosocial indicators, and health services utilization. Descriptive statistics will be conducted for primary outcomes and other indicators for each of the eight quarters. We will compare the quarters using regression models adjusted for demographic characteristics using weights or additional variables. Key health and psychosocial indicators will be reported publicly as soon as data analysis is completed for each quarter in the 12-month post-lockdown period by using a data visualization tool.

DISCUSSION

This rapid translation of routinely collected national interRAI data will provide a means to monitor the health and psychosocial well-being of vulnerable older New Zealanders. Insights from this study can be shared with other countries that use interRAI and prepare health and social services for similar epidemics/pandemics in the future.

Social Interactions among Older Adults Who Wish for Death

Objectives: When the need for relatedness is frustrated, some older adults feel that life is not worth living and wish for death (WD). The aim of this study was to look at the perception of social interactions among older adults who express the WD.Methods: A probabilistic sample of 2787 French-speaking community-dwelling older adults aged 65 to 96 years (M = 73.8) took part in the Seniors Health Survey, a study on the prevalence of mental disorders which also collected information on various demographic and social variables.Results: Results showed that 5% of participants expressed WD. Participants who WD felt significantly more isolated and in conflict with their children than participants without WD. When sociodemographic variables, self-rated physical health, and depression were controlled, three social variables predicted WD in a logistic regression: being distant toward others, dissatisfaction with social life, and a lack of participation in organizations.Conclusions: Results of the present study support the interpersonal theory of suicide, which suggests that self-reported thwarted belongingness can foster WD.Clinical implications: Clinicians should consider social dissatisfaction and withdrawal as risk factors for WD and design interventions that foster social skills or meaningful connections.

A Cross-Sectional Study of the Prevalence of and Risk Factors for Suicidal Ideation Among the Elderly in Nursing Homes in Hunan Province, China

Our study aims to explore the risk factors for suicidal ideation and their interaction among the elderly in nursing homes in Hunan province, China. A cross-sectional study was conducted among the elderly in nursing homes in Hunan Province. Twenty-four nursing homes were selected by multistage cluster random sampling, and 817 elderly residents were investigated using a set of structured questionnaires. The main outcome measures included general information, suicidal ideation, depression symptoms, social support, activities of daily living (ADL), stressful life events, and sleep quality. Multivariate binary logistic regression was performed to explore the risk factors for suicidal ideation among the elderly in nursing homes, and additive interaction was used to analyze the interaction between risk factors. The prevalence of suicidal ideation among the elderly in nursing homes in Hunan province was 17.9% (95% confidence interval(CI): 15.2%, 20.6%). Living in a rural area (odds ratio(OR)=1.88, 95% CI: 1.03, 3.44), infrequent visits from relatives (OR=2.61, 95% CI: 1.42, 4.78), history of chronic disease (OR=2.34, 95% CI: 1.09, 5.01), depression symptoms (OR=8.11, 95% CI: 4.52, 14.54), lower social support (OR=3.85, 95% CI: 1.94, 7.61), and ADL disability status (OR=4.38, 95% CI: 2.10, 9.14) increased the risk of suicidal ideation. Additive interactions were detected between depression symptoms and ADL status, with a relative excess risk due to interaction (RERI) of 8.73 (95% CI: 2.04, 15.43), and between depression symptoms and social support, with an RERI of 5.98 (95% CI: 0.86, 11.10). The prevalence of suicidal ideation among the elderly in nursing homes is relatively high. Both physical conditions and psychosocial factors were associated with suicidal ideation among the elderly. These findings have significant implications for the prediction and prevention of suicidal behaviors.

A Systematic Review Evaluating the Use of the interRAI Home Care Instrument in Research for Older People

Objective: To summarize studies that used the international Resident Assessment home care instrument (interRAI HC) to examine study outcomes for older people. Methods: A comprehensive systematic search was performed to identify relevant studies, using five databases from 1990 until October 2016. The Cochrane Risk-Bias assessment tool and Newcastle-Ottawa Scale was used to assess the quality of RCTs and non-RCTs, respectively. Results: Based on the full-text analysis, 40 studies met the inclusion criteria out of 506 total records. The review included 6 RCTs, 2 quasi-experimental, 17 prospective and retrospective studies, 13 cross-sectional and 2 longitudinal studies. A series of interventions and/or applications were identified from this review that employed the use of interRAI HC instrument: (a) in health services, (b) as a new integrated care model and for implementing machine learning algorithm, (c) as a comprehensive geriatric assessment tool, (d) in case management, (e) for care planning and screening, (f) in drug therapy assessment, (g) to assess caregiver burden, and (h) for various risk assessments. Studies that employed the interRAI HC instrument reported an array of health-outcome measures mostly related to functional, cognition, hospitalization and mortality. Conclusions: Application of the interRAI HC tool varied markedly across all studies, and the outcomes measures were heterogeneous. Future research directions are discussed. Clinical Implications: The results from this study facilitate the use of interRAI HC as a tool to measure an intervention's effect that leads to improvements in specific geriatric-related health outcome measures emphasizes on functional status and quality of life and ascertain its utility as a quality indicator for the care of older individuals.

Tiredness of Life in Older persons: A Qualitative Study on Nurses’ Experiences of Being Confronted With This Growing Phenomenon

Background and Objectives

With worldwide aging it is imperative to understand nurses’ perceptions of tiredness of life (ToL) and their ways of dealing with an increasingly common phenomenon. Most research on ToL relates to older individuals’ experiences. This study aimed to gain insight into nurses’ (a) perceptions of, (b) attitude(s) toward, and (c) ways of dealing with ToL in older patients.

Research Design and Methods

Qualitative study with elements of constructivist grounded theory. Data were collected by means of semi-structured interviews between February 2016 and June 2017 with a purposive sample of 25 nurses working in home care and nursing homes.

Results

A careful consideration indicative of an oscillation between 3 levels (e.g., behavioral, cognitive, and affective) is present. The confrontation with persons having ToL instigates a cognitive process of searching to understand the state a person is in, which on its turn ensues in an emotional balancing between courage and powerlessness and a behavioral approach of action or dialogue.

Discussion and Implications

Our findings indicate that nurses aim to provide good care, sensitive to the older person’s needs, but this process is not without ambiguity. This study provides nurse managers with valuable guidance to (a) support nursing staff in dealing with ToL, and (b) advance opportunities for emotionally sensitive care and (individual- and team-based) reflection. Finally, this study offers suggestions for education programs to incorporate ToL in curricula.