Meera Balasubramaniam

Rational Suicide in Elderly Adults: A Clinician's Perspective

Geriatricians are increasingly encountering older adults expressing suicidal wishes in the absence of overt mental illness. This is expected to grow as life expectancy increases. This article describes the case of an older adult who expressed the wish to end his life in the absence of a diagnosable mental illness. Although he had chronic medical illnesses, he was not terminally ill. The complex subject of rational suicide in elderly adults is approached from a clinicians perspective. Issues of ageism, gerontophobia, and changing perspectives on death are highlighted. The experience of being a Baby Boomer and its influence on rational suicide is reviewed. Finally, clinical topics such as aging, frailty, dependence on younger and healthier individuals, and the older adults need for a sense of control are explored.

Policy, Ethical, and Legal Issues

Physical and cognitive decline in old age often put the autonomy of older adults at risk. A comorbid mental illness is likely to further compound this problem, increasing their dependency on those around them. A key issue encountered in the clinical care of older adults is respecting their autonomy, while also ensuring their overall well-being. This chapter describes important ethical and medicolegal concepts relevant to the care of older adults. The first section of the chapter examines the role of a geriatric psychiatrist across health-care systems and models of care. The next section describes the commonly encountered task of assessing the decision-making capacity of older adults across domains of health care, finances, independent living, driving, and sexual relations. This is followed by a discussion of medicolegal issues germane to the older adult, which includes the concepts of advance care planning, surrogate decision-making, as well as the assessment and diagnosis of elder abuse. We will then review issues that relate to the elderly prisoner, namely, their care in the criminal justice system, as well as the assessment of criminal responsibility and competence to stand trial. The last section of the chapter is a description of treatment setting regulations in geriatric psychiatry, specifically the care of older adults in nursing homes.

A Psychodynamic Perspective on Suicidal Desire in the Elderly

The number of elderly individuals expressing the wish to end their lives in the absence of overt mental illness is increasing and is expected to grow further as life expectancy increases. Taking an individual’s statements at face value and consideration of only their current circumstances is likely to miss out unconscious meanings governing the wish to die. This chapter discusses psychodynamic factors at play among elderly individuals expressing suicidal thoughts. Prominent psychodynamic theories of suicide are first reviewed. Existing theories are then applied to a clinical case to provide a format for exploring psychodynamic factors that could influence suicidal thoughts among elderly individuals.