Each year, nearly 25,000 Canadians are hospitalized or die as a result of intentional self-harm.(1) People can deliberately harm themselves in a variety of ways: cutting themselves with sharp objects, burning their skin, taking "minor" drug overdoses, banging their head against a wall, or deliberately starving themselves.
People who intentionally injure themselves often do so to cope with stress. They may also wish to obtain some form of relief from painful or distressing feelings, as well as communicate their pain or distress to others.
Self-harm is closely associated with suicide in older adults and may provide an opportunity for intervention to prevent suicide. That said, suicide prevention among older adults is complex. Many factors make this population vulnerable, such as deteriorating physical and mental health, the onset of cognitive and functional impairments, and interpersonal and social factors such as social isolation, loss of network, death of a loved one and depression. According to the Canadian Association for Suicide Prevention, more than 10 adults over the age of 60 take their own lives every week.(2) Men aged 65 and older are at greater risk, with suicide rates of 20 per 100,000 rising to nearly 34 per 100,000 for men aged 90 and older.
So how can we intervene when older adults intentionally hurt themselves?
What the research tells us
A recent systematic review identified 20 studies of aftercare for older adults who have intentionally injured themselves.(3) The studies focused on three key elements of care for older adults: referral to specialized services, suicide risk assessment tools and safety, and engagement and intervention strategies. The patients examined came from a variety of urban and rural settings, and care was provided in a variety of settings: emergency departments, medical and psychiatric hospital care, community psychiatric care, residential care for the elderly, and primary care. The average age of patients ranged from 60 to 102 years.
Despite the low quality of the studies, the results provide an overall picture of the three components assessed:
1. Referral to specialized services
The main finding is that older adults who are depressed, who have suicidal thoughts and even suicidal behaviours are rarely referred to specialized or community mental health services. A British study reports that out of 10 elderly patients with suicidal behaviours, 1 patient was referred to mental health services and 6 received a prescription for an antidepressant. Is this a reflection of a limited understanding of the high risk of suicide in this vulnerable population or perhaps a sign of ageism in clinical decision making and care delivery?
Yet, one study showed that close follow-up at various levels appears to be effective in reducing suicide deaths: assignment of a psychogeriatric appointment within a week and urgent linkage to a case manager dedicated to the person in crisis, regular visits and calls, review of the care plan, and ongoing assessment of clinical progress.
2. Suicide Risk Assessment Tools and Safety
Standard suicide screening tools and questionnaires have low sensitivity, resulting in missed cases or high false positive rates. A clinical needs assessment, focused on older adults, would better address the reasons behind self-inflicted injuries, while taking into account the older adult's strengths, coping strategies and psychosocial circumstances.
Safety planning for older self-injured persons is primarily based on restricting means (e.g., restricting access to sharps, medications, firearms, etc.). However, it would be desirable to focus on other protective factors as well: social and family networks, artistic hobbies, strategies for coping with the challenges of aging, volunteerism, spirituality, etc.
3. Engagement and intervention strategies
To ensure that older adults who self-harm are appropriately cared for, consider a multi-pronged approach: address ageism, better diagnose and treat depression, increase awareness of available services and resources, collaboratively plan with older adults for services that will be effective, responsive and acceptable.
Ask for help
It is difficult to determine if a person is intentionally self-harming or having suicidal thoughts, as they often do not talk about it before they act. However, there are some warning signs or factors that may alert you to the possibility of self-harm: visible marks or wounds on the body, anxiety and depression, social isolation, insomnia, somatic pain, refusal to eat, or recent bereavement.
Whether it's you or a loved one, don't hesitate to:
- Call 911 if there is an immediate emergency
- Call the suicide prevention hotline in your area:
- Across Canada: 1 833 456-4566 or by text message to 45645, https://suicideprevention.ca/resources/
- In Quebec: 1-866-APPEAL (1-866-277-3553) or by text message to 535353, https://suicide.ca/
- Talk to your healthcare and social care professional.
