Why Do the Very Old Self-Harm? A Qualitative Study

Risk factors for dementia and self-harm: A linkage study

INTRODUCTION

People living with dementia experience poor mental health and high rates of self-harm. We investigated risk factors for self-harm in people aged > 40 years living with dementia and risk factors for dementia after self-harm.

METHODS

Using linked hospital data from New South Wales, Australia, we defined a dementia cohort (n = 154,811) and a self-harm cohort (n = 28,972). Using survival analyses, we investigated predictors of self-harm for the dementia cohort, and predictors of dementia for the self-harm cohort.

RESULTS

We found self-harm or dementia diagnoses occurred most often within 24 months of a dementia diagnosis or initial self-harm presentation, respectively. Men living with dementia, and people with complex psychiatric profiles, had the greatest risk of self-harm. Men who had self-harmed had the greatest risk of dementia diagnoses.

DISCUSSION

Men and people with complex psychiatric profiles and dementia may particularly benefit from post-diagnosis mental and behavioral support to reduce risk of self-harm.

Dying by Suicide in Nursing Homes: A Preventable End of Life Outcome for Older Residents

Suicide research and suicide prevention have given comparatively little attention to the older adult residents of nursing homes. This population is characterized by advanced age, significant infirmity, limited autonomy and social connections, and other factors associated with high suicide risk such as self-neglect. However, little is known of the actual incidence and prevalence of suicide in older adults in such residential care settings, partly because of how such deaths are reported. Suicide risk screenings are nominal, facility staff lack training to identify signs of suicidality, and suicide prevention programs are not common in the nursing home industry. These deficits can be remedied by increasing awareness among family members, facility caregivers, contracted providers, community aging services, accrediting and regulatory agencies, and residents.

A qualitative study of multiple voices to inform aftercare services for older persons following self-harm

OBJECTIVES

Self-harm and suicide are closely related in older adults, highlighting the opportunity for Aftercare interventions in targeted suicide prevention. The study aims were to explore strengths and shortfalls of current Aftercare services for older adults from the perspective of key stakeholders and researchers; and inform a set of guiding principles for older persons' Aftercare.

METHODS

Semi-structured interviews were undertaken with a convenience sample of older people with lived experience of self-harm, clinicians and suicide researchers (n = 22). Interviews were focussed on current practice (strengths and limitations), potential improvements, and identifying the core components of an acceptable Aftercare model. Interviews were audio-recorded, transcribed and subjected to a reflexive thematic analysis grounded in interpretive description.

RESULTS

Current practice strengths included validation, a person-centred approach and optimising aftercare delivery. Limitations included ageism, practical limitations (lack of service awareness, fragmented service provision, barriers to access, and traumatising approaches), and limited services, funding and training. Overarching themes included anti-ageism; anti-stigma; empowerment and agency; conveying hope; patience and pace; accessible; and finding purpose: connections and meaningful activity.

CONCLUSIONS

Older people who have self-harmed have complex, individualised needs. They sit within intersecting systems traversing healthcare, support services, family, and the social environment. Systemic, coordinated Aftercare founded upon core principles of anti-ageism, anti-stigma, partnership, empowerment, accessibility and provision of connections and meaning are needed.

A systematic review of evidence-based aftercare for older adults following self-harm

OBJECTIVE

Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies.

METHODS

Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently.

RESULTS

Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs.

CONCLUSION

Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Educating Crisis Supporters About Self-Harm and Suicide in Older Adults

OBJECTIVES

This study aimed to describe existing knowledge of crisis supporters (volunteers responding to crisis calls/texts/messages) regarding self-harm and suicide in older adults and investigate knowledge translation through use of a novel online adaptive learning tool.

METHODS

The online educational tool was tested in an Australian national sample of crisis supporters (trained volunteers) aged 18+. Knowledge Transfer was evaluated utilizing a pre/post intervention methodology for data collection. The collaboratively developed online educational tool comprised a pre-test (10 questions), middle learning module (individualised for participant's incorrect pre-test responses) and post-test (10 questions) on suicidal behaviours in older adults. Data analysed included the demographic characteristics of the participants, individual question scores, and summed pre- and post-tests scores. Group differences in change scores were assessed with either one-way between subjects ANOVA or independent samples t-test, depending on the number of groups within each variable. Pre-post education comparisons on individual change in scores were made using a paired samples t-test. Statistical significance was defined as p <0.05.

RESULTS

104 crisis supporters completed the tool (pre-test, middle lesson and post-test). There was significant improvement in knowledge of crisis supporters after the intervention (pre-test scores Mean (M) = 4.56, SD = 1.62 and post-test scores M = 7.61, SD = 1.60; t (103) = 17.242, p <0.001.).

CONCLUSION

Dedicated training about suicidal behaviors in older adults is needed given their high rates of suicide and differing underlying reasons and needs compared to younger adults.

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 Qualitative Study Exploring Negative Affect in Older Adults Residing in Long-Term Care Facilities

Purpose: To explore the experience of negative affect amongst older adults residing in long-term care facilities (LTCFs).Methods: A total of 38 participants aged 65 years or above from seven LTCFs in the Henan Province were interviewed in an unstructured manner by using the phenomenological research method. Data were analyzed by the Colaizzi method with NVivo11.0 software.Results: Three main themes emerged: (a) loneliness (lack of family affection, no common topic, and few entertainment activities), (b) chronic anxiety (suffering from disease, fear of death, and interpersonal tension), (c) subthreshold depression (diminished self-care ability, high economic pressure, and spousal bereavement).Conclusions: Older adults residing in LTCFs experienced the negative affect of loneliness, chronic anxiety, and subthreshold depression. By identifying the specific psychological issues of older adults, tailored practical initiatives need to be developed in order to reduce negative affect, improve psychological resilience, and enhance subjective well-being of older adults.

Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults

OBJECTIVE

The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework.

CONCLUSION

TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

The Development of an Online Training Tool for Crisis Supporters on Late Life Suicide: Improving Knowledge While Promoting Empowerment

Telephone crisis services have an increasing role in suicide prevention yet existing interventions have not empowered crisis supporters with adequate education targeting the needs of older people in crisis. An existing educational intervention was adapted for crisis supporters through collaboration between a crisis support service, clinician researchers, and an eLearning technology company. Empowering crisis supporters, through improving knowledge and highlighting their strengths and expertise, was emphasized. The adaptive learning technology featured a pretest, middle learning module (educational content), and post-test individualized to the participant's incorrect pretest answers. The online training tool on suicidal behaviors in late-life combined clinician researcher expertise and evidence, insights from crisis supporters, and adaptive learning technology to create a purpose-built educational tool addressing an unmet need.

Understanding the experience of living well, beyond the age of 85 years: a qualitative analysis using themes from a meta-ethnography

BACKGROUND

Increase in life-expectancy is not necessarily matched by an increase in quality of life.

OBJECTIVE

(1) To explore the quality of life of patients over the age of 85 in the second decade following unicompartmental knee replacement surgery (2) To understand the usefulness of a priori themes from an evidence synthesis as a framework for primary qualitative analysis.

DESIGN

Qualitative Research. A hermeneutic phenomenological approach, using a priori themes as sensitising concepts.

PARTICIPANTS

Adults over the age of 85 who were part of an outcomes study in the second decade following unicompartmental knee joint replacement.

METHODS

Semi-structured interviews in people's homes. Transcripts were coded and data sorted using a priori themes as sensitising concepts. Data that did not fit these themes, or that added nuance, were analysed thematically through constant comparison.

RESULTS

We interviewed seven white women and five white men, aged 85-100. Data resonated with a priori themes and supported additional themes that help us to understand older peoples' experience: (1) losing our autonomy can be challenging, so be kind; (2) we must take care of our own bodies and the NHS; (3) I am more afraid of not dying.

CONCLUSIONS

Findings indicate that health outcomes for older people should incorporate measures of participation and well-being; they highlight the importance of kindness in healthcare; they indicate that older people do not want to place additional burden on the NHS, and this can act as a barrier to care; they support the need for open conversations about dying well.

Is Suicide the End Point of Ageism and Human Rights Violations?

Ageism and human rights violations may pervade each of the potential factors underlying suicidal ideation or behavior in older persons, including physical and mental health, disability, relationships, and social factors. We outline how infringements of human rights and ageism may create or exacerbate risk factors associated with suicide in older persons. Strategies to address these issues are discussed, including tackling ageism, psychosocial interventions and education. A United Nations convention on the rights of older persons would create a uniform standard of accountability across health and social systems. Future studies are needed to evaluate the effects of alleviating ageism and human rights violations on suicide.

Suicidal behaviour in older age: A systematic review of risk factors associated to suicide attempts and completed suicides

In older age, several observational studies investigated risk factors for suicide attempts/completed suicides; however, contrasting evidence came from population-based setting. In the present systematic review, we described through a narrative synthesis the significant associations existing among risk factors and suicide attempts/completed suicides in subjects aged >65 years. From the 39 population-based studies selected in six different databases until February 15, 2021, we analyzed the most frequent 28 risk factors for suicidal behaviour. The risk factors more associated to suicide attempts than other variables frequently related to suicidal behavior in older age were: depressive disorders, methods employed to self-harm (particularly poisoning), and psychotropic drug utilization followed by psychological factors and disability. Moreover, male sex, violent methods to self-harm, any psychiatric disorder (depression, anxiety and bipolar disorders), a poor medical condition, stressors/bereavement, and living alone appeared to be more significant for predicting completed suicides in late life. In older age, efforts for suicide prevention should be based on strategies to assess and treat psychiatric disorders along with psychological interventions, particularly in males.

Evaluation of an Educational Intervention for Clinicians on Self-Harm in Older Adults

Clinicians may lack knowledge and confidence regarding self-harm in older adults and hold attitudes that interfere with delivering effective care. A 1-hour educational intervention for hospital-based clinicians and general practitioners (GPs) was developed, delivered, and evaluated. Of 119 multidisciplinary clinicians working in aged care and mental health at two hospitals, 100 completed pre/post-evaluation questions. There were significant improvements in knowledge, confidence in managing, and attitudes regarding self-harm in late life, and the education was rated as likely to change clinical practice. No GP education sessions could be conducted. A brief educational intervention had immediate positive impacts for hospital-based clinicians albeit with high baseline knowledge. The sustainability of these effects and effectiveness of the intervention for GPs warrant examination.

Undesirable social relations as risk factors for loneliness among 14-year-olds in the UK: Findings from the Millennium Cohort Study

In the current study, data collected from Wave 6 of the Millennium Cohort Study ( n = 11,872), a nationally representative sample survey of youth aged 14 years in the UK, are used to examine the prevalence of loneliness among this age-group, investigate the feelings associated with the experience of loneliness among youth, explore the risk factors for loneliness among young people, and learn how they coped with loneliness. Given recent findings that youth are vulnerable to loneliness, the study assesses the prevalence of loneliness among adolescents across some important sociodemographic characteristics, such as nation of residence, gender, and ethnicity. We also identify the kinds of social experiences that accompany loneliness during adolescence, exploring friendship, relations with parents, social support, and bullying. Our key finding is that, in addition to the absence of desired social relationships, which has been typically identified as the ultimate source of loneliness, the presence of undesirable and even harmful social relationships is a major source of loneliness. This study uniquely brings together psychological and sociological perspectives to understand the experience of youth loneliness.

Study of suicide burden of mortality in México 1990-2017

OBJECTIVE

The primary goal was to analyze the level and trend of the burden of suicide mortality in Mexico between 1990 and 2017 at a national and state scale.

METHODS

A secondary analysis based on the 2017 global burden of disease study. Mortality rates and years of life lost due to premature death (YLL) were reported here. A joinpoint regression analysis based on a log-linear model was used to analyze the trend of YLL.

RESULTS

The burden of disease due to suicides increased in Mexico, mainly in young males and females; though the raise that happened in the elderly is an additional challenge for the health system. The burden of disease varied substantially between states. The male mortality rates were higher than those of females during the whole period under study, nonetheless with a trend to reduce the difference between the sexes. A bimodal pattern of the burden of disease due to suicide in Mexico was also observed, with the higher rates located in those aged between 15 and 19 years, and an important increase in people older than 85 years of age.

CONCLUSION

These results show a worrisome picture, not only from a social, economic and health point of view but also from the needs of public policies. This situation represents a wake-up call about the need to implement timely identification actions, a comprehensive multisectoral prevention strategy and the detailed study of suicide associated risk factors.

Biggest decision of them all - death and assisted dying: capacity assessments and undue influence screening

Arguably, deciding the timing and manner of one's death is the biggest decision of all. With the Victorian Voluntary Assisted Dying Act 2017 commencing in 2019, assessing capacity to choose Voluntary Assisted Dying (VAD) becomes a critical issue for clinicians in Victoria, and elsewhere with on-going efforts to change the law across Australia and in New Zealand. We consider how capacity assessment and undue influence screening can be approached for VAD, the role and risks of supported decision-making, and argue for the importance of training to ensure health care professionals are educated about their role.

The Experience of Living to an Extreme Age: A Meta-Ethnography

Advances in health care mean that we can now treat diseases that once cut lives short. However, the increase in life expectancy has not been matched by improvements in quality of life. The World Health Organization warns us that all countries should prepare to meet the challenges of an aging population and this is integral to the United Nations 2030 Agenda for Sustainable Development. This may require a shift in attitude toward aging. We aimed to use meta-ethnography to explore the experience of adults living beyond the age of 80. Our conceptual model illuminates the phenomenon of connection in older age and reflects on the paradox of time: ephemeral, yet interminable. Our findings encourage us to reflect on the influence of enlightenment philosophies that underpin the desire for autonomy at all costs. Our study challenges the stereotypes of old age and has the potential to influence people's perspectives toward aging.

Self-harm in the very old one year later: has anything changed?

OBJECTIVES

To follow-up a cohort of older people who self-harmed, their carer, and general practitioner (GP) and examine their reflections on the self-harm, care experiences, and outcomes.

DESIGN

Qualitative in-depth interviews.

SETTING

Two teaching hospitals and associated community services.

PARTICIPANTS

Twelve-month follow-up of participants aged 80 or older who self-harmed, their nominated carers, and GPs.

MEASUREMENTS

A geriatric psychiatrist gathered data through patient and carer interviews using a narrative inquiry approach and from medical records. Interviews were audio recorded and transcribed. N-VIVO facilitated data organization for thematic analysis. Questionnaires sent to the patient's GP examined their perspectives and aspects of care relating to the self-harm.

RESULTS

Nineteen patients (63% baseline sample), 29 carers (90.6%), and 11 GPs (36.7%) were available at follow-up. Themes emerging from patients were "denial and secrets;" "endless suffering;" "more invalidation;" "being heard;" and "miserable in care." Themes from carer interviews were "denial and secrets;" "patient's persistent wish to die;" "abandonment by clinicians;" "unending burden for the carer;" and "distress regarding placement." General practitioner themes were "the problem is fixed;" "the troops have arrived;" and "I understand."

CONCLUSIONS

Factors contributing to self-harm persisted at follow-up. Positive and negative responses were identified in the older person's system, highlighting areas for potential intervention. A conceptual framework for understanding self-harm in the very old was derived that emphasized the importance of understanding individual needs, the interpersonal context of the older person, and carer burden. Interventions should improve communication, facilitate shared understanding of perspectives, and provide support at all levels.

Carer insights into self-harm in the very old: A qualitative study

OBJECTIVE

To examine the insights of carers to better understand self-harm in their older relatives.

METHODS

An in-depth interview was conducted with the nominated relative/friend (carer) of a person over 80 who had self-harmed within the last month. Carer interpretation and experience of the self-harm and clinical care were explored qualitatively. Audio recordings were transcribed and the content thematically analyzed using N-VIVO.

RESULTS

Thirty-two carers of 30 older people who self-harmed were interviewed. Physical, social, and psychological issues were identified as contributory to self-harm. Themes relating to the perceived barriers to seeking help included "they can't communicate," "suicide and secrets," and "invalidation." Themes for the intent of self-harm were "attention seeking" and "wanting to die." Themes which emerged for consequences of self-harm for carers were "anger," "guilt and self-blame," and "it made us ill." Themes for solutions to address the underlying factors leading to self-harm were "more practical support and structure," "improving communication," "removing means of self-harm," "advance care directives as a solution for suffering," and "ignoring self-harm." Clinical care themes were "shared shame and stigma," "safety and supervision vs being locked up," "clinicians dismissing the carer," and "relief and support."

CONCLUSIONS

Validation of carer perspectives and understanding family dynamics may improve communication at various system levels and inform interventions for older persons, concurrently support families, and potentially reduce risk of repeat self-harm. Good care must be holistic, be person-centred, and relieve carer burden. A shared understanding and psychotherapeutic approaches to management of self-harm in late life should be considered.

Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990-2016

Background

A systematic understanding of suicide mortality trends over time at the subnational level for India's 1·3 billion people, 18% of the global population, is not readily available. Thus, we aimed to report time trends of suicide deaths, and the heterogeneity in its distribution between the states of India from 1990 to 2016.

Methods

As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, we estimated suicide death rates (SDRs) for both sexes in each state of India from 1990 to 2016. We used various data sources for estimating cause-specific mortality in India. For suicide mortality in India before 2000, estimates were based largely on GBD covariates. For each state, we calculated the ratio of the observed SDR to the rate expected in geographies globally with similar GBD Socio-demographic Index in 2016 (ie, the observed-to-expected ratio); and assessed the age distribution of suicide deaths, and the men-to-women ratio of SDR over time. Finally, we assessed the probability for India and the states of reaching the Sustainable Development Goal (SDG) target of a one-third reduction in SDR from 2015 to 2030, using location-wise trends of the age-standardised SDR from 1990 to 2016. We calculated 95% uncertainty intervals (UIs) for the point estimates.

Findings

There were 230 314 (95% UI 194 058–250 260) suicide deaths in India in 2016. India's contribution to global suicide deaths increased from 25·3% in 1990 to 36·6% in 2016 among women, and from 18·7% to 24·3% among men. Age-standardised SDR among women in India reduced by 26·7% from 20·0 (95% UI 16·5–23·5) in 1990 to 14·7 (13·1–16·2) per 100 000 in 2016, but the age-standardised SDR among men was the same in 1990 (22·3 [95% UI 14·4–27·4] per 100 000) and 2016 (21·2 [14·6–23·6] per 100 000). SDR in women was 2·1 times higher in India than the global average in 2016, and the observed-to-expected ratio was 2·74, ranging from 0·45 to 4·54 between the states. SDR in men was 1·4 times higher in India than the global average in 2016, with an observed-to-expected ratio of 1·31, ranging from 0·40 to 2·42 between the states. There was a ten-fold variation between the states in the SDR for women and six-fold variation for men in 2016. The men-to-women ratio of SDR for India was 1·34 in 2016, ranging from 0·97 to 4·11 between the states. The highest age-specific SDRs among women in 2016 were for ages 15–29 years and 75 years or older, and among men for ages 75 years or older. Suicide was the leading cause of death in India in 2016 for those aged 15–39 years; 71·2% of the suicide deaths among women and 57·7% among men were in this age group. If the trends observed up to 2016 continue, the probability of India achieving the SDG SDR reduction target in 2030 is zero, and the majority of the states with 81·3% of India's population have less than 10% probability, three states have a probability of 10·3–15·0%, and six have a probability of 25·1–36·7%.

Interpretation

India's proportional contribution to global suicide deaths is high and increasing. SDR in India is higher than expected for its Socio-Demographic Index level, especially for women, with substantial variations in the magnitude and men-to-women ratio between the states. India must develop a suicide prevention strategy that takes into account these variations in order to address this major public health problem.

Funding

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.