7.6 Suicide and attempted suicide in old age

Epidemiology

• People aged 65 and over account for roughly a fifth of completed suicides in the UK, which reflects high lethality rather than high attempt rates.

• Self-harm is less frequent in later life, but about 1.5% of people aged 60 and over who self-harm die by suicide within the following 12 months.

• Men account for most suicide deaths, and recent rates in England and Wales have been highest in middle age.

• Frailty, reduced physiological reserve, careful planning and unlikely rescue all make an act more likely to be fatal.

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Risk factors

• Serious physical illness, cancer in particular, independently predicts completed suicide even after depression is allowed for.

• Social disconnection raises risk, but depression largely carries its effect.

• Huntington's disease carries a suicide rate roughly six times the general population rate.

• Other risk factors are previous self-harm, depression, psychosis, hopelessness, alcohol, pain, disability, recent diagnosis, bereavement and access to medicines.

Personality

The psychological autopsy study by Harwood and colleagues (2001) linked completed suicide in older people with Cluster C personality.

Contact with services

• Older people who die by suicide often saw their GP shortly before death: about two-thirds to three-quarters within the last month and about 40 to 50% within the last week.

• Far fewer had contact with specialist mental health services.

Prevention

• Educating GPs to recognise and treat depression is the strategy with consistent evidence of lowering suicide rates in older adults.

• Public awareness campaigns, risk screening, psychological therapy and antidepressant prescribing alone lack that evidence.

• Building social connectedness in the community is primary prevention, because it acts upstream on a risk factor such as isolation before illness or crisis.

Assessment and management

• Statements about being a burden, having no future or not wanting further care need direct, sensitive enquiry about suicidal thoughts.

• Withdrawal, poor self-care, missed medicines or refusing food may reflect suicidal intent, cognitive impairment or physical illness.

• A suicide attempt does not itself establish incapacity, though delirium or toxicity may impair capacity temporarily.

• Selective serotonin reuptake inhibitors (SSRIs) and mirtazapine are less toxic in overdose than tricyclics, and a blister pack alone does not stop access to extra supplies.

• Severe depression with life-threatening reduced intake may warrant electroconvulsive therapy.

• Under NICE NG225, initial aftercare follows within 48 hours of psychosocial assessment when safety concerns continue.

Wish for death, refusal and the law

• An adult with capacity can refuse life-sustaining treatment, and in England and Wales an advance decision refusing it must be written, signed, witnessed and state that it applies even if life is at risk.

• Depression and a capacitous refusal can coexist, so clinicians assess the person's actual ability to decide rather than inferring it from the diagnosis.

• Assisting suicide is an offence in England and Wales under the Suicide Act 1961, while Scotland has no equivalent statutory offence.

• The Republic of Ireland's Criminal Law (Suicide) Act 1993 decriminalised suicide but kept an offence of assisting it.