This article is from Volume 2, Issue 3 of Forensic Scholars Today, a quarterly publication featuring topics from the world of forensic mental health.
Elder abuse and elder suicide affect similarly vulnerable individuals. Psychosocial factors found in mistreated elders are often present in elders who attempted or completed suicide, yet there has been little recognition that these two problems may be closely related. This must be remedied as the aged population increases and may drive a sharp rise in the incidence of elder suicide and elder abuse. While elder suicide has drawn considerable research attention, abuse has largely eluded being identified as a contributor to elder suicidality. Over the years, there have been calls for more research in this area from both elder suicide specialists and elder abuse prevention advocates, but few studies are available.
Limited inquiry aside, why might an elder abuse-elder suicide overlap have eluded attention? Elders afflicted by abuse may be less likely to divulge suicidal sentiments than peers in less disagreeable circumstances. The way that elder abuse is identified may also mask possible suicidality. The majority of cases are reported on behalf of the victim. Elders able to speak up about mistreatment may not do so for fear of reprisals or to protect their abuser, who is likely to be a close family member, from legal penalties. Formerly, elder abuse was seen as a consequence of caregiver stress, which may have caused suicidality in the victim to be overlooked. The emphasis was on individual factors of the abuser, the victim-abuser relationship, the balance of control between the two, the dependence of either on the other, and the social and cultural context in which the mistreatment occurs. There may also have been gender bias. Abuse of older men, who make up the majority of elder suicides, is under-studied.
Suicidal ideation is the most common type of suicidal behavior, but occurs less frequently in the elderly, which may be a reason that suicide risk eludes recognition. Abused or not, older persons are less likely than younger persons to disclose suicidal thoughts or intent. Both suicide and domestic violence are highly stigmatized. Those who experience suicidal thoughts and physical abuse are not likely to readily or openly reveal either occurrence. Much of what has been learned about elder suicide has come from epidemiological studies that identify broad demographic risk factors or from psychological autopsy studies. The latter rely on information from secondary parties, such as relatives or friends, who may be unaware of any abuse or even possibly be an abuser.
The literature on abuse as a contributing factor in suicidal behavior in older adults is limited, but two recent reports are supportive. A Korean study found a relationship between exposure to abuse and suicide in persons over 65 years old. Individuals who had experienced abuse were at higher risk of suicide than those who had never been abused. A Chinese study also examined mistreatment and suicidal ideation in elders. It was found that mistreatment correlated strongly and positively with the presence of suicidal ideation. Replication of these studies in the United States would provide control over possible cultural influences related to how elders are regarded in Asian cultures and any attendant expectations regarding treatment held by elders in these societies.
Elder abuse intersects with suicide risk in three ways:
- Abused elders may acquire a propensity for suicidal behavior as a consequence of mistreatment.
- Elder homicide-suicide often occurs in abusive relationships.
- Elders who engage in self-neglect may develop “passive” suicidality and suicidal intent.
A number of psychosocial factors have been found to contribute to elder abuse. These include physical and psychological harm, sexual assault, financial loss, and social isolation. Suicide in elderly persons is also strongly associated with disabling medical illnesses, physical impairments, and other impediments to autonomy and self-sufficiency. A similar set of conditions restricting independence are risk factors for elder suicide. A lack of social relations, dementia, and living arrangements fostering dependency are risk factors for elder abuse. Inability to care for one’s self and reliance on others are found in victims of both elder abuse and elder suicide.
Elder homicide-suicide is among the most tragic possible outcome of domestic abuse in the aged; however, homicide-suicides in older adults are infrequent. Most cases are between couples in their 80s and are characterized by the husband murdering his wife and subsequently taking his own life. Elder homicide-suicides may be the outcome of a long-term abusive relationship or one that became abusive when the care needs of one partner increasingly burdened the other.
Self-neglect is the most common form of mistreatment in the aged. Giving up on self-care may be the result of physical or mental impairment or compromised capacity to perform essential activities of daily living. Indirect life-threatening behavior may also be an effort to resolve a life problem or even a cry for help. This behavior undermines well-being by denying oneself adequate food, water, clothing, shelter, safety, or medication. It can be a very gradual, progressive deterioration that may go unnoticed until serious harm has already occurred. When no cognitive or neurological deterioration is present, such intentional life-threatening self-neglect can be considered on the spectrum of suicidal behavior. Deliberate self-neglect with the desire to die constitutes a suicide plan.
Deliberate self-harm has been found to be the greatest risk factor for suicide in patients aged 60 and over who had physical illness and problems with family members and partners. Interpersonal or intimate partner violence is the worst form of family discord. Psychological and physical abuse may be inflicted on an elder by a frustrated or overwhelmed household caregiver. Survivors of domestic violence have been found to have high risk exposure to multiple suicide attempts.
Intentional self-harm in any form is evidence that the elder has overcome any normal and natural inhibitions to causing herself or himself possibly painful or even fatal injury. This can be a sign of suicidality and both a prerequisite and prelude to a suicide attempt. Self-neglect in elders has not been well-studied, so little is known as to how or when it may give way to suicidal behavior.
Self-neglect in the aged resembles “passive suicide” found in settings where elders have limited autonomy or access to lethal means (e.g., skilled nursing facilities or long-term residential facilities). Self-neglect and passive suicides in elders often entail similar methods. Passive suicide may involve self-starvation or non-adherence to necessary medical regimens, not keeping appointments, or refusing medical attention. Such disregard for one’s welfare reflects a devaluing self-worth and depletion of hopefulness, both of which are strongly associated with suicide risk. In advanced stages, these factors may bring about a transition to active suicidality.
A prevailing theory of suicide proposes two prerequisites to a potentially fatal suicide attempt: (i) a strong desire to die and (ii) the capability for lethal self-harm. In the elder population, an intense wish for death may come from believing that one is a burden to others or that one does not belong. Burdensomeness follows from a compelling conviction that one is a liability or not fulfilling expectations. Failed belongingness flows from an unmet need for social relationships. Both family conflict and functional impairments are associated with late-life suicide because they are likely to produce a sense of being a burden on others, and seeing oneself as a burden is linked to a loss of meaning in life in older adults. Emotional abuse, such as being humiliated, ridiculed, or ignored, may deplete self-worth and cause feelings of burdensomeness and disconnectedness in elders. It is also important for elders to experience a sense of belonging and feel that others value and care for them. When these needs are not met, a passive desire for death may arise.
Potentially fatal suicide attempts require the individual to overcome fear, pain, and the inborn instinct for self-preservation in order to self-harm. Trauma, violence, or self-injury are known to lower resistance to lethal self-harm, which, in turn, increases susceptibility to possibly fatal suicidal behavior over time. Additionally, being afflicted by violence creates a capacity for lethal self-harm. What this suggests is that elder abuse may be best thought of as a driver or enabler of suicidal behavior in that it precipitates a number of factors that may directly bring on suicidality.
This review suggests that elder abuse appears to be a serious risk factor for suicidal behavior in older adults and that suicide risk appears to be associated with elder abuse in some cases. This is supported by the few direct studies of this relationship to date. One fruitful approach for future studies would be to conduct psychological autopsies of deceased elders known to have experienced emotional, sexual, or physical abuse, self-neglect, or financial exploitation. This involves interviews of surviving relatives and friends as well as reports from coroners and emergency responders and other official documentation related to the death. Such retrospective inquiries would complement interviews of living at-risk elders and could provide a fuller picture of how elder abuse and suicidal behavior interact. In particular, research of this nature may shed light on cases where self-neglect was a passive but no less lethal means of elder suicide. This approach would be a break from most elder abuse research, which generally looks at the victim, the nature of the abuse, the source of the abuse, and the apparent cause, and rarely explores mortality in the abuse.
Risk of elder suicide emerges from exposure to adverse interpersonal and environmental conditions over time. Elder abuse is such an adversity, and addressing the suicide risk of abused elders must be added to the agenda for elder suicide research and prevention. These steps would provide critical knowledge to forensic professionals dealing with abuse, neglect, and self-harm among elders. Older adults found to be in need of protective services should be screened for signs of suicide risk or suicidal behavior. Conversely, elders presenting with signs of suicide risk or suicidal behavior should be evaluated for possible abuse or neglect. There is some urgency to making elder abuse a focus of elder suicide prevention. The eldest of baby boomers are in their late 60s. They will swell the ranks of the aged in the United States and other nations until 2030. It has been noted that this generation may enter its golden years more disadvantaged in terms of health and well-being than earlier generations. This may increase exposures to abuse, which may raise risk of suicidal behavior. This will place greater demands on community resources already taxed by the growing numbers of elders.
Tony Salvatore, M.A., is the Director of Suicide Prevention and Development at Montgomery County Emergency Service, a nonprofit psychiatric emergency response service in Norristown, Pennsylvania. He has served on state and county suicide prevention task forces in Pennsylvania and has written many articles on suicide prevention. Tony may be reached at firstname.lastname@example.org.