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The Journals of Gerontology Series B: Psychological Sciences and Social Sciences logoLink to The Journals of Gerontology Series B: Psychological Sciences and Social Sciences
. 2024 Jul 30;79(9):gbae129. doi: 10.1093/geronb/gbae129

Mild Cognitive Impairment and Suicidal Ideation Among Adults Aged 65 Years or Older From Low- and Middle-Income Countries

Lee Smith 1, Guillermo Felipe López Sánchez 2,✉, Pinar Soysal 3, Nicola Veronese 4, Louis Jacob 5,6, Karel Kostev 7, Masoud Rahmati 8,9, Yvonne Barnett 10, Helen Keyes 11, Poppy Gibson 12, Laurie Butler 13, Jae Il Shin 14,15, Ai Koyanagi 16
Editor: Annie Nguyen
PMCID: PMC11367256  PMID: 39078933

Abstract

Objectives

Mild cognitive impairment (MCI) is a unique indicator of underlying distress that may be strongly associated with suicide risk. Despite this, to date, no study has examined the association between MCI and suicidal ideation. Therefore, the present study aimed to examine the association between MCI and suicidal ideation among adults aged ≥65 years from 6 low- and middle-income countries (LMICs; China, Ghana, India, Mexico, Russia, and South Africa).

Methods

Cross-sectional, nationally representative data from the World Health Organization’s Study on Global Ageing and Adult Health were analyzed. MCI was defined using the National Institute on Aging-Alzheimer’s Association criteria. Self-reported information on past 12-month suicidal ideation was collected. Multivariable logistic regression and meta-analysis were conducted to assess associations.

Results

Data on 13,623 individuals aged ≥65 years were analyzed. The prevalence of suicidal ideation ranged from 0.5% in China to 6.0% in India, whereas the range of the prevalence of MCI was 9.7% (Ghana) to 26.4% (China). After adjustment for potential confounders, MCI was significantly associated with 1.66 (95% confidence interval [95% CI] = 1.12–2.46) times higher odds for suicidal ideation.

Discussion

Mild cognitive impairment was significantly associated with higher odds for suicidal ideation among older adults in LMICs. Future longitudinal studies from LMICs are necessary to assess whether MCI is a risk factor for suicidal ideation.

Keywords: Cognitive decline, Public health, Suicide risk, Suicidal thoughts

Approximately 703,000 people die by suicide each year, and there are many more people who attempt suicide. Importantly, 77% of global deaths by suicide occurred in low- and middle-income countries (LMICs) in 2019 (World Health Organization, 2021). The rate of suicide increases with age among people older than 60 years (Shah et al., 2016), while older men and women show the highest suicide rate in almost all countries (Conejero et al., 2018; World Health Organization, 2019). Importantly, nonfatal and fatal suicide attempts have profound impacts on society and families. For example, the literature suggests that suicide within the family unit has the potential to warp family patterns and contribute to the development of psychiatric disorder in surviving family members (Jordan, 2001).

Suicidal ideation, or having thoughts about dying by suicide, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide (Harmer et al., 2020). It is known that suicidal ideation usually precedes a suicide attempt, and that suicide attempt is the single most important risk factor for subsequent fatal suicides (Slade et al., 2009). Thus, identification of the risk factors for suicidal ideation is important to aid in the development of targeted interventions to prevent deaths by suicide.

Although a large body of literature exists on the risk factors or correlates of suicidal ideation (Smith et al., 2022; Smith, Shin, et al., 2021), one understudied potential risk factor for or correlate of suicidal ideation is that of mild cognitive impairment (MCI). MCI is a syndrome defined as cognitive decline greater than expected for an individual’s age and education level but that does not interfere notably with activities of daily life (Gauthier et al., 2006). MCI is a preclinical state of dementia with a high conversion rate to dementia (annual conversion rates ranging from 10% to 15% in clinical samples and 3.8% to 6.3% in community-based samples; Bohlken et al., 2019; Farias et al., 2009; Morris, 2005). It is possible for MCI to be a unique indicator of underlying distress that may be highly associated with suicide risk (Petersen, 2004; Petersen et al., 2009, 2018; Roberts & Knopman, 2013; Winblad et al., 2004). Literature has also identified that MCI is associated with a lower level of quality of life (QoL; Hussenoeder et al., 2020) and a low level of QoL has been shown as an important correlate of suicidal behavior (Alves et al., 2016). Moreover, MCI is associated with higher levels of systemic inflammation, such as serum amyloid A and tumor necrosis factor-α (Trollor et al., 2010). Importantly, systemic inflammation per se has been implicated in suicidal behaviors (Brundin et al., 2017). Despite this, only two previous studies have examined the association between MCI and suicidality or fatal suicide attempts. In one U.S. prospective study including 147,595 older adults, after adjustment for demographics and medical and psychiatric comorbidities, risk of suicide attempt was consistently highest for patients with a recent MCI or dementia diagnosis, with adjusted hazard ratios of 1.73 (95% confidence interval [95% CI] = 1.34–2.22; p < .001) for recent MCI and 1.44 (95% CI = 1.17–1.77; p = .001) for recent dementia. A prior diagnosis of these conditions was not significantly associated with suicide attempts (Günak et al., 2021). In contrast, in another prospective study including 10,169 older Korean patients diagnosed with dementia or MCI, the risk of death by suicide was not significantly different between those with and without cognitive impairment (An et al., 2019). These two studies have a number of important limitations. First, they were both carried out in high-income countries, and to date, there are no studies on this topic from LMICs. Second, the existing studies focus on either suicide attempt or death by suicide, but no study to date has investigated the association between MCI and suicidal ideation. Finally, no multicountry studies exist on this topic. Multicountry studies using standardized methods across countries are important as they can provide information on whether associations are context-specific.

Given this background, the aim of the present study was to examine the association between MCI and suicidal ideation in 13,623 adults aged ≥65 years consisting of representative samples from six LMICs (China, Ghana, India, Mexico, Russia, and South Africa).

Method

We analyzed data from the Study on Global Ageing and Adult Health (SAGE), which was a survey undertaken in China, Ghana, India, Mexico, Russia, and South Africa between 2007 and 2010. Based on the World Bank classification at the time of the survey, Ghana was a low-income country, and China and India were lower middle-income countries although China became an upper middle-income country in 2010. The remainder of the countries were upper middle-income countries. Details of the survey methodology can be found elsewhere (Kowal et al., 2012). Briefly, in order to obtain nationally representative samples, a multistage clustered sampling design method was employed. The sample consisted of adults aged ≥18 years with oversampling of those aged ≥50 years. Trained interviewers conducted face-to-face interviews using a standard questionnaire. Standard translation procedures were undertaken to ensure comparability between countries. The survey response rates were: China 93%; Ghana 81%; India 68%; Mexico 53%; Russia 83%; and South Africa 75%. Sampling weights were constructed to adjust for the population structure as reported by the United Nations Statistical Division. Ethical approval was obtained from the WHO Ethical Review Committee and local ethics research review boards. Written informed consent was obtained from all participants.

Suicidal Ideation

Information on suicidal ideation was assessed in the same way as in previous SAGE publications (Cabello et al., 2020; Ghose et al., 2019; Smith, Shin, et al., 2021), using an adapted version of the depression module of the WHO Composite International Diagnostic Interview (Kessler & Üstün, 2004). Those who screened positive in the depression module were further asked about suicidal ideation. A positive screen referred to having at least one of the three following conditions for more than 2 weeks in the past 12 months: sadness, loss of interest, or low energy. Suicidal ideation was assessed by the question “Did you think of death, or wish you were dead?” with “yes” and “no” answer options (Cabello et al., 2020; Ghose et al., 2019).

Mild Cognitive Impairment

MCI was ascertained based on the recommendations of the National Institute on Aging-Alzheimer’s Association (Albert et al., 2011). We applied the identical algorithms used in previous SAGE publications to identify MCI (Koyanagi et al., 2018, 2019). Briefly, individuals fulfilling all of the following conditions were considered to have MCI:

  • (a) Concern about a change in cognition: Individuals who replied “bad” or “very bad” to the question “How would you best describe your memory at present?” and/or those who answered “worse” to the question “Compared to 12 months ago, would you say your memory is now better, the same or worse than it was then?” were considered to have this condition.

  • (b) Objective evidence of impairment in one or more cognitive domains: was based on a < −1 SD cutoff after adjustment for level of education, age, and country. Cognitive function was assessed through the following performance tests: word list immediate and delayed verbal recall from the Consortium to Establish a Registry for Alzheimer’s disease (Morris et al., 1989), which assessed learning and episodic memory; digit span forward and backwards from the Weschler Adult Intelligence Scale (Tulsky & Ledbetter, 2000), that evaluated attention and working memory; and the animal naming task (Morris et al., 1989), which assessed verbal fluency.

  • (c) Preservation of independence in functional abilities was assessed by questions on self-reported difficulties with basic activities of daily living (ADL) in the past 30 days (Katz et al., 1963). Specific questions were: “How much difficulty did you have in getting dressed?” and “How much difficulty did you have with eating (including cutting up your food)?” The answer options were none, mild, moderate, severe, and extreme (cannot do). Those who answered either none, mild, or moderate to both of these questions were considered to have preservation of independence in functional activities. All other individuals were deleted from the analysis (666 individuals aged ≥65 years).

  • (d) No dementia: Individuals with a level of cognitive impairment severe enough to preclude the possibility to undertake the survey were not included in the current study.

Control Variables

The selection of control variables was based on previous literature (Günak et al., 2021; Lara et al., 2016), and included age, sex, years of education received, wealth quintiles based on income, diabetes, hypertension, and stroke. Stroke and diabetes were based solely on self-reported lifetime diagnosis. Hypertension was defined as having at least one of: systolic blood pressure ≥140 mmHg; diastolic blood pressure ≥90 mmHg; or self-reported diagnosis.

Statistical Analysis

The statistical analysis was performed with Stata 14.2 (StataCorp LP, College station, TX, USA). The analysis was restricted to those aged ≥65 years as MCI is an age-related condition, and because the focus of our study was on older people, for which a commonly used definition is ≥65 years (National Institute on Aging, 2024). We conducted a country-wise multivariable logistic regression analysis to assess the association between MCI (exposures) and suicidal ideation (outcomes). The regression analysis was adjusted for age, sex, education, wealth, diabetes, hypertension, and stroke. Furthermore, in order to assess the between-country heterogeneity that may exist in the association between MCI and suicidal ideation, we calculated Higgins’s I2 based on estimates from each country. Higgins’s I2 represents the degree of heterogeneity that is not explained by sampling error with a value of <40% often considered as negligible and 40%–60% as moderate heterogeneity (Higgins & Thompson, 2002). A pooled estimate was obtained by fixed-effect meta-analysis. All variables were included in the models as categorical variables, with the exception of age and years of education (continuous variable). For each country, we also conducted interaction analysis to assess whether age is an effect modifier in the association between MCI and suicidal ideation by including an interaction term of MCI × age in the model. The sample weighting and the complex study design were taken into account in the analyses. Results from the regression analyses are presented as odds ratios (ORs) with 95% CIs. The level of statistical significance was set at p < .05.

Results

A total of 13,623 individuals aged ≥65 years with preservation of independence in functional abilities were included in the analysis. The sample sizes by country were: China n = 5,094; Ghana n = 1,904; India n = 2,211; Mexico n = 1,179; Russia n = 1,820; South Africa n = 1,415. The sample characteristics are provided in Table 1. The prevalence of suicidal ideation ranged from 0.5% in China to 6.0% in India, while the range of the prevalence of MCI was 9.7% (Ghana) to 26.4% (China). The proportion of females was particularly high in Russia, while levels of education were lowest in Ghana and India. The prevalence of diabetes, hypertension, and stroke was highest in Mexico (17.7%), South Africa (82.3%), and Russia (9.2%), respectively. The prevalence of suicidal ideation was higher in those with MCI in all countries (Figure 1). For example, in Ghana, the prevalence of suicidal ideation in those without MCI was 4.4% but this increased to 9.3% among those with MCI. The country-wise association between MCI and suicidal ideation estimated by multivariable logistic regression is shown in Figure 2. In all countries, there was a positive association between MCI and suicidal ideation (i.e., OR > 1), with the exception of India. The overall estimates based on a meta-analysis showed that MCI is significantly associated with 1.66 (95% CI = 1.12–2.46) times higher odds for suicidal ideation, with a low level of between-country heterogeneity (I2 = 0.0%). No significant interaction by age was observed in the association between MCI and suicidal ideation in any of the countries included in the study.

Table 1.

Sample Characteristics by Country

Characteristic China Ghana India Mexico Russia South Africa
Suicidal ideation Yes 0.5 4.9 6.0 2.8 2.9 1.1
Mild cognitive impairment Yes 26.4 9.7 12.5 17.3 14.8 11.3
Age (years) Mean (SD) 72.1 (10.6) 74.0 (13.8) 71.2 (9.3) 73.9 (14.0) 73.8 (9.8) 72.7 (14.8)
Sex Male 46.8 52.5 53.2 45.6 32.4 39.0
Education (years) Median (IQR) 4 (0–8) 0 (0–4) 0 (0–5) 3 (1–6) 10 (7–13) 5 (0–8)
Diabetes Yes 9.3 3.7 6.9 17.7 8.6 12.1
Hypertension Yes 69.2 59.8 41.3 74.3 82.0 82.3
Stroke Yes 5.2 4.2 4.0 7.7 9.2 4.7
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Notes: IQR = interquartile range; SD = standard deviation. Data are % unless otherwise stated.

Figure 1.

Figure 1.

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Country-wise prevalence of suicidal ideation by mild cognitive impairment status. MCI = mild cognitive impairment. The prevalence refers to crude prevalence (i.e., not adjusted for covariates).

Figure 2.

Figure 2.

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Country-wise association between mild cognitive impairment and suicidal ideation estimated by multivariable logistic regression. CI = confidence interval; OR = odds ratio. Models are adjusted for age, sex, education, wealth, diabetes, hypertension, and stroke. Overall estimate was obtained by meta-analysis with fixed effects.

Discussion

Main Findings

The present study using nationally representative data from six LMICs found that MCI is associated with a significant 1.66 times higher odds for suicidal ideation among adults aged ≥65 years, and that there was a low level of between-country heterogeneity. To the authors’ knowledge, this is the first study to examine the relationship between MCI and suicidal ideation, and also the first to investigate the association between MCI and suicidality in LMICs.

Interpretation of the Findings

The results of our study are in line with one previous U.S. study on veterans, which found that a recent MCI diagnosis is associated with higher risk for suicide attempts (Günak et al., 2021). Moreover, the present findings support previous work that has investigated cognitive impairment per se and suicidality, finding a higher odds of suicidality among those with cognitive impairment compared to those without (Ayalon et al., 2007; Richard‐Devantoy et al., 2015). There are several plausible pathways that may explain the link between MCI and suicidal ideation. First, those with MCI may fear a potential progressive decline in cognition and a subsequent diagnosis of dementia, which may entail loss of autonomy and the possibility to become a burden to significant others, and this may result in suicidal ideation (Günak et al., 2021). Second, MCI is associated with higher levels of systemic inflammation (Trollor et al., 2010), which has been implicated in suicidal behaviors (Brundin et al., 2017). Third, MCI has been found to be associated with a reduction in interpersonal relationships (Lara et al., 2019). Importantly, loneliness and social isolation have both been observed to increase the risk of suicidal ideation (Beutel et al., 2017), possibly due to thwarted belongingness and increased levels of distress (Beutel et al., 2017; Nofuji et al., 2012). Finally, both anxiety and depression have been reported to be highly prevalent among those with MCI (Defrancesco et al., 2009; Smith, Jacob, et al., 2021). For example, MCI and depression may share similar underlying neuropathology including vascular diseases (Alexopoulos, 2003), while the link between anxiety and MCI may be explained by factors such as sleep problems. In turn, anxiety and depression have been implicated in the development of suicidality (Kułak-Bejda et al., 2021; Nepon et al., 2010).

Implications of the Study Findings

Our study results tentatively suggest that interventions targeting those with MCI may aid in the reduction of suicidal ideation, although studies of longitudinal design from LMICs are needed to confirm this. Although there is a paucity of literature in relation to interventions to address suicidality among those with MCI, we can draw on findings in relation to early-stage dementia. The literature suggests that such interventions should focus on improving perceived health, increasing activities of daily living and social support, and reducing depression (Kim & Yang, 2017). To achieve such aims, mind-body exercises (e.g., yoga and tai-chi) may be particularly useful in LMICs. Such interventions could be cost-effective, and have been found to improve mental and physical health (including cognition), activities of daily living, and increase interpersonal connections. Moreover, they have been found to be feasible to implement in LMICs (Chan et al., 2017; Kong et al., 2019; Penn et al., 2019; Valdivia et al., 2020; Yeh et al., 2009). Furthermore, an emerging body of literature from LMICs suggests that task-sharing may be an appropriate implementation approach to address mental health complications (Kohrt et al., 2018). Task-sharing refers to the use of nonspecialist providers, such as community health workers, lay volunteers, teachers, nongovernmental organization staff, and peers to deliver interventions (Kohrt et al., 2018). Such intervention delivery has been found to be feasible and effective for treating psychological distress and disorders in LMICs (Singla et al., 2017; Van Ginneken et al., 2013).

Strengths and Limitations

The use of large nationally representative samples from diverse LMICs is a clear strength of the present study. However, findings must be interpreted in light of the study’s limitations. First, the survey was cross-sectional in design and thus, temporal associations or causality could not be established. Second, the majority of the variables used in this study were self-reported. Thus, self-report and social desirability bias could exist. In relation to this, the outcome variable for suicidal ideation over the past 12 months was self-reported, and thus, relies on memory recall, which may be problematic among those with MCI. Third, there are currently no standard definitions for MCI especially in population-based studies (Petersen et al., 2014). We applied a definition used in previous SAGE studies (Koyanagi et al., 2018; Smith et al., 2023), which was based on the National Institute on Aging-Alzheimer’s Association, but we could not assess cognitive deficits beyond attention/working memory, learning/episodic memory, and language dysfunction due to lack of data. In addition, there is also currently no consensus in terms of the acceptable level of functional impairment that individuals with MCI could manifest (Lindbergh et al., 2016). We used a conservative definition for preservation of independence in functional abilities so as not to exclude MCI cases with disability not related to their cognitive ability. It is possible for the results to change slightly with the use of other definitions. Also, data on clinical dementia were not available. Thus, our sample could have included people with mild dementia. However, despite these potential issues regarding the definition of MCI, the prevalence of MCI in our study was similar to previously reported figures (Petersen, 2016). Furthermore, we omitted 666 individuals from the analysis to obtain a sample consisting only of people with preserved independence in functional abilities, as this is one of the main criteria of MCI based on the National Institute on Aging-Alzheimer’s Association. However, it is worth noting that it is possible that not all individuals who were omitted had problems in functional abilities due to limitations in cognition. For example, this could have been due to other physical conditions, but this could not be distinguished from the way in which the question was phrased in the survey. Next, the present measure of suicidal ideation was related to wish to die, which has been differentiated from active suicidal ideation (Jonson et al., 2023). However, the presence of wishes to die has been reported as clinically important as the presence of active suicidal ideation. It is possible that the present measure used captured individuals with varying degrees of risk of suicidal ideation. Future studies should seek to investigate the MCI/suicidal ideation relationship with more detailed measures of suicidal ideation, to further elucidate on the association. Importantly though, in older adults, reporting a wish to die appears to be more strongly associated with all-cause mortality than active suicidal ideation per se (Jonson et al., 2023). Also, because suicidal ideation was only assessed among those who had depressive symptoms (sadness, loss of interest, or low energy), it is possible for people with suicidal ideation without depressive symptoms to have been omitted from the group with suicidal ideation in our study. However, previous studies have shown that people with suicidal ideation very often manifest symptoms of depression (Kułak-Bejda et al., 2021). In relation to this, it was not possible to assess the role of depression in the association between MCI and suicidal ideation in our study. Finally, the sample consisted of a large number of people with low levels of education, especially in some countries. Given this, it is possible that our results are not generalizable to countries with higher levels of education.

Conclusion

In this large representative sample of older adults from six LMICs, we found that those with MCI had significantly higher odds for suicidal ideation. If future research confirms this association utilizing longitudinal designs, it may be prudent to implement effective interventions among those with MCI to aid in the reduction of suicidal ideation and ultimately deaths caused by suicide.

Acknowledgments

This paper uses data from WHO’s Study on Global Ageing and Adult Health (SAGE).

Contributor Information

Lee Smith, Centre for Health Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK.

Guillermo Felipe López Sánchez, Division of Preventive Medicine and Public Health, Department of Public Health Sciences, School of Medicine, University of Murcia, Murcia, Spain.

Pinar Soysal, Faculty of Medicine, Department of Geriatric Medicine, Bezmialem Vakif University, Istanbul, Turkey.

Nicola Veronese, Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy.

Louis Jacob, Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain; Department of Physical Medicine and Rehabilitation, Lariboisière-Fernand Widal Hospital, AP-HP, Université Paris Cité, Paris, France.

Karel Kostev, University Clinic of Marburg, Marburg, Germany.

Masoud Rahmati, CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, Marseille, France; Faculty of Literature and Human Sciences, Department of Physical Education and Sport Sciences, Lorestan University, Khoramabad, Iran.

Yvonne Barnett, Centre for Health Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK.

Helen Keyes, School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, UK.

Poppy Gibson, Faculty of Wellbeing, Education and Language Studies, The Open University, England, UK.

Laurie Butler, Centre for Health Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK.

Jae Il Shin, Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea; Severance Underwood Meta-Research Center, Institute of Convergence Science, Yonsei University, Seoul, South Korea.

Ai Koyanagi, Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.

Funding

G. F. López Sánchez was funded by the European Union—Next Generation EU. SAGE was supported by the U.S. National Institute on Aging through Interagency Agreements OGHA 04034785, YA1323–08-CN-0020, and Y1-AG-1005–01 and through research grants R01-AG034479 and R21-AG034263.

Conflict of Interest

None.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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