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Five days ago, this video of Stephen ‘tWtich’ Boss and his wife, Alison Holker, was posted on his wife’s Instagram feed celebrating their anniversary.  He posted something similar that same day.  Four days ago, his wife posted a video of them dancing together because it was Sunday.  On Monday he checked into a hotel and on Tuesday, he missed checkout and the staff found him dead as a result of a self-inflicted gunshot wound. 

Yesterday, Tyler Perry posted a video on Instagram reminding people of the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). The lifeline can also be contacted at 988.

It’s true that when a celebrity dies, all of their celebrity friends are quoted and share their grief very publicly.  When it’s sincere, I find it touching, to be honest. What stands out about Tyler Perry and Alison Holker is how they bluntly addressed the fact that tWitch committed suicide.  Perry shared that he made more than one suicide attempt and almost didn’t live to enjoy the best time of his life.  The stigma of mental illness can’t survive if people talk about it openly. We owe them and others a debt of gratitude for paving a path that makes our jobs easier.

Where all the publicity about suicide stops short is that it doesn’t consider the elderly.  

Imagine that you are all alone and can’t leave the house without a taxing effort or burdening a neighbor.  You could use a ride sharing service but that requires a smart phone which you cannot afford or maybe your cognitive functioning is such that you just can’t figure it out.  You’re retired and have no engagements or anyone vying for your time.  On the rare occasion that you can get out, your arthritis makes you regret that you even tried.  

That’s the life of many of our patients so please don’t be surprised to learn that elderly men have the highest rate of suicide.  And they are good at it.  For every 200 attempts made by youths, only one succeeds.  Compare that to the one of four suicide attempts in the elderly that are successful.  In younger people, about half of all suicides involve a firearm.  In the elderly, the percentage rises to 70 percent. When an elderly person attempts suicide they aren’t playing.  And ask if anyone really looks for a cause of death other than natural causes in people with multiple chronic diseases, too many medications to count and a history of multiple hospitalizations in recent years.

Most elderly people who take their lives suffer from depression.  Some of them hide it very well because they see it as a weakness.  They are not able to ask for help.  We assess for depression using the PHQ9 or other standardized test but without adding additional time to a visit, you can assess other signs of depression and suicidal thoughts or plans in case your patient doesn’t answer the questions truthfully.  

  1. Are there activities they used to enjoy but are now neglected?  Did they garden or play cards in the past and now just sit on the sofa?  Did they have any favorite shows but now the tv is off every time you visit?
  2. Did a patient who used to be compliant with meds suddenly just stop refilling meds?
  3. Do they talk about ‘when I’m gone’ more than usual? Be wary of a fascination with death.
  4. Are they careless about personal safety?
  5. Has isolation during the pandemic seemed to worsen their outlook on life more than what you see in others?

So if you know a patient suffers from depression and is at risk for suicide, what do you do?  

  1. If the threat is imminent as in they are holding a weapon or writing a suicide note when you arrive, call 911.  (That’s obvious, right?)
  2. Leave them the 988 number. Tape it to the phone. Ask them to promise to call 988 if they experience suicidal feelings or intents while they are home alone. The same people who consider it to be a weakness to ask for help are also very reluctant to break a promise.
  3. If they are listless and disinterested in life in general, consider asking for home health aide services to ensure they are eating properly and are at no added risk because of things left on the floor or eating off of dirty dishes. Skin care is always important but may be critical for patients who are depressed, diabetic, immobile and can’t take care of hygiene needs.
  4. Call the social worker if there is one at your agency.  If not, call the council on aging or another agency focused on the elderly.  Find the emergency contact information.  Ask the family if they have plans to visit soon.  Offer to help with a video call. Social contact is better than any medication.
  5. Notify the patient’s physician who can follow up with medication if indicated and a referral to counseling.  Assist the patient in getting his meds and refills and finding a ride to the MD.
  6. If self neglect and poor decision making is the result of dementia, the physician can assess their current meds and possibly add something.  
  7. Reach out to the patient periodically; maybe a phone call between visits.  Suggest that family members, even if far away, do the same. 
  8. Encourage exercise to the extent that the patient can complete it.  Even sitting on the porch getting fresh air and sunshine can take the edge off of depression.

Most importantly, consider depression like you would any other illness.  If a patient had significant physical pain, you wouldn’t write it off as normal, I hope.  You wouldn’t wait to see if chest pain went away on its own (and it always does – one way or another).  Call the MD and get orders. Teach about the illness, add a diagnosis if necessary and help your patient get help.  It’s no different from other newly diagnosed conditions.  

Holidays aren’t always occasions of joy and the incidence of suicide is higher than normal.  Visiting nurses and therapists are in a unique position to make a difference and even save lives during what should be a joyful and peaceful time.

And as healthcare workers during these stressful times, we are not immune to depression.  988.  Three little numbers that can put you in touch with life saving resources.

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