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Elderly individuals account for a significant proportion of death by suicide in the United States. Recent statistics from the Centers for Disease Control (CDC) indicated that 14.6 persons per 100,000 aged 65 years or older died by suicide, with the highest risk group being males aged 85 years or older. Within that group, the rate of suicide was 51 per 100,000. Although the overall suicide rate in the elderly population has slightly decreased since 1999 (15.9 per 100,000), nonetheless, death by suicide remains a significant concern.

Factors Associated with Suicide

The majority of suicides occur within the context of a mood disorder with the remainder related to some form of psychiatric disorder including substance abuse, personality pathology, or schizophrenia. In the general population, risk factors for suicide include living in a rural area, owning firearms, and unemployment. For elderly adults, the risk factors vary based on age- and health-related issues. Table 72-1 outlines the risk factors for suicide as well as protective factors that may decrease the possibility of suicidality in elderly patients. With relation to depressive episodes, there is inconclusive evidence discerning between whether late onset (after age 60 years) or early onset, or prior or current depressive episodes are associated with increased risk.

Table 72-1 Risk and Protective Factors Related to Elderly Suicide

Suicide is a complex construct with both biological and psychological etiologic factors. While there is limited information regarding biological components of suicide, the serotonergic system has consistently been implicated in suicide through mechanisms separate from affective disorders. Hydroxyindoleacetic acid, a serotonin metabolite, is significantly associated with suicide. Lower concentrations of hydroxyindoleacetic acid have been found to correlate strongly with suicide lethality, that is, patients with lower concentrations of hydroxyindoleacetic acid have been found to make more lethal suicide attempts. Regarding serotonin receptors, there tends to be an abnormality in the prefrontal cortex of patients who completed suicide, as evidenced by decreased presynaptic serotonin transporter sites. Also, compared to patients with no suicidal tendencies, patients with suicidal tendencies have increased serotonergic neurons in the dorsal raphe nucleus. The noradrenergic system has also been implicated in suicide, with research showing high noradrenalin levels in the prefrontal cortex and lower levels in the brainstem. In examining the dopaminergic system, while it has been found to be abnormal in patients with depression, there is too little research to conclude its association with suicide. Thus, research is required to further elucidate the psychiatric contributions to suicide as well as understand the connectivity between psychological, biological, ...

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