Unexpected suicidality in an older emergency department patient

To the Editor

Depression and suicidal ideation (SI) are unfortunately common among older adults,¹ with suicide rates peaking among older men.^{2, 3} However, clinicians under-diagnose and under-treat these conditions among older adults,^{3, 4} in part because of erroneous ideas that hopelessness or thoughts of death are a part of “normal aging.”⁵ Non-traditional presentations and concurrent cognitive impairment can also complicate diagnosis, especially when there is not an established provider-patient relationship.

Case Report

A 66 year-old white male presented to an emergency department (ED) with a foot wound that he sustained the previous day from stepping on a nail while gardening. The nail punctured through the sole of his shoe, and he was concerned about infection because of his type 2 diabetes mellitus. His past medical history also included hypertension, hyperlipidemia, depression and prostate cancer. He denied using tobacco, alcohol or drugs. He had not seen a provider or taken any medications in over a year because of insurance issues, but he had become eligible for Medicare just two days before his ED visit. He was affable and in no obvious physical or emotional distress, with normal vital signs other than a mildly elevated blood pressure. On examination, he had a shallow puncture wound on the sole of his right foot with mild surrounding erythema but no swelling, crepitus, or fluctuance. A radiograph was normal. The patient received a dTAP booster and was started on a course of oral antibiotics.

As part of a newly instituted ED protocol, the patient’s nurse asked him standard screening questions concerning recent depression and SI. To the care team’s surprise, the patient responded affirmatively, and he matter-of-factly reported a detailed suicide plan designed to look like an accident so his sister would receive his life insurance benefit. On supplementary questioning, the patient revealed multiple recent social stressors, including the one-year anniversary of his partner’s death and an impending eviction from his home with the loss of his beloved garden. The patient was evaluated by the ED’s mental health team and admitted to a psychiatric hospital. Upon discharge, he was on a stable dose of sertraline, had reestablished contact with his primary care provider and had no further SI.

Discussion

In 2007, there were over 7.6 million ED visits related to mental health conditions; 25% of these visits were by older adults, and total and mental health-related ED visits by older adults are increasing.⁶ However, there could be as many as 13 million ED patients with SI per year, based on an estimated prevalence of SI among all ED patients of up to 11%,⁷ and some figures suggest up to 20% of older ED patients have depression.⁸ Almost half of suicide victims visit an ED in the year before their death, often for non-psychiatric reasons, and they are more likely to have multiple recent ED visits than those who die by other causes.⁹

Most EDs rely on targeted SI questioning triggered by clinician concern, but some have begun standard screening all patients, in part due to Joint Commission patient safety goals related to suicide prevention. Although widespread SI screening has the potential to identify patients who might otherwise be missed, it is also controversial because of concerns about ED crowding, wait times, provider time constraints, and the lack of evidence for a benefit from such screening.¹⁰

Regardless of screening practices, clinicians should be aware of suicide risk factors among older adults. These include: male gender; white race; alcohol abuse; social isolation; a prior history of mental illness; particular kinds of social stressors (including bereavement or loss of social supports); access to firearms and other lethal means; physical illness; cognitive deficits; and functional impairment.^{2, 3} Of these, mood disorders appear to play the strongest role,³ highlighting the importance of their appropriate recognition and treatment.

Suicide prevention for older adults poses unique challenges because older suicidal individuals are more likely to employ advance planning and less likely to directly ask for help,³ with a suicide attempt to completion ratio among older adults of approximately 4:1, compared to up to 200:1 among young adults.³ SI among older adults is also more likely to stem from chronic medical or social issues rather than abrupt crises,³ so there may be a longer available period for intervention. Better mental health treatment, suicide interventions, and chronic disease management during this contemplative period might reduce morbidity and mortality.² However, there remains a need to improve the identification of SI/SA among older adults,⁴ and systematic screening protocols may be beneficial in selected clinical environments.