Introduction

Suicide is defined as the act of hurting and taking one’s life, most often as a result of depression or other mental health illnesses . Every year, approximately 800,000 lives are lost to suicide with one person dying every 40 seconds. Currently, it is the second leading cause of death in individuals between the ages of 15 and 29 .

Although the number of cases within this age group have markedly increased over the past few years, older individuals, particularly those that fall under the geriatric age group still possess the highest numbers.Older men ages 75 and above have the highest rates globally. Because of this, the need for assessment and effective management of suicide risk in older adults should be a mandatory practice all over the world.

Prioritizing goals such as incorporating suicide prevention into health care policies, transforming health care systems to prevent suicide, changing public view on suicide and suicide prevention, and improving the quality of data management on suicide cases are just some of the ways in which the incidence of suicide and suicide ideation can be decreased in the elderly. But with the aim of The National Strategy for Suicide Prevention to reduce such numbers by as much as 20% within the next 5 years and 40% in the next 10, addressing it at a more personal level focusing on the primary care setting seems to play a significant role to achieve such a goal.

Relevance

The term suicidality encompasses the different levels or degrees of suicidal ideation that represent different risk levels for actual or completed suicide. As one ages, one begins to contemplate on the concept of mortality or how near one can be to it, especially in the later stages of life, which can be considered a normative reflection and non-pathological. Pathological thoughts during this stage however are not uncommon and can be expressed as passive death wishes, active suicidal ideation, or an imminent intention to commit suicide (see figure). To determine the difference between pathologic and non-pathologic thoughts, the primary care physician plays an important role in determining one from the other. Within the past few years,patients who committed suicide were noted to have visited their primary care physician a month prior to itor have at least consulted with their physician within a year before completing it. 

Objectives
The goal of this review is to decrease the incidence of suicide in the elderly by providing various screening techniques which can be used to identify suicide ideation or suicidal thoughts by recognizing various factors other than that of depression or other mental health disorders, particularly in the primary care setting. Because the level of risk determines the level or type of response, the review also suggests management strategies once the degree of suicidal ideation is identified. 

Highlights

Suicide Risk Factors
Adults who suffered from depression had the highest risk of committing or attempting to commit suicide. Although it may be considered as the greatest predicting factor, those diagnosed with anxiety or somatoform disorders were also considered to be at risk. Other factors such as functional impairment due to a disability, or disability leading to unemployment seemed to also lead to suicide ideation. 

Whilesuicide was likely to be committed by adults who had gone through stressful events in their life (like the loss of a loved one), those living in isolation with limited social supportand individuals who did not practice their religion are also at risk. When it comes to personal and past medical history, smokers and substance abusers were also at an increased risk. In general, those from the lower socioeconomic bracket or those with low financial income were observed to have suicidal thoughts more common than those in the upper class. Attitude and personality types, specifically pessimistic individuals also seemed to predict suicidal behavior. Although this study sees the strong association between depression and suicide, it need not be present for an elderly person to commit suicide.

Suicide Screening and Assessment in the Primary Care Setting
Structured screening instruments are necessary in the evaluation and assessment of suicide in the elderly patient. The Patient Health Questionnaire or PHQ, is a screening tool used to determine how often the symptoms of depression are reported by the individual. Initial screening for depression is conducted through the first 2 questions in the PHQ, known as PHQ-2. When one screens positive in this part, seven more questions necessarily follow, thus completing the PHQ-9. Although relatively sensitive for screening depression, this tool may not be able to detect suicide ideation with those who do not suffer from it. 

Other tools used in the primary care setting are the Columbia-Suicide Severity Rating Scale or CSSR, the P4 Screener and the Geriatric Depression Scale or GDS. With the responses from the P4 screener, past and present suicidal history and the probability of completing suicide are determined and classified as minimal, lower, or higher risk for suicide. The GDS questions on the other hand, are directed more towards the related symptoms which may lead to suicide such as feelings of hopelessness or worthlessness since these emotions are more openly shared compared to suicidal thoughts. 

Importance of Clinical Assessment in Suicidal Ideation
With the various tools available for screening suicide and depicting suicidal ideation, a thorough interview by the clinician is still imperative and crucial in the prevention of suicide or suicidal ideation. A physician’s clinical judgement is vital in order to detect the presence of all possible risk factors to help determine its severity and overall risk level. 

When assessment is done through a thorough clinical interview, an open patient-doctor relationship is also established which helps draw out suicidal thoughts especially after screening positive in the diagnostic tools mentioned above. Through the interview, the physician is also able to determine whether such thoughts are pathological or non-pathological, active or passive, which can determine the urgency of referring to a mental health specialist or to immediate emergency services. 

Suicidality Management in the Primary Care Setting

Treatment Strategies in Suicidal Ideation
Based on the results from the screening tests and clinical interview of the primary care patients, a collaborative mode of therapy is provided by a team of specialists composed of the physician, nurse, social worker or psychologist depression care manager, who effectively communicates and monitors patient symptoms, side effects, and treatment adherence. Evidence-based psychotherapy was also performed by the care manager, if and when requested by the patient. These early intervention techniques were shown to decrease depressive symptoms and the presence of suicidal ideation, with a further decline over a longer period of time. 

A peer-led intervention known as the Senior Connection was also studied, wherein early intervention was performed through strengthening of social connections. This focused specifically on companionship and supportive interpersonal interactions in community-based aging facilities, which helped address those who had a very low sense of belongingness or those who felt they were burdensome to others in their old age.

To address older adults with failed suicide attempts brought for consult in emergency departments, safety planning intervention was done as a way to help prevent future attempts. A concrete plan is laid out for them, that helps them recognize warning signs, make use of coping strategies or ask for social support when needed.

A Guide on Responding to Suicide Ideation
As mentioned above, screening tools and clinical assessment help determine the risk level for suicide in an individual. Once identified, the presence of passive ideation entails further evaluation to determine the presence of depression or other psychiatric disorders, with a re-evaluation in the primary care later on.  With active ideation in the absence of a suicide plan, immediate treatment by the primary care physician or referral to a mental health specialist is advised. When a specific plan or intention to harm themselves is present, the elderly patient is immediately brought in for emergency services and referral to a mental health specialist. 

Conclusion
Suicide and suicidal ideation in the elderly primary care patients are not uncommon. By using the different screening tools and through clinical interviews, appropriate treatment and referrals to specialists can be made. Although most of the tools are sensitive and specific, broader screening tools are advised especially with those who show no symptoms of depression but merely express thoughts or feelings of suicidal ideation. Through this study, early screening and intervention even in the primary care setting was shown to reduce suicidal ideation and poor health outcomes in this specific age group. 

References:

http://www.apa.org/topics/suicide/index.aspx

http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

Raue, P. et al. Suicide Risk in Primary Care: Identification and Management in Older Adults. Current Psychiatry Reports. September 1, 2015