Whether the coronavirus disease 2019 (COVID-19) pandemic influences suicide rates in older adults remains unknown. Nevertheless, experts suggest a convergence of risk factors for suicide, which may uniquely impact the elderly.
As countries are affected by COVID-19, governments have adopted various policies such as social distancing, social isolation, and quarantine in order to reduce rates of infection. The severity of symptoms and fatality ratio of COVID-19 have been found to be higher among the elderly, underprivileged, immunosuppressed, and those with pre-existing respiratory conditions and/or medical diagnoses, all of which may serve predisposing risk factors with increased age. A study by Liu and colleagues (2020) showed that COVID-19 patients over the age of 55 had a three times increased mortality rate, as well as higher rates of hospitalization, more rapid disease progression, delayed clinical recovery, and higher rates of pulmonary involvement. Medical risk is further amplified by the pandemic’s broad impact on healthcare in that standard check-ups, non-essential surgeries, biopsies, and scans have all been delayed. As the elderly are facing heightened medical vulnerabilities, this same group may already be facing unique physical, psychosocial and environmental vulnerabilities.
While isolating the elderly might reduce transmission, the adverse effects of isolation may be especially felt by older individuals (Armitage & Nellums, 2020). The elderly were the first to be instructed to self-isolate given their increased vulnerability. As health officials provided clear instruction for elderly individuals to remain home, avoid social contact and have medication and groceries delivered, we may have inadvertently jeopardized our elderly population by leaving them extremely isolated. Well before the COVID-19 pandemic, objective isolation (e.g. living alone), subjective sense of loneliness, and social isolation have been established risk factors for suicide in older adults (Draper, 2014).
Isolation and loneliness will disproportionately affect elderly individuals who are institutionalized or whose only social contact is outside the home (e.g., daycare settings, community centers, and religious institutions). In fact, even those residing in senior housing communities specifically designed to proactively reduce social isolation continue to report at least moderate levels of loneliness (Morlett Paredes et al., 2020), likely exacerbated by quarantine and social distancing recommendations. In response to a public health ordinance, several living facilities worldwide have prohibited all visitors and have ceased group dining and group activities, attempting to protect their vulnerable residents from potential exposure. This ordinance intended to increase safety, has generated significant secondary effects including increased muscle atrophy, symptoms of depression and anxiety, and suicidal thoughts and behaviors. These outcomes are consistent with research conducted by Santini and colleagues (2020), who demonstrated that social disconnection in older adults increases their risk of depression and anxiety.
The incredible loneliness that has accompanied the grief process has been particularly heartbreaking. The inability to accompany loved ones in the last moments of their life has been remarkably challenging. For many, this has robbed them of the opportunity to say goodbye to their loved one, hold their hand, affirm their bond, or make amends. The bereavement process is further complicated by the inability for mourners to come together to grieve, leaving those mourning absent of the comforts of a hug or a smile in their most difficult moments. While virtual grieving rituals have been recommended, they certainly cannot substitute the physiological impacts of proximity, such as the production of “feel good” hormones such as oxytocin, dopamine and serotonin. Experts in the field presume that the resulting widespread grief is expected to increase suicide rates (Wand et al., 2020).
Across the globe, we have seen the use of online technologies to provide social support networks and a sense of connectedness. Nevertheless, there may be disparities in access to or literacy in digital resources in older adults. Individuals who are not well-versed with technology may face emotional distancing in absence of both personal and digital contact with the families. Older adults may already feel marginalized given the ageism that has been magnified by the pandemic. The confluence of generation limitations together with sensory and cognitive deficits, may lead to challenges in obtaining accurate information regarding precautionary measures. For those with access and literacy in online technologies, this era of “information overload” may exacerbate feelings of fear, apprehension, anxiety and even somatic symptoms. All of these factors can undoubtedly impede any sense of autonomy and self-dignity (Wand et al., 2020).
In her blog “COVID-19, Connectedness and Suicide Prevention” Dr. Lisa French discusses the increased suicide risk associated with social isolation, pointing to key theories of suicide which have identified a connection between suicidal thoughts and a lack of social connection with others (Joiner, 2005; Klonsky & May, 2015). It is easy to see how elderly individuals are particularly vulnerable to suicide through a heightened sense of disconnectedness from society, physical distancing, and loss of usual social opportunities
So what can we do to help support elderly individuals during COVID-19?
Effective Communication: Accurate information is vital to mitigate the risk of psychological distress. Information delivered in clear and understandable language, including a clear rationale for guidelines, is critical. Use of television as an information outlet may be particularly palatable for many older individuals.
Computer Literacy: As online technologies are encouraged for receipt of healthcare and for social connectedness, it is critical to develop services to help teach new skills to this digitally excluded population group.
Enhanced Mental Health Services: Medical and behavioral healthcare providers should review their patient caseloads to identify elderly individuals who might be particularly vulnerable to isolation, lack of care, mental illness or suicide risk. Standard protocols for welfare checks and enhanced follow-up care should be instituted to ensure proper support services are available.
Promoting Connectedness: Fostering connection can simply involve more frequent telephone contact with significant others, close family and friends, healthcare professionals, or even community outreach programs. Grassroots initiatives to promote connectedness have emerged such as The Kindness Pandemic, developed by Celebrate Ageing. Established on 14 March 2020, this innovative group grew to over 500,000 members in just two weeks with a mission of promoting acts of intersectional kindness.
Bereavement Support: Developing programs to support loved ones struggling with complex grief at a time in which grief rituals have been suppressed can be valuable. One example of such efforts was illuminated when a group of palliative care physicians, social workers, and chaplains at Vanderbilt University Medical Center began making personal phone calls to connect with families who lost a loved one during the pandemic. You can access more information about their efforts at the following link https://www.vumc.org/coronavirus/latest-news/bereavement-calls-helping-aid-grieving-families.
Physical Health and Exercise: Making information easily available and accessible for older individuals regarding safe exercise regimens in and outside of the home are crucial to help mitigate physical deconditioning and muscle atrophy that can lead to increased pain and greater disability. Since exercise has been shown to reduce depressive symptoms, engaging in a regular exercise routine can help mitigate medical and mental health symptoms.
Mental Health Coping for Older Adults: Various organizations have developed resource materials to help cope with mental health symptoms during the pandemic. The Australian Psychological Society (APS), for example, developed a handout entitled Coronavirus (COVID-19) anxiety and staying mentally healthy: For older adults with specific tips to help older adults stay mentally healthy.
The confluence of various medical, psychological, social, economic and political factors will likely have an impact of suicide in older adults. I encourage you to write additional prevention recommendations for suicide in older adults during the global pandemic in the comments section.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Sharon Birman, Psy.D. is a clinical psychologist serving as a Senior Military Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Armitage, R., & Nellums, L. B. (2020). COVID-19 and the consequences of isolating the elderly. Lancet Public Health. https://doi.org/ 10.1016/S2468-2667(20)30061-X.
Draper B. M. (2014). Suicidal behaviour and suicide prevention in later life. Maturitas, 79(2), 179–183. https://doi.org/10.1016/j.maturitas.2014.04.003
Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Klonsky, D. E., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the "ideation-to-action" framework. International Journal of Cognitive Therapy, 8(2), 114-129.
Liu, K., Chen, Y., Lin, R., & Han, K. (2020). Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients. The Journal of infection, 80(6), e14–e18. https://doi.org/10.1016/j.jinf.2020.03.005
Morlett Paredes, A., Lee, E. E., Chik, L., Gupta, S., Palmer, B. W., Palinkas, L. A., Kim, H. C., & Jeste, D. V. (2020). Qualitative study of loneliness in a senior housing community: the importance of wisdom and other coping strategies. Aging & mental health, 1–8. Advance online publication. https://doi.org/10.1080/13607863.2019.1699022
Santini, Z. I., Jose, P. E., York-Cornwell, E., Koyanagi. A., Nielsen, L., Hinrichsen. C., Meilstrup, C., Madsen, K. R., & Koushede, V. (2020). Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis. Lancet Public Health, 5, e62–e70. https://doi.org/10.1016/S2468-2667(19)30230-0
Wand, A., Zhong, B. L., Chiu, H., Draper, B., & De Leo, D. (2020). COVID-19: the implications for suicide in older adults. International psychogeriatrics, 1–6. Advance online publication. https://doi.org/10.1017/S1041610220000770