Suicide risk?

Vague physical complaints that bring an elder to the emergency department can be a cover for emotional distress. DEBORAH ANTAI-OTONG " ames Lewis, a disheveled, agitated, 76 year old, came to the emergency department (ED) three times in five days complaining of shortness of breath, insomnia, fatigue, and forgetfulness. His physical examination showed

J

Deborah Antai-Otong, RN, MS, is a psychiatric clinical nurse specialist in the Outpatient Psychiatric Triage Unit of the Department of Veterans Affairs Medical Center, Dallas, TX.

228 Geriatric Nursing September/October 1990

no abnormalities except for a 25pound weight loss in the previous two months caused by anorexia. When questioned about his frequent ED visits, he insisted, "I'm not crazy. Something is wrong with me!" Ethel Sampson, a 70-year-old retired lawyer, was brought to the ED by her husband who reported that his wife frequently complained of fatigue and had difficulty eating. During the previous two weeks Ms. Sampson had refused to eat, bathe, or manage her personal hygiene.

Mr. Sampson had taken his wife to their family physician several times for treatment of a variety of complaints. Despite a thorough physical exam and numerous diagnostic tests, her physician could find no reason for her complaints. After a careful history, both Mr. Lewis and Ms. Sampson were diagnosed to have the same common, deadly disease---depression. Approximately 10 percent of elders 60 years and older suffer from depression (1,2). Of those people who commit suicide each year, 23 percent are elderly. Elders use more violent methods to commit suicide, too, which leads to a higher"success" rate than in other age groups (I). (See "'Who's at High Risk for Suicide?" on the next page.) These alarming figures stress the importance of promptly diagnosing and treating depression in elderly patients. As the cases of Mr. Lewis and Ms. Sampson suggest, the ED nurse is often critical in recognizing the underlying problem. Whenever a patient f~equently visits the ED with somatic complaints for which no physical basis can be found, suspect depression. While depression in elders is no different than in other age groups, the elderly may be more reluctant to complain of emotional distress. Instead, they may make only general comments about chest pain, fatigue, or "just not feeling good." Ask about lifestyle changes, losses, support systems, suicidal thoughts, substance abuse, current medical treatment, and duration of presenting symptoms. These questions will help elicit information that may suggest depression. Suspect depression in patients who have suffered a significant loss, such as the death of a spouse. Those who have recently had a major lifestyle change, such as retirement, are at risk, too. Changes in a person's body image caused either by illness or the natural effects of aging can also lead to depression. When a nurse is doing the iniffal assessment, he or she should first note the patient's level of consciousness. The patient's memory can be tested by asking about his general condition and whatever problems he

may have had recently that brought him to the ED. It's important to note the patient's general appearance. Mismatched, dirty clothing and a generally unkempt appearance are signs of problems. Speech patterns are also important. Note whether the patient is speaking too fast or too slowly and if his thought process is logical. We Were Married 50 Years With careful questioning, the ED nurse discovered that Mr. Lewis's wife of 50 years had died several months ago. Mr. Lewis seemed to be having trouble coping with this loss. While talking with the nurse, he began to cry and said he didn't know how he was going to live without his wife and that he wasn't sure life was worth living without her. While he denied having thoughts of killing himself, he did admit that he wished he were dead instead of his wife. When questioned about his support groups, Mr. Lewis revealed he and his wife did not have children and most of their mutual friends had died. The ED nurse concluded that Mr. Lewis exhibited the signs and symptoms of situational depression and grief reaction with a high risk for suicide potential (3,4). If you were the ED nurse, what would be your next step in providing care for Mr. Lewis? 1. Tell him he will be O.K., it takes time to get over losing a loved one. 2. Send him to a psychiatrist for antidepressants. 3. Encourage him to admit himself to the hospital immediately. 4. Tell him to join a senior citizen's group immediately. The best choice in this case is to encourage Mr. Lewis to accept immediate psychiatric hospitalization. The combination of his recent significant loss, the fact that he has few support systems, and his admitted preoccupation with death mean that his life is in danger. Immediate, short-term hospitalization will provide support and safety for Mr. Lewis and help him work through the grief process. If Mr. Lewis, who was assessed to be imminently suicidal, refused to be

hospitalized, the nurse would contact the ED physician to evaluate Mr. Lewis for involuntary commitment. Normally, when a patient is told that both the nurse and the physician think he is in danger, he will agree to be admitted. After a period of hospitalization and treatment, Mr. Lewis can be encouraged to join a community senior citizen group or do volunteer work to keep his life busy. I Used to Be Important During the nurse's initial interview, Ms. Sampson accused her husband of trying to get her out of the house so he could date their neighWHO'S AT HIGH RISK FOR SUICIDE? 1. persons over age 70 2. white males 3. any eider whose spouse has died recently or been diagnosed with a terminal illness 4. persons who have suffered multiple losses over a short span of time 5. anyone with limited support systems 6. elders with a history of alcoholism and/or substance abuse 7. anyone with a history of family suicide, or who has attempted suicide

bor. Mr. Sampson responded to this statement by telling his wife that her problem was all in her head. The nurse's questioning revealed that Ms. Sampson had retired from her law practice lO months ago and had had few social contacts since then. Also, her only daughter was seriously injured in an automobile accident two months before. The nurse determined, based on her interview, that Ms. Sampson has

severe psychotic depression due to lifestyle changes and her daughter's recent injury, with her psychotic tendencies manifested by paranoia/suspiciousness and an inability to take care of her basic needs. Immediate hospitalization and further assessment for suicide potential was recommended. (See Ms. Sampson's

"Psychosocial Assessment" on the next page.) If you were the ED nurse, which of the following signs would you see as indicating psychotic depression? 1. Inability or lack of motivation to

take care of basic needs 2. Persecutory delusions such as paranoia and suspiciousness 3. Tearfulness and frequent crying spells 4. Extreme fatigue and apathy Lack of motivation for self-care and delusions indicate physical, social, and psychological decompensation. Patients who are unable to bathe or feed themselves are at risk of skin and nutritional breakdown. Elders experiencing delusions become extremely agitated and eventually have auditory hallucinations that may tell them to protect themselves against others. Tearfulness and fatigue are signs of less severe depression. Immediate hospitalization will allow Ms. Sampson to get medication and therapy in a supportive environment. Her relationship with existing support groups (including her husband) can also be analyzed. After hospitalization, joining a senior citizens' group and a community support group, plus doing volunteer work, will help keep Ms. Sampson better balanced emotionally. If Ms. Sampson refuses to be hospitalized, because she is overtly psychotic, involuntary commitment is possible. In this case, the nurse would refer Ms. Sampson back to the ED physician, who would initiate commitment. I Just Can't Sleep Elrod Jones, a 67-year-old man, came to the ED complaining of insomnia and memory problems. After a physical assessment, an astute ED nurse suspected a psychological basis for Mr. Jones's problems. Mr. Jones was angry about his referral to psychiatry and insisted he only needed a pill to help him sleep and think more clearly. He appeared anxious and depressed. Questioning revealed that Mr. Jones had smoked two to three packs per day of cigarettes for the past 40 years and was diagnosed six months ago with lung cancer. Since his cancer diagnosis, he had had difficulty sleeping and eating. In fact, he had lost about 12 pounds in three months. The signs pointed to depression related to Mr. Jones's

Geriatric Nursing September/October 1990 229

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changing body image and death and dying issues(l). Medications alone will not resolve this type of situational depression. Patients like Mr. Jones, whose body is changing rapidly as a result of a serious, possibly fatal, disease are at greatly increased risk for suicide. If you were the ED nurse trying to assess Mr. Jones's suicidal risk what would be the best question to ask? 1. Do you own a gun? 2. I am concerned about you, are you O.K.? 3. How often do you have thoughts about killing yourself?. 4. Have you ever had psychiatric treatment? The best question is number 3. It's clear and precise and is likely to elicit a candid response. When the nurse asked Mr. Jones the question, his firm denial of suicidal thoughts indicated to the nurse that he was, indeed, not suicidal. Also, his speech was clear, and he showed no evidence of psychosis. Now it's up to the nurse to help Mr. Jones understand that a pill won't solve his problems. Mr. Jones needs help in identifying realistic goals for the future. Interventions may include crisis intervention, grief work, or other forms of outpatient short-term treatment. Joining a support group would also help. Patients with this form of situational depression need support systems that include both hospital and community resources.

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When elders come to the I~D, they are asking for help. A thorough assessment of their mental as well as physical condition will help nurses spot depression and direct elders to the resources they need. GN

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References

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I. Charatan, F. B. Depression and the elderly: diagnosis and treatmenL Psychiatr. Ann. 15:313-316,

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1985.

2. Hendrie, H. C., Crossitt, J. H. W. An overviewof I NTERVENTIONS/ RECOt~ENDATIONS: I.

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depression in the elderly. Psychiatr. Ann. 20:.6470, 1990. 3. AmericanPsychiatricAssociation.Diagnosticand Statistical Manual of Mental Disorders. 3rd rev. ed. Washington, DC: The Association, 1987, pp. 218-224. 4. Robins, L. N., Kulbok, P. A. Epidemiological stud-

ies in suicide. Psychiatr. Ann. 18:619-627, 1988.

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