A controlled examination of acute warning signs for suicide attempts among hospitalized patients.

BACKGROUND: Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt. METHODS: Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period). RESULTS: Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses. CONCLUSIONS: The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

A Paucity of Data on Veterans 65 and Older and Risk of Suicide: A Systematic Review.

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.

Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia.

OBJECTIVES: To examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time. DESIGN: Retrospective cohort study based on secondary data analyses. SETTING: New York State Medicare beneficiaries who were admitted to an SNF in 2014. PARTICIPANTS: Total of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home. MEASUREMENTS: We used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics. RESULTS: Among SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD. CONCLUSION: Newly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.

Improving Suicide Risk Detection and Clinical Follow-up after Discharge from Nursing Homes.

Objectives: Suicide Awareness for Veterans Exiting Community Living Centers (SAVE-CLC) is a brief intervention to standardize suicide-risk screening and clinical follow-up after VA nursing home discharge. This paper examines the outcomes of SAVE-CLC compared to care as usual.Methods: A quasi-experimental evaluation was conducted (N = 124) with SAVE-CLC patients (n = 62) matched 1:1 to a pre-implementation comparison group. Data were obtained through VA Corporate Data Warehouse resources and chart reviews. Outcomes examined (within 30/90 days of discharge) included mortality rates, frequency of outpatient mental health visits, emergency department visits, rehospitalizations, depression screens (PHQ-2), and the latency period for outpatient mental health care.Results: A greater portion of SAVE-CLC patients received a depression screen after discharge, n = 42, 67.7% versus n = 8, 12.9%, OR = 14.2 (5.7, 35.3), p < .001. The number of days between discharge and first mental health visit was also substantially shorter for SAVE-CLC patients, M = 8.9, SD = 8.2 versus M = 17.6, SD = 9.1; t = 2.47 (122), p = .02. Significant differences were not observed in emergency department visits, hospitalizations, or mortality.Conclusions: SAVE-CLC is a time-limited intervention for detecting risk and speeding engagement in mental health care in the immediate high-risk post-discharge period.Clinical Implications: Care transitions present an important opportunity for addressing older adults' suicide risk; brief telephone-based interventions like SAVE-CLC may provide needed support to individuals returning home.

Social Connection and Psychosocial Adjustment among Older Male Veterans Who Return to the Community from VA Nursing Homes.

OBJECTIVES: The goal of this study was to examine psychosocial adjustment following transition from the nursing home (NH) to community and understand the ways in which adjustment intersects with social connection. METHODS: We conducted interviews with community-dwelling older male Veterans after they were discharged from an NH. Interviews focused on Veterans' experience during the transition process. We utilized conventional content analysis to inductively code the interviews. We reviewed evidence in each identified domain for common themes. RESULTS: We interviewed 13 NH residents after recent transitions from the NH back to the community. Four themes were identified: (1) access to and quality of social support network are important for social connection, (2) engagement in meaningful activities with family and friends improves well-being, (3) service providers form link to social connection, and (4) external stressors affect the quality of social connections. CONCLUSIONS: Identified themes aligned with respondents' social connectedness and perceived psychosocial and physical well-being. Our results suggest that social connectedness is one part of the larger milieu of healthy aging including the importance of engagement with social opportunities and having a purpose. CLINICAL IMPLICATIONS: Social connectedness is critical to assess for older adults transitioning between care settings. Developing screening tools and other interventions focused on social isolation are needed.

Serious Mental Illness in Nursing Homes: Roles and Perceived Competence of Social Services Directors.

Providing nursing home psychosocial care to persons with serious mental illnesses (SMI) requires understanding of comorbidities and attention to resident rights, needs and preferences. This quantitative study reports how 924 social service directors (SSDs) taking part in the National Nursing Home Social Service Director survey identified their roles and competence, stratified by the percentage of residents with SMI. More than 70% of SSDs, across all categories of homes, reported the social services department was "always" involved in conducting depression screening, biopsychosocial assessments and PASRR planning. SSDs in homes with lower concentrations of residents with SMI reported less involvement in anxiety screening. Those employed in homes with higher concentrations of residents with SMI reported lower involvement conducting staff interventions for resident aggression or making referrals. More than one-fifth of SSDs lacked confidence in their ability to compare/contrast dementia, depression, and delirium or to develop care plans for residents with SMI. SSDs' perceived competence in developing care plans for residents with SMI was associated with education and involvement in care planning. About one-quarter of social services directors reported not being prepared to train a colleague on how to develop care plans for residents with SMI. Training in SMI could enhance psychosocial care.

Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes.

Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.

About a Third of Nursing Home Social Services Directors Have Earned a Social Work Degree and License.

Nursing home (NH) residents have high psychosocial needs related to illness, disability, and changing life circumstances. The staff member with the most expertise in addressing psychosocial needs is the social worker. However, federal regulations indicate that only NHs with 120+ beds need hire a social services staff member and that a "qualified social worker" need not have a social work degree. Therefore, two-thirds of NHs are not required to employ a social services staff member and none are required to hire a degreed social worker. This is in stark contrast to NASW professional standards. Reporting findings from this nationally representative sample of 924 social services directors, we describe the NH social services workforce and document that most NHs do hire social services staff, although 42% of social services directors are not social work educated. 37% of NHs have a degreed and licensed social worker at the helm of social services. The odds of hiring a degreed and licensed social workers are higher for larger NHs, especially if not-for-profit and not part of a chain. NH residents deserve psychosocial care planned by staff with such expertise. Quality of psychosocial care impacts quality of life.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Older Veterans following Discharge from VA Nursing Facilities.

Objective: We describe the development and implementation of a telephonic intervention (SAVE-CLC) piloted at three VA sites for Veterans returning to the community from VA nursing facilities (Community Living Centers or "CLCs"). Care transitions present a known period of medical risk for older adults and may pose increased risk for suicide. Veterans discharging from CLCs are at elevated risk compared to age and gender matched controls.Methods: Using a quality improvement approach, input was gathered from key stakeholders to aid in the development of the intervention. Veterans were screened for depressive symptoms and need for additional support by phone.Results: Of the Veterans who received the SAVE-CLC intervention, 87.9% had at least one prior mental health diagnosis, though only 19.7% had an outpatient mental health appointment arranged at CLC discharge. Results suggest that the intervention is feasible across multiple outpatient settings and is generally well-received by Veterans and caregivers, with 97% of those contacted reporting that the telephone calls were helpful.Conclusion: This flexible, telephone-based intervention addresses the unmet need of integrating mental health care into discharge planning during care transitions.Clinical Implications: SAVE-CLC offers a feasible and acceptable solution to suicide risk in older Veterans exiting a CLC.

Safety Planning to Manage Suicide Risk with Older Adults: Case Examples and Recommendations.

Adults age 65 and older have high rates of suicide, despite recent efforts to reduce the suicide rate in this population. One suicide prevention strategy with burgeoning empirical support is safety planning; however, there is a lack of information and resources on safety planning for older adults to support uptake of this evidence-based practice in clinical settings where older adults are commonly seen. Safety plans can address risk factors for suicide in older adults, including social isolation, physical illness, functional limitations, and use of highly lethal means. Safety plans also promote relevant protective factors, including increasing use of coping strategies, social support, and help-seeking. Clinicians may encounter challenges and barriers to safety planning with older adults. This paper describes a collaborative, creative approach to safety planning that is relevant and useful for this vulnerable population. Using two case examples, we illustrate how to engage older adults in safety planning, including ways to minimize barriers associated with the aging process.

Age Differences in Suicide Risk Screening and Management Prior to Suicide Attempts.

OBJECTIVE: This study examined differences by age in suicide risk screening and clinical actions to reduce suicide risk among patients with visits to Veterans Health Administration (VHA) medical facilities in the year prior to an attempt. METHODS: Ninety-three VHA patient records were reviewed specific to the last visit before an attempt. Information was extracted regarding documentation of individual suicide risk factors and provider actions to reduce risk. RESULTS: The authors examined differences by patient age (≥50 versus 18-49). Older patients' medical records were less likely to have evidence of 1) screening for impulsivity and firearms access and 2) engagement in safety planning, referrals for mental health services, and consideration of psychiatric hospitalization. General medical providers were less likely to document these risk factors and action steps in comparison with mental health clinicians. CONCLUSION: Lethal means education and collaborative care are universal strategies that may improve identification of and lower suicide risk in older veterans.

Treatment of depression in nursing home residents without significant cognitive impairment: a systematic review.

BACKGROUND: Depression in nursing facilities is widespread and has been historically under-recognized and inadequately treated. Many interventions have targeted depression among residents with dementia in these settings. Less is known about depression treatment in residents without dementia who may be more likely to return to community living. Our study aimed to systematically evaluate randomized control trials (RCTs) in nursing facilities that targeted depression within samples largely comprised of residents without dementia. METHODS: The following databases were evaluated with searches covering January 1991 to December 2015 (PubMed, PsycINFO) and March 2016 (CINAHL). We also examined national and international clinical trial registries including ClinicalTrials.gov. RCTs were included if they were published in English, evaluated depression or depressive symptoms as primary or secondary outcomes, and included a sample with a mean age of 65 years and over for which most had no or only mild cognitive impairment. RESULTS: A total of 32 RCTs met our criteria including those testing psychotherapeutic interventions (n=13), psychosocial and recreation interventions (n=9), and pharmacologic or other biologic interventions (n=10). Seven psychotherapeutic, six psychosocial and recreation, and four pharmacologic or other biologic interventions demonstrated a treatment benefit. CONCLUSIONS: Many studies had small samples, were of poor methodological quality, and did not select for depressed residents. There is limited evidence suggesting that cognitive behavioral therapies, reminiscence, interventions to reduce social isolation, and exercise-based interventions have some promise for decreasing depression in cognitively intact nursing home residents; little can be concluded from the pharmacologic or other biologic RCTs.

Professional and practice characteristics associated with self-efficacy in assessment and intervention among social workers in aging.

This study examined professional and practice characteristics associated with assessment and intervention self-efficacy among gerontological social workers in Ontario, Canada who participated in online surveys. Results from multivariate analyses indicated that higher client acuity, longer duration of practice experience, smaller caseloads, and a greater proportion of clients 85 and over were significantly associated with greater assessment self-efficacy. Greater client acuity and smaller caseloads were also significantly associated with greater intervention self-efficacy. Implications for education include the importance of providing practical experience with the oldest old and with clients with greater biopsychosocial complexity. Also recommended is the need for manageable caseloads, especially when older adults with complex needs are part of the practice milieu.

Job Satisfaction Among Gerontological Social Workers in Ontario, Canada.

Little is known about job satisfaction among Canada's social work workforce in aging, although social workers remain a key component of interdisciplinary care in health and social service settings. This study begins to address this gap in knowledge by examining individual, interpersonal, and job-design factors influencing the job satisfaction of gerontological social workers in Ontario. Data were collected via two online surveys with a sample drawn from the Ontario Association of Social Workers' membership list (N = 104). A multiple regression model explained 37% of the variance in job satisfaction, F = 5.47[10, 93], p < .001). Three independent variables were significant (positive affect, ß = .21; promotional chances, ß = .21; and client acuity, ß = -.18). The results suggest the importance of promoting strategies for enhancing job satisfaction, advancing promotional opportunities for social work clinicians, and providing educational and clinical supports to clinicians.

Gerontological social workers' perceived efficacy for influencing client outcomes.

Using a sample of practitioners (n = 269) from the 2004 National Study of Licensed Social Workers, this article employs a quality assurance structure-process-outcome model to examine factors at the practitioner, workplace, and service delivery levels that influence the perceived efficacy of licensed gerontological social workers to affect client outcomes in the context of a highly challenging health care environment. A regression model accounted for 33.9% of the variance (adjusted R (2) = .291) in perceived efficacy with 3 aspects of service delivery satisfaction having significant effects: ability to address complex/chronic care, to influence the design of services, and to help clients navigate the system.

Care Transitions to the Community from Veterans Affairs Nursing Homes: Experiences of Social Connection and Disconnection.

OBJECTIVE: This study aimed to further knowledge of older Veterans' experiences with transitioning to the community from Veterans Affairs nursing homes (Community Living Centers or CLCs) with emphasis on social functioning. DESIGN: A qualitative study design was used in addition to administration of standardized depression and mental status screens. SETTING AND PARTICIPANTS: Veterans (n = 18) and caregivers (n = 14) were purposively sampled and recruited from 2 rural CLCs in Upstate New York. METHODS: Semistructured interviews were completed with Veterans in the CLC prior to discharge (to explore experiences during the CLC stay and expectations regarding discharge and returning home) and in the home 2-4 weeks postdischarge (to explore daily routines and perceptions of overall health, mental health, and social functioning). Caregivers participated in 1 interview, completed postdischarge. The 9-item Patient Health Questionnaire and the Brief Interview for Mental Status were administered postdischarge. RESULTS: Thematic analysis of verbatim transcriptions revealed 3 inter-related themes: (1) Veterans may experience improved social connectedness in CLCs by nature of the unique care environment (predominantly male, shared military experience); (2) Experiences of social engagement and connectedness varied after discharge and could be discordant with Veterans' expectations for recovery prior to discharge; and (3) Veterans may or may not describe themselves as "lonely" after discharge, when physically isolated. Veterans lacked moderate to severe cognitive impairment (Brief Interview for Mental Status: range = 14-15); however, they reported a wide range in depressive symptom severity postdischarge (9-item Patient Health Questionnaire: mean = 4.9, SD = 6.1, median/mode = 3, range = 0-23). CONCLUSIONS AND IMPLICATIONS: This study identified a potential for increased social isolation and disengagement after discharge from Veterans Affairs nursing homes. Nursing homes should integrate social functioning assessment for their residents, while extending care planning and transitional care to address patient-centered social functioning goals.

Assessing Social Functioning During COVID-19 and Beyond: Tools and Considerations for Nursing Home Staff.

Social functioning is defined as how a person operates in their unique social environment (ie, engagement in activities, connectedness with others, and contributions to social roles). Healthy social functioning is important for nursing home residents as they are at increased risk for loneliness and isolation. Social functioning has long been an underacknowledged aspect of nursing home residents' health, but now, with the COVID-19 pandemic, residents' risk for decreased social functioning is increased. Several reliable and well-validated tools are available to supplement routine care planning and delivery and track and improve changes in social functioning over time. The overarching aim of this article is to provide resources and recommendations for interdisciplinary team assessment related to social functioning for nursing home residents. We describe 2 domains of social functioning measures, care-planning measures and outcome measures, and provide recommendations for how to integrate said measures into practice. Healthy social functioning is needed to maintain nursing home residents' well-being and quality of life. Measures and recommendations outlined in this article can be used by nursing home staff to understand residents' social preferences and address social functioning during COVID-19 and beyond.

Sleep and Suicide in Older Adults: An Opportunity for Intervention.

Whether as a standalone disorder or as a symptom associated with existing pathology, the prevalence of sleep disturbance increases with age. Older adults also experience a myriad of risk factors for suicide, including depression, and have elevated rates of suicide. There is now significant evidence linking sleep disturbances to suicidal thoughts and behaviors. The use of pharmacologic means to treat insomnia (e.g., sedative hypnotics) is also commonplace among older cohorts and has been associated with suicide. Behavioral treatment of insomnia represents an efficacious alternative to pharmacotherapy among older adults, which while improving sleep, may concurrently reduce depressive symptomatology. Implications and clinical recommendations of the sleep-suicide relationship are discussed.

State of innovation in suicide intervention research with military populations.

A systematic search was performed to identify active, externally funded randomized controlled trials (RCTs) that target suicidal ideation or behavior as a primary or secondary outcome among U.S. military service members, guard-reservists, and veterans. Twenty-three studies were identified, most funded by the U.S. Department of Defense or U.S. Department of Veterans Affairs. Several innovations were identified based on departures from or modernizations of usual practices and included the targeting of suicide deaths or attempts as primary outcome, delivery of interventions through technology and/or outside clinical settings, and examinations of rarely studied treatments.

Aging and place in long-term care settings: influences on social relationships.

OBJECTIVE: This article presents results of a qualitative research study that examined how living in a long-term care (LTC) home influences the quality of residents' relationships with peers, family members, and outside friends. METHOD: Semistructured interviews using a phenomenological approach were conducted with 23 residents of a LTC home. Thematic analysis was employed to illuminate residents' perspectives on the nature of social relationships in this setting. RESULTS: Four key themes were identified that highlight the role of place in social relationships. Residing in a LTC home influences the context of social interactions, impacts their quality and process, clusters individuals with health and functional declines that hinder socialization, and poses structural and cultural barriers that impede social interactions. Health and functional limitations posed the greatest challenge to socialization relative to characteristics of the facility itself. DISCUSSION: Residents' insights emphasize how personal characteristics influence community culture and the experience of place.