suicide in the elderly by glenda j. abercrombie
TRANSCRIPT
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
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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.
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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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