Late life is commonly a period of transitions (eg, retirement, relocation) and adjustment to losses.
Retirement is often the first major transition faced by older adults. Its effects on physical and mental health differ from person to person, depending on attitude toward and reason for retiring. About one third of retirees have difficulty adjusting to certain aspects of retirement, such as reduced income and altered social role and entitlements. Some people choose to retire, having looked forward to quitting work; others are forced to retire (eg, because of health problems or job loss). Appropriate preparation for retirement and counseling for retirees and families who experience difficulties may help.
Relocation may occur several times during old age—eg, to retirement housing with desirable amenities, to smaller quarters to reduce the burden of upkeep, to the homes of siblings or adult children, or to a residential care facility. Physical and mental status are significant predictors of relocation adjustment, as is thoughtful and adequate preparation. People who respond poorly to relocation are more likely to live alone after their move and/or to be socially isolated, poor, and/or depressed. Men respond less well than women.
The less control people perceive they have over the move and the less predictable the new environment seems, the greater the stress of relocation. People should become acquainted with the new setting well in advance. For the cognitively impaired, a move away from familiar surroundings may exacerbate functional dependence and disruptive behavior. Because of financial, social, and other complications, some older adults feel they must remain in a problematic home or neighborhood despite their desire to relocate. Social workers can help such people assess their options for relocation or home modification.
Bereavement affects many aspects of an older person’s life. For example, social interaction and companionship decrease, and social status may change. The death of a spouse affects men and women differently. In the 2 years after death of a wife, the mortality rate in men tends to increase, especially if the wife’s death was unexpected. For women who lose a husband, data are less clear but generally do not indicate an increased mortality rate.
With bereavement, some sleep disturbance and anxiety are normal; these effects usually resolve in months without use of medications. In contrast, grief that is prolonged and overwhelming is considered pathologic grief. It is characterized by the following:
Symptoms that are typical of a major depressive episode Major depressive disorder (unipolar depressive disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more and that last > 2 months
Strong and frequent feelings of yearning for the deceased and urges to join the deceased in death
Preoccupation with thoughts about the deceased or the circumstances or consequences of the death
Intense feelings of loneliness, shock, emptiness, numbness, unfairness, anger, or meaninglessness
Continuing to hear or see the deceased, or experiencing the pain that the deceased suffered
Avoiding or reacting intensely to reminders or memories of the deceased
Caregivers and health care professionals should look for such symptoms and be aware that bereaved patients are at high risk of suicide Suicidal Behavior Suicide is death caused by an act of self-harm that is intended to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors to completed... read more and declining health status. Worldwide in 2017, death by suicide was documented in about 16 per 100,000 people age 50 through 69 and in about 27 per 100,000 people age ≥70 worldwide, compared with about 11 per 100,000 people age 15 through 49 (1 References Late life is commonly a period of transitions (eg, retirement, relocation) and adjustment to losses. Retirement is often the first major transition faced by older adults. Its effects on physical... read more ).
In the United States in 2020, the rate of suicide was about 4 times higher in older men than in older women (2 References Late life is commonly a period of transitions (eg, retirement, relocation) and adjustment to losses. Retirement is often the first major transition faced by older adults. Its effects on physical... read more ). Rates of death by suicide for older adults are thought to be greatly underestimated because deaths secondary to opioid overdose are not investigated and intentional deaths due to voluntarily stopping eating and drinking are not documented (2 References Late life is commonly a period of transitions (eg, retirement, relocation) and adjustment to losses. Retirement is often the first major transition faced by older adults. Its effects on physical... read more ). Older adults often do not give warnings about suicide and seldom seek mental health treatment. Physicians are less likely to offer treatment for depression to older patients than to younger patients. Although older adults attempt suicide less often than those in other age groups, they have a much higher rate of death by suicide because they are more likely to use firearms in the attempt (in 71.3% of suicide deaths among older adults [ 2 References Late life is commonly a period of transitions (eg, retirement, relocation) and adjustment to losses. Retirement is often the first major transition faced by older adults. Its effects on physical... read more ]), have more health problems, be frail, and avoid interventions, and less likely to live with other people who might detect and respond to suicide attempts. Thus, the risk of death by suicide among older adults with suicidal ideation is very high.
Timely screening for depression and suicidal ideation is essential when working with older adults. Clinicians should ask directly about suicide (eg, “I know that you have been experiencing difficulties and that you spend quite a bit of time alone. I wonder if there are times you are thinking about suicide.”). Evidence of suicidal ideation should lead to immediate suicide safety planning. Before the end of an interaction with suicidal older adults, clinicians should do the following:
Enter the Suicide Prevention Lifeline or Crisis Text Line into their phone (1-800-273-8255 or text the word “Hello” to 741741) and show them how to find and use the information in their phone.
Discuss guns and other means of suicide that they have access to.
Show caring and sensitivity to the patient's situation (eg, "I know you have been through a lot. I care about you and want to see you again; your safety matters.")
Connect caregivers and family members to educational resources.
Develop a suicide safety plan that helps people recognize what leads to suicidal ideation and provides a list of coping strategies and support resources, including tablet and smartphone apps for patients to use.
Counseling and supportive services (eg, National Widowers Organization) may facilitate difficult transitions. Short-term use of anxiolytic medications can help patients with excessive anxiety, and antidepressant therapies can reduce the intensity of depressive symptoms. However, excessive or prolonged use should be avoided because it may interfere with the process of grieving and adjustment. Prolonged, pathologic grief usually requires psychiatric evaluation and treatment.
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
National Institute of Mental Health (NIMH): Ask Suicide-Screening Questions (ASQ) Toolkit. This web site provides an easy-to-use, brief, direct, validated screening instrument that helps health care professionals assess a person's risk of suicide. This tool consists of 4 questions and takes 20 seconds to use. The NIMH provides guidance and scripts for health care professionals. Accessed 3/19/23.
The Columbia Lighthouse Project: The Columbia Protocol for Healthcare and Other Community Settings. This protocol (also known as the Columbia-Suicide Severity Rating Scale) is a free, evidence-based screening instrument with tailored guidance for different settings and free online training. It helps health care professionals determine whether a person is at risk of suicide, assess how severe and imminent the risk is, and estimate how much support that person needs. Accessed 3/19/23.
Suicide Is Different: This web site provides guidance, tool kits, and coaching to help family members and caregivers support a person with suicidal ideation and to remain well themselves. Accessed 3/19/23.
Zero Suicide: This web site provides resources and training tools to improve suicide care in health care systems. It discusses strategies that can help improve care; they include training for staff members, use of comprehensive screening and assessment tools, involving people at risk of suicide in their management plan, and using evidence-based treatments.
Substance Abuse and Mental Health Services Administration (SAMHSA): SAMHSA provides a mobile app that helps health care professionals identify and evaluate patients who are at risk of suicide. It provides information, assessment tools, and resources where patients can get support.