​In late 2023, an assisted living facility in southeastern Pennsylvania was shocked by the suicide of an 81-year-old resident. No one had any idea that he was at risk of suicide. No one realized that four men aged 75 and older take their lives in that state every week, and well over 700 men aged 65 and over die by suicide in the United States each month.

In-house suicide risk among long term care providers is increasing with a steadily growing segment of residents. Men aged 75-85 and older have long had the highest suicide rates of any age group. This tragic distinction will persist and worsen in coming decades as Baby Boomers, a generation characterized by a high incidence of suicide across the lifespan, age out.

Suicide risk in older men must be acknowledged and aggressively addressed. Little suicide prevention targets the “oldest old” in general and less still focuses on the oldest men. More problematic is a comparable lack of awareness of the problem among those who serve and advocate for older adults.

Know the Risk Factors of Suicide

Providers must be familiar with the major risk factors for suicide in older men:

• Caucasian
• History of suicidal behavior or self-injury
• Physical/psychological harm/sexual assault/domestic conflict
• Social disconnectedness and isolation
• Financial loss/insecurity/exploitation
• History or presence of psychiatric disorders
• Chronic illnesses; disabilities; other impediments to independent living
• Veteran; military service

Suicidal thoughts may arise after a hospitalization that results in chronic pain, impaired mobility, reduced autonomy, or other conditions limiting self-care.

Circumstances Conducive to Suicide Risk

Providers must pay attention to conditions that may trigger suicidal thoughts in older men such as:

• Loss of spouse or partner
• Depression and anxiety
• Worsening of a long term chronic illness
• Onset of comorbid medical/neurological illness
• Feeling a loss of dignity and control
• Pessimism and seeing life as pointless

Providers should be alert to suicide risk in new residents. Giving up one’s home, community ties, and residing with a spouse or partner are disruptive and traumatizing experiences. These factors are aggravated when such life transitions occur because of an inability to manage activities of daily living or the death of a caregiver spouse.

How Suicide Attempts Happen

The prevailing theory of suicide posits two prerequisites to a potentially fatal suicide attempt: (i) an extremely strong desire to die; and (ii) the capability for lethal self-harm. Intent to die arises from a strong belief that one is a burden to others and/or the belief that one does not belong.

Negative self-perceptions can produce a desire to die. These may lead to a sense of entrapment and defeat. Burdensomeness follows from thinking that one’s death may be more valued than one’s life. A lack of belonging flows from an unmet need for social relationships and a belief that one is not cared for by relatives and friends. Internalization of ageist views may also foment suicidal thinking.

An ability for lethal self-injury must be present for suicidal desire to become suicidal action and override the instinct for self-preservation. Attempting suicide requires the capability for serious self-harm. This is fostered by an elevated pain tolerance, a diminished aversion to severe injury, and a reduced fear of death.

Exposure to hurtful, painful, or violent experiences such as self-neglect and self-injury, elder abuse, interpersonal violence, and other types of trauma promote suicide capability. Repeated physical abuse may bring about indifference to living and lower resistance to both thoughts and acts of self-harm.

Warning Signs of Suicide

Providers must recognize behaviors possibly signaling the presence of suicidality. Examples are statements about being a burden to spouse or family or that they would be better off if he were dead. Other warning signs include:

• Feeling useless, purposeless, and hopeless
• Increasing alcohol use or misuse of prescription medications
• Withdrawing from family, friends, or community activities
• Major mood shifts
• Onset of anxiety, agitation, and sleep problems

Sadly, signs such as these appear all too evident after a suicide. They may be missed in older men who live alone, have minimal social connections, do not engage with caregivers or deliberately hide their feelings. 

Immediate intervention (911) is necessary when imminent danger is indicated by:

• Threats of serious self-injury or suicide
• Seeking lethal means such as weapons, medications, toxins
• Voicing an actionable suicide plan giving the when, how, and possibly where

Screening for Suicide Risk

Screening is a means of detecting thoughts or actions that may signal danger. It generally relies on a structured instrument that distinguishes where a particular individual stands in relation to selected suicide risk factors.

A suicide risk screener should be brief, easy to use, and have demonstrated validity. An example is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is freely available online and does not require any special training. 

The C-SSRS consists of six questions:

1. Have you wished you were dead or wished you could go to sleep and not wake up?
2. Have you had any thoughts of killing yourself?
3. Have you been thinking about how you might do this?
4. Have you had these thoughts and had some intention of acting on them?
5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Suicide risk screening and assessment is not a “one and done” event in older men.

Concluding Comments

Given the inherently high risk of suicide in older men, providers must accept that it may occur in their facility at some point. They must create a context for suicide prevention by making it a policy and practice. There must be ongoing suicide prevention training for all staff and routine resident suicide risk-screenings. Providers must accept that the emergence of suicidal ideation among residents is a hazard akin to falls and infection and treat it similarly.

Tony Salvatore, MA, is the director of suicide prevention at Montgomery County Emergency Service in Norristown, PA. He has a background in home care and long term care and has published several articles on older adult suicide prevention in those settings. He may be contacted at tsalvatore@mces.org.