Promoting Connectedness among Older Adults

Yeates Conwell, MD, Co-Director, Injury Control Research Center for Suicide Prevention, University of Rochester Medical Center and member of the SPRC Steering Committee

The scope of suicide by older adults is often underappreciated. Global suicide rates rise with age for both men and women. Between 5,000 and 6,000 older adults will die by suicide in the United States this year. A large majority of these suicide deaths will occur among older men, who have the highest suicide rate of any age group in the U.S.

We know a great deal about the risk factors for suicide in later life. Several stand out. One is clinical depression, which we know increases the relative risk of suicide greatly in older adults as well as younger people. Also at the top of the list are risk factors related to a lack of social connections. Study after study demonstrates the importance of social connections to the health and well-being of older adults as well as the risk for suicide posed by the absence of these connections. Living alone, being disconnected from one’s family, and having fewer confidants all raise the risk of suicide.

These findings are important because they reveal opportunities to reduce suicide risk in settings other than the medical care system and to expand our repertoire of effective interventions beyond the early detection of mood disorders and the aggressive treatment of depression.  In New York State, we’ve done a lot of work with a group of senior service agencies funded by the Older Americans Act to provide nonmedical services to maintain older adult independence and quality of life. These agencies are the experts in connectedness. They provide care management services, transportation for isolated older people, respite services, senior nutrition centers, peer support programs, and the like. This service network deals routinely with disconnected older adults, linking them to services and supports, improving outcomes and mitigating risk.  Partnering with them offers valuable opportunities for bridging the medical and community-based social service divide in order to reduce suicide morbidity and mortality among older adults. 

There are a number of interventions that demonstrate the promise of linking older people to care and to their communities. A program in Italy provided voice- activated social service telephone contacts to community-residing older adults at risk for hospitalization. Over time, the suicide rate in the group that received the intervention was substantially lower than what would have been expected. A series of studies in rural Japan connected older people to their communities through outreach, systematic screening for depression and referral to care, and, importantly, engagement in volunteer and peer support activities. These projects also found that suicide was reduced among people living in villages that received the intervention compared to older people living in similar settings that did not receive the intervention. A study conducted among younger people found that individuals at increased risk for suicide and suicide attempts tended to have fewer subsequent attempts when they simply received letters of caring and support after discharge from psychiatric care. So even very inexpensive interventions might have a potent effect on people who feel particular pain as the result of social isolation, lack a sense of belonging, or feel like a burden on others.

While these interventions hold promise, we need more research. In both the Japanese and Italian projects, the effect of the intervention was far more pronounced in older women than in older men. Given that older men are the group at higher risk by far, we have a lot of work to do to understand what it might be about connectedness interventions that works particularly well for women and why they come up short for men. Perhaps it is about the difficulty men have engaging with others so that they feel a sense of belonging. Men may be more subject to the risk of feeling like a burden on others when they can no longer contribute in the face of disability in older adulthood. Those kinds of ideas need more attention.

The innovations in health care delivery stimulated by the Accountable Care Act and the Center for Medicare and Medicaid Innovation may provide valuable opportunities for promoting connectedness. These innovations include patient-centered medical homes and pay-for-performance reimbursement systems. If we believe that mental health and behavioral factors are potent determinants of overall health and well-being, then these service system innovations and financing experiments might enable us to include some of the community-based interventions that support connectedness as reimbursable services – services that would save lives and reduce the rate of suicide among older adults.

For a bibliography of articles by Dr. Conwell and his colleagues that provide more information on the ideas and research described in this blog posting, click here.

Listen to the recording of the February 28, 2013 SPRC webinar on connectedness