May/June 2022

Elder Suicide
By Tony Salvatore, MA
Today’s Geriatric Medicine
Vol. 15 No. 3 P. 12

Addressing Risk in Assisted Living Facilities

Assisted living facilities (ALFs) are congregate residences providing around-the-clock service, aging in place, and optimal resident dignity, autonomy, and choice in a homelike environment. ALFs are a rapidly growing segment of long term care serving the fastest-growing population in the United States.

ALFs take a variety of configurations. Most are freestanding, but many are linked to nursing homes or part of continuing care retirement communities. ALFs evolved from personal care homes. They are regulated by individual states with no national oversight. With the exception of states with Medicaid waivers, residents or their families pay for ALF care.

According to the National Center for Assisted Living, there are 28,900 ALFs in the United States, with each caring for about 30 residents. Most residents are impaired to some degree by chronic illness or disability. The health conditions most commonly found among ALF residents are Alzheimer’s disease and dementia, cardiovascular disease, and arthritis. Depression afflicts about one-third of the residents.

ALFs and Suicide Risk
Suicide risk in ALF residents has not received much attention among providers or in the field of suicide prevention. There have been few research studies on suicide in ALF residents, and reporting of suicides among older long term care residents is inconsistent. ALFs will contend with greater suicide risk in residents in coming years as baby boomers, a demographic with a high suicide rate at every age, will increasingly occupy the majority of ALF beds.

ALF residents are largely in the age group with the highest rate of suicide compared with any other group in the United States. The average age of ALF residents is 84, and more than one-half are 85 years of age or older. Older women, a population with a historically low suicide rate, comprise the largest share of ALF residents; older men, especially those older than 85 years of age, have a much higher suicide rate. Suicide risks in ALFs will grow in coming years as the older male resident segment rises.

Though seldom recognized, residents of ALFs may have risk factors for suicide at the time of admission, some of which may be exacerbated during their stay. Suicide risk factors may also emerge at any point during residency. In some cases, the reasons for entering an ALF (eg, chronic illness, disability) are themselves latent risk factors for suicide in older adults.

Relocating to an ALF involves giving up one’s home, community ties, and, in some cases, one’s spouse. These losses may raise suicide risk in new ALF residents. In addition, more residents will be entering ALFs with significant suicide risk factors such as depression, early-stage dementia, and comorbid health conditions. These conditions inevitably worsen during ALF stays, increase care needs, and eventually necessitate a higher level of care. The National Center for Assisted Living notes that about 60% of ALF residents move to nursing homes. Transitions to care settings associated with increased dependence may foster suicide ideation.

Firearms are the most common means of suicide by older men. Firearms may remain a source of risk in independent living auspices, but be less so in ALFs that ban or restrict firearms on their premises. Older men in residential care may use other means at hand. A review of suicides and attempts in men with an average age of 65 in VA long term care facilities found cutting with a sharp object, overdose, and hanging to be the primary means employed.

Older women turn to prescription medications, particularly analgesics, as a means of suicide more so than do older men. ALF administration of medications can reduce access to such means, but staff must remain alert to the potential for stockpiling pills and medications brought in by visitors. Changes in medications and refill frequency should be checked in residents who self-administer medications. Consultant pharmacists can assist.

ALFs must be aware of how suicide risk in their older adult residents differs from that in younger groups. Older adults more deliberately plan their suicide attempts, take steps to minimize discovery and rescue, and are more likely to die from self-inflicted harm because of greater physical frailty. A facility should never underestimate the ability of a suicidal resident to contrive a doable and lethal suicide plan with the opportunities available no matter what their mental or physical status. Being under around-the-clock care and supervision does not contain all sources of risk or deter all suicidal behavior by older residents.

Suicide Risk Factors in ALF Residents
Following are the basic risk factors for suicide in older adults that may be found among ALF residents:

• white male 80 years or older;
• previous suicide attempt;
• comorbid physical health conditions;
• depression and other mental health problems;
• social isolation;
• disability and pain;
• substance use problems (including abuse of prescription medications);
• stressful life events and loss;
• access to lethal means; and
• difficulty adjusting to change.

Suicide risk is strongly linked to alcohol consumption in older men. A University of Pittsburgh survey of ALF staff found a high rate of drinking among residents. ALFs generally restrict drinking, but residents may use alcohol in their units.

The following are some suicide risk factors specific to ALF residents:

• feelings of burdensomeness to one’s family brought on by the need for assisted living and its ongoing costs;

• high rate of sleep disturbance brought on by transition to ALF; and

• a recent hospitalization giving rise to fears that subsequent long term care may be needed.

An analysis of narrative data on older adult suicides gathered by the National Violent Death Reporting System found references to concern about the financial cost of long term care in documentation on decedents living in or moving to such facilities.

Other serious suicide risk factors may emerge in ALF residents over the course of stay, including the following:

• onset or worsening of dementia or other neurocognitive disorders;
• declining functional independence; and
• pending transfer to a skilled nursing facility.

Preexisting or residual suicide risk factors in ALF residents include being a veteran and having a work history in a profession or occupation with a high suicide rate. Examples of the latter include physicians and other health care professionals; emergency responders such as police officers, fire fighters, and paramedics; and workers in farming and construction.

Older male residents represent a particular challenge. Their risk rises with age, and they are more likely to use lethal means, such as firearms, which contributes to their increased likelihood of suicide attempt resulting in death. While older male residents warrant attention, older women residents are not immune to suicide. A Virginia study found a higher rate of suicide in older women in long term care facilities than in women of the same age living in the community.

Depression and Dementia as Risk Factors
Depression is a critical risk factor for suicide. On the one hand, depression is frequently underdiagnosed and undertreated in older adults. On the other hand, older men whose severe depression is recognized and those who experience longer depressive episodes have a lower rate of response to all classes of antidepressants. Residents in larger ALFs are likely to be treated with antidepressants. However, the majority of depressed residents are unlikely to have a regular source of psychiatric care.

In addition to its ties to suicide risk, depression is significantly associated with medical comorbidity, social withdrawal, psychosis, and agitation. It has also been found to be related to length of residence in the facility and plays a role in ending ALF stays. Depressed ALF residents are discharged to nursing homes at higher rate than are nondepressed residents.

One current theory of suicide posits that it’s an outcome of a process that commences with passing thoughts of suicide that may become persistent and uncontrollable. Suicidal ideation is a recognized side effect of depressive disorders in older adults and other age groups. Suicidal thoughts may progress to a desire to die and, eventually, to suicidal intent. In older adults, this progression may be driven by rising hopelessness and pain.

Dementia is a major health problem in older adults. Risk factors for suicide in dementia include depression, hopelessness, and mild cognitive impairment. ALF residents with mild or early dementia may have better cognition and more sustained insight into their diseases and their inevitable outcomes. They are well able to develop and carry out a suicide plan.

Suicide risk related to dementia sets in with the diagnosis. Recent research found that individuals with dementia had an increased risk of dying by suicide within one year after diagnosis compared with those without a dementia diagnosis. In a Yale study, adults older than age 65 diagnosed with Alzheimer’s disease or other dementia were more than twice as likely to die from suicide compared with older adults who do not suffer from dementia. Increasing functional loss due to dementia precipitates many moves to ALFs, and neither debilitation or suicide risk abate with ALF residence.

Specific aspects of dementia may generate suicidal thinking and aggravate suicide risk. These may include rising emotional distress, diminishing quality of life, and growing functional impairment. Deliberate self-neglect may occur in early stages of dementia and constitutes self-harm, a suicide risk factor.

Co-occurring dementia and psychiatric disorders are believed to be common in ALFs but are poorly recognized and treated. This interferes with the ability of residents to age in place and contributes to suicide morbidity.

Protective Factors
Less is known about positive personal and environmental variables that offset suicide risk or deter its onset. Ongoing ties to family and friends, religious beliefs and spirituality, and the availability of supportive counseling are believed to be very effective suicide risk protectors in older adults. Reasons for living, optimism and a future orientation, and a strong sense of self-worth are also regarded as counteractive to suicidality.

There is no research on protective factors in ALF residents. However, there are a number of individual characteristics believed to be buffers against suicidality in older adults, which have good fit with ALFs and which should be fostered in such settings, including the following:

• social connectedness;
• skills in coping and adapting to change;
• a sense of purpose and meaning; and
• participation in community activities.

These elements are intrinsic to the generally accepted philosophy of assisted living, but their application may vary across facilities. Industry reports indicate that many ALF providers are actively promoting social connection, help-seeking skills, and community engagement in the design and operation of their facilities. This will mitigate suicide risk, as will offering and maintaining positive, pleasant, and homelike residential settings.

What Can ALFs Do?
The inherently higher risk of suicide and suicidal behavior in older adults must prompt ALFs to accept that they will experience both among their residents at some point. The best way to create a context for suicide prevention in a facility is to make it a policy. This can cover the following:

• staff training suicide-prevention requirements;
• resident suicide risk-assessment measures;
• protocols outlining how to respond to a suicide attempt by a resident;
• what to do if a resident dies by suicide; and
• how to help residents, staff, and family members affected by the loss of a resident to suicide.

State ALF regulations set requirements for staff training in first aid, CPR, and managing obstructed airways, among other situations. Given the incidence of depression and the level of suicide risk present in older residents, consideration should be accorded to mandating “gatekeeper trainings” in ALF. Mental Health First Aid and QPR (Question, Persuade, Refer) are examples.

ALFs must recognize that the emergence of suicidal ideation among residents is a hazard akin to falls and infection and must be treated similarly. All staff must be familiar with the general warning signs of suicidality in older adults. These include withdrawing from routine social contacts; noticeable changes in mood; greater evidence of anxiety, agitation, and anger; disturbed sleep patterns; voicing hopelessness; and feelings that one has no purpose or is trapped by some situation. These signs should be discussed in trainings and posted at sites frequented by staff.

ALFs should make use of a valuable facility-oriented resource available from the federal Substance Abuse and Mental Health Services Administration entitled “Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities” (available at store.samhsa.gov/product/Promoting-Emotional-Health-and-Preventing-Suicide/SMA10-4515). This publication offers a wide range of recommendations for promoting the well-being of older residents, guidelines to help staff identify help residents at risk of suicide, and appropriate responses to resident suicide attempts and deaths. It also presents a number of self-assessments that ALFs can use to determine their suicide prevention readiness.

Suicide prevention awareness in ALFs would be enhanced by greater transparency in reporting of resident suicide attempts and deaths. Regulations in some states, such as Pennsylvania, mandate suicide reporting to the state agency overseeing ALFs. However, questions have been raised about the consistency of this reporting as well as facilities routinely bringing resident suicides to the attention of county coroners and medical examiners. Few suicides in long term care are investigated or autopsied.

Bottom Line
The mission of assisted living is to help older adults retain autonomy, privacy, and quality of life in a personalized environment. Greater effort should be made to detect and treat depression and other risk factors for suicide in this setting to reduce suffering and prolong the residents’ ability to remain in their preferred environments.

Suicide prevention has given only nominal notice to the risk of older adults in both community and residential care settings. Nonetheless, a growing body of research has significantly enhanced our understanding of the factors fostering suicidal behavior in older adults. ALFs must draw on what is being learned in research on older adult suicide to assure the safety and quality of life of those they serve.

— Tony Salvatore, MA, directs suicide prevention activities at a nonprofit emergency psychiatric provider in southeastern Pennsylvania and has a strong background in crisis intervention. He has been advocating for directing more attention to suicide risk in older adults for more than 20 years and has written several articles on the topic.