A woman who has buried her husband and one of her adult children reaches the age of 80 only to feel isolated, lonely, and as if she has never healed from her grief. A grandfather who proudly served in the armed forces now feels like a burden to his children and uses his hunting gun to end it all. A couple looking forward to retirement is devastated when one partner develops dementia and, as all the dreams for their golden years come crashing down, the other partner begins drinking to drown the pain.
These are just a few of the scenarios that gerontologist Patrick Arbore, EdD, has seen or heard of in his 40 years as director of the Center for Elderly Suicide Prevention and Grief-Related Services, a program of the Institute on Aging in San Francisco that he founded in 1973. The service is an accredited 24-hour suicide prevention and crisis intervention line just for older people. “It is a warm line, as well,” Arbore explains. “What that means is an older person does not have to be in a suicidal crisis to contact our Friendship Line service.” (The Friendship Line, which also makes 3,500 outgoing calls a month to reach out to elderly residents locally and nationally, can be reached at 800-971-0016.)
Suicide and addiction are more prevalent than we realize among senior citizens. Arbore, who has his doctorate in counseling psychology, has devoted the past four decades to helping older people deal with, or avoid, psychiatric issues and to spread awareness about these issues. Depressive disorders are the leading mental health issues faced by the elderly, he says. They are
The Suicide Ratio: Sad Statistics for Older People
The goal of the Friendship Line is to try to avert a crisis that can lead to deeper depression or self-harm. “We are wanting to prevent older people from getting to a suicidal crisis because the ratio of suicide attempts to completed acts of suicide is much more scary for older people than for younger people,” he says. It's four attempts for every completed act of suicide in older people, whereas for the general population it's estimated at 8 to 25 attempts to one death by suicide, or with younger people, 100 to 200 attempts to one completed.
“We know that older people are less ambivalent about whether or not they are going to live, and that’s a concern,” Arbore notes. “When you look at the suicide literature in terms of how to intervene when someone’s suicidal, you really want to work with the state of ambivalence. But older adults tend not to give you that option.”
Arbore says that one of the crucial needs for the older population is mental health specialists to care for them and awareness among family, caregivers, and healthcare practitioners about how to spot and treat depression. “An overall in change of behavior would be significant with elderly people when it comes to depression,” he says. “For older adults, it’s a little less clear. Any change in behavior, whether in eating or sleeping habits, would be enough to warrant that you want to talk to somebody.”
Arbore says there are about 2 million older adults considered at risk for depression. The rates are:
- About 1-5 percent among older people who live in the community
- Almost 12 percent among hospitalized older people (which indicates the relationship between illness and depression, he says)
- About 14 percent among those that have home healthcare
The numbers get higher — up to 5 million — when you take into consideration people who have symptoms of depression, also called subclinical depression, but are not at risk for major depression or major depressive disorder. “Those symptoms can accumulate,” Arbore says. “Loneliness and isolation are such a concern among community-dwelling elderly. If that milder depression isn’t recognized, it can get worse, for example, with the death of a spouse or adult son or daughter. That loss could trigger a major depressive episode.”
Here are more observations about depression, suicide, addiction and other aspects of mental health in older adults from Arbore.
Everyday Health: Why do you think suicide has become such a concern among the elderly? Is it that people become tired of living? Or is it due to health concerns, loneliness, or financial situations?
Patrick Arbore: All of those are factors can increase the risk of suicide with older people. What researchers tend to see is that one of the most rigorous risks factors is depression. Depression is an important factor in terms of suicide risk. And so if it's somebody's risk factor, depression can be recognized and/or treated. That certainly that makes a huge difference in whether they will be able to survive.
EH: Is depression easily recognized in older adults? Is it maybe confused with other conditions?
Arbore: Although it is estimated that approximately 2 million older people are experiencing depression right now, sadly, most of those people will not be recognized as having depression. So it’s hard to treat a condition if it’s never recognized. The issue is we tend in our society, because of ageism, to think of depression and older age as being synonymous. So we don’t see that the older person may or may not have depression. That’s a problem that has to be rectified. Sadly, mental health issues in older adults still carry a stigma, and that stigma contributes to the the lack of recognition of depression and other mental health issues in older adults.
EH: Is part of the stigma because they come from the old school and are ashamed to ask for help, or don’t know to ask for help?
Arbore: I think it is a combination of both, but I would say that the former carries a little bit more weight. Because the value of independence — and the value of autonomy — is so powerful in this culture, one believes, “I have to do everything for myself.” It’s going to make them less likely to say to somebody like “I haven’t been sleeping that well,” “I’m not making good decision,” or “I’m not eating very well.” That would normally trigger a question about, “Hey, what’s going on?” But often – even if they are aware that something has been changing – they still won’t ask for help.
The other factor that plays into this is that if they tell anybody it will be their primary care physician, who generally doesn’t have a lot of specific training in geriatrics or mental health issues, so that primary care physician who cares for them may not be the best practitioner to try to help them resolve this issue.
EH: Do you think we need more geriatric psychiatrists or psychologists?
Arbore: That’s one of the significant issues: We don’t have enough geriatricians. And with the continued increase in the sheer numbers of older people [it is more important]. We know that the aging baby boomers started turning 65 in January 2011. And it’s estimated that tens of thousands people each day since have been turning 65. There’s this huge increase in older adults but there’s not an accompanying increase in geriatricians.
EH: We’ve heard that one of greatest causes of anxieties among older people is the fear of falling.
Arbore: I just want to emphasize that. There is a lot of training for elderly living in communities, as well as elderly in assisted livings, on fall prevention. The reason for that is if an elderly person falls in the bathroom and hits their head on the sink they could have a traumatic brain injury, which could really affect their ability to live independently. Or they fall and break a hip, and then that will change dramatically the way in which they had been living.
We know that falls can be prevented, but this is where the risk is connected to substance abuse and taking sleep aids at night: If you wake up during the night to go to the bathroom but you are groggy and slip and fall, that could have tremendous negative consequences on your quality of life.
EH: In terms of addiction you are seeing, are these late-in-life alcoholics? Did they start when they were over 65?
Arbore: When it comes to substance abuse, the group that is of most concern would be early-onset alcoholics — people drinking since their teenage years. Then we also have late-onset alcoholics, who in their fifties and sixties turn to alcohol. People will drink to dull strong emotion. For example, they are looking forward to retirement and a couple retires; then one partner develops dementia or has a heart attack or a stroke and dies. All the plans they had for retirement fall apart and the surviving spouse winds up isolated, sad, and grieving, and instead of trying to get support for their grief, turns to alcohol. Alcohol works really well because it always dulls strong emotion. Then you start seeing a lot of older people drinking too much. It’s also a concern because it is a hidden epidemic.
Why Some Are at Higher Risk for Suicide
EH: You mentioned that more men than women take their own lives. Is this true in older people as well?
Arbore: If you look across the age span, when you look at the ratio of gender among all ages, male-to-female suicide death ratio is four men to one female. When you look at the suicide death stats, men are four times more likely to kill themselves. When you look at the older age group, 65-plus, the male-to-female ratio is 12 to 1. Older white men in particular commit suicide more readily than men of other ethnicities and cultures. Firearms are the most frequent way men in this culture commit suicide.
EH: Why are men so overrepresented in the suicide stats? Are these older vets and men of a certain generation who feel they are no longer useful, or a burden to others?
Arbore: One of things is that when someone has the acquired ability for self-injury, a serious suicide attempt can follow. Veterans are very much an at-risk group for suicide. Law enforcement personnel are very much at risk, and both of those populations have acquired the ability for death. Hunters — men who have grown up hunting and killing animals — have acquired the ability to kill and can turn that ability on themselves.
[Suicide can occur] when you combine that with two psychological states, both connected to depression: Perceived burdensomeness and failed belongingness, which is “I don’t feel like I belong again because I fell and broke my hip. I’m in a convalescent center and may never get back to my independent living.” Feeling like you are a burden and feeling like you don’t belong is a lethal combination, and men, more so than women, have acquired that ability for self-injury.
EH: It seems so shocking and unsettling to think your parent or grandparent could grab a gun and end it all.
Arbore: The underlying factor is that we don’t allow ourselves to be aware that our lives are connected to impermanence, and that we are going to die. One of the problems in society is that we live as if we are going to live forever. One of the worst things to be in America today is old. Ageism exists because younger people don’t want to see those old people. What that reminds them of, unconsciously, is that people get old; that you won’t be 30 the next 40 years. In our society we tend to segregate people. We tend to shuttle older people into senior buildings or gated communities as if we can’t have them living with people in their thirties or with children. People don’t really see that it’s a natural experience and that we will all have this experience. That’s a real problem.
Other Mental Disorders Among the Elderly
EH: How prevalent are late in life diagnosis’s of disorders such as bipolar and schizophrenia?
Arbore: The prevalence is not real clear in terms of bipolar disorders in older adults, and that might be because older adults underutilize mental health services and it's under-reported. Or they go to their primary care physicians, who don’t know how to diagnose bipolar disorders. It’s really hard to say. We have a better sense with depression than we do bipolar. If an older person is diagnosed with bipolar disorder, the manic symptoms tend to be milder than in younger people. As for schizophrenia, when you look at people after the age of 40, it tends to be 7 percent to 10 percent who may have features of late-life psychosis.
EH: What about sexuality in older age? Can dementia or loss of cognitive ability lead to loss of control over the erotic impulse?
Arbore: In our culture we act as if sexuality is a taboo subject for older people. That is a very ageist view, and older people internalize that ageist attitude and repress it. What happens, particularly when you have cognitive impairment, is that the capacity to repress that which is an intellectual function no longer operates. What you see then is that people lose that inhibition. Oftentimes this is treated as if they have done a bad thing, so we shame a lot of old people.
We wouldn’t have that particular situation if we recognized that human beings are sexual beings. When you have for generations considered sexuality and sensuality in older people as ugly and taboo, you have to educate the caregiver and older person about appropriate expression of sensuality and sexuality. A caregiver could be projecting negative stereotypes onto that older person. It’s a matter of debunking those negative stereotypes and just simply acknowledging the truth — that older people want to be touched.
EH: Some people would say that it is difficult to talk elderly people into doing something they do not care to do — including something that is best for their well-being.
Arbore: I understand. It is really tough. And there is an ageist attitude, and that ageism is very insidious, because it says older people are rigid in thought and they can’t change; they dig in their heels. That is something we have taught people in this culture. Younger people internalize that negative view of older people, and all of a sudden they are old. We have to teach people that those beliefs can change. That is why we need to have a new view of what it means to grow old in this society. We don’t have to be invisible or rigid in thought. As with sexism and racism, we have to change those beliefs.