Suicide in elders and suicide risk assessment

Magnitude. Suicide rates are higher in older adults than in most other age groups and have risen over the last decade. The WHO estimates rates at age 75 of about 50 per 100,000 in men and 16 per 100,000 in women — older men account for considerably more deaths by suicide than women. In India, NCRB data show suicides among those aged 60 and above rose from about 11,000 in 2019 to over 15,000 in 2022 — a 40% increase, nearly double the rise in overall suicides, with illness the leading recorded cause.

Why elderly suicide is different — the high-yield contrast. Older adults give fewer warnings, use more lethal methods, and have a far lower attempt-to-completion ratio — about 4:1, compared with 200:1 in adolescents. Intent is more often determined and less impulsive, so every attempt in an older person must be treated as high risk.

The missed opportunity. Some 20–50% of older adults who die by suicide have seen their primary care physician within the preceding week, and most have visited a care facility within the year. Clinicians are less apt to decide that suicidal thinking in an older adult is a serious condition that may respond to treatment — this ageist assumption is the central barrier to prevention.

Risk factors. Depression is the strongest risk factor for suicide and for suicidal ideation, and non-fatal self-harm is the strongest risk factor for subsequent suicide. Others include alcohol and substance misuse, loneliness, recent loss, previous suicide attempt, unrelenting pain, loss of purpose, feelings of being a burden, feelings of being abandoned or rejected by family, and physical disability, together with male sex, widowhood and living alone. Protective factors are strong ties to social, family and religious support networks.

Risk assessment. Ask directly — asking about thoughts of death or suicide is not linked to an increased risk of an attempt; most patients are relieved, and it builds patient–physician trust. A thorough assessment covers not only stated suicidal wishes but also behaviours indicating hopelessness and intention to end one's life — withdrawal, giving away possessions, settling affairs, refusing food or medication. Use collaborative assessment involving family, nurse and social worker, and formal instruments (GDS-15, Columbia Suicide Severity Rating Scale, Beck Hopelessness Scale). Every older adult with suicidal ideas or self-harm needs assessment by a psychiatrist, preferably a geriatric psychiatrist.

Management and prevention. Ensure immediate safety — admit where there is intent, a plan, psychosis or inadequate supervision; arrange means restriction with family involvement. Prompt and vigorous treatment of depression reduces suicide risk, and ECT rapidly relieves expressed suicidal intent in severe suicidality. At population level, depression care managers and education of primary care providers reduce suicide risk regardless of depression severity; treat loneliness and social isolation; and involve the family in understanding the meaning of the suicidal thoughts, with education and family therapy where appropriate.

India's National Suicide Prevention Strategy, 2022 — the country's first, targeting a 10% reduction in suicide mortality by 2030. Its pillars are restricting access to means (including regulation of highly hazardous pesticides), strengthening health services and gatekeeper training, responsible media reporting, and improved suicide surveillance. It specifically recommends psychosocial support within the treatment plan for older adults with chronic or terminal illness, a provision now being routed through NPHCE. This sits alongside Section 115 of the Mental Healthcare Act 2017, which decriminalised attempted suicide by presuming severe stress, and the national helplines Tele-MANAS (14416) and Elder Line (14567).