Forensic Science, Medicine, and Pathology Copyright © 2006 Humana Press Inc. All rights of any nature whatsoever are reserved. ISSN 1547-769X/06/2:253–262/$30.00 (Online) 1556-2891 DOI: 10.1385/Forensic Sci. Med. Pathol.:2:4:253
ORIGINAL ARTICLE
Suicide in Our Elders A 10-Year Review of Kentucky Medical Examiner Cases Lisa B. E. Shields,1 Donna M. Hunsaker,1 and John C. Hunsaker, III2 1Office
of the Chief Medical Examiner, and the Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY; and 2Office of the Associate Chief Medical Examiner, Frankfort, KY and Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, KY Address for correspondence and reprints: Donna M. Hunsaker Office of the Chief Medical Examiner Urban Government Center 810 Barret Avenue Louisville, KY 40204 E-mail:
[email protected] Accepted for publication: March 14, 2006
Abstract The suicide rate in the United States is consistently higher in the elderly (≥65 years) than among younger cohorts, reaching approx 5500 deaths in 2002. In this article, we present a 10-year (1993–2002) retrospective review of 348 Kentucky medical examiner cases ascribed to suicide between 65 and 96 years. Most victims were males (86.8%) and Caucasian (98.9%). The predominant cause of death was firearm injury (80.7%), followed by hanging (4.9%) and overdose (4.3%). The pervasiveness of elderly suicide by firearm requires a multidisciplinary approach to the recognition of indicators and the development of strategies for treatment and prevention of suicide in at-risk elders. Key Words: Forensic pathology; suicide; elderly; firearms; toxicology. (DOI: 10.1385/Forensic Sci. Med. Pathol.:2:4:253)
INTRODUCTION During the 20th century, the population of elderly Americans rose 10-fold, concomitantly with an increased life expectancy from 47 years to more than 75 years (1). As the post-World War II “baby boomer” generation (the 75 million people born between 1946 and 1964) advances in age, the elderly population is projected to increase to 54 million by 2020 (1). Suicide rates are higher among the aged than in younger cohorts. Although the elderly comprised 12.4% of the population in 2000, they accounted for 18.1% of completed suicides (2,3). The estimated ratio of attempted suicides to completed suicides in adolescence is 200:1 (4) compared with an estimated 10–25:1 in the general population (5). In distinct contrast, the elderly are less likely to attempt—yet are more likely to complete— suicide: this ratio is approx 4:1 in the older generation (6). Compared with younger persons, older adults confront specific age-related suicidal risk factors. The following triad of biopsychosocial components tends to precipitate suicidal behavior in the older adult: (a) declining physical state, specifically, illness and functional impairment; (b) clinically evident psychopathology such as depression and hopelessness; and (c) the social milieu, quite commonly characterized by
isolation, lack of social bonds, and loss of independence (7–9). Dorpat and colleagues concluded that medical illness directly contributed to the suicide in approx 70% of victims over the age of 60 years (10). Illnesses associated with an increased risk of suicide run the gamut from malignancy, disorders of the central nervous system (CNS), musculoskeletal disabilities, cardiopulmonary disease, to visual and hearing impairment (8,10). Between 71 and 95% of suicides 65 years or older recorded a clinical diagnosis of a major psychiatric disorder (7,8). The elderly are more likely to experience depressive rather than psychotic illness (schizophrenia or delusional disorder), personality disorders, or anxiety disorders. Furthermore, alcoholism and substance abuse occur less frequently in the elderly population (11). Unlike younger people, older adults typically select more immediately lethal methods of suicide. This age-specific modus operandi is deemed to represent an expression of well-conceived determination, which evinces greater intent, planning, and execution (7–9,12–14). Regarded as resolute in their inclination to die, the elderly infrequently reveal explicit expressions of suicidal intent. They are less likely to survive injury as a result of both physical frailty and the decreased likelihood of
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254 ______________________________________________________________________________________Shields et al. discovery after the suicidal act, which commonly occurs in a setting of diminished social support. Older suicides are less likely to have been acknowledged by family and caregivers in contact with them as being at risk for suicide. Either the elder person did not express suicidal inclinations in the short time prior to death, or others around them failed to recognize cues of suicidal ideation (13,15). The attitudes of elderly persons toward death and dying are also significant factors underlying the significantly higher rate of completed suicide. Many of the aged, who often experience greater anxiety facing stressful life conditions, rarely fear death (16). This 10-year (1993–2002) retrospective study, which is based on analysis of (a) autopsy reports (including toxicological results) issued by forensic pathologists serving as appointed medical examiners and (b) associated investigatory findings by lay coroners and law enforcement officials, summarizes the preeminent features of suicide among a selected subset of older adults in Kentucky. Kentucky is by statute (KRS Chapter 72) a dual coroner–medical examiner system, in which the coroner of jurisdiction exercises official discretion to determine whether a decedent shall undergo autopsy. Within this statutory framework, the authors did not evaluate all certified cases of suicide in Kentucky among the aged population over the review period. Specifically, this analysis covers only those cases that were referred by the coroner to the medical examiner’s office for a postmortem examination and subsequently certified as suicide. The authors highlight the large number of markers and characteristics unique to the older members making up this selected population who commit suicide.
METHODS The population in this 10-year (1993–2002) retrospective study comprised individuals 65 years or older whose manner of death was classified as suicide at the medical examiners’ offices (MEO) in Kentucky. Such a determination was made only after thorough scene investigations, review of medical and social history, postmortem examination, and toxicological evaluation. Pursuant to statute, the Kentucky legislature (KRS Chapter 72) established a dual coroner–medical examiner system in which the lay coroner determines whether to perform solely an external examination and toxicological analysis of the victim or to refer cases to the MEO for autopsy. The case may not be referred to the medical examiner for autopsy in certain situations of a highly presumptive suicide based on physical findings at the scene and historical evidence demonstrating verbal or written suicidal ideation. In collaboration with the coroner and other official investigators, forensic pathologists at the MEO perform autopsies and oversee the scientific and other facets of the investigation. In addition to documenting personal data such as age, race, and gender of each victim, chart review specifically addressed the following:
• • • • • •
Cause-of-death formulation. Toxicological findings. Time of year of demise. Location of death. Presence or absence of a suicide note. Historical evidence of dyadic murder–suicide, suicide attempts, or suicide by a family member. • Recent life stressors such as domestic turmoil, medical illness, or financial instability. Toxicological analyses were performed on blood, urine, or other matrices. Initial screening was for ethanol and other volatiles, as well as for a wide variety of prescription, overthe-counter, and illicit drugs commonly used or abused in Kentucky. Preliminary screening was by thin-layer chromatography (TLC), gas chromatography (GC), and immunoassays. Confirmation and quantification were accomplished by either GC or GC–mass spectroscopy (GC-MS). Ethanol and other volatiles were analyzed by dual-column headspace GC. Confirmation of ethanol was by immunoassay. Extraction techniques included both liquid–liquid and solid-phase extractions. Carbon monoxide (carboxyhemogobin) was analyzed spectrophotometrically.
RESULTS Demographics A total of 2864 cases spanning 11 to 96 years of age from all 120 Kentucky counties were ascribed to and certified as suicide after postmortem examination at the Kentucky MEO between 1993 and 2002 (17). Of these, 348 subjects were 65 years or older, reflecting 12.2% of all suicides. According to the Centers for Disease Control (CDC), 940 individuals aged 65 years or older committed suicide in Kentucky between 1993 and 2002 (2). During this decade, 348 deaths between ages 65 and 96 were certified suicidal after the coroner’s referral to the medical examiner. This reflects 37% of the suicide deaths in this cohort reported by the CDC. The elders drawn from medical examiner cases were subdivided into three discrete brackets by age, which are tabulated by the absolute number and percentage of suicides, after the model of Maris and colleagues (18): 1. The young-old (65–74 years): 168 (48.3%). 2. The old-old (75–84 years): 142 (40.8%). 3. The oldest-old (≥85 years): 38 (10.9%). The gender and race of the victims are presented in Table 1. The vast majority was Caucasian (98.9%) and male (86.8%). Distinctly few African Americans committed suicide, representing only 1.1%. In 2001, individuals no younger than 65 years comprised 12.5% of the population in Kentucky (2). The racial and ethnic composition of the jurisdiction for this age group was 55.9% Caucasian females, 38.4% Caucasian males, 3.2% African-American females, and 2.0% African-American males. As to seasonality, the time of year for suicide was evenly
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Suicide in Our Elders ______________________________________________________________________________255
Fig. 1. Suicide in relation to month of the year of elderly suicides examined in Kentucky Medical Examiners’ Offices, 1993–2002.
Table 1 Race and Gender of Elderly Suicides Examined in Kentucky Medical Examiners’ Offices, 1993–2002 Race Caucasian 344 subjects (98.9%) African American 4 subjects (1.1%) Total 348 subjects
Males
Females
300 (86.2%)
44 (12.6%)
2 (0.57%)
2 (0.57%)
302 (86.8%)
46 (13.2%)
distributed among the months: percentages ranged from 6 to 11.8% (Fig. 1). Suicide peaked in May and July and tapered to the lowest percentages during November and December.
Location of Pronouncement of Death and Extent of Postmortem Examination The subject’s residence was the most common location at which the pronouncement of death occurred, accounting for 269 (77.3%) suicides. The remainder of decedents were pronounced dead at one of the following sites: hospital, 51 cases (14.6%), public location, 22 cases (6.3%); motel, 1 case (0.29%); and unknown, 5 cases (1.4%). Investigation confirmed that 43 (12.4%) of the elderly individuals had composed a suicide note prior to death.
A complete autopsy was performed on 289 (83%) of the victims. The rest underwent a focused autopsy, as, for example, in selected cases of a firearm injury of the head. In these instances, the examination consisted solely of an external, cranial, and toxicological examination, together with recovery of physical evidence. In other cases of directed partial autopsy, the subjects underwent organ or tissue procurement for donation prior to the autopsy.
Method of Suicide Fatality by firearm was the most prevalent suicidal method for both men and women, representing 281 (80.7%) of victims. Table 2 catalogues the various causes of death. Gunshot wounds of the head were the most common finding, accounting for 213 (75.8%) of the firearm fatalities and 61.2% of the total suicides. The distribution of the remainder of entrance sites involved the following regions: chest only, 54 cases (19.2%), including 4 with multiple firearm wounds of the chest; abdomen, 7 cases (2.5%); neck, 6 cases (2.1%), including 1 of multiple cervical wounds; and a combination of the above sites and other bodily sites, 8 cases (2.8%) (Table 3). The second and third leading causes of death among men, respectively, were hanging followed by carbon monoxide poisoning, and among women were overdose followed by hanging. The “Others” category consisted of one case involving bimodal causes of death consisting of simultaneous firearm wound and hanging. This 76-year-old Caucasian male was found
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256 ______________________________________________________________________________________Shields et al. Table 2 Cause of Death of Elderly Suicides Examined in Kentucky Medical Examiners’ Offices, 1993–2002 Both sexes (N = 348) Firearm injuries Directed at head Hanging Overdose CO intoxication Asphyxiation (Bag) Blunt force injurya Drowning Incisions/stabbing Others a
Male (N = 302)
Female (N = 46)
N
%
N
%
N
%
281 213 17 16 10 10 6 4 3 1
80.7% 75.8% 4.9% 4.6% 2.9% 2.9% 1.7% 1.1% 0.8% 0.29%
262 204 12 4 8 5 6 2 2 1
86.7% 77.8% 4.0% 1.3% 2.6% 1.6% 2.0% 0.66% 0.66% 0.33%
19 9 5 12 2 5 0 2 1 0
41.3% 47.4% 10.9% 26% 4.3% 10.9% 0.0% 4.3% 2.2% 0.0%
All cases were the result of a fall from a height.
Table 3 Bodily Location of Firearm Injuries (N = 281) of Elderly Suicides Examined in Kentucky Medical Examiners’ Offices, 1993–2002 Entrance of firearm wound(s) Head only Chest only Abdomen Neck Combinations of above and other
Number of cases 205 (73.0%) (includes 5 multiple) 54 (19.2%) (includes 4 multiple) 8 (2.8%) 6 (2.1%) (includes 1 multiple) 8 (2.8%)
Table 4 Postmortem Blood Toxicological Analysis of Elderly Suicides Examined in Kentucky Medical Examiners’ Offices, 1993–2002 Psychoactive substance Blood collected Negative Ethanol Negative
