Life-Weariness, Wish to Die, Active Suicidal Ideation, and All-Cause Mortality in Population-Based Samples of Older Adults.

OBJECTIVES: To investigate potential differences in the strength of associations between different levels of passive and active suicidal ideation and all-cause mortality in older adults. DESIGN: Prospective cohort study. SETTING: Population-based samples of older adults in Gothenburg, Sweden. PARTICIPANTS: Older adults aged 79 and above who participated in any wave of the Gothenburg H70 Birth Cohort Studies or the Prospective Population Study of Women between 1986 and 2015 (n = 2,438; 1,737 women, 701 men; mean age 86.6). MEASUREMENTS: Most intense level of passive or active suicidal ideation during the past month: life-weariness, wish to die, or active suicidal ideation. The outcome was all-cause mortality over 3 years. RESULTS: During follow-up, 672 participants (27.6%) died. After adjustments for sex, age, and year of examination, participants who reported a wish to die (HR 2.01; 95% CI 1.55-2.60) as the most intense level of ideation, but not participants who reported life-weariness (HR 1.40; 95% CI 0.88-2.21) or active suicidal ideation (HR 1.10; 95% CI 0.69-1.76) were at increased risk of all-cause mortality. Reporting a wish to die remained associated with mortality in a fully adjusted model, including somatic conditions, dementia, depression, and loneliness (HR 1.70; 95% CI 1.27-2.26). CONCLUSION: In older adults, reporting a wish to die appears to be more strongly associated with all-cause mortality than either life-weariness or active suicidal ideation.

Engage coaching for caregivers: a pilot trial to reduce loneliness in dementia caregivers.

OBJECTIVES: There are no evidence-based interventions for reducing loneliness in family caregivers of people with dementia (ADRD caregivers), despite heightened risk. We examined feasibility, acceptability, and potential efficacy of a brief behavioral intervention, Engage Coaching for Caregivers, to reduce loneliness and increase social connection for older ADRD caregivers experiencing stress and loneliness. METHODS: A single-arm clinical trial of 8 individual sessions of Engage Coaching delivered remotely. Outcomes assessed 3-months post-intervention included loneliness and relationship satisfaction (co-primary) and perceived social isolation (secondary). RESULTS: Engage Coaching was feasible to deliver, with n = 25 of 30 enrolled completing at least 80% of sessions. 83% indicated the program met expectations and 100% reported the program was suitable and convenient. Improvements were observed in loneliness (standardized response mean [SRM] = 0.63), relationship satisfaction (SRM = 0.56), and perceived social isolation (SRM = 0.70). CONCLUSION: Engage Coaching is a promising behavioral intervention to enhance social connection for older ADRD caregivers.

The Use of Robotic Pets with Older Adults during the COVID-19 Pandemic.

OBJECTIVES: We describe two robotic pet demonstration projects during the COVID-19 pandemic. METHODS: Key project components are stakeholders (settings), inputs (activities), and outputs (interest in programs and participant benefit). RESULTS: Stakeholders are an aging services organization in western NY (Lifespan) which served community-dwelling older adults, and a Veteran's Dementia Care Neighborhood (nursing home) that served 14 older Veterans. Project activities: both sites used commercially available robotic pets, with setting-specific deployment procedures. Outputs: 289 pets were distributed by Lifespan; nine Veterans selected pets and four engaged more actively. Community-dwelling older adults reported high satisfaction; satisfaction with the program in Veterans is evidenced by ongoing engagement via staff observation. CONCLUSIONS: Procedures used by our programs may be useful for agencies and care programs interested in implementing robotic pet programs for community-dwelling older adults and those residing in long-term care. CLINICAL IMPLICATIONS: Robotic pets were sought by individuals and care providers in community and long-term care settings to provide companionship for older adults during the COVID-19 pandemic and may be of benefit to older adults.

A Pilot Randomized Trial of Engage Psychotherapy to Increase Social Connection and Reduce Suicide Risk in Later Life.

BACKGROUND: Targeting social connection to prevent suicide in later life shows promise but requires additional study to identify the most effective and acceptable interventions. This study examines acceptability, feasibility, and efficacy of Engage Psychotherapy to improve subjective disconnection (target mechanisms: low belonging and perceived burden), and improve clinical and functional outcomes (depression, suicide ideation, quality of life). METHODS: Pilot randomized trial with adults age 60 and older who reported feeling lonely and/or like a burden. Participants were randomly assigned to 10 sessions of 'Social Engage' (S-ENG; n = 32) or care-as-usual (CAU; n = 30), with follow-up assessments at 3 weeks, 6 weeks, and 10 weeks. RESULTS: S-ENG is feasible to deliver over 10 sessions and acceptable to older adults who report social disconnection-a population at risk for suicide. Participants were willing and able to focus each session on social engagement and demonstrated high levels of compliance. Social Engage did not show preliminary evidence of impact on belonging or perceived burden but was effective in reducing depressive symptoms and improving social-emotional quality of life. DISCUSSION: S-ENG holds promise for improving social-emotional quality of life and depressive symptoms. Future research is needed to identify and measure target mechanisms that account for clinical and functional improvement.

Social Disconnection in Late Life Suicide: An NIMH Workshop on State of the Research in Identifying Mechanisms, Treatment Targets, and Interventions.

Both social disconnection and suicide are significant public health concerns among older adults, and social disconnection is associated with greater risk for suicide-related thoughts and behaviors in late life. We present a synthesis of research discussed during a workshop hosted by the National Institute of Mental Health on social disconnection and late-life suicide. Social disconnection is related to suicide risk in late life via a variety of mechanisms, including biological, behavioral, and psychological correlates. Researchers in several scientific fields have begun to establish these connections and identify targets for interventions to reduce risk in late life. While research has demonstrated that social connection is amenable to change, there is little research to date on the most evidence-based interventions to mitigate social disconnection or the related risks. However, there are several promising biological, behavioral, and psychological interventions that may target various mechanisms, as well as social disconnection itself. With a relative paucity of research in this area, these lines of study are ripe for innovative investigation. In order to most effectively advance the field, we must establish more consistent definitions of social connection and disconnection; more accurately measure and assess older adults' social needs; examine the most effective approaches and modalities for assessment and intervention; take into account important contextual factors; and apply a translational, convergent scientific approach.

Strategies to Promote Social Connections Among Older Adults During "Social Distancing" Restrictions.

Older age and medical comorbidity are factors associated with more severe illness and risk of death due to COVID-19 infection. Social distancing is an important public health strategy for controlling the spread of the virus and minimizing its impact on the older adult population. It comes at a cost, however. Loneliness is associated with myriad adverse health outcomes, one of which is impaired immune functioning, which adds even greater risk for coronavirus infection, complications and death. Older adults, therefore, are at compound risk, making effective management of loneliness and social isolation in our older patients a high priority target for preventive intervention. In this paper, the authors describe a cognitive-behavioral framework for social connectedness, including evidence-informed strategies clinicians can use to help patients develop a "Connections Plan" to stay connected and promote their social, mental, and physical health during "social distancing" restrictions. This set of strategies can be provided during brief (30 minute) telephone sessions and is analogous to creating a "Safety Plan" for suicide risk. The approach is illustrated with three case examples.

Peer Companionship for Mental Health of Older Adults in Primary Care: A Pragmatic, Nonblinded, Parallel-Group, Randomized Controlled Trial.

OBJECTIVES: To determine whether peer companionship delivered by an aging services agency to socially-disconnected older adult primary care patients was associated with improvement in suicidal ideation depression, anxiety, and psychological connectedness. DESIGN: Pragmatic, nonblinded, parallel-group, randomized controlled trial comparing peer companionship, The Senior Connection (TSC), to care-as-usual (CAU). SETTING: Lifespan, a nonmedical, community-based aging services agency. PARTICIPANTS: Adult primary care patients ages 60 years or older who endorsed feelings of loneliness or being a burden on others. INTERVENTION: TSC was delivered by Lifespan volunteers who provided supportive visits and phone calls in the subjects' homes. CAU involved no peer companion assignment. MEASUREMENTS: The primary outcome was suicidal ideation assessed by the Geriatric Suicide Ideation Scale; secondary outcomes were depression, anxiety, and feelings of belonging and being a burden on others. Data were collected at baseline, 3-, 6-, and 12-months. RESULTS: Subjects (55% female) had a mean age of 71 years. There was no difference between groups in change in suicidal ideation or belonging. Subjects randomized to TSC had greater reduction in depression (PHQ-9; 2.33 point reduction for TSC versus 1.32 for CAU, p = 0.05), anxiety (GAD-7; TSC 1.52 versus CAU 0.28, p = 0.03), and perceived burden on others (INQ; 0.46 TSC versus 0.09 CAU, p <0.01). CONCLUSIONS: TSC was superior to CAU for improving depression, anxiety, and perceived burden, but not suicidal ideation. Although effect sizes were small, the low-cost and nationwide availability of peer companionship justify further examination of its effectiveness and scalability in improving mental health outcomes of socially disconnected older adults.

Domains of Functional Impairment and Their Associations with Thwarted Belonging and Perceived Burden in Older Adults.

Objectives: Functional impairment and social disconnection are risk factors for suicide in later life. This paper examines associations between domains of functional impairment and two forms of social disconnection that are empirically linked to suicide in later life - low (or thwarted) belonging and perceived burden on others.Methods: Participants are 62 older primary care patients (67.68% female, mean age = 72.05) who endorsed feeling lonely or like a burden. Participants completed self-report measures of low belonging and perceived burden (INQ-R) and domains of functional impairment (WHODAS 2.0) at a single time point.Results: Greater perceived burden was associated with greater impairment in activities of daily living ("self-care"), while greater thwarted belonging was associated with greater impairment in social functioning, when controlling for depressive symptoms and age. Domains of mobility, cognition and social participation were not associated with either belonging or perceived burden.Conclusions: Impairment in self-care (ADLs) and social functioning may be more strongly associated with perceived burden and thwarted belonging than other domains of functional impairment.Clinical Implications: Considering specific domains of functional impairment - rather than functioning more broadly - may facilitate tailored interventions to target suicide risk.

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.

Does the timing of suicide risk assessments influence ratings of risk severity?

Clinicians are often tasked with identifying and managing patients who are at risk for suicide. Therefore, greater understanding of factors that impact the efficacy of suicide risk assessments (SRA) are of critical importance. One potential factor that may affect assessments of risk severity is the timing of the evaluation during clinical interview. Given that some patients are reluctant to disclose suicide-related symptoms, it is possible that asking about suicide at the beginning of an interview elicits more false negatives. It is also possible that if risk assessments are conducted in a manner that is encouraging to the patient, timing does not significantly impact patient report. This study examined whether SRA timing within an initial intake interview affects risk severity ratings. Adult psychiatric outpatients (N=169) were randomly assigned to receive a SRA during the beginning or middle of a one-hour intake. We failed to find a significant difference in suicide risk ratings between those who were evaluated at the beginning as compared to the middle of intake (14% versus 15% rated at elevated risk). Findings were not moderated by age, gender, or attempt history. Our results provide preliminary evidence that the timing of SRA may not impact risk severity ratings.

Issues in research on aging and suicide.

OBJECTIVE: Late-life suicide is a complex clinical and public health problem. METHOD: In this article, some of the key complexities inherent in studying late-life suicide are discussed in the service of promoting high-quality late-life suicide prevention science. RESULTS: We discuss the following research issues: the relatively greater lethality of suicidal behavior in later life (compared to younger ages); the lack of data on whether thoughts of death in later life are indicators of suicide risk; the fact that older adults do not tend to seek specialty mental health care, necessitating moving research into primary care clinics and the community; the lack of theory-based research in late-life suicide; the unclear role of cognitive impairment; and the promise of taking a 'patient centered' and 'participatory research' approach to late-life suicide research efforts. CONCLUSION: We believe that these perspectives are too often not capitalized upon in research on suicide prevention with older adults and that voice of the older person could contribute much to our understanding of why older adults think about and act on suicidal thoughts, as well as the most acceptable ways to reach and intervene with those at risk.

The interpersonal needs questionnaire with a shortened response scale for oral administration with older adults.

OBJECTIVES: The purpose of this paper is to examine the psychometric properties and construct validity of the interpersonal needs questionnaire (INQ) using a modified three-point response scale for oral administration with older adults. METHODS: In-home interviews were conducted with 269 participants aged 60 and older who were completing an eligibility interview for a randomized control trial. The INQ was administered orally, as were measures of social support, death and suicide ideation, and meaning in life. RESULTS: A confirmatory factor analysis demonstrated acceptable fit, with all of the items loading significantly onto the associated latent variable of thwarted belongingness or perceived burdensomeness. Construct validity of the measure was supported through an examination of discriminant validity using constructs hypothesized by the interpersonal theory of suicide to be related to the measured constructs, including social support and social integration for thwarted belongingness, social worth and death ideation for perceived burdensomeness, and meaning in life and suicide ideation for both. CONCLUSION: The INQ yields reliable and valid scores of thwarted belongingness and burdensomeness when administered orally using a shortened response scale with older adults. These results help establish the measure as a valuable and practical tool for use in the field of late-life suicide prevention.

Spirituality attenuates the association between depression symptom severity and meaning in life.

OBJECTIVES: This cross-sectional study examined whether spirituality moderates the association between depression symptom severity and meaning in life among treatment-seeking adults. METHOD: Participants were 55 adults (≥60 years of age) newly seeking outpatient mental health treatment for mood, anxiety, or adjustment disorders. Self-report questionnaires measured depression symptom severity (Patient Health Questionnaire-9), spirituality (Spirituality Transcendence Index), and meaning in life (Geriatric Suicide Ideation Scale-Meaning in Life subscale). RESULTS: Results indicated a significant interaction between spirituality and depression symptom severity on meaning in life scores (ß = .26, p = .02). A significant negative association between depression symptom severity and meaning in life was observed at lower but not the highest levels of spirituality. CONCLUSION: In the presence of elevated depressive symptomatology, those participants who reported high levels of spirituality reported comparable levels of meaning in life to those without elevated depressive symptomatology. Assessment of older adult patients' spirituality can reveal ways that spiritual beliefs and practices can be can be incorporated into therapy to enhance meaning in life.

Reasons for attempted suicide in later life.

OBJECTIVE: Using the Interpersonal Theory of Suicide as a guiding framework, we investigated older adults' causal attributions for suicidal behavior. We hypothesized that older adults who attributed their suicidal behavior to thwarted belongingness or perceived burdensomeness would be more likely to use more immediately lethal means and to re-attempt suicide during the 12-month follow-up. DESIGN: Prospective cohort study in western Sweden. PARTICIPANTS: A total of 101 older adults who presented to medical emergency rooms for suicide attempts. MEASUREMENTS: Participants were asked why they attempted suicide. RESULTS: Attributions included: a desire to escape (N = 29), reduced functioning and autonomy (N = 24), psychological problems, including depression (N = 24), somatic problems and physical pain (N = 16), perceived burdensomeness (N = 13), social problems that reflected either thwarted belongingness or family conflict (N = 13), and lack of meaning in life (N = 8); 41 participants provided more than one reason. No specific reason was given by 28 participants, 15 of whom reported not understanding or remembering why they attempted suicide and 13 reported simply wanting to die (or go to sleep and not wake up). As hypothesized, patients who attributed the attempt to thwarted belongingness were more likely to use more immediately lethal means for their index attempt and were more likely to re-attempt during follow-up. This was not the case for those reporting burdensomeness. CONCLUSION: People who attribute suicide attempts to thwarted belongingness use more lethal methods and have a poorer prognosis. Replications across diverse cultural settings are needed to determine whether attributing suicide attempts to thwarted belongingness may warrant increased monitoring.

Course of late-life depression in China is chronic and unremitting.

OBJECTIVE: The world's largest aging population resides in China. Depressive disorders represent a public health problem among older adults in China; however, little is known about the course and natural outcomes with routine treatment in primary care. METHODS: We examined the one-year naturalistic course of depressive symptoms in older adult Chinese primary care patients (Hangzhou, China). FINDINGS: We found slight improvement among most of the older adults who initially presented with mild or subsyndromal depressive symptoms, but marked increase in severity in one group of initially mildly depressed older adults; a lack of improvement among all older adults with severe initial presentations. Greater physical illness burden, lower functional capacity, and lower family support were associated with greater initial depressive symptom severity and lack of improvement over time. CONCLUSION: The naturalistic course of depressive illness in older adult primary care patients in urban China is typically chronic and unremitting for those with severe symptoms and slowly improving for those with milder symptoms. Because access to specialty mental health care is limited, treatments for late-life depression need to be developed that can be effectively and feasibly implemented in Chinese primary care practices.

The association between higher social support and lower depressive symptoms among aging services clients is attenuated at higher levels of functional impairment.

OBJECTIVE: Adults seeking services from the Aging Services Provider Network (ASPN) are at risk for depression. ASPN clients also have high prevalence of both functional impairments and social morbidities. Study of the relationships between these factors may inform the development of interventions for depression in this service setting. METHODS: We interviewed 373 older adults accessing ASPN services and assessed depression symptom severity, functional impairment (instrumental activities of daily living and activities of daily living), and social support. RESULTS: Lower social support and greater functional impairment were associated with greater depressive symptoms. At a high level of functional impairment, the inverse associations between indices of social support and depressive symptoms were attenuated. CONCLUSIONS: Results suggest that older adults with more severe functional impairment may benefit somewhat less from increased social support with respect to depression symptom severity.