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Factors associated with the wish to die in elderly people

Age and Ageing, Sept, 1995 by A.F. Jorm, A.S. Henderson, R. Scott, A.E. Korten, H. Christensen, A.J. Mackinnon

Introduction

According to a recent survey of Australian medical practitioners, 47% had at some time been asked by a patient to hasten death and 96% of these practitioners believed that such requests can sometimes be 'rational' [1]. However, in the context of the debate about euthanasia and assisted suicide, Conwell and Caine [2] have questioned the notion of a rational decision to end one's life. They have argued that most individuals who want to end their life are clinically depressed and that to make a 'rational' decision a person must not be unduly influenced by a mental disorder like depression. A similar view has been expressed by Lindesay [3] specifically concerning elderly patients: '. . tit is remarkable how often elderly suicides are explained away as rational choices, particularly if the individual is physically ill. All too often, this attitude is the result of ageism and therapeutic nihilism; it should be borne in mind that even in the terminally ill elderly, suicidal thoughts are associated with depression and respond to treatment. . .' (p. 359). These views raise the issue of the determinants of the wish to die. Is this invariably a symptom of depression or can other factors lead to a rational decision?

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Despite the large amount of research on suicide and attempted suicide, remarkably little is known about the factors associated with the wish to die per se. In a community survey of the general adult population carried out in the USA in the late 1960s, it was fauna that 5% of people had wished they were dead at some time in the previous year, 1.5% had seriously considered taking their life and 0.6% had made a suicide attempt. Suicidal feelings were more common in women and were associated with psychiatric symptoms, social isolation, physical illness and undesirable life events [4]. Research with elderly samples has shown that the wish to die is a predictor of subsequent mortality, although the factors contributing to this are not known [5, 6].

The present paper used an epidemiological study to investigate factors associated with the wish to die in the elderly. Three classes of factors were investigated: sociodemographic factors (age, sex, marital status), mental health factors (depression, cognitive impairment), and physical health factors (poor self-rated health, disability, pain, sensory Impairment, living m a nursing home or hostel). The choice of these factors was guided by issues surrounding the debate about a rational wish to die and by the literature on suicide and attempted suicide in the elderly [7].

Methods

A general description of the methodology of the survey has been given in previous publications [8-10]. Here we present only the details of the methods which are of particular relevance for this paper.

Survey participants: A sample of persons 70 years and older was selected from the electoral rolls for the adjacent Australian cities of Canberra and Queanbeyan. The sample was drawn to give equal numbers of men and women. For each sex there were three age strata (70-74, 75-79 and 80+ years), with the size of each stratum chosen to be proportional to the number of individuals in that age group. Because individuals who are in residential care may have their names removed from the electoral roll, a separate sample was drawn from the nursing homes and hostels (sheltered accommodation) in the game community. The individuals in residential care were sampled approximately in accordance with their proportion in the total elderly population aged 70+.

The people sampled were sent a letter inviting participation in the survey and then approached at their place of residence by trained professional interviewers. At least some interview data were obtained from 945 community residents and 100 nursing-home or hostel residents. This represents a refusal rate of 31% for the community residents and 30% for the nursing home and hostel residents.

Identification of those who wished to die: A major component of the interview with the subject was the Canberra Interview for the Elderly (CIE) which is a standardized psychiatric interview for use by lay interviewers covering dementia, depression and related disorders [11]. The depression section of the CIE contains questions about thoughts of death and suicide. One question is: `In the last two weeks, have you felt as if you wanted to die?' If the subject answers `yes' or `depends', they are asked: `Have you had such thoughts repeatedly?' Those who had repeated thoughts of wanting to die were defined as the case group and all other subjects (including those with a transient wish to die) as the control group. Data on this question were available from 923 subjects, 868 living in the community and 55 in residential care.

Assessment of associated factors: Three general classes of factors were assessed: socio-demographic factors (age, sex, marital status), mental health (`depression, cognitive impairment), physical health (poor self-rated health, disability, sensory impairment, pain, being in residential care).

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Factors associated with the wish to die in elderly people

Age and Ageing, Sept, 1995 by A.F. Jorm, A.S. Henderson, R. Scott, A.E. Korten, H. Christensen, A.J. Mackinnon

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