摘要：Objectives. We investigated the epidemiology of suicide among adults aged 50 years and older in nursing homes and assisted living facilities and whether anticipating transitioning into long-term care (LTC) is a risk factor for suicide. Methods. Data come from the Virginia Violent Death Reporting System (2003–2011). We matched locations of suicides (n = 3453) against publicly available resource registries of nursing homes (n = 285) and assisted living facilities (n = 548). We examined individual and organizational correlates of suicide by logistic regression. We identified decedents anticipating entry into LTC through qualitative text analysis. Results. Incidence of suicide was 14.16 per 100 000 in nursing homes and 15.66 in the community. Better performance on Nursing Home Compare quality metrics was associated with higher odds of suicide in nursing homes (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.21, 3.14). Larger facility size was associated with higher suicide risk in assisted living facilities (OR = 1.01; 95% CI = 1.00, 1.01). Text narratives identified 38 decedents anticipating transitioning into LTC and 16 whose loved one recently transitioned or resided in LTC. Conclusions. LTC may be an important point of engagement in suicide prevention. Approximately 40% of adults aged 65 years and older will need skilled residential nursing care at some point in their lifetime. 1 Older adults have among the highest suicide risks in the United States 2 ; the rate of suicide among men aged 65 years and older is 30 per 100 000; by contrast, it is 7 per 100 000 for men younger than 25 years. 3 A key element of suicide prevention is the identification of points of engagement to interact with potential victims. 4 Risk factors for suicide, such as social isolation, depression, and functional impairment, are common among long-term care (LTC) residents, 5–7 and these facilities may therefore be important locations for preventing suicide among older adults. Indeed, the 1987 Nursing Home Reform Act mandated screening of LTC admissions to facilitate appropriate placement and increased psychiatric services, 8 and the Minimum Data Set 3.0 includes a mandatory screener for depressive symptoms and suicidal ideation. 9 Nearly 1.5 million adults reside in nursing homes, 10,11 and another 1 million reside in assisted living facilities. 12 Little is known regarding risk and protective factors for suicide in LTC. 13 In 2011 the Substance Abuse and Mental Health Services Administration released a tool kit on preventing suicide in senior-living communities, which notes, We do not know how many residents of senior living communities attempt suicide or die by suicide. But, we do know that a suicide in a facility . . . profoundly impacts the lives of everyone concerned—residents, families, and staff. 14 (p4) Suicidal ideation is common among LTC residents, with between 5% and 33% reporting ideation (active or passive) within the past month. 15 As a result, suicide risk may be substantial in these facilities despite countervailing factors such as regular monitoring by staff and limited access to lethal means. The handful of studies that have compared incidence of completed suicide in LTC to the general community are mixed, with 1 reporting higher 16 and another reporting lower 17 risk in these settings. Suicidal behavior in LTC likely reflects a combination of factors shared with community cases (e.g., presence of a psychiatric disorder), as well as factors that are unique to LTC (e.g., facility characteristics). For example, bed size (number of beds) and high staff turnover have been associated with higher risk of suicidal behaviors among residents. 18,19 However, these studies were conducted in the 1980s, prior to the growth of assisted living, 20 which reduces their applicability to modern facilities. Finally, it is unknown whether the transition to LTC, or the process of having a loved one transition, is a risk factor for suicide. 21 These transitions often involve a complex interplay of social and psychological factors, including feelings of autonomy, social connectedness, and identity, 22,23 and can produce feelings of anxiety, loneliness, and hopelessness because they affect a people’s sense of being at home, which is not simply their physical residence. 24 Such transitions have potential implications for the psychological well-being of caregivers of the person moving into LTC as well. 25 To identify whether LTC settings are important points of engagement for reducing suicide risk among older adults, 4,26 we analyzed data from the 2003 to 2011 Virginia Violent Death Reporting System (VVDRS). We aimed to (1) describe the epidemiology of completed suicide in nursing homes and assisted living facilities, (2) examine whether facility characteristics were related to suicide risk, and (3) assess whether the process of transitioning into an LTC facility was associated with suicide.
