Deliberate selfharm

It is less possible to make a clear distinction between deliberate self-harm and completed suicide in older than younger people. In a study of drug overdose in elderly people, in which the admitting medical team classified cases as 'accidental' or 'deliberate', a considerable overlap was found between the two groups. (8) Deliberate self-harm at all ages has been quite extensively studied, but for obvious reasons mainly in hospital samples. Draper(9) has argued that some older people who harm themselves stay at home and are missed. Broadly speaking the incidence curve for deliberate self-harm is highest for the young and declines with age, whereas that for completed suicide rises with age. By the same token suicidal intent behind acts of deliberate self-harm in older people is greater than in younger adults, whose motives are much more varied. In clinical practice it is therefore wise to consider deliberate self-harm in those over 75 as failed suicide.

As with completed suicide, rates for deliberate self-harm differ quite widely from country to country. In Europe they were found to vary from 14 to 111 per 100 000. (!°) As with younger deliberate self-harm attempters, females outnumber males at a raw number ratio of approximately 3:2. However, as there are fewer males surviving into old age the proportionate gender ratio is approximately unity. (9) These ratios contrast with that for completed suicide where men clearly outnumber women.

Deliberate drug overdose is the favoured method for deliberate self-harm at all ages in Western countries; in Hong Kong, however, corrosive poisons or detergents are usedA1 The most common types of drug for overdose are benzodiazepines, analgesics, and antidepressants. After drugs, self-cutting is the next most frequent method.

Risk factors for deliberate self-harm in elderly people include widowhood, divorce, separation from a cohabitee, and (possibly) lower socio-economic status. (9) Older people are also more likely to be assigned a psychiatric diagnosis, fy2 just over half suffering from major depressive disorder, up to 32 per cent from alcohol abuse, and under 10 per cent from other disorders. Those assigned no psychiatric diagnosis vary from 0 to 13 per cent. (9) Alcohol abuse together with depressive disorder augments the risk of deliberate self-harm in older people. ^„i The status of cerebral organic disorder in deliberate self-harm in elderly people is uncertain because selection bias in reported case series reduces comparability.(9) However, mild cognitive impairment and a comorbid depressive disorder have been considered risk factors, and should be borne in mind by the clinician, if only on common-sense grounds. Personality factors have been implicated in deliberate self-harm in older people, but research data are too poor and too few to make reliable statements on the subject.

Similarly, physical illness, which might be considered to be a risk factor for deliberate self-harm in older people, has not definitely been established as such. In one study, 63 per cent were thought to be suffering from a significant physical illness, but in only 18 per cent was it adjudged to have contributed to the act. (14) Surprisingly perhaps, terminal illness is not commonly found in older patients who attempt suicide but fail, (9) although hitherto undiagnosed but treatable physical disorders are sometimes revealed.(1,5)

Social risk factors for deliberate self-harm in elderly people include social isolation, loneliness (not the same thing), or simply living alone. ^MD Unresolved grief, usually after death of a spouse, is commonly found—up to 44 per cent in one series. (9) The threat of transfer to a nursing home is, unsurprisingly, a precipitant of deliberate self-harm, although once an elderly patient is transferred to institutional care the risk of an overdose or some other attempt at suicide is reduced, probably because of lower access to the means and higher supervision. (7,9)

In keeping with the fact that more older suicide attempters are assigned a psychiatric diagnosis than younger ones is the fact that about 50 to 90 per cent, depending on the case series, undergo some form of psychiatric treatment as a result of the act of deliberate self-harm.(9) There are few good follow-up studies which focus on deliberate self-harm in older people. ^l4,!8 The most important thing to emerge from these studies is that, although the repetition rate is lower (about 5 per cent compared with 12 per cent) the risk of subsequent completed suicide is higher, compared with people of all ages (about 7 per cent compared with 3 per cent). (119) Individual risk factors for later successful suicide include being male, having a prior psychiatric history, divorce, and current treatment for a persistent depressive illness.

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