Click to Enlarge: Cumulative Incidence of Any Suicide Attempt and Death by Suicide Across Frailty Categories Source: JAMA Network
SAN FRANCISCO — Veterans who are 65 and older and have symptoms of frailty are at increased risk of attempting suicide, and those with lower levels of frailty were found to have greater risk of suicide death, according to a new study.
More than 9,000 adults in the United States aged 65 years or older died by suicide in 2020, up from nearly 6,000 in 2008. Frailty, which is associated with reduced physiological reserve, lack of independence and depression, might be significant for identifying older adults at increased risk of suicide attempt.
Late-life suicide requires evaluation beyond traditional risk factors, according to the longitudinal cohort study, published in JAMA Psychiatry. It examined the association between frailty and risk of suicide attempt and how risk differs based on components of frailty. The study is touted as the first to comprehensively investigate how varying degrees of accumulated health and lifestyle deficits affect the risk of late-life suicide.1
Study participants were U.S. veterans 65 years or older who used VA inpatient and outpatient healthcare services from Oct. 1, 2011, to Sept. 30, 2013; they were then followed longitudinally through Dec. 31, 2017.
The researchers analyzed VHA electronic health record data and records from the Centers for Medicare & Medicaid Services, as well as data on suicide attempts provided by the national Suicide Prevention Applications Network (nonfatal attempts) and Mortality Data Repository (fatal attempts).
Frailty level and components of the frailty index (morbidity, function, sensory loss, cognition and mood and other) were assessed as potential factors associated with suicide attempt. Frailty is categorized into five levels: nonfrailty, prefrailty, mild frailty, moderate frailty and severe frailty.
Of the 2.9 million study participants, 8,955 (0.3%) had attempted suicide over six years, with 5,497 (0.2%) having died by suicide at follow-up. The greatest percentage of suicide attempts was among those with mild and moderate frailty (0.4%), and the smallest percentage was among those without frailty (0.2%).
“Suicide prevention is a top priority for VA,” Amy L. Byers, PhD, MPH, a research career scientist at San Francisco VA Health Care told U.S. Medicine. “Our research sought to examine key factors that might contribute to suicide attempts among older veterans.”
“The association between frailty and increased risk of suicide attempt in U.S. veterans 65 years and older was relatively robust across the spectrum of frailty (prefrailty, mild, moderate and severe compared with nonfrailty group). We further found that death by suicide was largely associated with lower levels of frailty (i.e., prefrailty and mild), suggesting greater capacity to carry out lethal attempt than at higher levels of frailty,” Byers, who is also a professor of psychiatry/behavioral sciences and medicine at the University of California, San Francisco, wrote in an email.
The mean age of participants was 75.4 years old, and 97.7% were men, 2.3% were women, 0.6% were Hispanic, 9.0% were non-Hispanic Black, 87.8% were non-Hispanic white and 2.6% had other or unknown race and ethnicity. Compared with patients without frailty, risk of suicide attempt was uniformly higher among patients with prefrailty to severe frailty.
40% Increased Risk of Suicide Attempt
Mild, moderate and severe frailty were associated with more than 40% increased risk of any suicide attempt. Older veterans with moderate frailty had the highest risk (48%) compared with veterans without frailty, the study reports.
The frailty index included 31 variables related to a range of health domains, including:
- morbidity (e.g., diabetes, kidney disease),
- functional status (e.g., arthritis, use of durable medical equipment and resources [e.g., motorized wheelchair,
- home-based practitioner care]),
- cognition and
- mood (e.g., dementia, depression),
- sensory loss (e.g., blindness, hearing impairment), and
- other conditions common among older adults (e.g., chronic pain, weight loss in past year).
The researchers assigned frailty scores to each individual by adding up the total number of deficits (variables) acquired and dividing by the total number of possible deficits.
Lower levels of frailty were associated with greater risk of lethal suicide attempt, while bipolar disorder, depression, anxiety, chronic pain, use of durable medical equipment and lung disease were all associated with increased risk of suicide attempt, according to the study.
“To our knowledge, this is the first study to assess the association of frailty overall as a risk of suicide in late life,” Byers explained. “It is important to us to identify salient factors that increase suicide risk for older veterans, as most veteran suicide deaths occur in mid- to late-life. Thus, we know this evidence will inform ongoing suicide prevention efforts within the VA. Finally, though the focus of our study was on veterans, we think our findings suggest that frailty is likely a suicide risk for all older Americans.”
Prior studies on late-life suicide have mostly focused on individual risk factors, such as depression or pain alone, or have used a limited form of physical and psychiatric multi-morbidity to assess suicide risk, rather than comprehensively examining how frailty influences suicide risk.
To reduce risk of suicide attempts, it’s important to increase screening measures and monitoring for suicide risk in patients with frailty complications, as well as evaluate involvement of supportive services into the patient’s care management, Byers explained in an email.
“Additional suicide prevention efforts should be directed toward patients in late life who experience frailty complications,” Byers added. “Better understanding perceptions of burdensomeness, desire to die by suicide and capacity to attempt suicide among patients with frailty are indicated by this work, and, ultimately, critical for connecting patients with appropriate services.”
Limitations of this study include the study population consisted mostly of white, male veterans and the use of secondary databases for outcome status may have resulted in misclassification of those attempting suicide as those who did not attempt suicide when patients were instead lost to follow-up. Non-medically serious suicide attempts may have never been documented in the internal VHA suicide event case management and tracking system, and consequently may not have been captured in the study.
- Kuffel RL, Morin RT, Covinsky KE, Boscardin WJ, Lohman MC, Li Y, Byers AL. Association of Frailty With Risk of Suicide Attempt in a National Cohort of US Veterans Aged 65 Years or Older. JAMA Psychiatry. 2023 Feb 22:e225144. doi: 10.1001/jamapsychiatry.2022.5144. Epub ahead of print. PMID: 36811913; PMCID: PMC9947807.