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Canadian Coalition for Seniors’ Mental Health www.ccsmh.ca Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers Funded by the Public Health Agency of Canada Adapted from a presentation by Dr. Marnin J. Heisel, Project Lead, Suicide Prevention in Older Adults

Canadian Coalition for Seniors Mental Health Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

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Page 1: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Canadian Coalition for Seniors’ Mental Healthwww.ccsmh.ca

Suicide Assessment & Prevention for Older Adults:

Life Saving Tools for Health Care Providers

Funded by the Public Health Agency of Canada

Adapted from a presentation by Dr. Marnin J. Heisel, Project Lead, Suicide Prevention in Older Adults Committee, Canadian Coalition for Seniors’ Mental Health

Page 2: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Contact Information

Canadian Coalition for Seniors’ Mental Health

Address: c/o Baycrest

3560 Bathurst Street

Room 311, West Wing, Old Hospital

Toronto, Ontario, M6A 2E1

Phone: 416-785-2500 ext. 6331

Fax: 416-785-2492

Web: www.ccsmh.ca

Page 3: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Contributors

Dr. Martha Donnelly, MD (Project Lead)Head of the Division of Geriatric PsychiatryDepartment of PsychiatryUniversity of British Columbia

Dr. Marnin J. Heisel, PhD, C. Psych. (Project Lead and DVD Content Expert)

Assistant ProfessorDepartments of Psychiatry and Epidemiology & Biostatistics Schulich School of Medicine and DentistryThe University of Western Ontario

Dr. Sharon Moore, RN, MEd, PhD, C. Psych. (Project Lead) Associate ProfessorCentre for Nursing & Health StudiesAthabasca University, Alberta

Charlene Foster, BATrainer and Volunteer CoordinatorLondon and District Distress Centre, Ontario

Ian Ross, MScExecutive DirectorCrisis Intervention and Suicide Prevention Centre

of British Columbia

Joan Seabrook, MEd, SOEducational ConsultantSurvivor Chair, Canadian Association for Suicide Prevention

Diane Yackel, MA, FTExecutive DirectorCentre for Suicide Prevention, Alberta

Sherri Helsdingen, BAProject ManagerCanadian Coalition for Seniors’ Mental Health

Kimberley Wilson, MSW, BAScExecutive DirectorCanadian Coalition for Seniors’ Mental Health

Page 4: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Learning Objectives

By the end of this workshop, you will be able to:

Demonstrate a basic understanding of the epidemiology of late life suicide;

Be aware of the risk factors for suicide, as well as protective factors; Identify suicide warning signs; Initiate life-saving conversations about depression and suicide risk using

key questions to assess for suicide risk; Be familiar with late-life suicide risk assessment and clinical intervention

strategies; Integrate components of the CCSMH Late Life Suicide Prevention Toolkit

into clinical care.

Page 5: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Epidemiologic Considerations

The World Health Organization estimates that approximately One Million lives are lost to suicide worldwide every year.

Suicide is a leading cause of preventable death that accounts for more deaths annually than homicide and war combined.

Every death by suicide leaves at least 6 survivors. Suicide is a leading cause of preventable morbidity and mortality

worldwide.

Page 6: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

World Health Organization (WHO) Data

Page 7: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

The Epidemiology of Late Life Suicide

Older adults have high rates of suicide worldwide, including in Canada and the U.S.

There are currently over 4.3 million Canadians aged 65 years and older.

1 out of every 7 Canadians is a senior citizen. In 2006, seniors accounted for a record high of 13.7% of the total population.

Between 2006 and 2026, the number of seniors is projected to increase from 4.3 million to 8.0 million. Their share of the population is expected to increase from 13.2% to 21.2%.

“Baby boomers” have high rates of suicide.

Page 8: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Year

25

20

15

10

5

01921 1931 1941 1951 1961 1971 1981 1991 2001 2011 2021 2031 2041

Perc

enta

ge

65-74 75-84 85+

Canada, 1921-2041

Reality: Seniors (by age sub-groups) as % of the Total Population

Page 9: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Mortality Statistics

Demographic risk factors include sex (Male), age (Older), and ethnicity (Caucasian/White).

In 2004, 427 Canadians 65+ died by suicide, including 319 men and 108 women.

Men between 85 and 89 years of age had a suicide rate (26.8/100,000) that more than doubled the national average of approximately 13/100,000.

Suicide mortality data underestimate “true” suicide rates, and do so differentially.

Page 10: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

2004 StatsCan Suicide Rates (per 100,000)

0

5

10

15

20

25

30

65-69 70-74 75-79 80-84 85-89 90+

Male

Female

Total

Page 11: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Mortality Statistics

The ratio of suicidal behaviour to deaths for older adults is between 1-4:1, while that for adolescents is as high as 200-300:1

Many older adults may end their lives by refusing food and / or needed medications; however, these deaths are typically not officially deemed suicides.

Means of suicide differ by age, gender, and location. Detection of suicide risk in older adults is crucial;

interventions can then follow.

Page 12: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Prevention Among Older Adults

Barriers exist to effective risk detection and intervention. Until recently, one such barrier was the absence of practice

guidelines for suicide risk assessment and interventions for older adults.

CCSMH recently released 4 federally funded (Public Health Agency of Canada) National Guidelines for the care of mental health issues affecting older adults:

• Assessment and Prevention of Suicide

• Delirium

• Depression

• Mood and Behavioural Problems in Long-term Care Homes

All are available free of charge online at www.ccsmh.ca

Page 13: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

CCSMH Late Life Suicide Prevention Toolkit

CCSMH National Guidelines for Seniors’ Mental Health: The Assessment of Suicide Risk and Prevention of Suicide

Clinician pocket-card - Suicide: Assessment & Prevention for Older Adults

DVD - Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Page 14: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Warning Signs

Q: What are the warning signs that someone is at risk for suicide?

Page 15: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Warning Signs

Remember “IS PATH WARM?”– I Ideation

– S Substance Use

– P Purposelessness

– A Anxiety/Agitation

– T Trapped

– H Hopelessness/Helplessness

– W Withdrawal

– A Anger

– R Recklessness

– M Mood Changes

From the American Association of Suicidology (AAS) website (www.suicidology.org).

Page 16: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Factors

Q: What are the risk factorsfor suicide?

Page 17: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Factors

1. Suicidal Ideation and / or Behaviour

Prior suicidal behaviour (including suicide attempt), prior self-harm behaviour, previous expression of suicide ideation

Feels tired of living and/or wishes to die Thinks about suicide, has suicidal wishes and / or desires Has a suicide plan / note

2. Family History

Family history of suicide, suicide ideation, mental illness

Page 18: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Factors

3. Mental Illness (can include) Any mental disorder, co-morbidity Major depressive disorder Any mood disorder Psychotic disorder Substance misuse disorder / addictions

4. Personality Factors Personality disorders Emotional instability Rigid personality Poor coping skills, introversion

Page 19: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Factors

5. Medical Illness Pain, chronic illness Sensory impairment Perceived or anticipated / feared illness

6. Negative Life Events and Transitions Family discord, separation, death or other losses Financial or legal difficulties Employment/retirement difficulties Relocation stresses

7. Functional Impairment Loss of independence Problems with activities of daily living

Page 20: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Resiliency Factors

Q: What are some of the resiliency (protective) factors?

Page 21: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Resiliency Factors

1. Sense of meaning and purpose in life.

2. Sense of hope.

3. Sense of optimism.

4. Religious (or spiritual) practice.

5. Active social networks and support from family and friends.

6. Good health care practices.

7. Positive help-seeking behaviours.

8. Engagement in activities of personal interest.

Page 22: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Assessment Process

Q: How do I tell if someone is atrisk of suicide?

Page 23: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Assessment Process

1. Establish rapport and assess for suicide risk in a sensitive and respectful fashion.

2. Respect the dignity of older adults. Acknowledge their experiences and validate their feelings.

3. Assess for suicide risk factors.

4. Assess for psychological resiliency.

5. Assess for suicide warning signs IS PATH WARM.

Page 24: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Assessment Process

6. Where appropriate, access collateral information (medical chart, family members, other providers).

7. Be mindful of ambivalent wishes to live and to die.

8. Develop a risk management/action plan.

9. Seek consultation and/or assistance if you do not have specialized training in mental health or in suicide prevention.

Page 25: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Key Questions

Q: What questions do I ask?

Page 26: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Key Questions

1. Ask about their feelings Do you feel tired of living? Have you been thinking about harming yourself and/or

ending your life? Have you been thinking about suicide?

Page 27: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Key Questions

2. Ask about a suicide plan

Have you thought of specific ways of hurting yourself or ending your life?

Have you made any specific plans or preparations (giving away possessions, tying up 'loose ends')?

Have you asked someone to help you end your life or join you in death?

Do you have access to lethal means like a gun or other implements?

Have you collected pills in order to take an overdose? Have you started to put a suicide plan into action?

Page 28: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Key Questions

3. Ask about their reasons to live What has kept you from harming yourself? Who or what makes life so worth living that you would not

harm yourself?

What other questions could you ask?…

Page 29: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults

Q: What are some strategies for intervening and managing risk?

Page 30: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Management

RISK MANAGEMENT STRATEGIES:

Help the older adult connect with a team of supports: other medical and/or mental health care providers, social service providers, clergy, family members, friends,

and/or other community members.

Page 31: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Management

Immediate Risk Management

1. Do not leave the person alone until you have arranged for the involvement of another appropriate care provider or source of protection.

2. Establish an immediate safety plan that includes:

family support homecare support 24-hour (or in-home) care providers police intervention (if needed)

Page 32: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Management

Immediate Risk Management (Cont.):

3. Consider care needs: emergency services telephone and / or in-person crisis / distress / support services mental health services medical services social service providers, community supports

4. Ensure that follow-up care is arranged.

5. Where possible, restrict access to lethal means.

Page 33: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Management

Ongoing Risk Management1. Address underlying issues: medical illness mental health problems social problems, concerns, transitions environmental factors

2. Continually re-assess suicide risk, resiliency, and warning signs.

3. Continue to build and sustain the therapeutic relationship.

4. Look for ways to foster hope and enhance a sense of meaning in life.

Page 34: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Risk Management

Ongoing Risk Management (Cont.)

5. Develop a safety plan that includes after-hours support.

6. Read and continually review CCSMH National Guidelines and other appropriate treatment guidelines.

7. Work within a culturally competent model of care.

8. Work within an inter-disciplinary care model where possible: Develop relationships with mental health teams for support and

ongoing follow-up. Be aware of community resources and referral sites / processes.

Page 35: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Treatment & Management

Treatment and Management: Suicidal Seniors

Foster hope in clients who are suicidal Assist in finding and maintaining meaning and purpose in life Attend to the therapeutic relationship Work in a team setting - don’t work alone (collaborative care) Consult colleagues, keep detailed notes, use crisis services Restrict access to lethal means Mental health outreach

Page 36: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Treatment & Management

Recommendation: Treatment and Management

Health care providers working with suicidal older adults should ensure that their clients are appropriately assessed and treated for depression. (Please refer to the National Guidelines for Seniors’ Mental Health: The Assessment and Treatment of Depression by the CCSMH, 2006) [B]

Copies of the CCSMH National Guidelines for the Assessment and Treatment of Depression, can be downloaded for free at www.ccsmh.ca.

Page 37: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Treatment & Management

SYMPTOMS OF DEPRESSION: REMEMBER SIG E CAPS(Source: Michael Jenike, 1989)

S Sleep is disturbed

I Interest is decreased

G Guilt (feelings of guilt or regret)

E Energy is less than usual

C Concentration is poor

A Appetite is disturbed

P Psychomotor agitation or retardation

S Suicidal Ideation, including passive wish to die

Page 38: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Treatment & Management

SYMPTOMS OF DEPRESSION:

Depressed people often experience sadness, despair, and low energy. However, many depressed older adults do not appear obviously sad. It is important to assess for "hidden depression".

Page 39: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults: Summary

SUMMARY

Older adults have high rates of suicide and the population of older Canadians is growing.

Detection of elevated suicide risk is essential for suicide prevention efforts for seniors.

Barriers exist to effective risk detection and treatment. New assessment instruments appear very promising. Efforts are underway to develop/modify clinical interventions for

at-risk older adults.

Page 40: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

SUMMARY

Practice guidelines are now available through the CCSMH to help address the need for evidence-based recommendations for improving detection of at-risk older adults and prevention of suicide.

These highlight the need to listen to and empathize with older patients/clients, develop clinical rapport, and endeavour to work in team settings.

Increasing attention to the problem of late life suicide may help decrease risk of loss in a growing and valued segment of our population.

Suicide Assessment & Prevention for Older Adults: Summary

Page 41: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 1: Suicide Assessment What makes it difficult to assess depression and suicide

risk in older adults?

Page 42: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 1: Suicide Assessment What did the physician do to assess Mr. Johnson’s

depression and suicide risk? Was this adequate? What else, if anything, could the

doctor have done differently?

Page 43: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 1: Suicide Assessment What are some of the risk management strategies shown

or discussed in the DVD? What will be important in terms of ongoing risk

management for Mr. Johnson?

Page 44: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 1: Suicide Assessment What resources could you access to help a suicidal

patient / client? What can you do in advance to be prepared for potential

crises?

Page 45: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 1: Suicide Assessment In your own practice setting, what can you do to inspire

hope with your patient / client?

Page 46: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 1: Suicide Assessment The DVD suggests some key questions to ask people at

risk for suicide. Can you think of other questions to ask?

Page 47: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 2: Suicide Risk & Resiliency Factors What are the risk factors for suicide?

Page 48: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 2: Suicide Risk & Resiliency Factors What are the greatest risk factors?

Page 49: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 2: Suicide Risk & Resiliency Factors Which of these risk factors can be modified?

Page 50: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 2: Suicide Risk & Resiliency Factors What are some resiliency / protective factors?

Page 51: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 3: Suicide Warning Signs What does “IS PATH WARM” stand for? What are the

warning signs for suicide risk?

Page 52: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 3: Suicide Warning Signs Should the mnemonic “IS PATH WARM” be used as a

checklist? Why or why not?

Page 53: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 4: Suicide & Stigma: Survivors’ Voices How can the stigma about suicide and depression

affect your assessment and treatment strategies?

Page 54: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 4: Suicide & Stigma: Survivors’ Voices What factors can contribute to the stigma surrounding

depression and suicide?

Page 55: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Chapter 4: Suicide & Stigma: Survivors’ Voices Take time to reflect on your personal feelings /

experiences with late life depression and late life suicide.

Page 56: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Discussion Questions

Overall: What was your overall reaction to the DVD? Can you list 1-2 new points or concepts you learned in

this session? In what ways did the DVD affect your attitudes toward

depression and suicide in older adults? What changes will you make in your practice as a result

of what you’ve learned in the DVD? If you are experiencing stress or burn-out while doing

this type of work, what resources can you access?

Page 57: Canadian Coalition for Seniors Mental Health  Suicide Assessment & Prevention for Older Adults: Life Saving Tools for Health Care Providers

Suicide Assessment & Prevention for Older Adults

Thank you!We welcome your feedback online:

www.ccsmh.ca/en/projects/suicide.cfm