Suicide risk in frail elderly people relocated to nursing homes

S u i c i d e R i s k in Frail

Elderly People Relocated to Nursing Homes In general, elders who consider suicide are over 85 years old, want to retain control of their lives, and have a high degree of s e l f - e s t e e m . BY

BARBARA

K.

HAIGHT

ince 1980 the suicide rate for those o v e r 65 increased by 17% and for those in their 80s by 38%. 1 Early studies identified those at risk as male, white, widowed, or divorced. 2 More recent studies identified frail elders o v e r age 85 as being at increasing risk. 3 To date, no one has e x a m i n e d suicide ideators who reside in nursing homes or who are at risk specifically because of relocation to a nursing home. In this article I report on a group of nursing h o m e residents, some identified as ideators at risk for suicide, and c o m p a r e ideators to nonideators. This work begins to build a profile of frail elderly persons at risk for suicide in nursing h o m e settings.

S

Risk Factors in a Community Sample S u i c i d e in o l d e r p e o p l e does not get the attention g a r n e r e d by suicide in y o u n g e r p e o p l e . For exa m p l e , Y o u n g e r et al. 4 n o t e d that r e s e a r c h e r s r a r e l y use p s y c h o l o g i c a u t o p s y m e t h o d s in studies o f elders who c o m m i t suicide. We tend to a c c e p t the m y t h of s o c i a l i s o l a t i o n in the a v e r a g e older v i c t i m o f suicide e v e n t h o u g h 90% of older adults who c o m m i t suicide had a k n o w l e d g e a b l e i n f o r m a n t . I f this is the case, then p s y c h o l o g i c a u t o p s y is also a v a l u e d tool for use with o l d e r p e o p l e . By using p s y c h o l o g i c a u t o p s y m e t h o d s , the authors p r o m o t ing the t e c h n i q u e l e a r n e d that d e l i r i u m and the dia g n o s i s o f c a n c e r c o n t r i b u t e d m o r e to death than did i s o l a t i o n , a c o m m o n l y h e l d belief. 4 BARBARA K. HAIGHT, RNC, DrPH, FAAN, is a professor of nursing at the Medical University of South Carolina, in Charleston. GERIATR NURS 1995;16:104-7. Copyright 9 1995 by Mosby-Year Book, Inc. 0197-6554/95/$3.00 + 0 34/1/57279

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In an e x a m i n a t i o n of the c o m m u n i t y care of suicidal patients in G r e a t Britain, Morgan 5 found that 57% of the suicidal patients were o v e r 65. He stressed the need to identify risk factors for this comm u n i t y - b a s e d population, as well as to provide intensive, personal support during times of crisis. Because m o r e chronically mentally ill older people are living in the community, he noted the need for a small inpatient unit to deal with acute clinical crises.

We tend to accept the myth of social isolation in the average older suicide victim. M a n y authors r e p o r t identified risk factors in the aging suicidal p o p u l a t i o n . I d e n t i f y i n g these risk f a c t o r s is e s s e n t i a l if suicide is to be p r e v e n t e d , esp e c i a l l y in older p e r s o n s d w e l l i n g in the c o m m u nity who do not h a v e r e a d y r e s o u r c e s for intense p e r s o n a l support. One group of r e s e a r c h e r s identified h o p e l e s s n e s s and a p a t h y as clinical p r e d i c t o r s for c o m m u n i t y - d w e l l i n g patients with a f f e c t i v e disorders. 6 D a y - o f - t h e - m o n t h e f f e c t s were also strong p r e d i c t o r s of e l d e r l y male suicide. The first 5 days of the m o n t h put older m e n m o r e at risk for suicide. 7 P e r h a p s if the authors t o o k this analysis one step further, they m i g h t c o n n e c t day of the m o n t h r i s k f a c t o r s to the a r r i v a l o f Social S e c u r i t y checks. T h e y either h a v e a r r i v e d by the 5th or are n o t i c e a b l y absent. For e x a m p l e , L e s t e r and Yang 8 c o r r e l a t e d e c o n o m i c d e p r i v a t i o n with i n c r e a s e d suicide rates in older people. E c o n o m i c d e p r i v a t i o n m a y relate to d a y - o f - t h e - m o n t h risk factors as well.

May/June 1995 GERIATRICNURSING

M e l l i c k et al. 9 r e p l i c a t e d an earlier study on suicide to i d e n t i f y v a r i a b l e s a s s o c i a t e d with suicide a m o n g elderly white m e n in I o w a . T h e i r study s h o w e d a d a y - o f - t h e - w e e k , instead of a d a y - o f - t h e month, effect. The m e n they studied had b e e n P r o t e s t a n t and retired with r e d u c e d i n c o m e , had lived with s o m e o n e else and had had at least one c o n f i d a n t , had b e e n b e r e a v e d , had o w n e d f i r e a r m s , had had low s e l f - e s t e e m , had suffered f r o m illness and chronic sleeping p r o b l e m s , and had b e e n unh a p p y and d e p r e s s e d b e f o r e c o m m i t t i n g suicide at h o m e during the day. Each had also v i s i t e d a physician within a m o n t h b e f o r e c o m m i t t i n g suicide. K r e i t m a n 1~ r e p o r t e d that the r e l a t i v e risk associated with suicide and d i v o r c e has b e e n d e c r e a s i n g in Scotland. Canetto 1~ suggests that the g e n d e r diff e r e n c e in elderly suicide rates is a result of differences in coping. She p o s t u l a t e s that w o m e n learn f l e x i b l e c o p i n g and that this t e c h n i q u e m a k e s t h e m better s u r v i v o r s . A n o t h e r a s s u m p t i o n is that a lack of r e l a t i o n s h i p s causes suicide in men; h o w e v e r , m a n y others who h a v e e x a m i n e d risk f a c t o r s find that suicidal men are m a r r i e d or h a v e a c o n f i d a n t e . R i s k f a c t o r s in elders who c o m m i t suicide are still u n d e r g o i n g a n a l y s i s . S e v e r a l t h e m e s s e e m to hold, but not always. For e x a m p l e , b e i n g m a l e is a risk factor, but b e i n g a l o n e or d i v o r c e d is losing p o w e r as a risk factor. W h i l e c o n t i n u i n g to a n a l y z e risk f a c t o r s in a c o m m u n i t y s a m p l e , it is also essential to build a p r o f i l e of risk f a c t o r s for an institutionalized sample. Risk Factors in an Institutionalized Sample Few authors have e x a m i n e d suicide risk in persons who live in institutions. Osgood 12 looked at environmental factors associated with suicide in l o n g - t e r m care facilities. Osgood isolated four factors associated with suicidal behavior: staff turnover, size of facility, auspices (private, church, public, or other), and per diem cost. Larger facilities had higher suicide rates, and those with a high cost per day had lower rates. Auspices were unclear b e c a u s e the authors did not explain the categories of "other. ''12

r e p e a t e d m o v e s within the i n s t i t u t i o n s h o w e d that i n t r a i n s t i t u t i o n a l r e l o c a t i o n was a l m o s t as s t r e s s f u l as the first m o v e to the i n s t i t u t i o n . The l i t e r a t u r e on suicide in n u r s i n g h o m e s o c c a s i o n a l l y i d e n t i f i e s the n u r s i n g h o m e i t s e l f as the c a u s e of s u i c i d a l b e h a v i o r . L o e b e l et al. 14 r e p o r t e d a n t i c i p a t i o n o f n u r s i n g h o m e p l a c e m e n t as a r i s k f a c t o r for suicide in older p e o p l e . O f 60 p e r s o n s studied, e i g h t i n d i c a t e d they p r e f e r r e d d e a t h o v e r a d m i s s i o n to a n u r s i n g h o m e . A n o t h e r g r o u p o f authors w r o t e o f the g i v i n g up of older people, "the giving up" indicating a c h o i c e o f death. T h e y called this g i v i n g up a " p s y c h o g e n i c m o r t a l i t y s y n d r o m e " and saw a n e e d f o r i n t e r v e n t i o n s to p r e v e n t this s y n d r o m e . 15 L a s t l y , N e l s o n and F a r b e r o w 16 w r o t e of i n d i r e c t s e l f d e s t r u c t i v e b e h a v i o r in the n u r s i n g h o m e a n d l a b e l e d this b e h a v i o r as h a v i n g direct suicide potential. P e r h a p s i n d i r e c t s e l f - d e s t r u c t i v e b e h a v i o r should be i d e n t i f i e d as a n o t h e r r i s k f a c t o r for suicide. This includes m a n y b e h a v i o r s , such as r e f u s i n g to eat and r e f u s i n g to take m e d i c i n e as p r e s c r i b e d , that show a d i s r e g a r d for o n e ' s o w n h e a l t h and resuiting in a p a s s i v e suicide. Since few r e s e a r c h e r s h a v e r e p o r t e d suicide r i s k f a c t o r s for frail elders r e s i d i n g in n u r s i n g h o m e s , the p u r p o s e of this p r o j e c t was to b e g i n to b u i l d a p r o f i l e o f r i s k f a c t o r s for this p o p u l a t i o n . Me~od A s e c o n d a r y data a n a l y s i s of an i n t e r v e n t i o n study d e s i g n e d to p r e v e n t d e p r e s s i o n and suicide in n e w l y r e l o c a t e d n u r s i n g h o m e r e s i d e n t s p r o v i d e d the data for this study. Within 6 w e e k s of rel o c a t i o n to a n u r s i n g h o m e , 390 frail elders w e r e s c r e e n e d by r e s e a r c h e r s . O f these 390 p e o p l e , 90 f a i l e d the M e n t a l Status Q u e s t i o n a i r e , 86 w e r e unable to c o m m u n i c a t e , and 115 r e f u s e d to p a r t i c i pate. N i n e t y - n i n e s u b j e c t s q u a l i f i e d for the study. The r e s e a r c h e r s t e s t e d those w h o q u a l i f i e d With m e a s u r e s o f suicide i d e a t i o n , h o p e l e s s n e s s , dep r e s s i o n , w e l l - b e i n g , and life s a t i s f a c t i o n . Suicide Ideation Scale

The literature on suicide in nursing homes occasionally identifies the nursing home itself as the

cause

of suicidal behavior.

B r a n t and O s g o o d 13 then c o n d u c t e d a study to i d e n t i f y r i s k f a c t o r s r e l a t e d to the i n s t i t u t i o n a l i z e d elders t h e m s e l v e s . T h e y p r e s e n t e d three case studies that h i g h l i g h t e d loss (of p o s s e s s i o n s , of p h y s i cal ability, of friends, of p r i v a c y , of i n d e p e n d e n c e and c o n t r o l ) as the m a j o r risk factor. In addition,

GERIATRIC NURSING Volume 16, Number 3

B e c k ' s S u i c i d e I d e a t i o n S c a l e w a s u s e d to m e a s u r e suicidal intent. The i d e a t i o n scale is for i n d i v i d u a l s w h o h a v e not a t t e m p t e d suicide, but h a v e ideas a b o u t d o i n g so. The i t e m s w e r e b o t h c l i n i c a l l y and r a t i o n a l l y d e r i v e d to f o r m a 1 9 - i t e m scale. E a c h i t e m c o n s i s t s of three a l t e r n a t i v e statem e n t s g r a d e d f r o m 0 to 2, with 0 b e i n g " l e a s t t h r e a t e n i n g . " Scores, w h i c h m a y r a n g e f r o m 0 to 38, a s s e s s the extent, c h a r a c t e r i s t i c s , and a t t i t u d e of suicidal thought. I n t e r n a l c o n s i s t e n c y was determ i n e d in a 9 0 - p a t i e n t s a m p l e and e v a l u a t e d by two m e t h o d s . An i t e m analysis s h o w e d 16 of 19 items s i g n i f i c a n t l y c o r r e l a t e d with the total scale score. C r o n b a c h ' s alpha o b t a i n e d a r e l i a b i l i t y c o e f f i c i e n t

Haight 105

Sample and Analysis TABLE 1. S I G N I F I C A N T RISK FACTORS FOR A G E D IDEATION Variable

YES Suicidal

NO Suicidal

Two-tailed p value

Interpretation Suicidal = YES

Significant

83%

45%

0.012

Higher % w/o sig. other

Arthritis-Yes

92%

60%

0.032

Higher % w / arthritis

Age

85.8

78.5

0.009

Older

other-No

Depression

18.8

9.0

0.000

More depressed

Hopelessness

20.3

28,9

0.001

Lower hope

Life

16.3

21.2

0.023

Lower life satisfaction

7.9

0.6

0,000

Higher suicide ideation

21.8

18,7

0.045

Higher selfesteem

satisfaction Suicide

Ideation Self-esteem

T w e n t y - f i v e p e r c e n t o f the q u a l i f i e d s a m p l e of 99 was m a l e . Ten p e r c e n t was A f r i c a n - A m e r i c a n , 90% white. The sample had a m e a n age o f 78.9, and m o s t (67%) w e r e w i d o w e d . O f the 99 subjects tested, 12 e x p r e s s e d s u i c i d a l t h o u g h t s or s c o r e d m o r e t h a n 5 on the B e c k Scale. One man and 11 w o m e n , all white, w e r e at risk for suicide. R e s e a r c h e r s v i s i t e d the 12 subjects with suicidal intent for f o l l o w - u p interv i e w s and c o m p a r e d t h e m with the rem a i n i n g 87 s u b j e c t s on all c a t e g o r i c a l and d e p e n d e n t v a r i a b l e s , using a twotailed t-test to d e t e c t d i f f e r e n c e s bet w e e n the two g r o u p s (Table 1).

Results and Discussion

A l t h o u g h there w e r e 25 men and 74 w o m e n in the s a m p l e , sex was not a well-being being s i g n i f i c a n t i n d i c a t o r o f s u i c i d e risk. The Rosenberg Self-Esteem Scale is usually scoredso thatthelower the score,the higher the selfN e i t h e r was race, with only 10% of the esteem. For this study, scoreswere revereed so that • higher score reflected • higher self-esteem. p o p u l a t i o n A f r i c a n - A m e r i c a n and the rest white. Marital status was not an indicator. N o r was r e l i g i o n , though an inof .89 for 90 cases. Inter-rater reliability on 25 of the t e r e s t i n g p a t t e r n was b e g i n n i n g to form, with 92% 90 patients revealed a coefficient of .89.17 Correlating (10) of the i d e a t o r s b e i n g P r o t e s t a n t , 8% (1) scores with similar measures such as the self-harm Catholic, and none Jewish. E d u c a t i o n , the p r e s e n c e items on depression inventory ensured concurrent va- o f f a m i l y m e m b e r s , f i n a n c e s , s e l f - r e p o r t of health, lidity. Discriminative validity was excellent in sepa- m o s t c h r o n i c i l l n e s s e s ( d i a b e t e s , h y p e r t e n s i o n , rating patients admitted for suicide attempts from heart disease, and c a n c e r ) - - a l l p r o v e d to be nonthose admitted for depression. B e c k ' s Scale as the s i g n i f i c a n t indicators. criterion measure with hopelessness (.47) and depression (.30) determined construct validity. Finally, the Those who lacked a instrument was sensitive over time, which is essential for a r e p e a t e d - m e a s u r e s study. Psychological

-3.3

2.4

0,000

Lower well-

confidante ideated about

Procedure A m a s t e r ' s p r e p a r e d g e r o p s y c h i a t r i c nurse c o n d u c t e d the t e s t i n g a f t e r s c r e e n i n g . First, the nurse a s k e d the s u b j e c t to p a r t i c i p a t e in the study; if the s u b j e c t agreed, the n u r s e had the p a t i e n t sign the c o n s e n t sheet. The n u r s e spent s o m e t i m e visiting with the p a t i e n t and then a d m i n i s t e r e d the o u t c o m e m e a s u r e s by r e a d i n g the q u e s t i o n s aloud and scoring the answers. The p r i n c i p a l i n v e s t i g a t o r c h e c k e d inter-rater reliability every few months after the initial phase to see that raters continued to think the same way. At completion of the testing period, the research assistants entered the scores by hand into the computer. The o r i g i n a l 12 i d e a t o r s w e r e l o o k e d at as an a g g r e g a t e and c o m p a r e d with the 87 o t h e r p e o p l e in the g r o u p on all d e m o g r a p h i c and d e p e n d e n t v a r i a b l e s . With this i n f o r m a t i o n , a p r o f i l e of a n u r s i n g h o m e p a t i e n t at high risk for suicide b e g a n to d e v e l o p .

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suicide significantly more than did those who had a significant other person in their life. A l t h o u g h the p r e s e n c e of f a m i l y m e m b e r s , m a r ital status, and s u p p o r t , b o t h social and financial, w e r e not s i g n i f i c a n t i n d i c a t o r s , the p r e s e n c e of a s i g n i f i c a n t o t h e r p e r s o n was an indicator. T h o s e who l a c k e d a c o n f i d a n t e i d e a t e d a b o u t suicide sign i f i c a n t l y m o r e than did those w h o had a significant other p e r s o n in their life. W h i l e the older p e r s o n s felt c o n n e c t e d with one other individual, they were less l i k e l y to ideate a b o u t suicide. The d e s c r i b e d s i g n i f i c a n t other was not a f a m i l y m e m ber and was not n e c e s s a r i l y a spouse. To s u m m a r i z e , the subjects d i s p l a y e d no significant differences in sex, race, finances, religion, report

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of self-health, most chronic illnesses, and activities of daily living. However, the suicide ideators were significantly more depressed (p < 0.0001), more hopeless (p < 0.001), had lower life satisfaction (p < 0.023), and lower well-being (p < 0.000). The ideators were also older (p < 0.009), had arthritis (p < 0.32), and had higher self-esteem (p < 0.045). An u n e x p e c t e d finding w a s that s e l f - e s t e e m was higher in the suicidal group. This is exactly o p p o s i t e for adolescents, for w h o m low s e l f - e s t e e m is a significant risk factor for suicide. Perhaps in old age high s e l f - e s t e e m is n e c e s s a r y to c o m p l e t e the act of suicide. It m a y take "guts" to c o m p l e t e a suicide in old age, and guts m a y be linked to high s e l f - e s t e e m . A g e was a s i g n i f i c a n t indicator. I d e a t o r s had a m e a n age of 85 y e a r s , while n o n i d e a t o r s had a m e a n age of 78.5 years. The r e p o r t s of the suicide rate i n c r e a s i n g by age r e f l e c t s this indicator. One c h r o n i c illness, arthritis, was also a s i g n i f i c a n t indicator. The arthritis i n d i c a t o r was s u r p r i s i n g bec a u s e in an earlier study of the i n c i d e n c e and c o r r e l a t e s of d e p r e s s i o n in an a s s i s t e d - l i v i n g center, arthritis was not a c o r r e l a t e o f d e p r e s s i o n , but cancer, heart d i s e a s e , and chronic o b s t r u c t i v e pulm o n a r y d i s e a s e were. The p o p u l a t i o n in a s s i s t e d living was y o u n g e r by 8 years f r o m the i d e a t o r s , with an a v e r a g e age of 78 years. P e r h a p s cancer, h e a r t disease, and c h r o n i c o b s t r u c t i v e p u l m o n a r y d i s e a s e are t h r e a t e n i n g at a y o u n g e r old age, but w h e n one is a l m o s t 86, those i l l n e s s e s are no l o n g e r t h r e a t e n i n g . At 86, one m a y h a v e lived with the p a i n of a r t h r i t i s l o n g e n o u g h . R e s e a r c h e r s s h o u l d l o o k m o r e c l o s e l y at s p e c i f i c c h r o n i c illn e s s e s and their r e l a t i o n s h i p to d e p r e s s i o n and suicide. T h e r e s e e m s to be a v a r i a n c e in suicide risk by disease. As a n t i c i p a t e d , test scores for d e p r e s s i o n , h o p e l e s s n e s s , and suicide i d e a t i o n w e r e higher, w h i l e scores for life s a t i s f a c t i o n and p s y c h o l o g i c w e l l b e i n g were l o w e r o r d e c r e a s e d i n s t e a d o f lower. In interviews many other factors became apparent, the m o s t i m p o r t a n t b e i n g that the i d e a t o r s w a n t e d to k e e p c o n t r o l of their lives. The r i s k of losing p e r s o n a l c o n t r o l t h r o u g h nursing h o m e p l a c e m e n t was t h r e a t e n i n g to e a c h of them. T h e y o f t e n exp r e s s e d a n g e r at the p e o p l e they t h o u g h t were res p o n s i b l e for putting t h e m in the n u r s i n g h o m e and w e r e v e r y a g a i n s t b e i n g p l a c e d there. E a c h i d e a t o r was a n g r y with s o m e o n e and p a r t i c u l a r l y a n g r y at the loss of c o n t r o l o v e r his or her o w n life. The second factor was that m a n y of these frail elders were ready to die because it was time. The test for suicidal intent did not clearly differentiate between those who were waiting to die and those who would actively end life. Ideators scored m o r e poorly on a test of activities of daily living, but not significantly. Some, though they wished to die, were deterred from suicide b e c a u s e of religion or because of family members. H o w e v e r , they did ideate, and some were depressed, while others were ready and waiting.

GERIATRIC NURSING Volume 16, Number 3

Conclusions This p r o j e c t b e g i n s a p r o f i l e for p e o p l e at risk for suicide in n u r s i n g h o m e s . N u r s e s , p h y s i c i a n s , and all those caring for p e o p l e in n u r s i n g h o m e s should be a w a r e of these s i g n i f i c a n t r i s k f a c t o r s and c o n s i d e r t h e m w h e n p l a n n i n g care to p r e v e n t v i o l e n t d e a t h f r o m suicide. With m o r e r e s e a r c h on the subject, a v a l i d a t e d suicide p r o f i l e m a y identify those who are at risk and m o s t a m e n a b l e to health-promoting interventions. P r e s e n t l y , the p e r s o n r e l o c a t i n g to a n u r s i n g h o m e who is at risk for suicide is m o r e d e p r e s s e d and h o p e l e s s and e x p e r i e n c e s d e c r e a s e d life satisf a c t i o n and p s y c h o l o g i c w e l l - b e i n g . In g e n e r a l , the a t - r i s k i n d i v i d u a l is at l e a s t 85 y e a r s old with arthritis, high s e l f - e s t e e m , and a need to c o n t r o l life. Suicide m a y be the last m e t h o d o f c o n t r o l o p e n to the 8 5 - y e a r - o l d p e r s o n in a n u r s i n g h o m e , and high s e l f - e s t e e m m a y p r o v i d e a p e r s o n the s t r e n g t h n e c e s s a r y to a c c o m p l i s h the act. 9 S p e c i a l a c k n o w l e d g e m e r i t to K a t h y B r u n g a r d , S h i r l e y H e n d r i x , a nd A m y H u n t for t h e i r c o n t r i b u t i o n s . F u n d e d by t he N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h ( N I M H ) grant #1R29MH45323. REFERENCES 1. Meehan PJ, Saltzman LE, Sattin RW. Suicides among older United States residentsi epidemiologic characteristics and trends. Am J Public Health 1991 ;81 (9): 1198-200. 2. Kirsling RA. Review of suicide among elderly persons. Psychol Rep 1986;59:359-66. 3. Mclntosh JL. Epidemiology of suicide in the elderly. Suicide Life Threat Behavior 1992;22:15-35. 4. Younger SC, Clark DC, Ochmig-Lindroth R, Stein RJ. Availability of knowledgeable informants for a psychological autopsy study of suicides committed by elderly people. J Am Geriatr Soc 1990;38:1169-75. 5. Morgan HG. Suicide prevention: hazards on the fast lane to community care. BRr J Psychiatry 1992;160:149-53 6. Fawcett J, Scheftner W, Clark D, Hedeker D, Gibbons R, Coryell W. Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. Am J Psychiatry 1987;144:35-40. 7. McCleary R, Chew KSY, Hellsten JJ, Flynn-Bransford M. Age- and sex-specific cycles in United States suicides, 1973 to 1985. Am J Public Health 1991;81:1494-7. 8. Lester D, Yang B. Social and economic correlates of the elderly suicide rate. Suicide Life Threat Behav 1992;22:36-47. 9. Mcllick E, Buckwalter KC, Stollcy JM. Suicide among elderly white men: development of a profile. J Psychosoc Nurs 1992;30(2):29-34. 10. Kreitman N. Suicide, age and marital status. Psychol Med 1988;18:121-8. 11. Canetto SS. Gender and suicide in the elderly. Suicide Life Threat Behav 1992;22:80-97. 12. Osgood NJ. Environmental factors in suicide in long-term care facilities. Suicide Life Threat Behav 1992;22:98-106. 13. Brant BA, Osgood NJ. The suicidal patient in long-term care institutions. J Gerontol Nurs 1990;16(2): 15-8. 14. Loebel JP, Loebel JS, Dager SR, Centerwall BS, Reay DT. Anticipation of nursing home placement may be a precipitant of suicide among the elderly. J Am Geriatr Soc 1991;39:407-8. 15. Maizler JS, Solomon JR, Almquist E. Psychogenic mortality syndrome: choosing to die by the institutionalized elderly. Death Education 1983;6:353-64. 16. Nelson FL, Farberow NL. Indirect self-destructive behavior in the elderly nursing home patient. J Gerontol 1980;35(6):949-57. 17. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the scale for suicide ideation. J Cor_sult Clinical Psychol 1979;47:343-52. 18. Haight BK. Depression: incidence and correlates in high-rises and nursing homes. Gerontologist 1992;32(Special Issue II):222.

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