The role of health care providers: The links between physical and psychological illness frequently place older adults with suicidal ideation or plans in contact with primary care providers.  Medical professionals must be aware of predisposing and precipitating factors increasing the risk of suicidal thoughts and behavior. The older adults’ sense of usefulness and feeling of social connectedness should be assessed, as these factors have an inverse correlation with suicidal behavior. This assessment should especially be considered when patients are encountering major life changes or have multiple or new stressors, such as the loss of a spouse or the loss of functional independence (1).

Treating Older Adults with Suicidal Ideation

1. Identify Risk Factors: Risk factors for suicide attempts in older adults include:

• Previous Suicide Attempts
• Depression
• Social Isolation
• Hopelessness, Impulsiveness, Aggressiveness
• Poor Physical Health or Function
• Financial Stress
• Access to Lethal Means
• Family History of Suicide

2. Identify and Treat Depression: Depression may be co-morbid with suicidal ideation.

• Depression may be identified in older adults using the PHQ-2 or PHQ-9 as a screening tool (1). However, tools specific to this population such as the Geriatric Depression Scale (GDS) will provide greater subsequent information.
• If starting an antidepressant, consider drug-drug interactions and side-effect profiles. Antidepressants with minimal anti-cholinergic side effects should be utilized. Common SSRIs used in older adults include escitalopram and sertraline. Other antidepressant medications such as mirtazapine, bupropion, and venlafaxine may also be good first-line choices. 

3. Utilize the Safety Plan Worksheet

• The Safety Plan Worksheet is a critical part of all psychiatry emergency department visits; it is commonly utilized at discharge from Veterans’ Affairs Medical Centers. This document helps patients identify signs of crisis and provides quick access to numbers and information related to dealing with crisis events. The plan should be brief, easy to read, and in an individual’s own words.
• The following worksheet - https://www.healthquality.va.gov/guidelines/MH/srb/PHCoEPatientSafetyPlanSelfPrint3302020508.pdf - could easily be adapted to any clinical setting and can be a helpful tool for use in patient care. 

4. Connect Patients to Resources: Loneliness and social isolation place older adults at greater risk for suicide. Social connection during times of social distancing adds difficulty as videoconferencing, text messaging and emails can be challenging. Phone calls may be a more convenient option.

• The United States National Suicide Hotline number is 988.
• The US Medicare system approves telephone visit reimbursement for mental health concerns.
• While online psychotherapy courses are available for anxiety and depressive illnesses and loneliness, some older adults may require additional support and education from families, friends, and healthcare professionals to access these services.
• Strategies to improve social connectedness can include home visits from nurses and home meal delivery services.  
• Local community Aging and Disability Resource Centers (ADRC) provide resources for connection of older adults to psychological and social services.