Suicide in older men: A community health emergency
Know the risk factors and how to implement a screening tool during patient transports
Tony Salvatore, MA
Suicide is always preventable. If you are having thoughts of suicide or feeling suicidal, please call the National Suicide Prevention Hotline immediately at 988. Counselors are also available to chat at www.suicidepreventionlifeline.org. Remember: You deserve to be supported, and it is never too late to seek help. Speak with someone today.
In 2021, men accounted for 85% of U.S. suicides in those aged 65 and over. Men aged 85 and over and those ages 75-84 had the highest suicide rates in the U.S. From 2001-2021, men aged 75 and over consistently had the highest suicide rate. In 2021, there were 8,043 suicides among men aged 65 and over in the U.S. – 23 a day and just under one an hour.
EMS providers were on scene at many of these older male suicides. However, little attention is given to suicidal older men in the EMS literature or suicide prevention trainings. EMS providers should have at least a basic knowledge of the nature of suicidal risk and behavior in a population segment they have contact with almost every day.
Risk factors for suicide in older men
The common factors most identified as risk factors for suicide in older men include:
- Physical/psychological harm, sexual assault, domestic conflict
- Social disconnectedness and isolation
- Financial loss/insecurity/exploitation
- History or presence of psychiatric disorders
- Chronic illnesses, disabilities or other impediments to independent living
- Veteran/military service
Emergent suicide risk may be apparent in older men after a hospitalization that may leave them with chronic pain, impaired autonomy or other conditions acquired as a result of surgery or other medical treatment. Many medical conditions and their psychosocial side effects constitute older adult suicide risk factors.
Older men may have backgrounds that contribute to suicide risk late in life. Some may have residual risk from occupations with high rates of suicide. The suicide risk of police officers, firefighters, EMTs, paramedics, correctional officers, probation officers, farmers, physicians, nurses, dentists and veterinarians may carry over into retirement.
Some older men have undocumented histories of self-injury or suicide attempts that may be unknown to family members.
Beyond BLS: Suicidality and postvention
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Circumstances associated with suicide risk in older men
Unfavorable life-changing situations may trigger suicidal thoughts in older men. These include:
- Being widowed or divorced
- Depression and anxiety
- Long-term chronic illness
- Living alone or in a nursing home
- Suffering comorbid medical/neurological illness
- Feeling a loss of dignity and control
- Consuming three or more alcoholic drinks daily
- Pessimism and seeing life as pointless
EMS providers should be alert to suicide risk in new or pending long-term care residents. Suicide risk may emerge at such transitions because of the disruptive and traumatizing nature of such events. The reasons for such relocations (e.g., inability to manage activities of daily living, death of a caregiver spouse) are emotionally debilitating.
Suicidal behavior may occur in the early stages of dementia. Suicide risk has been found to increase in individuals who have received a recent diagnosis of dementia. In one study, many suicides took place within 90 days of the diagnosis. Risk was highest in those under 75.
How suicide attempts happen
The prevailing theoretical model of suicide posits two prerequisites to a potentially fatal suicide attempt:
- An extremely strong desire to die; and
- The capability for lethal self-harm.
Intent to die arises from a strong belief that one is a burden to others and/or the belief that one does not belong.
Negative self-perceptions and low self-image caused by ageism and elder abuse can also produce a desire to die. Such experiences may lead to a sense of entrapment and defeat. Burdensomeness follows from thinking that one’s death may be more valued than one’s life. A lack of belonging flows from an unmet need for social relationships and a belief that one is not cared for by relatives and friends.
A desire to die, regardless of intensity, may not be enough to promote acting on thoughts of suicide. An ability for lethal self-injury must be present for suicidal desire to become suicidal action and override the innate instinct for self-preservation. Attempting suicide requires the capability to carry out potentially fatal self-harm. This is fostered by an elevated pain tolerance, a diminished aversion to severe injury, and a reduced fear of death. These arise through exposure to hurtful, painful or violent experiences.
The capability for suicide in elders may be a byproduct of self-neglect and self-injury, or exposure to elder abuse, interpersonal violence or other types of trauma. Repeated physical or sexual mistreatment may bring about indifference to living and lower resistance to both thoughts and acts of self-harm in older men.
Warning signs of suicide in older men
Indications of suicidality in older men may be statements about being a burden to spouse or family, that others would be better off the individual were dead, and that significant others no longer care for the person or that there is a strong feeling of complete disconnection from them.
Other warning signs include thoughts of:
- Feeling useless, having no purpose and hopeless
- Sense of being trapped or having lost control
- Increasing alcohol use or misuse of prescription medications
- Withdrawing from family, friends or community activities
- Major mood shifts
- Onset of anxiety, agitation and sleep problems
These are clear indications that something is wrong and that the individual may be pre-suicidal or in the early stages of suicidality.
Imminent danger of suicide is signaled by:
- Threats of serious self-injury or suicide
- Seeking lethal means, such as weapons, medications, toxins
- A strong focus on death, dying or suicide
These are signs of strong intent. Another is voicing an actionable suicide plan giving the when, how and possibly where suicide may be attempted. An older adult disclosing a plan with any measure of specificity and feasibility needs immediate intervention.
Passive suicidality describes behaviors by older men which, over time, can be expected to result in death. It mostly occurs in circumstances in which older men have limited autonomy and no access to lethal means, such as nursing homes or other long term care settings.
Passive suicidality ranges from feeling that life is not worth living to thinking about dying. It may be voiced in statements such as, “I wish that I could go to sleep and not wake up,” or “Why must I go or living? Why can’t I just die?” It may remain inactive or it may proceed to active suicidal ideation with the specific thoughts of doing something to end one’s life.
Passive suicidality furthers a disregard for personal wellbeing, devalues self-worth and promotes hopelessness. All are associated with suicide risk.
Passive suicidality may be expressed as willful failure to provide oneself with adequate food, water, clothing, shelter, safety, personal care or medications. Older men who engage in this behavior are usually depressed or extremely frail. They may be trying to assert control over their circumstances. Such acts may not initially be suicidal, in nature, but they increase risk. Self-neglect enhances capability for more lethal self-harm.
Screening for suicide risk in older men
Screening for suicide risk is a means of detecting thoughts or actions that may signal danger. Screening may indicate the need for further assessment at an emergency department or crisis center. Screening generally relies on a structured instrument that distinguishes where a particular individual stands in relation to selected suicide risk factors.
An optimal suicide risk screener should be brief, easy to use and have demonstrated validity. The Columbia-Suicide Severity Rating Scale (C-SSRS) for emergency responders has these features. It is freely available and does not require any special training.
The C-SSRS has six questions useful in identifying suicide risk in older men:
- Have you wished you were dead or wished you could go to sleep and not wake up?
- Have you actually had any thoughts of dying by suicide?
- Have you been thinking about how you might do this?
- Have you had these thoughts and had some intention of acting on them?
- Have you started to work out or worked out the details of how you would die by suicide? Do you intend to carry out this plan?
- Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Screenings can be done during transports of older men whose mood, condition or behavior suggest possible risk.
EMS providers have been serving aging Baby Boomers for a number of years. This generation has had a high rate of suicide at every age. The oldest Boomers are driving older adult suicides now and this will continue for some time. This upsurge in risk is reason enough for EMS providers to become more familiar with a condition endemic to a key patient population.
Beyond that, older male suicide must be seen as a medical emergency as well as a community health problem. EMS providers are positioned to play a critical role in older adult suicide prevention and suicide crisis intervention. Going forward, initial EMS training and continuing education must better prepare EMS providers for dealing with older adult suicidality as a life threatening emergency.