Age-related response to redeemed antidepressants measured by completed suicide in older adults: a nationwide cohort study

Use of Psychoactive Medications and Risk of Suicide in Late Life (75+): A Total Population Study

BACKGROUND

Psychoactive medications play an important role for the mental health and risk of suicidal behaviour in the oldest segment of the population (75+). A better understanding of psychoactive medication use is advocated to prevent suicide in this age group.

PURPOSE

We investigated the risk of suicide associated with the use of psychoactive medications in the total population aged ≥ 75 years, with and without exposure to antidepressants.

METHOD

A national population-based register study, including all Swedish residents aged ≥ 75 years between 2006 and 2014 (N = 1,413,806). A nested case-control design was used to investigate psychoactive medications associated with suicide among users and non-users of antidepressants. Risk estimates were calculated in adjusted conditional logistic regression models for the entire cohort and by gender.

RESULTS

Suicide occurred in 1305 persons (907 men and 398 women). Among them, 555 (42.5%) were on an antidepressant at the time of suicide. Adjusted incidence rate ratio (aIRR) for suicide was increased in those who were on hypnotics in the total cohort (aIRR 2.05, 95% confidence interval 1.74 to 2.41), in both users and non-users of antidepressants and for both genders. Elevated suicide risk was observed in those who concomitantly used anxiolytics with antidepressants (1.51, 1.25 to 1.83). Decreased risk of suicide was observed among those who were on anti-dementia drugs, in the total cohort (0.33, 0.21 to 0.52) and in both users and non-users of antidepressants. Use of antipsychotics and mood stabilisers showed no effect on suicide risk.

CONCLUSION

Use of hypnotics and concomitant use of anxiolytics with antidepressants was associated with increased risk of late-life suicide. Our findings suggest the need for careful evaluation of the benefit-risk balance of psychoactive medications as well as their availability as a possible suicide means. Future research should consider the indication of use of the psychoactive medications and the severity of psychiatric and medical illnesses of the patients.

Diagnosis and Management of Cognitive Concerns in the Oldest-Old

Purpose of review

The fastest-growing group of elderly individuals is the "oldest-old," usually defined as those age 85 years and above. These individuals account for much of the rapid increase in cases of dementing illness throughout the world but remain underrepresented in the body of literature on this topic. The aim of this review is first to outline the unique contributing factors and complications that must be considered by clinicians in evaluating an oldest-old individual with cognitive complaints. Secondly, the evidence for management of these cognitive concerns is reviewed.

Recent findings

In addition to well-established associations between impaired cognition and physical disability, falls, and frailty, there is now evidence that exercise performed decades earlier confers a cognitive benefit in the oldest-old. Moreover, though aggressive blood pressure control is critical earlier in life for prevention of strokes, renal disease, and other comorbidities, hypertension started after age 80 is in fact associated with a decreased risk of clinical dementia, carrying significant implications for the medical management of oldest-old individuals. The oldest-old are more likely to reside in care facilities, where social isolation might be exacerbated by a consistently lower rate of internet-connected device use. The COVID-19 pandemic has not only highlighted the increased mortality rate among the oldest-old but has also brought the increased social isolation in this group to the forte.

Summary

Differing from the "younger-old" in a number of respects, the oldest-old is a unique population not just in their vulnerability to cognitive disorders but also in the diagnostic challenges they can pose. The oldest-old are more likely to be afflicted by sensory deficits, physical disability, poor nutrition, frailty, and depression, which must be accounted for in the assessment of cognitive complaints as they may confound or complicate the presentation. Social isolation and institutionalization are also associated with impaired cognition, perhaps as sequelae, precipitants, or both. Ante-mortem diagnostic tools remain particularly limited among the oldest-old, especially given the likelihood of these individuals to have multiple co-occurring types of neuropathology, and the presence of neuropathology in those who remain cognitively intact. In addition to the symptomatic treatments indicated for patients of all ages with dementia, management of cognitive impairment in the oldest-old may be further optimized by use of assistive devices, augmentation of dietary protein, and liberalization of medication regimens for risk factors such as hypertension.

Antidepressant Use and Suicide Rates in Adults Aged 75 and Above: A Swedish Nationwide Cohort Study

Background: The treatment of depression is a main strategy for suicide prevention in older adults. We aimed to calculate suicide rates by antidepressant prescription patterns in persons aged ≥ 75 years. A further aim was to estimate the contribution of antidepressants to the change in suicide rates over time.

Methods: Swedish residents aged ≥ 75 years (N = 1,401,349) were followed between 2007 and 2014 in a national register-based retrospective cohort study. Biannual suicide rates were calculated for those with selective serotonin reuptake inhibitor (SSRI) single use, mirtazapine single use, single use of other antidepressants and use of ≥ 2 antidepressants. The contribution of antidepressants to the change in biannual suicide rates was analyzed by decomposition analysis.

Results: There were 1,277 suicides. About one third of these were on an antidepressant during their last 3 months of life. In the total cohort, the average biannual suicide rate in non-users of antidepressants was 13 per 100,000 person-years. The corresponding figure in users of antidepressants was 34 per 100,000 person-years. These rates were 25, 42 and 65 per 100,000 person-years in users of SSRI, mirtazapine and ≥ 2 antidepressants, respectively. In the total cohort, antidepressant users contributed by 26% to the estimated increase of 7 per 100,000 in biannual suicide rates. In men, biannual suicide rates increased by 11 suicides per 100,000 over the study period; antidepressant users contributed by 25% of the change. In women, those on antidepressant therapy accounted for 29% of the estimated increase of 4.4 per 100,000.

Conclusion: Only one third of the oldest Swedish population who died by suicide filled an antidepressant prescription in their last 3 months of life. Higher suicide rates were observed in mirtazapine users compared to those on SSRIs. Users of antidepressants accounted for only one quarter of the increase in the suicide rate. The identification and treatment of suicidal older adults remains an area for prevention efforts.

Depressed older adults may be less cared for than depressed younger ones

The aim of the study was to investigate depression treatment use, either psychotherapy (PT) or antidepressant drugs (ADT) in the older and younger depressed population. Cohorts of 6316 elderly (≥65 year-old) and 25,264 matched non-elderly (25-64 year-old) depressed patients were created from a large national claims database of managed care plans from 2003 to 2006. Factors associated with ADT or PT were assessed using multivariate logistic models. During the 120 days following the depression diagnosis, the elderly persons were less often treated than the younger adults either by ADT (25.6% vs. 33.8%) or by PT (13.0% vs. 34.4%). ADT dispensing occurred later in the elderly group (51 vs. 14 days). ADT was associated with comorbid chronic conditions or polypharmacy in the elderly and younger adults. The selection of treatment (ADT or PT) was associated with the history of treated depression using the same type of treatment, in both groups. Thus, depression goes commonly untreated. Comorbidity was associated with higher ADT dispensing rates. However, although depressed elderly commonly presented with comorbidity, this age group was at higher risk of untreated illness or later treatment.

Triggers of suicide ideation and protective factors of actually executing suicide among first onset cases in older psychiatric outpatients: a qualitative study

BACKGROUND

Suicide is a global issue among the elderly, but few studies have explored the experiences of suicide ideation in older Asian psychiatric outpatients.

METHOD

Older psychiatric outpatients (N = 24) were recruited by convenience from one medical centre and one regional hospital in northern Taiwan. Participants were recruited if they met these inclusion criteria: 1) ≥ 65 years old, 2) without severe cognitive deficit, 3) outpatients in the psychiatric clinics at the selected hospitals, and 4) self-reported first episode of suicidal ideation within the previous year. Data were collected in individual interviews using a semi-structured guide and analysed by content analysis.

RESULTS

Suicide ideation was triggered by illness and physical discomfort, conflicts with family members/friends, illness of family members, death of family members/friends, and loneliness. Participants' reasons for not executing suicide were family members' and friends' support, receiving treatment, finding a way to shift their attention, fear of increasing pressure on one's children, religious beliefs, and not knowing how to execute suicide.

CONCLUSION

Understanding these identified triggers of suicide ideation may help psychiatrists open a channel for conversation with their elderly clients and more readily make their diagnosis. Understanding these identified protective factors against executing suicide can help psychiatrists not only treat depression, but also enhance protective factors for their clients.

Suicide in older adults: the role of emotions and cognition

Suicide in older adults is a significant clinical concern. In this review of recent findings, we concentrate on the role of emotions and cognition in suicide risk and behavior in older adults. We discuss the epidemiology of suicide in older adults, integrate recent findings on non-psychotic major depression, schizophrenia and suicidal ideation, explore the relationship of emotion regulation with suicide, present recent advances on suicide in demented patients, and describe the latest developments on cognition and decision processes in suicide.