SUICIDE IN THE ELDERLY By GLENDA J. ABERCROMBIE

SUICIDE IN THE ELDERLY

By

GLENDA J. ABERCROMBIE

A project submitted in partial fulfillment of

the requirements for the degree of

MASTER OF NURSING

WASHINGTON STATE UNIVERSITY

Intercollegiate College of Nursing

MAY 2006

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To the Faculty ofWashington State University:

The members of the committee appointed to examine the

project of GLENDA J. ABERCROMBIE find it satisfactory and recommend

that it be accepted.

Chair: Renee Hoeksel, PhD, RN, CCRN

cf~~~~~~---__ LauralIahn, MSN,ARNP, FNP-C

ii

ACKNOWLEDGEMENT

I am grateful to Washington State University and Intercollegiate Center for Nursing

Education for the distance learning opportunities. The Washington Higher Education

Teleconlmunications System (WHETS), video streaming, electronic blackboard, and online

classes were technologies that allowed me to pursue my educational goal of Master of Nursing,

while continuing to live in Yakima.

I would also like to thank the nursing faculty and staff. As our country experiences a

shortage in nllrses and nurse educators, they continue to provide quality education to help meet

the needs of our country.

A very special thanks goes to nlY chairperson and comnlittee members, who have offered

expertise and passion from their specific areas of nursing interest.

Thanks also to my classmates who have encouraged me along the way.

iii

SUICIDE IN THE ELDERLY

Abstract

by Glenda Abercrombie, RN BSN Washington State University

May 2006

Chair: Renee Hoeksel

Suicide among the elderly is a growing issue and the greatest incidence of suicide occurs

in elderly white males. Though research has identified risk and protective factors, assessment

tools and prevention programs have been developed, few are specifically focused on the elderly.

The concept of hopelessness has been investigated in relation to depression and linked to suicidal

ideation; in one study the elderly identified spirituality as an unmet need. The attitudes and

knowledge of the young and old, professional and non-professional differ, and have changed

over time. Suicide prevention is an issue that cannot be delegated solely to mental health

professions because primary care providers have been found to be a frequent point of contact for

the elderly, offering an opportunity to impact their depression, hopelessness and potential

suicidal ideation. Basic help for patients may be in the primary care providers approach to patient

management and interaction, including a focus on hope renewal, and referral to appropriate

community resources. A review of research studies reveals some common agreements on issues

as well as areas in need of further research. Incorporating community involvement and referring

outside the nOffilal realm of social and medical support may help reduce suicidal deaths. Through

a holistic and community approach a reduction in suicide among the elderly may be realized. The

purpose of this paper is to provide a review of current research information and provide an

example ofpotential community referrals.

IV

TABLE OF CONTENTS

ACKNOWLEDGEMENTS.................... III

ABSTRACT. . . .. . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV

TABLE OF CONTENTS................................................................. V

LIST OF TABLES...... VI

DEDICATION............................................ VII

CHAPTERS 1. INTRODUCTION............................................................ 8

2. WORLD ISSUE............................................................... 10

3. KNOWLEDGE & ATTITUDES......................................... ... 12

4. DISEASE, DEPRESSION, ANXIETY,& OTHER RISK FACTORS..................................................................... 15

5. HOPELESSNESS............................................................. 19

6. HOPE........................................................................... 22

7. PRIMARY CARE CONTACT......................................... 25

8. ASSESSMENT................................................................ 28

9. INTERVENTION/PREVENTION; HOPE/SPIRITUALITY CONNECTION......... 31

10. COMMUNITY RESOURCES.............................................. 35

11. CONCLUSION...... 37

BIBLIOGRAPHY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 39

v

LIST OF TABLES

1. Risk Factors.................................................. 16

2. Signs of Depression in the Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19

3. Protective Factors........................................................... 23

4. Quick Reference of Suicide Assessments............................... 29

5. The Nurses' Global Assessment of Suicide Risk.................... ... 30

6. Proposed Hope Scale....................................................... 38

vi

DEDICATION

This project is dedicated to my parents, Lloyd and Dorothy Curfman, to my husband

John, and to our adult daughters Cherish and Caress.

To my parents for their endless encouragement and prayers.

To my husband for his day-to-day support in the demands of living, working and

studying.

To my daughters for their emotional support dllring the challenges of college, career and

family life.

vii

Suicide in the Elderly

Introduction

Suicide rates increase witll age and are highest among Americans aged 65 and older.

(Centers for Disease Control and Prevention, 2003). Persons over 65 make up about 12°~ of the

population, but account for 18°~ of the suicides (Bruce et aI., 2004; Conwell, 2001). Research

studies have shown nurses scored less than 50o~ when tested on their knowledge about the signs

of potential suicide (Wang, Anderson, & Mentes, 1995; Valente, Saunders, & Grant, 1994). In

order to intervene, nurses must become aware of the issues surrounding suicide in the elderly.

This project reviews research related to causes and discusses possible interventions of suicide in

the elderly within a framework of hope.

Elders in some societies are valued for their age, knowledge and wisdom. Our American

society values youthfulness, productivity and a rapid pace. Stereotypes abollnd related to older

Americans, portraying them as slow, unhappy, unproductive, and incompetent (Murray, Zentner,

Pinnell, & Boland, 2001). There has been a rise in suicide among the elderly in this environment

of the minimized and misllnderstood elder. When categorized by gender and race, non-Hispanic

white men over 85 have one of the highest rates of suicide, a rate of 59 suicides per 100,000

(National Institute of Mental Health [NIMH], 2003).

It is important to consider several factors regarding the statistics about suicide. First is the

potential for under reporting of suicide cases (Osgood, 1992; Meehan, Saltzman, & Sattin, 1991).

Suicides that occur by overt nlethods such as guns, hanging, or jumping, are reported. Less overt

methods may not be captured as suicides that occur in this group, because elderly people starve

themselves to death, fail to take their medications, mix drugs and alcohol, or have intentional

fatal accidents. Many deaths from suicide are never investigated, but are reported as accidents or

8

deaths from natural cause, because the victinl is old (Miyabayashi, 2002). The non-uniformity of

death certification procedures and those certifying deaths, as well as reluctance to certify the

death of an older person as suicide, are all issues that contribllte to underreporting of suicide.

Baldwin (2001) reports that researchers believe suicides are underreported in Ireland to spare

relatives shame.

A second issue to consider in regard to the statistics about suicide in the elderly is the

anticipated increase in the aging population of America. The 65 and over age group is expected

to increase from 12.4% in 2000 to 19.6% in 2030 (Centers for Disease Control and Prevention

[CDC], 2003). Other projections suggest the number of suicides committed in later life will

double by 2030 (Conwell, 2001). A potential decrease in suicide among the elderly may occur

due to the nature of many baby boomers seeking health preventative interventions across their

lifespan. Boomers may maintain healthy life styles, seek out physical and mental health services

for early intervention of depression, hopelessness or suicidal ideations, and inlpact the incidence

of suicide statistics in this nation. Though the future is not clear, what is known is that hope is an

element that needs to be explored within the realm of elder suicide. The expected increase in the

population of the elderly, and the potential for an increase in elder suicide makes this a relevant

subject to study at this time.

The elderly non-Hispanic white male has the highest risk of suicide. This fact was

confirmed in a retrospective review of all suicides age 65 and older that were referred to the

Medical University of South Carolina from January 1988 to December 1997. The study group

included 85% men, and 94% white. Gunshot wound was the most common method of suicide.

The victim was most likely to have a chronic or debilitating disease or nlalignancy. Rates of

suicide reach the highest levels in the oldest age groupings. Rates for females increase with age,

9

peak at middle adulthood, and then decline slightly with advancing age (Bennett & Collins,

2001). Another study confirmed that men and the elderly are at the highest risk for suicide, and

they are likely to choose the most lethal methods (Spicer & Miller, 2000). As with any suicide,

surviving friends and family members are left with loss, grief, and many questions. Grief

following a death by suicide is unique from other kinds of bereavement, and involves a complex

combination of depression, guilt and anger (Conwell, 2001). There is a significant impact on our

health care system to support the survivors through their unanswered questions of why and what

they could have done to help prevent the suicide, their own guilt, and years of grief and fears

related to the suicidal death of their loved one.

Our elderly population is an industrious generation; they lived through the Great

Depression, and have seen many rapid changes in their life. Average life expectancy has

increased because of the advances in medicine and public health; they are surviving illnesses and

disease that were previously life limiting. They are dealing with advance age, medications,

treatments, and frequent visits to their health care provider. They are blazing their own trail in

dealing with advancing age, declining physical and mental stamina and the lack of a socialization

model to follow in coping with these issues.

Another interesting factor has developed as people continue to live longer lives.

Identifying who is old can be very subjective. Each study defines its specific age categories.

Some commonly used categories for reference to the elderly include the young old as ages 65 to

74. The middle old are ages 75 to 84, while the old old are often considered to be 85 and older.

World Issue

The World Health Organization (WHO) has identified suicide as a global health care

concern. In 1980 the United States (US) recognized a dramatic increase in suicide in the elderly.

10

As of 2003 those levels have continued to increase. The Surgeon General, Healthy People

initiatives and the Centers of Disease Control and Prevention (CDC) show evidence of concern

and the need for suicide prevention programs (Centers for Disease Control and Prevention

[CDC], 2003). Healthy People 2010 defined specific goals aimed at the reduction of suicide by

increasing interventions, screening, and treatment services for the elderly (U.S. Department of

Health and Human Services [USDHHS], 2001)

Several nations have published research studies that focus on the elderly. A study in

Denmark examined suicide trends among the old (65-79 years) and the oldest old (80 + years).

This study included suicides dllring 1972-1998. The findings during the study period showed

suicide trends an10ng the middle-aged and older adults decreased, while the trend among the

oldest old remained stable. Suicide patterns of the oldest old are not following the same decline

as those of younger age groups (Erlangsen, Bille-Brahe, & Jeune, 2003).

A study conducted in Sweden looked at the association between physical illness and

suicide in elderly people. The design of this study was case-control with illness determined from

interviews with relatives of those who committed suicide and from medical records. The

conclusion was that visual in1pairment, neurological disorders and n1alignant disease were

independently associated with increased risk of suicide in elderly people, and that serious

physical illness may be a stronger risk factor for suicide in men than in women (Waern et aI.,

2002).

Finland reviewed 1397 suicides in 1987 to understand the circun1stances of the deaths.

They report that the rates of depression, alcoholism and psychiatric disorders are close to the

international average, and do not correlate directly to suicide. Individuals typically have some

risk factors like depression or alcoholism, but also some specific event happens during the last 6

11

months to trigger suicidal action. The World Health Organization has created a suicide

prevention model based on the prevention program the Finnish have developed (Wilson, 2004).

Knowledge & Attitudes

Attitudes toward suicide have changed since the mid- 20th century views. Suicide is now

regarded as an important and preventable public health problem, and has received increasing

national and international focus in recent years (Moscicki, 2004). Suicide is not generally viewed

by our society as an acceptable way to cope and failed attempts at suicide have been viewed as a

call for help. For the elderly, there is often no wake up call for opportunity to intervene, as they

are more likely to successfully complete suicide on their first attempt, as compared to other age

groups. They may even make efforts to hide their intelltions. Some of the activities that may

indicate thoughts of suicide include getting affairs in order, creating or changing a will, and

giving away possessions. These are all activities expected of tIle elderly and may not be

recognized as warning signs for suicide. (Weinreich, 1999).

In a review of perceptions regarding the timing of death, the views of the elderly were

summarized into three main categories. Those three categories were: death is controlled by God,

controlled by physician and individual collaboration, or controlled entirely by the individual

(Courage, Godbey, Ingram, Scllfamm, & Hale, 1993). In a study of attitudes toward suicide, the

elderly were found to be more tolerant of suicide than middle-age persons (Parker, Cantrell, &

Demi, 1997).

An attitude of tolerance and the increased incidence of elder suicide suggest an

acceptance of suicide as a means of dealing with diminished life circumstances associated with

the aging process (Parker, Cantrell, & Demi, 1997). Attitudes toward death, dying and

bereavement are influenced by culture. American attitudes have changed over the last 20 years.

12

Hayslip and Peveto (2005) replicated a study and compared the findings to one completed in

1976. The areas of focus were death attitudes and behaviors towards one's own death, the deaths

of others, and the grief and mourning of survivors. The attitudes of multiple cultural groups were

examined, as well as the influence of age and gender on attitude. They concluded that culture

would continue to influence attitudes towards death and dying.

Prevention programs should impart knowledge that there are a disproportionate number

of suicides among the elderly. The general public and many health care professionals often have

limited knowledge about the facts related to this phenomenon (Segal, 2000; QPR Institute

[QPR], 1999). In addition to the investigation of facts and myths about suicide, others have

studied individual attitudes about suicide. The attitudes of the young and old are different. One

study examined the attitudes of96 YOllnger (age 17-26 years old) and 79 older (60-95 years old)

adults. The older adults indicated suicide was more acceptable, more strongly related to a lack of

religious conviction, more lethal, more normal, more irreversible or permanent, more strongly

related to demographics, and individual characteristics. The author concluded the difference in

attitudes about suicide might be useful in providing a social and cultural context to study, prevent

and treat elder suicide (Segal, Mincic, Coolidge, & O'Riley, 2004).

Research reports about suicide in general and specifically about suicide in the elderly are

most often conducted by mental health professionals and reported in their journals. Those in

general medical practices need to be aware of these findings. A recent article discusses the

inadequacies of the available knowledge base, education, and training of clinicians related to

suicide prevention. These inadequacies have slowed research and the development of suicide

prevention programs. Reasons for inadequate knowledge includes the lack of attention to

demographic differences, definitional in1precision (precise definitions and clearly stated

13

concepts), conceptual conflation (fusion), and lack of research focus on older adults (Heisel &

Duberstein, 2005).

There is a paucity of research related to the knowledge level of professionals about

suicide. Four research reports were found which addressed individual knowledge level of

suicide. Only two of those reports (Valente, Sallnders, & Grant, 1994; Wang, Anderson, &

Mentes, 1995) focused on nursing knowledge, and only one was specific to knowledge of suicide

in the elderly (Wang et al). In the two non-nursing studies Holmes and Howard (1980) compared

the knowledge base of physicians, mental health professionals, ministers and college students,

while Segal (2000) looked at misconception about suicide, questioning groups of younger (age

17-52) and older (age 55-79) persons. The methodology of reporting varied among these studies.

Two of the studies reported percentage of correct answers (Segal; Valente et aI.), with degrees of

acceptability from 70 to 80%, while others reported a mean score (Holmes & Howard; Wang et

al).

Only two studies found related to nursing knowledge of suicide. Wang (1995) assessed

the knowledge of nurses who worked in home health agencies, and Valente et aI., (1994)

evaluated the knowledge and actions of Oncology Nurses. Both studies included a measurement

of knowledge, as well as a separate measurement of attitude about suicide. Wang gave three

questionnaires to 27 nurses employed by three commllnity health agencies. Valente et al gave

110 nurses employed by two cancer centers an 84 item questionnaire. The contents of the

questionnaires were not available for direct comparison, however each study was investigating

the knowledge of nurses about the signs ofpotential suicide. Oncology nurses on average were

able to identify three of eight suicide risk factors. Home health nurses scored a mean of 6.9 out

of a possible 13-item questionnaire. These scores cannot be considered exceptional, but indeed

14

rather dismal. Scores of the home health nurses were compared to scores of physicians and other

professionals. Nurses did not score as well as physicians and psychiatrists, however they did

score better than ministers and college students (Wang et al., 1995). Segal (2000) investigated

the misconceptions about suicide in younger and older adults. It assessed the differences in levels

of knowledge between younger and older persons. The degree of understanding was similar in

the yOU11g and the old, but the areas of understanding and n1isconceptions differed.

In a separate research study Brockopp, Ryan &, Warren (2003) looked at pain

management by nurses. This study evaluated nurses' willingness to give pain medication, and

found that nurses were less inclined to medicate the elderly and patients who had attempted

suicide. Nurses demonstrated a greater willingness to give pain medication to patients with Auto

Imn1une Deficiency Syndrome (AIDS) and cancer. The framework of this study was the concept

of stereotyping or preconceived notions. This study concluded that nurses develop notions about

particular groups of patients and those notions can have a negative influence on the care they

give patients. Nurse Practitioners have been trained in multicultural/diversity aspects, and need

to maintain an unbiased approach to patients.

Disease, Depression, Anxiety & Other Risk Factors

Treatment for multiple illnesses was strongly related to a higher risk of suicide. Specific

illnesses associated with suicide included congestive heart failure (CHF), chronic obstructive

pulmonary disease (COPD), seizure disorder, urinary incontinence, anxiety disorders,

depression, psychotic disorders, bipolar disorder, moderate pain and severe pain. Those that

committed suicide were found to have more depressive illness, physical illness burden and

functional limitations when compared to patients in the control group (Conwell et aI., 2000).

Mood disorders and psychiatric illness have also been linked to elderly suicide attempts and

15

completions (Uncapher, Gallagher-Thompson, 'Osgood &, Bongar, 1998). Loss of a spouse,

depression, alcoholism, and chronic illness place elderly persons at increased risk for suicide

(Osgood, 1992; Conwell, 2001). See Table One for a list of risk factors.

TABLE ONE: RISK FACTORS

-Previous suicide attempts -History of depression -I-Iistory of substance abuse -Family history of suicide -Feelings of hopelessness -Physical illness -Impulsive or aggressive tendencies -Easy access to lethal methods -Barriers to mental health treatment -Loss (relational, social, work or financial) -Unwillingness to seek nlental health services due to stigma -Cultural and religious beliefs -Local epidemic of suicide -Isolation, feeling cut off from other people

In a study of primary care patients that were 60 years and older who had depression, four

general health indicators were nleasured: physical status including presence of chronic diseases,

mental functional status, disability and global quality of life. The conclusion of this study was

that recognition and treatnlent of depression has the potential to improve functioning and quality

of life in spite of the presence of other medical co-morbidities. (Hitchock Noel et aI., 2004). In a

study of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISMe

study) Bartels et aI. (2002) observed older primary care patients with depression, anxiety and at-

risk alcohol use. Active suicidal ideation and passive death ideation were compared. The highest

amount of suicidal ideation occurred with major depression and anxiety disorder. In this study

Asians had the largest portion of suicidal ideation; however, completed suicide was not studied.

16

The fact of death is inevitable, even with the great medical advances. Medicine is focused

on cure. When cure of disease cannot be accomplished, hope needs to be considered. When

modem medicine has offered all the procedures, medications and alternative cures, then hope

needs to be considered as the focus. If the elderly do not see the possibility of a cure, it may be

the beginning of hopelessness. Helping people face their own mortality and cope with the dying

process is delegated to hospice programs that are often called upon as a resource just days or

hours before death, leaving little time to become socialized in the dying process. Time for open

discussion about wishes, hopes or dreams may be lost to the urgent issues ofjust enough time to

get ones' affairs in order. Ogle, Mavis and Wyatt (2002) identified llnderutilization of hospice

care as a continued public health issue. Two years later Hanley (2004) discussed some of the

issues that surround the underutilization of hospice services. Our society as a whole, including

nurses and providers, continues to find death and dying a challenging subject to discuss (Field &

Copp, 1999; Williams & Payne, 2003)

With the increase in medical illness the elderly are visiting the prinlary care provider

(PCP) more frequently. This is supported by research that has found the elderly are more likely

than the young to have seen their primary care provider within one month of committing suicide

(Luoma, Martin, & Pearson, 2002). Death and suicide are not topics that are easily discussed

neither in our society, nor in a visit with a health care provider. It is the management of disease,

the extension of life, and providing quality of life that the advances in medical care are able to

provide for our population. Death as an outcome of a disease is not readily addressed, yet in

reviewing the literature, there are patients with basic medical conditions such as CHF and COPD

that encounter medical providers on a regular basis (Conwell et aI., 2000). The providers work to

provide increased disease management, and quality of life. Since these two diseases have been

17

identified as increased risk of suicide, in the course of treating tIle physical conlponent of this

disease, it is especially important to remember the psychological, social, and emotional

components.

A study by Kaplan, Adamek, & Calderon (1999) exanlined differences by specialty of

primary care physicians in managing suicidal and depressed geriatric patients. Significant

differences were found between these specialties in their estimates of the prevalence of

psychiatric disorders, use of assessment procedures, treatment approaches, and referrals.

Investigators concluded that meeting the mental health needs of the rapidly growing older

population will require greater emphasis on geriatric mental health and consistency across

primary care specialists (Kaplan, Adamek, & Calderon, 1999). Early treatment of depression

should be considered as part of suicide prevention. The presenting symptonls of depression may

be confused with the nOffilal aging process. See Table Two for a list of symptoms, that when

seen together in clusters may indicate depression (Harris, 2003). Depression may be considered

one of the more obscure risk factors in the elderly for suicide, evidence based medicine has

found sufficient evidence only to support a B recommendation for screening adult patients for

depression at primary care visits. This recomnlendation by TIle U. S. Preventive Services Task

Force (USPSTF) means that the evidence to screen for depression is likely to outweigh any

potential harm. The best outcomes have been seen when screening results are coordinated in

effective follow-up and treatment plans. The USPSTF found at least fair evidence that screening

for depression improves important health outcomes and concludes that benefits outweigh harms.

(U.S. Preventive Services Task Force. Screening for depression; recommendations and rationale.

[USPSTF],2002).

18

TABLE TWO: SIGNS OF DEPRESSION IN THE ELDERLY

Depressed mood or no interest or pleasllre in anything. In addition to the depressed mood at least five symptoms must be present for at least two weeks.

1. Problems with appetite, either under eating or overeating 2. Problems with sleep, either oversleeping or not being able to sleep 3. Physical restlessness or physically slowing down 4. A loss of energy, fatigue, or tiredness 5. Feeling of worthlessness or excessive guilt 6. Poor concentration or extreme indecisiveness. 7. Thoughts of death and suicide or just wishing to be dead.

Generally a suicide attempt is a risk factor for a futllre attempt at suicide. Research has

shown that the elderly are more likely to succeed with a first attempt at suicide (Bennett &

Collins, 2001). The elderly can make the decision quickly and not provide clues to their intent

(Conwell et al., 1998). Elderly suicide note-leavers are more likely to be unknown to psychiatric

services and tl1ey most often used a non-violent method of suicide (Salib, Cawley, & Healy,

2002). The absence of a suicide note is not an indication of a less serious attempt. Two studies

found that the content of their notes is more likely to contain themes of burden to others and ill

health than suicide notes of younger people (Foster, 2003; Black & Lester, 2002-2003). Notes of

the elderly indicated tl1e primary cause of suicide was intolerable life circumstances (Courage et

aI., 1993).

Hopelessness

Nurses have long been aware of the impact of hope and hopelessness on health. The

North American Nursing Diagnosis Association (NANDA) has identified hopelessness as a

nursing diagnosis, with recommended interventions and goals, to guide patient care (Ackley &

Ladwig, 2006). A descriptive study explored the relationship of health status, functional status,

stressful life events, stress resistance resources and emotional distress (depression and

hopelessness) in 60 men with life-threatening illness. The group that was idel1tified as having 19

severe emotional distress 11ad significantly poorer functional status, a greater number and

severity of negative stressors, less satisfaction witl1 social support and less hopefulness

(VanServeleen, Sarna, Padilla, & Brecht, 1996). Two research studies of geriatric persons

demonstrated a correlation between hopelessness and high levels of depression, suicidal ideation

and completed suicide (Uncapher, Gallagher-Thompson, Osgood, & Bonger, 1998; Weinreich,

1999). Tl1e study by Weinreich explored constructs evident in a review of suicides in persons 56

to 89 years old. While hopelessness, physical and mental decline were evident, the hypothesized

construct that was not supported in this study was intolerance for the normal aging process

(Weinreich, 1999). The theme of hopelessness or nothing to live for was present in 21 % of

suicide notes in a recent study from Northern Ireland (Foster 2003).

A recently completed review of literature analyzed hopelessness as a psychological

response to physical illness, differentiated hopelessness fron1 depression, and discussed measures

of hopelessness (Dunn, 2005). The review showed that although hopelessness is closely related

to depression, distinct characteristics of hopelessness were identified. A contil1uum of attributes

of hopelessness and depression was derived. Further study is needed to help differentiate

110pelessness from depression, and further analyze the continuums of hopelessness and

depression. Dunn summarized the consequences of hopelessness in the general population and

compared it to the psychiatric population. Physical illness may lead to hopelessness. Depression,

hypertension, coronary heart disease (CHD) and increased mortality may be a consequence of

hopelessness in the general population. Hopelessness related to physical illness can lead to

decreased functional status, increased distress and poorer adjustment to disease. Hopelessness in

psychiatric populatiol1s can lead to depression and suicidality. Dunn proposed that hopelessness

20

can be viewed as a continuum, from hopelessness to hopelessness depressiol1, and it is

hopelessness depression that will lead to suicide (Dunn).

Hopelessness of outpatients at a center for cognitive therapy was measured using the

Beck Hopelessness scale (Beck, Brown, Berchick, Stewart, & Steer, 1990). Hopelessness was

significantly related to eventual suicide. Hopelessness, unlike other predictors of suicide, such as

age, sex or race, is a characteristic that can be modified (Cutcliffe & Herth, 2002). Hopelessness

is not a simple product of prognosis, but is shaped by state and trait psychological factors. Hope

at the end of life can come in various forms: for cure, for survival, for comfort, for dignity, for

intimacy, or for salvation. Hopelessness therefore is not simply the absence of hope, but

attachment to a form of hope that is lost. To be successful at diversifying hope at the end of life,

one must foster a trusting interpersonal environment when this is possible (Sullivan, 2003).

Theoretical and empirical literatures relating to hopelessness indicate that, given the

known link between suicide and a sense of pervasive hopelessness, it is necessary for the

practitioner to understand the methods of hope inspiration. Hope is future oriented, dynamic,

multidimensional and personal. Hopelessness is also dynamic, and multidimensional, but it is

also disempowering and threatens the quality and longevity of life. Chronically ill people in a

state of hopelessness make little effort to set goals or plal1s, and tend to emphasize current

failures. Developing a therapeutic relationship, one tl1at is built on trust and understanding is

importal1t. In this study tl1e authors looked at approaches to mental health counseling.

Therapeutic relationships as a basis for effective cognitive therapy were examined (Collins &

Cutcliffe, 2003). A primary care provider can develop a therapeutic relationship with his or her

patient, and if necessary refer for counseling and cognitive therapy. Hope is interwoven with

caring. Consequently, one would believe hopelessness may be interwoven with non-caring or an

21

uncaring approach. It is important to remember that non-caring is what is perceived by the

patient. In our complex world and health care system, suicide is a complex condition to address.

To identify a basic component that puts people at risk for suicide, will help to simplify our

process ofproviding quality care. The fact that hopelessness can be n10dified identifies an area

for ongoing research about ways to impact loss of hope. The need for research related to

hopelessness and suicide risk was identified by (Conwell, 2001, 42).

Hope

A pilot study of 35 elderly persons explored the links between depression, integrity and

hope in the elderly. Chinich and Nekolaichuk (2004) conducted a research study of a voluntary

sample of cognitively intact elderly patients receiving psychiatric care. The findings suggest that

depression, integrity, and hope are highly interrelated in the elderly population and may

influence mastery of the developmental tasks of aging. One of the implications was tl1at integrity

and hope may be resilient or protective factors for depression. See Table Three for a list of

protective factors (Anonymous, 2003). Further research is warranted to better understand these

complex experiences in late life. (Chinich & Nekolaichuk).

Hope in older adults with chronic illness was the focus of a research study validating two

methods of qualitative research (Forbes, 1999). The study validated the qualitative research

methods of concept mapping and phenomenology as a project, and identified the need for more

focused work in the area of hope. The study concluded that the two methods did have similar

outcomes. The topic reviewed was hope in the older adult with chronic illness. The qualitative

research processes included 14 older adults, and found similarities in their development of hope,

and overcoming barriers and limitations in coping with their illness (Forbes). In a report on

gerontological nursing and 110pe, Herth and Cutcliffe (2002) reported on several research studies

22

that have found a positive correlation to physical and mental health and hope. This relationship

however, needs further investigation to determine the strength and direction of the relationships

fOtlnd among hope, health and other psychosocial variables. The findings of research on hope do

suggest that hopefulness can be nurtured even in the direst circumstances.

TABLE THREE: PROTECTIVE FACTORS

+Children in the honle + Sense of responsibility to family +Religiosity +Life satisfaction +Reality testing ability +Positive coping skills +Positive problem solving skills +Positive social support +Positive therapeutic relationships +Effective clinical care for mental, physical and substance abuse disorders +Easy access to clinical interventions +Support for help seeking behaviors +Support from ongoing medical and mental health care relationships +Skills in problenl solving, conflict resolution, and nonviolent handling of disputes

Cutcliffe (1997) provided the following working definition of hope: "Hope is a multi­

dimensional, dynamic, empowering, state of being, that is central to life, related to external help

and caring, orientated towards the future and highly personalized to each individual." Care, help

and hope are concepts that are interwoven. A research study of critical care patients identified

how nursing care provided help, and as a result feelings of hopefulness were then evident in

patiel1ts (Cutcliffe). Care provides external help and help in tum offers hope. Nurse practitioners

are in a key position to offer care that supports help and provide the initial steps toward hope.

In search of a uniform definition of hope, 46 research articles were reviewed that were

published between 1975 and 1993. The articles were compared for purpose of the study,

population, methods of data collection and analysis. There was a lack of precision in the

23�

research. Hope was described as an emotion, an experience or a need. There is a clear emphasis

on the necessity and dynamism of hope. The most important dynamic dimension was between

hope and despair. The research on hope focused mainly on individuals who were unwell. There

is need for further research to clarify the concept of hope, to include different stages of the life

cycle and include healthy individuals and families. (Kylma & Vehvilainen-Julkllnen, 1997).

In a comparison of the key elements of hope, the definitions of hope by six different

authors showed that all agreed that hope was dynamic, central to life, future oriented, and

individualized (Cutcliffe & Herth, 2002). Five of the authors concurred on the multidimensional

aspect of hope and two of the authors associated hope with nursing in their definition. The

dimensions of help that can be provided by nurses include spiritual, physical, intellectual,

emotional, and social aspects. The physical dimension of care is traditionally the focus of

medicine. If a person has a chronic disease, they will typically visit a clinic on a routine basis.

Physical disease impacts hope.

There is growing evidence in the literature that engagement as a means to inspire hope

shows benefits over the old system of observation only. The best approach to managing an in­

patient suicidal client was exan1ined, al1d supports the care by engagement and inspiring hope,

rather than pure observations. Engagement requires personal contact and caring. (Cutcliffe &

Barker, 2002). The definition of engagement is emotional involvement or commitment

(Merrian1-Webster OnLine [MWOL], 2005-2006). Hope is dynamic, and is 110t limitless; hence

people can become hopeless (Cutcliffe, 1997). As health care providers, one needs to identify

their patient's source of hope. By strengthening individual hope, one will be better able to assess

hopelessness in others, most importantly in their patients. Nurse practitioners need to care for

themselves, their fellow professionals, and their patients.

24

Hope is central to life, and care is central to nursing (Cutcliffe, 1997). Since hope is

empowering, and can spur a desire for living in the potentially suicidal patient, nurse

practitioners are in a position to offer help, care and inspire hope. Hope is highly personal;

therefore nllrse practitioners need to be in tune to the issues relevant to each of their patients.

Knowing what factors put an individual at risk for suicide will aid nurse practitioners in focusing

on the care, help and hope needed by those individual patients. Providers need to be aware of the

physical component of hope.

Since hope is dynamic, and is not limitless, it needs to be replenished, renewed, or

redeveloped as needed. Nurse practitioners can offer care and help, and assist in the renewal of

hope. A therapeutic relationship and cognitive behavior techniques are beneficial when dealing

with hopelessness (Collins & Cutcliffe, 2003).

Primary Care Contact

Increased incidence in chronic medical conditions results in increased routine visits to the

PCP for the elderly. Several studies have been completed that show the frequency of contact with

their primary care provider prior to suicide. Two research reports have reported that 80% of

individuals have visited their health care provider within six montl1s prior to their suicide (Bruce

et aI., 2004). A case-control study looked at whether physical and psychiatric illness, functional

status, and treatment history distinguished older primary care patients (age 60 and over) who

committed suicide from those who did not. The suicides (who had seen a primary care provider

within 30 days of suicide) and controls (patients from a group practice) were measured for

psychiatric diagnosis, depressive symptom severity, physical health and function and psychiatric

treatment history. The results showed that completed suicides had more depressive illness,

physical illness burden and functional limitations than controls (Conwell et aI., 2000).

25

In Finland's suicide prevention efforts and researcll they reviewed all of the suicides in

1987 (a total of 1397 cases) to understand the circumstances of the deaths. They found that 75%

of the elderly at least 65 years of age who committed suicide had visited a physician during the

.. month before their death. (Wilson, 2004). Luoma, Martill, & Pearson, (2002) reviewed 40

studies to correlate findings. One of the areas of focus was contact with primary care and mental

health care professionals by individuals before they died by suicide. On average, 45% of suicide

victims had contact with primary care providers within 1 month of suicide. Older Adults age 55

and older had higher rates (58%) of contact with primary care providers within 1 month of

suicide than younger adults.

During a 9-year period, 1354 patients age 66 and older that died of suicide were studied.

In this recently completed study, Jurrlink, Hermann, Szalai, Kopp, and Redelmeier (2004) using

a control group, identified treatment for multiple illnesses was strongly related to a higher risk of

suicide. Almost half the patients who committed suicide had visited a physician in the preceding

week.

In a report that discussed how the elderly view the tinling of death, it was concluded that

tIle elderly would like to talk about the ending of their lives, depression and suicide, and they

need health care providers to respond empathetically (Courage et aI., 1993). The subject of

suicide is often a sensitive and emotional subject, not always an easy topic to discuss. Suicide is

considered to be a mental deficiency by some and physical issues are often easier to address than

mental issues. Nurses and nurse practitioners are in a key position to respond to the elderly in the

discussions oftl1e patient's choosing, if they will allow the time and opportunity.

There is a need for primary care providers to be aware of some of the issues that are

summarized in the findings of suicide in the elderly. Suicide is a topic generally considered to be

26

one that belongs in the realm of the mental health professionals. Witl1in our current health care

environment, and the n1ultiple settings in which primary care providers work, however, there

may be limited resources for referrals to mental health care/services. With evidence from studies

demonstrating that the elderly are more likely to see a primary care provider than a mental health

professional within a short period before the completed suicide, suicide has become an important

issue of focus for primary care providers and their office staff.

The primary care provider is the one who makes the diagnoses and develops a treatment

plan. The office staffhas an important impact on the patients seen in primary care facilities. The

first contact with a patient is often the front office staff, or a triage nurse. The final farewell from

the office may be the schedulil1g clerk, wl10 needs to be aware of the comment fron1 an elderly

patient "1 won't need a follow up appointment". This staten1ent n1ay be indicative of suicidal

ideation. In the current climate of productivity focus, patients spend less time with a provider

than in years past. It becomes important to keep all office staff informed of issues related to elder

suicide.

In an effort to address the continued high rate of elder suicide, new approaches to

management need to be considered. Education in nursing, medical, and psychological arenas

needs to address not only the prevalence of elder suicide, but collaborative, interdisciplinary

interventions (Zweig, 2005). Interdisciplinary interventions have been identified as being n10re

effective than usual care (Bruce et aI., 2004). Developing training for an interdisciplinary

approach is a long-term goal, and practitioners in practice now need to be aware of the current

issues and needs to change approaches to assessment and management of the elderly patient.

27

Assessment

Range and Knott con1piled a list of twenty suicide assessment instruments and provided

evaluation and recommendations (Range & Knott, 1997). The assessment tools evaluated include

their top recommendations of: Beck's Scale for Suicide Ideation, Linehman's Reasons for

Living Inventory, and Cole's self-administered adaptation of Linehman' s structured interview

called the Suicidal Behaviors Questionnaire. While some of the studies completed with these

instruments included a few adults, none focused on the elderly and their unique characteristics. A

more recent review of assessment measures for adults and older adults offers a list of 31 different

assessment tools, and includes an appendix with the author and contact information for each of

the instruments (Brown, 2002). Several assessment tools evaluate depression, hopelessness, and

quality of life, but few focus on the elderly. This article also offers a table that lists the

measurement tools and their mode of administration, the number of items in each tool, evidence

of predictive validity, and study setting for each tool. A review of each tool including reliability,

and concurrent validity can be seen on line at:

http://www1.endingsuicide.com/PageReq?id=3048: 14564, (National Institute of Mental Health

[NIMH], 2003-2005) under the category of adult and older adult suicide assessment measures.

Table four "Quick Reference Of Suicide Assessments" lists some acronyms used in

various suicide assessments. Sad or Sad Persons, is an assessment for sllicidal risk factors

(Patterson, Dohn, Bird, & Patterson, 1983). SLAP, is an assessment of the lethality of suicide

plans, standing for specify, lethality, availability, and proximity. This assessment seeks to

identify if an individual has a specific plan, how lethal is the plan, is the mechanisn1 available to

them, and how near is the mechanisn1. DIRT is an assessn1ent of previous suicide attempts. The

letters stand for dangerous, intent, rescue potential, and timing. How dangerous was the previous

28

attempt, did the patient try to hang himself, take an overdose of three Aspirin? Patient intent

tries to determine if the patient was trying to commit suicide or trying to get attention. Rescue

potential looks at the location of the atten1pt, could they be easily found? Timing assesses when

the previous attempt occurred, was it last week or 20 years ago? These acronyms represent brief

outlines of more detailed assessments that are needed for the suicidal patient.

TABLE FOUR: QUICK REFERENCE OF SUICIDE ASSESSMENTS

SAD PERSONS (risk assessment) Sex: men at greater risk than women Age: elderly at higher risk Depression: unrealistic hopelessness Previous attempt Ethanol abuse removes inhibitions Rational thinking loss Social supports lacking Organized plan in place No spouse Sickness, loss of independence

SLAP (assessing suicide plan) Suicide Lethality Availability Proximity

DIRT (assessing previous attempts)

Dangerous Intent Rescue potential Timing

QPR (intervention plan) Question Persuade Refer

29

Nurses' global assessment of suicide risk (NGASR) is a recently developed risk

assessment tool used by psychiatric nurses for inpatient assessments. It is felt to be an easy tool

to use, and requires minimal training. Background and rationale of the tool development are

discussed by Cutcliffe and Barker (2004). Table Five provides a list of the indicators and the

value assigned to each variable. A score of 12 or more is scored as a very high risk of suicide.

TABLE FIVE: NGASR

THE NURSES' GLOBAL ASSESSMENT OF SUICIDE RISK

Predictor variable Value� Presence/influence of hopelessness 3� Recent stressful life event, for example, job loss, financial worries, pending 1� court action� Evidence of persecutory voiceslbeliefs 1� Evidence of depression/loss of interest or loss of pleasure 3� Evidence of withdrawal 1� Warning of suicidal intent 1� Evidence of a plan to commit suicide 3� Family history of serious psychiatric problems or suicide 1� Recent bereavement or relationship breakdown 3� History of psychosis 1� Widow/widower 1� Prior suicide attempt 3� History of socio-economic deprivation 1� History of alcohol and/or alcohol misuse 1� Presel1ce of terminal illness 1� Total�

Question, persuade and refer (QPR) is a systematic approach that lay people can learn

to 11elp speak to a person that they feel may be suicidal. Question is to ask the individual if they

have thoughts, feelings or plans for suicide. Persuade the person to get help, offer help, and refer

the individual to someone that can intervene. The QPR system was developed by Paul Quinnett

to save lives from suicide. Colleges and businesses have had gatekeepers trained in this process.

30

As of2003 over 250,000 Anlerican citizens had been trained in the QPR process (QPR Institute

[QPR], 1999).

There has been recent interest in the developnlent of scales that are appropriate for use

with the older adults. Heisel and Duberstein (2005) discussed three scales that have been

developed with focus on the elderly adult. A Harmful Behaviors Scale (HBS) was developed for

use with nursing home residents, and requires direct observation. The Reasons for Living Scale­

Older Adults version (RRFL-OA) and Geriatric Suicide Ideation Scale (GSIS) are two other

scales developed specifically for the elderly. Lengthy assessment tools are often not suitable for

primary care. A PCP is challenged to be aware of the assessment tools, screening techniques, and

risk factors as they address basic care issues with their elderly clientele, especially when multiple

physiological issues need to be addressed, within the tinle limits of routine office visits.

The elderly are not inclined to share their intentions or feelings (Conwell et aI., 1998),

making it necessary for providers to ask direct questions. To ask a question regarding sllicide

intent will not put the idea of suicide in their mind, but will provide an opportunity for patients to

share their thoughts, and for the nurse practitioner to provide a sense of hope by addressing the

concerns and making referrals as needed. Some of the possible reasons the questions are not

asked may be concerns about time constraints, lack of knowledge or comfort with what questions

to ask, fear of a positive answer, or the lack of a clearly defined system to efficiently refer a

patient for appropriate follow up. Nurse practitioners need to become comfortable asking

patients about suicide, and have a clearly defined referral process in their practice.

Intervention/Prevention; Hope/Spirituality Connection

Hope is not a concept limited to nursing and mental health care, but is being recognized

for its impact on life. In a report on completed and future research plans: empowerment and hope

31

have been identified as key components in management of life issues related to health. Syme

(2004) presented information to the CDC in relation to public health and preventing chronic

disease. In a review of studies on chronic disease and interventions that may be preventative, it is

believed that hope is a basic focus that may have a greater inlpact on life and healtll than any

education, training or health care interventions. In a new study of social issues, rather than

looking at cigarette smoking, drug use, violence, poor school performance, or sexual behavior,

they are instead looking at hope, and a way ofimplenlenting hope in the fifth-grade low-inconle

children (Syme, 2004).

Hill, Gallagher, Thompson, & Ishida (1988) examined the use of assessment tools. Adults

age 55 and older completed Hope Scale (HS), Beck Depression Inventory (BDI) and Schedule

for Affective Disorder and Schizophrenia (SADS) assessment prior to psychotherapy for

depression. They were assessed for suicidal ideation. Hopelessness has been found to be more

predictive of suicidal ideation than level of depression. Results of the HS scale were an

acceptable level of internal consistency for use with a geriatric outpatient population. The

findings did not correlate with hopelessness and suicide intent found in younger populations. It is

plausible that the SADS measure may not be sufficiently sensitive to the unique variance of

hopelessness and depression in older adults. Thus beyond knowing that an older depressed

person has suicidal ideation, an awareness of interacting factors, namely hopelessness and health

perceptions, may suggest distinctive avenues for intervention (Hill, Gallagher, Thompson, &

Ishida, 1988).

An essential component of hope for the elderly was identified in review of articles in

gerontological journals. The review authors Weaver, Flannelly, and Flannelly, (2001) looked for

mention of religion or spirituality. Two of the findings were that religious and spiritual beliefs

32

are an essential component of hope. Religious beliefs and practices are especially important for

older adults. One of the conclusions was that gerontological nursing is in a unique position

among health professionals to make contributions to the understanding of religion and

spirituality in mental and physical health assessment and care (Weaver et al.).

A review of nursing research by Holt (2001) explored the factors people identify as

supportive of hope, the interventions nurses use to support hope, and the congruence between

these two sets of studies. The factors that supported hope for patients and families were social

and professional support, cognitive strategies, spiritual or religious activities, relying on inner

resources and setting goals. Nurses used interventions to support families, assist with goal

setting and distraction, affirm patient worth, and provide symptom relief. While there were

substantial congruencies between people's needs and nursing actions, the main incongruence was

the lack of interventions supporting spiritual or religious activities (Holt, 2001).

Nurse practitioners need to be aware of the factors that may put an elderly person at risk

for suicide. External help can replenish an individual's personal hope. In 1997 Cutcliffe stated,

"It is logical to suggest then that nursing, in the form of external help is therefore inseparable

from hope inspiration". If the nurse practitioner is not aware of these factors, the extra measure

of hope needed may not be given. Hope may be a first step in suicide prevention; treatment of

underlying depression, chronic illness, and social isolation must be ongoing.

Two nurse-managed health centers in Philadelphia enrolled in a "Depression

Collaborative" to improve care to patients with major depression. A focused systematic process

was followed for the identification, treatment and follow up of depressed patients. This study

concluded that nurses are a critical part of the health care workforce and have strong

relationships with their patients. Nurses are likely to be the first level of recognition for

33

depression among their clients. They are in a key position to take the lead among primary care

providers in integrating behavioral health and primary care. (Torrisi & McDanel, 2003).

In a randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary

Care Elderly: Collaborative Trial), patients were recruited from 20 primary care practices in the

Eastern US. TIle objective of the study was to determine the effect of a primary care intervention

on suicidal ideation and depression in older patients. The planned intervention was enhancing

physician knowledge about the treatment of geriatric depression, and second was treatment

management by a depression care manager. There was statistical significant evidence of the

effectiveness of the interventions. However, they identified new challenges related to

sustainability. Not every primary clinic is able to provide depression care management or staff

that focus on the treatment of depression in the elderly. The fact that the interventions were

effective reinforces the role of preventive strategy to reduce risk factors for suicide in late life

(Bruce et aI., 2004).

As hope is interwoven with caring, hopelessness may well be interwoven with a non­

caring or uncarillg practitioner. Studies that have measured changes in levels of hope as a result

of nursing interventions, found that when hope increased there was an inversely proportionate

decrease in feelings of hopelessness. (Collins & Cutcliffe, 2003). In 2001 Conwell discussed

hopelessness as one of the areas of focus needed in the development of elder suicide prevention

programs.

Nurses are rated as the most trusted persons (Clinical Rounds, News, Updates, Research,

2005). Trust is earned by continuing to serve our patients by increasing our knowledge, and

working to inlprove the way care is provided. One of the ways to improve care is to continue to

look at the patient holistically. In our care for the elderly, hope can be one of those basic

34

questions that is asked in assessing their overall health status. The need to help patients identify

their hope helps them focus on futuristic hopefulness. Hope is related to external help and caring

(Cutcliffe, 1997) and needs to be a core element that is incorporated in our care of the elderly.

Hope is hidden within the health care provider, unless intentionally activated. In a study

investigating the hope-focused learning process, the findings indicate that participants had to first

make personal meaning of hope before using it with otl1ers. Hope is a common factor across

helping professionals and is a complex construct consisting of components such as the language

of hope, possibilities and options, state and tr~it hope, hope syn1bols and metaphors and the

relationship ofhope to time (Massey, 2003). Care plans and practices need to be designed that

will move the knowledge base of hope forward and define ways in which nurse practitioners can

engage in a hope-focused practice and use strategies that empower hope in their patients (Herth

& Cutcliffe, 2002).

Physical illness, depression, limited functional status and social isolation contribute to

elder suicide. With the frequent PCP visit and history of inadequate treatment of depression in

the elderly, it is essential that the NP be aware of these facts. In the absence of evidence based

research to guide our practice, one must rely on nursing intuition to actively address hope.

Spiritual needs are part of an essential elderly assessment and referrals need to be made to

community resources including churches or spiritual reSOllrces of the patient's choice.

Con1munity Resources

In the research in the areas of nursil1g care one area identified as deficient was offering

spiritual support. Spirituality has been linked to hope. The areas of politics and religion are

usually considered to be topics kept separate from patient care. But if holistic care is to be

offered, one must become comfortable with supporting and encouraging spiritual connections,

35�

which the elderly have identified as a source of hope. Even if not comfortable with the patient's

chosel1 method of spiritual support or religious belief, in order to encourage patients to seek or

renew their hope, it is necessary to support their connections with what is fanliliar to them.

Altll0ugh PCPs may feel they are self-sufficient and do not need religion or spirituality to sustain

their life, it is necessary to move outside of our values and consider the elderly client and what is

important in their life.

Referrals to community resources, such as faith based organizations for support of hope

and suicide prevention, may not be sources routinely considered; but different and unique

avenues must continue to be explored. Results fronl two such venues provide positive findings.

Health promotion, chronic illness self-management, and peer support intervention was studied in

a one year randomized, controlled trial by Davis, Leveille, & Logerfo (1998). The findings

revealed that the volunteers themselves improved in health and function, and nurses involved in

health promotion progranls could extend their efforts by using trained volunteers. (Davis,

Leveille, & Logerfo, 1998). In a region in northern Italy, a system of telephone support was

utilized to assist the elderly, and an unexpected finding in a 4-year evaluation was a decrease in

suicide rates among the telephone support users when compared to the general elderly

community population (DE Leo, DelIo Buono, & Dwyer, 2002). Spokane WA has developed a

community system known as the Gatekeeper model. This model is a nontraditional system that

"utilizes community members to refer at-risk elders to a case mal1agement progranl that is able to

respond to the complex variety of needs of the elderly (Conwell, 2001).

Refer when able but always look for opportunity to give hope. One way to support the

elderly patient in their hope development is to ask about their hope, spiritual belief or religious

affiliation. Ask if they currently have, or have had a group connection. Would they like a referral

36

for someone with in that group to contact them? Make a referral and ask the organization to visit

or call your patient to provide spiritual support. This is one way to help address the hope and

spiritual needs of our elderly patients.

Conclusion

The elderly are characterized as an industrious generation; many lived through the great

depression, and have seen numerous rapid changes in their generation. Average life expectancy

has increased and they are often living 1011ger than their parents or grandparents. Because of the

advances in nledicine they are surviving illnesses and disease that were previously life limiting.

Dealing with the medications and treatments, and visits to the physician, they are blazing their

own trail in dealing with advallcing age, declining physical and mental stamina and the lack of a

socialization model to follow in coping with the issues with which they are now faced.

A review of the evidence that supports the recommendations and rationale for the

screening for suicide risk, the US Preventative Services Task Force (USPSTF), concluded that

the evidence is insufficient to recommend for or against routine screening by primary care

clinicians to detect suicide risk in the general population. There is a paucity of well-designed

research studies of this complex issue (Gaynes, West, Ford, & Frame, & et aI., 2004). With such

limited evidence, there is a need to continue to do better. Routine information that frames our

assessment includes basic vital signs; blood pressure, temperature, pulse, respiration, height,

weight, and even a pain scale. Pain is a subjective element; why not add hope to your simple

vital statistic assessment? Physical issues are evaluated and referred to specialists as needed. If

there are emotional issues a referral is made to mental health. Social problems get a referral to

the social worker. If a hope scale were developed, with 10 as the most hope you can have and 0

represents no hope, ask a patient how much hope they have, and explore the source of their 110pe.

37

Hope is subjective, and can be anything that the patient chooses it to be. Table Six provides a

proposed hope scale. Currently there is no scientific evidence to support the interpretation of

findings of such a scale. But to simply ask a question about hope will let YOllr patient know you

care about their mental and emotional status. This question about hope may be a beginning to

determine the extent of need for further assessment and referral.

TABLE SIX: PROPOSED HOPE SCALE

Word Clues Numeric scale

How frequently do How much hope do How often do you you feel hopeful? you have? have hope?

10 Hopeful all the time More than enough Always 9 8 Most of the time Plenty Often 7 6 7 Moderate amount of Moderate an10unt Occasionally 6 time 5 4 3 Some of the time Very little Rarely 2 1 0 Never, always None Never

hopeless

More research needs to occur regarding all aspects related to suicide in the elderly. The

use of a basic hope scale and the impact of potential early intervention into depression and

possible suicide needs to be researched. The futllre is not clear, but hope is an element that needs

to be explored within the realm of elder suicide.

38

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