Deliberate self-harm in older people revisited

BACKGROUND: Deliberate self harm (DSH) in later life is under researched and is believed to be related to both mental illness and suicide. AIMS: The aim of the study was to examine deliberate self-harm (DSH) in older people presenting to acute hospital services over three years. METHOD: This was a retrospective observational study. We reviewed 97 episodes of DSH involving 82 patients aged 65 and over referred to the Liaison Psychiatric Service of the Tees and North East Yorkshire NHS Trust South Locality from 2000 to 2002. RESULTS: There was a year on year increase in the number of older people presenting with DSH, especially in men. Twenty-one percent of older men had no discernible psychiatric diagnosis. There were a small number of people who repeated DSH within a year and males were as likely to be repeaters as females. Twenty-three percent of all patients saw a General Practitioner (GP) in the 7 days before the episode of DSH and this increased to 58% in the 4 weeks preceding the episode of DSH. More males (56%) than females (26%) who presented with DSH were married. The most common method of DSH (93%) was medication overdose of which 66% used prescribed medication. There was no difference in the methods used to self-harm between men or women. CONCLUSION: DSH in the elderly may start to mirror some of the characteristics seen in younger adults with DSH. While the numbers of DSH per year are small among the elderly compared to younger adults, the observations suggest an increase in DSH in men. Marriage may no longer be a protective factor in prevention of DSH among older men. Longer-term observational studies of DSH in older people are required to confirm these changing patterns. GPs may have an important role to play in prevention of DSH in later life.     

Deliberate self-harm in older adults: a review of the literature from 1995 to 2004

BACKGROUND: The prevention of suicide is a national and international policy priority. Old age is an important predictor of completed suicide. Suicide rates in old age differ markedly from country to country but there is a general trend towards increasing rates with increasing age. In 1996 Draper reviewed critically the evidence on attempted suicide in old age in the 10 years between 1985 and 1994. The review highlighted a need for prospective controlled studies in older people with more representative samples as well as studies examining the interaction of risk factors, precipitants, motivations, psychopathology and response to treatment. The aim of this paper is to update this review and to summarise the advances in our understanding of DSH in later life. METHOD: We have critically reviewed relevant studies published between 1995 and 2004 to summarise the advances in our understanding of factors associated with deliberate self-harm in later life. RESULTS: The main advances in understanding have been to clarify the effect of personality and cultural factors, service utilisation pre and post attempt, and the (lesser) impact of socio-economic status and physical illness. Methodological weaknesses continue to include inadequate sample sizes performed on highly selected populations, inconsistent age criteria and lack of informant data on studies relating to role of personality. CONCLUSIONS: Future studies should include prospective, cross-cultural research with adequate sample sizes and which are population-based. Such approaches might confirm or refute the results generated to date and improve knowledge on factors such as the biological correlates of deliberate self-harm, service utilisation, costs and barriers to health care, and the interaction of these factors. Intervention studies to elucidate the impact of modifying these factors and of specific treatment packages are also needed.     

Deliberate self-harm in people aged 60 years and over: characteristics and outcome of a 20-year cohort

BACKGROUND: Little information is available about older deliberate self-harm (DSH) patients and their outcome. METHODS: This study is a prospective investigation and follow-up of 730 consecutive patients (459 females and 271 males) aged 60 years and over who presented to a general hospital following DSH over a 20-year period, 1978-1997. Outcome has been examined in terms of repetition of DSH, and deaths by the end of 2000 identified through official death registers. RESULTS: DSH involved self-poisoning in 88.6% of cases, 49.3% of the overdoses including paracetamol (acetaminophen), 24.0% minor tranquillizers, and 15.9% antidepressants. Nearly three-quarters of episodes involved high suicidal intent. Common problems preceding DSH were physical illness (46.1%), social isolation (33.5%), relationship problems with family (29.4%) or partner (25.9%), and bereavement or loss (16.7%). Repetition of DSH occurred in 15.3% of cases, 8.2% in the first year following DSH. By the end of 2000, 432/661 (65.4%) of traced patients had died. There were 30 suicides and open verdicts, which were 49 times and 33 times more frequent respectively than expected from general population death rates. Prior DSH before initial presentation was the main risk factor for suicide, with some evidence of high suicide intent being another factor. There were also excess deaths due to several types of physical disorder. CONCLUSIONS: DSH in older people is closely related to suicide, both in terms of suicidal intent and risk of eventual suicide, especially when DSH is repeated. The range of problems experienced by older DSH patients requires extensive and multidisciplinary clinical interventions.     

Psychiatric disorders among older prisoners: a systematic review and comparison study against older people in the community

Objectives: Despite emerging evidence that older prisoners experience poor mental health, literature in this area is still limited. In the present systematic review and meta-analysis, we report on the prevalence of psychiatric disorders among older prisoners and compare our findings against community studies on older people.

Methods: We searched on Assia, PsycInfo, MedLine, Embase, Web of Science, Google and Gov.uk. We carried out bias assessments, rated studies for quality and ran a heterogeneity test. We meta-analysed prevalence rates of psychiatric disorders through an aggregate weighted mean and calculated relative risk (RR) and statistical significance against community studies. Sensitivity analyses were further performed.

Results: We reviewed nine studies and obtained the following prevalence: ‘Any psychiatric disorder’ 38.4%, depression 28.3%, schizophrenia/psychoses 5.5%, bipolar disorder 4.5%, dementia 3.3%, cognitive impairment 11.8%, personality disorder 22.9%, alcohol abuse 15.9%, anxiety disorders 14.2%, PTSD 6.2%. Older prisoners were found to have higher RR for every single psychiatric disorder against older people in the community, with the sole exception of alcohol abuse (RR = 1) and dementia (RR = .75). The prevalence rates were statistically significantly higher (p < .05) among the prisoners for ‘Any psychiatric disorder’, depression and personality disorder. Overall, the sensitivity analyses confirmed our original results.

Conclusion: Our findings point at a high prevalence of every single psychiatric disorder among older prisoners, who also experience rates of dementia and alcohol abuse comparable to those reported in the community. Our results have relevant implications for policy and practice in this area. Further research is crucial to confirm findings from this study.     

Knowledge of dementia among South Asian (Indian) older people in Manchester, UK

OBJECTIVES: The aim of this study was to examine knowledge of dementia in South Asian older people, as compared with Caucasian older people. METHODS: Attendees, not known to suffer from dementia, of one South Asian and two predominantly Caucasian day centres for older people in Manchester (UK) were asked to complete the Dementia Knowledge Questionnaire (DKQ). The DKQ was translated into Gujarathi and Urdu by the professional translators. RESULTS: One hundred and ninety-one DKQs from Indian and 55 DKQs from Caucasian (white UK/Irish/European) older people were included in the analyses. Knowledge of dementia was poor in both Indian and Caucasian older people, especially so in the former. The median (25th-75th percentile) total DKQ scores were 3 (2-5) in Indians and 6 (3.5-9) in Caucasians (p < 0.001). Indian older people showed significantly less knowledge about basic aspects (p < 0.001) and epidemiology (p < 0.001) of dementia when compared to Caucasian older people. Both groups faired equally badly on questions about aetiology (p = 0.91) and symptomatology (p = 0.66). Indian older people were less aware of personality, reasoning, and speech being the affected in dementia (p < 0.001, p < 0.001 and p = 0.04, respectively). CONCLUSION: Indian older people in Manchester (UK) do not seem to have sufficient knowledge about dementia, which may be one of the reasons for their relative absence in the local dementia treatment clinics.     

The association of physical illness and self-harm resulting in hospitalisation among older people in a population-based study

Objectives: With population ageing, self-harm injuries among older people are increasing. Further examination of the association of physical illness and self-harm among older people is warranted. This research aims to identify the association of physical illness with hospitalisations following self-harm compared to non-self-harm injury among older people.

Method: A population-based cohort study of individuals aged 50+ years admitted to hospital either for a self-harm or a non-self-harm injury using linked hospital admission and mortality records during 2003–2012 in New South Wales, Australia was conducted. Logistic regression and survival plots were used to examine the association of 21 physical illnesses and mortality at 12 months by injury intent, respectively. Age-adjusted health outcomes, including length of stay, readmission and mortality were examined by injury intent.

Results: There were 12,111 hospitalisations as a result of self-harm and 474,158 hospitalisations as a result of non-self-harm injury. Self-harm compared to non-self-harm hospitalised injury was associated with higher odds of mental health conditions (i.e. depression, schizophrenia, bipolar and anxiety disorders), neurological disorders (excluding dementia), other disorders of the nervous system, diabetes, chronic lower respiratory disease, liver disease, tinnitus and pain. Tinnitus, pain, malignancies and diabetes all had a higher likelihood of occurrence for self-harm compared to non-self-harm hospitalisations even after adjusting for mental health conditions, number of comorbidities and alcohol and drug dependency.

Conclusion: Older people who are experiencing chronic health conditions, particularly tinnitus, malignancies, diabetes and chronic pain may be at risk of self-harm. Targeted screening may assist in identifying older people at risk of self-harm.     

Asymptomatic spontaneous cerebral emboli and cognitive decline in a cohort of older people: a prospective study

BACKGROUND: Asymptomatic spontaneous cerebral emboli (SCE) are common in dementia and are associated with cognitive decline in dementia. The significance of their presence in older people is unknown. METHOD: We included 96 participants (mean (SD) age 76.8 (6.7) years, 46% female) who were the control group in a case-control study to evaluate SCE in dementia. Cognitive functioning was assessed prospectively over 2.5 years, using the MMSE and CAMCOG. RESULTS: The mean (SD) MMSE score was 28.7 (1.4) at baseline with an average (SD) drop of 0.79 (0.91) per year. The presence of SCE was not related to the annual drop in MMSE score, nor to the CAMCOG score at follow-up (p = 0.88 and p = 0.41, respectively). Linear regression analyses identified higher age in years (beta = 0.29, p = 0.003), history of stroke (beta = 0.31, p = 0.001) and carotid stenosis (beta = 0.28, p = 0.003) as independent predictors of cognitive decline. CONCLUSION: We found no association between the presence of SCE and subsequent cognitive decline in older people without dementia.     

Social support and mental health status of older people: a population-based study in Iran-Tehran

Objectives: To investigate direct and stress-buffering associations between social support from family and the mental health of older people in Iran, a country which has recently undergone an exceptionally fast fertility transition and is consequently experiencing rapid population ageing.

Method: A cross-sectional stratified random survey of 800 people aged 60+ years resident in Tehran was conducted. In total, 644 people responded. The Social Provisions Scale and the General Health Questionnaire were used to measure perceived social support and mental health, respectively. Multilevel mixed-effects models were used to examine the hypotheses.

Results: The findings supported the hypothesis of a direct association between perceived and received social support and mental health. However, we did not find strong evidence to suggest that social support buffered the effects of stress arising from limitations of physical functioning. Lack of help doing paperwork was associated with worse mental health for women but not men. Source of support did not seem to be important.

Conclusion: Our results indicated that in Tehran, as in Western settings, social support is important for the mental well-being of older people. Recommendations for policy and further research priorities based on the study findings were provided.