Diminished appetite, irregular sleep habits and poor personal hygiene are all clues that an elderly person may be depressed. But the caregivers at Marguerite's House in Lawrence, Mass., have learned one of the best ways to assess if a resident is suicidal is to ask.
"It is a myth that you will give them ideas if you ask," said social worker Pamela Bowen. "They are looking for help and are happy you asked them. They don't want to die. They just want to stop the pain." Suicide, she said, "is an act of desperation."
In 2008, Covenant Health Systems of Tewksbury, Mass., developed comprehensive suicide screening assessment tools and suicide prevention policies for its hospitals, nursing facilities, assisted living facilities and adult day care centers. The effort was a response to both the Joint Commission national patient safety goals of 2007 and some suicide attempts within its facilities. Covenant is parent company of Lawrence's Mary Immaculate Health/Care Services, which includes the 106-bed assisted living facility Marguerite's House and senior apartments.
Mary Schaefer, Covenant's corporate director of risk management, convened a group of clinicians and social workers to explore the different challenges each facility faced.
"We wanted to develop some concrete tools," said Schaefer. "Nursing homes and the assisted living side really didn't have well-developed policies or screening. Our psychiatrists were fairly adamant — you need to be direct."
Today, Covenant caregivers ask incoming residents, "Are there any stressors in your life? If the answer is yes, the caregiver probes further: Have you ever wished you could go to sleep and not wake up? Is death something you have thought about recently? Have you ever thought about harming yourself? If a patient reveals a suicide plan, the caregiver refers the patient immediately to a hospital emergency department.
"Typically I'll get, 'I'm a little sad about leaving my home. My husband and I built it together.' Or they have lost someone," said Bowen. "Those are typical answers. Absolutely, it is not unusual for someone to say they've imagined going to sleep and not waking up. We wouldn't not admit someone based on that response. It just bears watching. But if there has been ideation, then we are concerned. It's not a perfect science, but you can glean from their answers if they are hedging them."
Although the people age 65 and older comprise only 12 percent of the U.S. population, they accounted for 16 percent of suicide deaths in 2004. Some studies show a slight decrease in more recent years; still, suicide among the elderly is a top concern among health systems charged with their care.
Fortunately, none of the residents who have applied to Mary Immaculate Health/Care Services have been suicidal. And among existing residents, only a few have exhibited behaviors considered to be warning flags.
Still, the staff remains diligent. Bowen conducts annual training about recognizing depression in elderly patients, and caregivers closely monitor their residents' habits.
"We talk about different things you may hear. 'I don't know why I'm still alive.' Or, 'I wish God would take me.' Those you may hear a lot," said Bowen. "But (when) someone who is well-groomed doesn't care about their appearance or hygiene, or someone who is active is now isolating, or someone is not eating or eating too much — we want to investigate further."
Marguerite's House certified nurse assistants see the same group of residents daily. Such consistent interaction allows caregivers to develop a close rapport and better identify shifts in behavior.
Recently one CNA came across notes expressing a patient's wish to kill herself. In that case, the staff immediately called the family and stayed with the patient. The patient was admitted to a psychiatric facility where her medications were adjusted. She since has returned. The protocol says that in cases like this, staff should remove any potentially dangerous objects such as robe belts, telephone cords and medications.
"You have to keep them safe," said Bowen. "You want to do it in a discreet way that preserves their dignity, but I'm worried more about keeping them safe."
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