Social Interactions among Older Adults Who Wish for Death

Systematic review on attitudes towards death and dying in adults 50 years and older living in countries with community transmission of COVID-19

BACKGROUND

The COVID-19 pandemic has underscored older adults' vulnerability to severe illness or death. Increased public awareness of mortality, with daily reminders of preventive measures, spurred interest in understanding the impact on death-related thoughts. This systematic review analyses existing literature on death attitudes among individuals aged 50 and older during the COVID-19 pandemic and focuses on associated factors.

METHODS

A systematic literature search was conducted using the WHO COVID database without any language limit, up until April 2023. The review protocol was registered in PROSPERO and PRISMA guidelines were followed. Included studies were systematically analysed and summarized using a predefined data extraction sheet.

RESULTS

Of the 2297 studies identified, 9 met inclusion criteria. The review showed moderate to high levels of death anxiety during the pandemic, linked to direct health risks from COVID-19 rather than mitigation measures. The impact of health and personal factors on older people's death anxiety was complex, with a range of health and personal factors such as chronic conditions, loss of capacity, loneliness, occupation, and resilience associated with it, suggesting potential intervention avenues.

CONCLUSION

The systematic review shows a significant link between COVID-19 and heightened death anxiety among individuals aged 50 and above. Negative attitudes to death can harm physical and mental health, diminish life satisfaction, increase avoidance behaviour, impair coping mechanism and undermine end-of-life decision making. Findings underscore the need for further research into risk and protective factors (personal, health, and environmental) and the importance of standardized data collection to guide interventions and public health strategies aimed at mitigating death anxiety.

Factors associated with attitudes toward death and dying in the second half of life: A scoping review

How we think and feel about death and dying affects how we live our lives and our opportunities for healthy aging. This scoping review, using the PRISMA guidelines and drawing on the World Health Organizations public health framework for healthy aging, examined the personal, health and environmental factors associated with attitudes toward death and dying in persons 50 years and older. Most of the 74 eligible studies focused only on negative attitudes to death and few studies investigated the comprehensive range of factors that influence attitudes to death and dying. In the context of population aging and the United Nations Decade of healthy aging (2021-2030) attention to death attitudes and the factors that influence them are imperative to enable current and future generations to age and die well.

Risk and protective factors of a wish to die and suicidal ideation in community-dwelling, older, Flemish adults: results of the Belgian ageing studies

OBJECTIVES

This study aims to increase the understanding of suicidality in older adults by investigating the prevalence, characteristics, risk and protective factors of suicidal phenomena in community-dwelling older adults (60+) in Flanders, specifically of a current wish to die (WTD) and lifetime suicidal ideation and behaviour (LSIB).

METHOD

Cross-sectional data from the Belgian Ageing Studies (BAS) is used (N = 3050). The BAS aims to monitor the needs and quality of life of community-dwelling older adults through a standardised survey. Statistical methods used are bivariate analyses and binary logistic regression.

RESULTS

Prevalence rates of 4.8% for WTD and 8.2% for LSIB are found. LSIB is the biggest predictor of a current WTD, followed by requiring support on three domains, elder abuse, depression and subjective cognitive complaints, and elder abuse were significant risk factors for both WTD and LSIB. Limited effects of protective factors were found.

CONCLUSION

Previous research regarding risk factors to be confirmed in this study, and new insights on the effect of elder abuse, subjective indicators of cognitive complaints and requiring support are added. Further research into protective factors and underlying mechanisms is required.

Interpersonal interactions, sense of loneliness and perceived depressive emotions among older adults: A cultural-psychological perspective from heterogeneous roles of different relationships

In the context of the "Chinese Differential Mode of Association" in traditional Chinese culture, this paper examines the heterogeneous effects of interpersonal interactions in different relationships on older adults' depressive emotions from a cultural-psychological perspective. Results using data from Chinese General Social Survey demonstrate that: interactions with children are the most helpful in reducing perceived depression for the elderly, followed by communications with siblings and relatives. However, interactions with friends and other fellows do not significantly reduce older people's perceived depression. This reflects the "Chinese Differential Mode of Association" in interpersonal relationships. When using different perceived depression measures, and Double Debiased Machine Learning (DDML) approaches for robustness and endogeneity tests, above findings are very robust. The impact mechanism is that interactions with children and siblings reduce depressive emotions by decreasing older adults' sense of loneliness, while communications with others do not have such a significant effect. This paper further discusses the roles of different types of interactions with adult children. It is found that receiving and providing emotional support can prominently decrease depressive emotions for older people, whereas the effects of monetary support and non-material assistance are less pronounced. In addition, interpersonal interactions' impacts are more significant for those who are female, older than 75 and with poorer health, as well as older people who exercise less frequently, have higher social status, and hold more traditional beliefs. In the current context of active promotion of healthy aging, findings of this paper have important implications for a deeper understanding and scientific management of depressive emotions among the elderly.

Social disconnection correlates of a "Wish to Die" among a large community-dwelling cohort of older adults

Introduction

Social disconnection and deaths by suicide among older adults are both important public health concerns, particularly in the context of ageing populations. The association between death ideation and behaviours, and social disconnection is well established and both functional and structural social relationships have been identified as predictive of suicide-related thoughts and behaviours. The "Wish to Die" (WTD) involves thoughts of or wishes for one's own death or that one would be better off dead is a commonly used indicator to capture death ideation. It has been shown to be as predictive as active ideation of future suicide attempt.

Methods

Data were from a large cohort of community-dwelling older adults aged 50+, The Irish Longitudinal Study on Ageing (TILDA). Cross-sectional analyses of the association between numerous markers of social disconnection (loneliness, social isolation, living alone, marital status, social participation, volunteering, and attending religious service) and WTD were conducted.

Results

Multiple markers of social disconnection were associated with a "wish to die". However, loneliness was the strongest risk factor while attendance of religious services was an important protective behaviour.

Discussion

There is a strong association between social disconnection and a WTD among older adults. There is also a strong association between depression and a WTD, while attending religious services or similarly prosocial settings may protect older adults from experiencing negative thoughts about dying.

Optimizing Older Adult Mental Health in Support of Healthy Ageing: A Pluralistic Framework to Inform Transformative Change across Community and Healthcare Domains

This paper describes a pluralistic framework to inform transformative change across community and healthcare domains to optimize the mental health of older adults in support of healthy ageing. An extensive review and analysis of the literature informed the creation of a framework that contextualizes the priority areas of the WHO Decade of Health Ageing (ageism, age-friendly environments, long-term care, and integrated care) with respect to older adult mental health. The framework additionally identifies barriers, facilitators, and strategies for action at macro (social/system), meso (services/supports), and micro (older adults) levels of influence. This conceptual (analytical) framework is intended as a tool to inform planning and decision-making across policy, practice, education and training, research, and knowledge mobilization arenas. The framework described in this paper can be used by countries around the globe to build evidence, set priorities, and scale up promising practices (both nationally and sub-nationally) to optimize the mental health and healthy ageing trajectories of older adults as a population.

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.

Talking really does matter: Lay perspectives from older people on talking about suicide in later life

Background

The cumulative body of research on suicidality in later life describes its unique and complex features in older people when compared with that in other population groups. Yet significant gaps exist in how research informs the further development of suitable interventions. The perspectives of older people are also limited in research findings.

Aims

Therefore, this exploratory study aimed to (1) identify potential barriers and enablers in discussing suicidal thoughts and their expression in later life from the perspectives of lay older people and (2) explore where opportunities might occur in approach, place, relationships, and language with older people to discuss suicidal thoughts and their expression.

Method

We conducted in-depth qualitative individual interviews with 15 people aged 70-89 years. This method helped explore older peoples' own lay perspectives on suicidal thoughts in later life and how these are expressed, and their understanding of where and how people might seek support.

Results

A total of three themes were generated from the dataset: (1) intergenerational and socio-cultural differences in suicide expression, (2) the normalization of suicidal thoughts in later life, and (3) the importance and difficulties of everyday discussion and opportunities to express suicidal thoughts.

Conclusion

Suicidal thoughts and their expression appear commonly and are normalized in later life yet remain taboo and hidden. The participants revealed how such thoughts and behaviors are typically expressed through colloquial or "off-hand" remarks and comments and the importance of authentic listening. The findings highlight the importance of more informal discussions around these topics and how care professionals, practitioners, and providers might frame opportunities for dialogue with people who may want to access support. Further engagement with community-informed participatory research methods in which older people provide their own perspectives and experiences is important in addressing these gaps. There is a need for co-designing in developing screening, assessment, and signposting outside of clinical settings that can be used in everyday caring relationships with people in later life.

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.

Assessing suicide ideation among older adults: a systematic review of screening and measurement tools

OBJECTIVES

Rates of suicide in older adults may be higher than reported due to poor understandings of presentation of suicide ideation in this group. The objectives of this paper were to (i) review current measurement tools designed for older adults to detect suicide ideation and (ii) assess their psychometric properties.

DESIGN

We used a systematic review approach to identify measurement tools developed specifically for older adults without cognitive decline or impairment.

RESULTS

Ten articles that reported on a total of seven different measurement tools were identified. These included tools that focused on resiliency to suicide and those that measured risk of suicide behavior. There was wide variation across the articles: some were adaptations of existing scales to suit older populations, others were developed by authors; they varied in length from four to 69 items; a range of settings was used, and there was a mix of self-report and clinician-administered measures. Most displayed good psychometric properties, with both approaches showing similar quality. Limitations in terms of samples, settings, and measurement design are discussed.

CONCLUSION

The case for specific measures for older adults is clear from this review. There appear to be unique factors that should be considered in understanding suicide ideation and behavior among older adults that may not be directly assessed in non-specific measurements. However, there is a need to expand the diversity of individuals included in measurement development to ensure they are appropriate across gender, culture and minority status, and for the views of professionals to be considered.

"Withstanding ambivalence is of particular importance"-Controversies among experts on dealing with desire to die in palliative care

In order to investigate controversies surrounding the desire to die phenomenon in palliative care by analyzing expert opinions on the topic, we carried out a secondary qualitative data analysis of free text comments collected during a Delphi survey that was designed to develop a conversation aid for dealing with desire to die in everyday clinical practice. Between 01/2018 and 03/2018, a two-round Delphi survey was carried out with national (German) and international palliative care experts. Free text comments were reinvestigated to identify controversies surrounding the desire to die phenomenon. An additional in-depth analysis focused on statements expressing attitudes towards proactively addressing (potential) desires to die. Within the Delphi survey, 103 of 149 multi-professional participants (almost all of them with practical and only six with exclusively theoretical expertise in palliative care) generated 444 free text comments. Thereof, we identified three main categories related to dealing with desire to die: "outer framework", "extended care system" and "health-professional-patient-relationship". Ambivalences, taboos and uncertainties surrounding desire to die in palliative care became apparent. Experts are divided concerning the practice of proactively addressing desire to die. Even if these conversations-especially the proactive approach-are also viewed critically, we conclude that open-ended and respectful communication about desire to die between health professionals and patients can be understood as an eligible intervention in palliative care. Proactively addressing the topic is a possible way to open up such conversations.

Understanding the Reasons for Suicide Among Older Adults in Rural China Using In-Depth Interviews

Background: Suicide is a complex public health problem. Suicide rates are higher in rural areas than in urban areas and among older adults than any other age group in China. Aims: This study aimed to acquire a comprehensive understanding of rural older adults' reasons for suicide through qualitative exploration and to provide additional insights for suicide prevention work. Method: In-depth interviews were conducted with people familiar with older adults who had died by suicide ("informants"). The data were analyzed using a thematic approach. Results: Data were available for 242 people who died by suicide. Informants identified two or more reasons for suicide among most people who had died. Physical illness, psychological distress, and interpersonal conflicts were the most common reasons. The rate of mental disorders as diagnosed by psychiatrists was higher than that reported by the informants. Limitations: Information bias is inevitable because of the use of proxy informants. Conclusion: The reasons for suicide are complex and diverse, and research on suicide should focus more on the mechanisms of interaction between reasons. Greater attention should be paid to physical and mental health as well as to improving interpersonal and problem-solving skills for older adults in China.

The 'Wish to Die' in later life: prevalence, longitudinal course and mortality. Data from TILDA

BACKGROUND

'Wish to Die' (WTD) involves thoughts of or wishes for one's own death or that one would be better off dead.

OBJECTIVE

To examine the prevalence, longitudinal course and mortality-risk of WTD in community-dwelling older people.

DESIGN

Observational study with 6-year follow-up.

SETTING

The Irish Longitudinal Study on Ageing, a nationally representative cohort of older adults.

SUBJECTS

In total, 8,174 community-dwelling adults aged ≥50 years.

METHODS

To define WTD, participants were asked: 'In the last month, have you felt that you would rather be dead?' Depressive symptoms were measured using the CES-D. Mortality data were compiled by linking administrative death records to individual-level survey data from the study.

RESULTS

At Wave 1, 3.5% of participants (279/8,174) reported WTD. Both persistent loneliness (OR 5.73 (95% CI 3.41-9.64)) and depressive symptoms (OR 6.12 (95% CI 4.33-8.67)) were independently associated with WTD.Of participants who first reported WTD at Wave 1 or 2, 72% did not report WTD when reassessed after 2 years, and the prevalence of depressive symptoms (-44%) and loneliness (-19%) was more likely to decline in this group at follow-up.Fifteen per cent of participants expressing WTD at Wave 1 died during a 6-year follow-up.

CONCLUSIONS

WTD amongst community-dwelling older people is frequently transient and is strongly linked with the course of depressive symptoms and loneliness. An enhanced focus on improving access to mental health care and addressing social isolation in older people should therefore be a public health priority, particularly in the current context of the Covid-19 pandemic.

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.

Attachment anxiety, depression, and perceived social support: a moderated mediation model of suicide ideation among the elderly

OBJECTIVES

Issues concerning the association among attachment anxiety, depression and suicidal ideation among the elderly have rarely been explored. The present study investigated the relationship among attachment anxiety, depression and perceived support concerning suicidal ideation among older people.

DESIGN

Cross-sectional study.

SETTING

Tertiary care settings.

PARTICIPANTS

The authors recruited 191 elderly patients from 10 tertiary care settings in Thailand.

MEASUREMENTS

Participants provided data on their suicidal ideation and suicidal attempt using Module C of the Mini-International Neuropsychiatric Interview. Their attachment anxiety was assessed using the revised Experience of Close Relationship questionnaire (ECR-R-18), while their level of depression was investigated using the Geriatric Depression Scale. In addition, their perception of being supported was ascertained using the Multidimensional Scale of Perceived Social Support. We performed two mediation analyses and moderation analyses separately using the product of coefficients approach. First, we created a mediation model to examine the role of attachment anxiety and depression on suicidal ideation. Second, a moderated mediation model was created to explore the relationship of perceived social support as a moderator of depression.

RESULTS

We found that depression significantly mediated the association between attachment anxiety and suicidal ideation. The association between depression and suicidal ideation was moderated by the level of perceived social support.

CONCLUSION

Findings of this study may broaden our understanding of how suicidal ideation develops among the elderly and further stimulate future research exploring the interaction of positive and negative factors of suicidality among the elderly. Implications of the findings were also discussed.