Geriatric Nursing xx (2015) 1e4

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Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

Suicidal ideation and suicide attempts in older adults: Influences of

chronic illness, functional limitations, and pain
Su Hyun Kim, PhD, RN *
College of Nursing, Research Institute of Nursing Science, Kyungpook National University, Daegu 700-422, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: This study aimed to examine the associations between suicidal behavior in older Korean adults and
Received 20 April 2015 chronic illnesses, functional limitations, and pain. Data were obtained and analyzed for 8500 adults over
Received in revised form 65 years of age from the 2007e2012 Korea National Health and Nutrition Examination Survey IV and V.
20 July 2015
Multivariate logistic regression analyses were conducted to examine the associations between suicidal
Accepted 27 July 2015
behavior, chronic illness, functional limitations, and pain. The presence of arthritis and renal failure were
Available online xxx
significantly associated with a higher risk of suicidal ideation and suicide attempts. Moderate limitation
in usual activities and extreme pain significantly increased the risk of both suicidal ideation and suicide
Keywords:
Chronic disease
attempts, over and above the existence of chronic illnesses and depression status.
Disability Ó 2015 Elsevier Inc. All rights reserved.
Pain
Suicide

Introduction
Suicide is a serious global public health problem. According to
the report of the World Health Organization (2014), an estimated
804,000 suicide deaths occurred worldwide in 2012, representing
an annual global age-standardized suicide rate of 11.4 per 100,000
people, and making suicide the 15th leading cause of death.1
Although there is some variability across countries, suicide rates
are highest in persons aged 70 years or over in almost all regions of
the world,1 which warrants attention to suicide in late life from
health care providers.
In particular, older Korean adults are one of the most vulnerable
populations to suicide; the suicide rate in this group has increased
five-fold during the last two decades (about 70 per 100,000 in
2014).2 While undergoing a rapid increase of the older population
in a short period of time, Korean society has been unprepared for
aging and has experienced weakening social integration and
erosion of the traditional family support base for the elderly.3 In the
U.S., suicide rates in older adults have declined since 1991, after
being consistently higher than younger age groups for the previous
two decades.4 However, as the “baby boom” cohortda group with
historically high rates of suicidedenters older adulthood, the rate
of suicide in older adults is expected to rise again.5
This research was supported by the Kyungpook National University Research
Fund, 2014.
* Corresponding author. Tel.: þ82 53 420 4928; fax: þ82 53 421 2758.
E-mail address: suhyun_kim@knu.ac.kr.
The literature on suicide in late life has noted increased risk with
depression, social isolation, physical illness, demographic charac-
teristics of older age, low income, and the male gender.5 In com-
parison to suicides in young and middle adulthood, typically
associated with interpersonal discord, financial/job problems, and
legal difficulties, physical illness and functional impairment have
been explained as one of the most common stressors in older adults
who commit suicide.5 In fact, the burden of chronic illness is ex-
pected to increase substantially in the future worldwide, not only in
advanced countries but also in developing countries.1 Similar to the
U.S., more than 80% of older adults in Korea have chronic diseases,
which seriously compromise their quality of life.6,7 Given that
almost half of older adults who committed suicide had visited a
health care provider in the preceding week,8 health care assess-
ment that identifies the impact of the chronic illness in terms of
suicide risk may be useful for screening individuals at high risk.
Although the clinical guidelines for suicide prevention in older
adults have emphasized increasing health care providers’ aware-
ness of patients’ loss of body functions, and training such providers
to screen for suicide risk,9 the extent of increased risk of suicide
with chronic illnesses and the impact on health status are unclear,
particularly as related to functional impairment and pain in older
adults.10 In the literature, a high risk of suicide has been reported to
be associated with specific medical conditions, such as asthma,
cancer, congestive heart failure, epilepsy, and stroke, but the find-
ings have been inconsistent across studies where the sample
population consisted of multiple age groups, or depression was
uncontrolled.9e12 Functional impairment and pain also have been

0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2015.07.006
2 S.H. Kim / Geriatric Nursing xx (2015) 1e4
associated with increased risk of suicide,9,13 but evidence has been
insufficient to support the importance of functional limitations and
pain, over and above depression and demographic characteristics.10
A comprehensive examination of the effects of chronic illnesses as
well as pain and functional limitations imposed by the illness,
adjusting for depression and demographic variables, is necessary.
Therefore, it was hypothesized that the presence of chronic
illnesses, functional limitations, and pain would have significant
associations with suicidal behavior in older Korean adults, after
controlling for depression and demographic characteristics.
Because suicidal ideation and suicide attempts are significant and
potent predictors of completed suicide, the present study focused
on the risk factors of suicidal ideation and suicide attempts as
measures of suicidal behavior.
Methods
Design and study population
The present study was conducted using data from the 2007e
2012 Korea National Health and Nutrition Examination Survey
(KNHANES) IV and V. Data from these two waves of the KNHANES
survey were merged for the analysis in order to increase statistical
power, given the low incidence of suicide attempts in the popula-
tion during this period. Data for the KNHANES have been collected
by the Korea Centers for Disease Control and Prevention every
three or four years to provide national estimates of the health and
nutritional status of community-dwelling Koreans.14 The KNHANES
uses a stratified multistage probability sample of region, gender,
age, and average size and price of housing to represent the Korean
population. As part of the KNHANES survey, respondents over 12
years of age were asked about suicidal ideation and suicide at-
tempts. A total of 73% and 81% of eligible individuals completed the
KNHANES IV and V, respectively. Of the 47,345 respondents who
completed one of these two waves of the survey, respondents aged
65 or older were selected for this study. As a result, the final sample
for the current analysis was 8500 adults over age 65, including 714
adults (8.4%) in 2007, 1488 (17.5%) in 2008, 1555 (18.3%) in 2009,
1555 (18.3%) in 2010, 1607 (18.9%) in 2011, and 1581 (18.6%) in 2012.
Measurements
All measures in this study were administered at a mobile
examination center, as part of the health survey of the KNHANES.
The health survey was conducted with a structured interview
schedule developed for the KNHANES. The KNHANES interviewers
were trained for seven days on the content and practical manner of
administering the health survey and interviewing.6 The process of
collecting data was checked by random site visits of the KNHANES
executive team to maintain the data quality.6 Suicidal ideation and
suicide attempts were determined by responses (“yes” or “no”) to
the following questions in the self-administered paper-and-pencil
questionnaires: “Have you ever thought of committing suicide
during the last 12 months?” and “Have you attempted suicide
during the last 12 months?”
For the presence of chronic illness, participants were asked by
the KNHANES interviewers whether they had any of the following
illnesses: asthma, arthritis, cancer, diabetes, hypertension, ischemic
heart disease, renal failure, stroke, or thyroid disease. The list of
chronic physical conditions was selected to represent chronic ill-
nesses that were both prevalent and associated with substantial
morbidity in the Korean population.6,15 The prevalence of major
depression was also assessed by asking whether the individual had
been diagnosed with depression by a physician. Functional limita-
tions and pain were assessed by KNHANES interviewers via the
subscales of the Korean version of the EuroQol (EQ)-5D.16 Re-
spondents were asked to rate their functional status in terms of
mobility, self-care, and usual activities, and their pain/discomfort
on a Likert-type scale ranging from 1 (no problem) to 3 (unable to
perform or extreme pain). The physical dimensions (i.e., functional
limitation, pain) of the Korean version of the EQ-5D have exhibited
good validity and reliability in Korean patients.17 Demographic
information, including age, gender, income, and marital status,
were also assessed in the interviews.
Ethical considerations
This study utilized data from the KNHANES, which is a national
database that does not contain any personal identifiable informa-
tion. The author obtained permission for using KNHANES data from
the Korea Centers for Disease Control and Prevention. Data were
handled and processed as required by the code of conduct for
scientific researchers.
Statistical analysis
To ensure appropriate estimates and standard errors, sample
weights indicated in the Korea Centers for Disease Control and
Prevention (2014) guidelines were incorporated into the statistical
analyses for the current study. According to the guidelines for
statistical analysis,14 sample weights, incorporating information on
stratification and clustering of sampling design, selection rate, and
response rates, were applied in the analysis to ensure appropriate
estimates and standard errors to represent the national population.
The prevalence of suicidal ideation, suicide attempts, and
demographic characteristics were analyzed using descriptive
statistics.
The associations between suicidal behavior and chronic illness,
pain, and functional limitations were analyzed using multivariate
logistic regression. Two regression models were developed, one for
each dependent variable, namely suicidal ideation and suicide at-
tempts, and each model included a series of predictor variables (the
presence of each chronic illness and functional limitations of
mobility, self-care, and usual activities) plus control variables
(depression, age, income, sex, and marital status). An alpha level of
0.05 was selected for statistical significance. Statistical analyses
were performed using SPSS 19.0 Complex Samples Procedures
(SPSS, Inc., Chicago, IL, USA).
Results
Characteristics of the sample
Table 1 presents the characteristics of the sample. A total of
25.7% of the respondents reported suicidal ideation, and 1.4% had
attempted suicide in the last 12 months. The rank order of illness
frequency was as follows: hypertension, arthritis, diabetes,
ischemic heart disease, asthma, stroke, thyroid disease, cancer, and
renal failure. The prevalence of major depression was 4.8%.
Suicidal behavior and chronic illness, functional limitations, and
pain
The regression model for suicidal ideation showed that
moderate and severe limitations in self-care and usual activities
were associated with a higher risk of suicidal ideation (moderate
limitations in self-care: OR 1.41, 95% CI [1.14, 1.75]; severe limita-
tions in self-care: OR 2.37, 95% CI [1.38, 4.08]; moderate limitations
in usual activities: OR 1.72, 95% CI [1.43, 2.07]; severe limitations in
usual activities: OR 2.14, 95% CI [1.49, 3.06]) (Table 2). Additionally,
 S.H. Kim / Geriatric Nursing xx (2015) 1e4 3

Table 1 Table 2
Characteristics of the sample (N ¼ 8500). Suicidal ideation and suicide attempts in older Korean adults with chronic illness
(N ¼ 8500).
Characteristics n %
Age, mean (SE), years 72.97 (0.09) Suicidal ideationa Suicide attemptb
Gender, female 5032 59.2 Odds ratio [95% CI] Odds ratio [95% CI]
Income level
Chronic illness
Quartile 1 (lowest) 2117 24.9
Arthritis 1.13 [0.97, 1.31] 2.17 [1.24, 3.79]*
Quartile 2 2150 25.3
Asthma 1.28 [0.94, 1.74] 1.54 [0.67, 3.54]
Quartile 3 2108 24.8
Cancer 0.84 [0.45, 1.55] 1.88 [0.68, 5.19]
Quartile 4 (highest) 2125 25.0
Diabetes 1.03 [0.86, 1.23] 0.87 [0.49, 1.55]
Marital status
Hypertension 0.97 [0.85, 1.11] 0.70 [0.43, 1.15]
Married 5236 61.6
Ischemic heart disease 1.29 [0.98, 1.69] 1.44 [0.69, 3.01]
Divorced or single 229 2.7
Renal failure 1.81 [0.83, 3.95] 4.26 [1.12, 16.25]*
Bereaved 3035 35.7
Stroke 1.09 [0.82, 1.45] 0.81 [0.35, 1.88]
Suicidal ideation within previous year 2185 25.7
Thyroid disease 0.89 [0.58, 1.35] 0.26 [0.03, 2.01]
Suicide attempt within previous year 119 1.4
Functional limitationsc
Chronic illness
Mobility
Arthritis 2814 33.1
Some problems 1.09 [0.92, 1.28] 0.76 [0.39, 1.50]
Asthma 399 4.7
Confined to bed 1.13 [0.74, 1.73] 0.47 [0.16, 1.39]
Cancer 119 1.4
Self-care
Diabetes 1454 17.1
Some problems 1.41 [1.14, 1.75]* 0.92 [0.51, 1.69]
Hypertension 4233 49.8
Unable to perform 2.37 [1.38, 4.08]* 2.28 [0.44, 11.67]
Ischemic heart disease 485 5.7
Usual activities
Renal failure 43 0.5
Some problems 1.72 [1.43, 2.07]* 2.14 [1.06, 4.32]*
Stroke 332 3.9
Unable to perform 2.14 [1.49, 3.06]* 2.27 [0.90, 5.72]
Thyroid disease 170 2.0
Pain/discomfortd
Major depression 408 4.8
Moderate 1.51 [1.26, 1.81]* 1.63 [0.81, 3.28]
Extreme 2.04 [1.56, 2.65]* 3.63 [1.69, 7.83]*
Cox and snell 0.13 0.02
moderate and extreme pain were significantly associated with the Nagelkerke 0.19 0.15
likelihood of suicidal ideation (OR 1.51, 95% CI [1.26, 1.81]); (OR *p < .05.
2.04, 95% CI [1.56, 2.65]; respectively). However, there were no a, b
Adjusted for depression, age, gender, income, and marital status, c Reference ¼ no
significant associations between any of the chronic illnesses and problem, d Reference ¼ no pain or discomfort.
suicidal ideation, after controlling for depression and demographic
variables. limitations, pain, and depression. These findings suggest that sui-
The regression model for suicide attempts showed that, after cidal behavior in those with renal failure might be prompted by
adjusting for covariates, arthritis and renal failure were signifi- failure to cope with the stress of managing the illness, including
cantly associated with a higher risk of suicide attempts (arthritis: unwillingness to seek treatment or dialysis because of social
OR 2.17, 95% CI [1.24, 3.79]; renal failure: OR 4.26, 95% CI [1.12, stigma, social isolation, and stressful life events, rather than
16.25]) (Table 2). Moderate limitations in usual activities and mediated by depression, functional limitations, or pain.22 Thus, it is
extreme pain were significantly associated with the likelihood of essential for nurses who care for older people with renal failure to
suicide attempts (OR 2.14, 95% CI [1.06, 4.32]; OR 3.63, 95% CI [1.69, identify the risk of suicide, particularly at the start of dialysis or
7.83]; respectively). Limitations in mobility and self-care were not after other stressful life events.
associated with suicide attempts. In addition, the presence of arthritis was significantly associated
with a higher risk of suicide. This finding is consistent with a
Discussion previous study conducted with adult participants from 14 coun-
tries, which revealed significant associations between arthritis and
In the present study, the prevalence of suicidal ideation in the suicidal behavior,11 but it is inconsistent with a study of adults in
last 12 months in older adults was 25%. The exceptionally high rate the United Kingdom that demonstrated a protective effect of
of suicidal ideation in this population, compared to 6% in the osteoarthritis against suicide.23 The reasons for the discrepancy in
European, Taiwanese, and U.S. populations,18e20 suggests an urgent the literature may be associated with country income level. In the
need for intervention to prevent suicide in older Korean adults. The studies with a cross-national sample, arthritis was more strongly
literature has often pointed out depression and sociocultural in- associated with suicide attempts and ideation in lower-income
fluences on suicide in older Korean adults, such as economic countries than in higher-income countries.11 Webb et al (2012)
hardship and the weakening of the family support base,17 with analyzed data from a primary care database in the United Kingdom;
inconsistency in the association between health status and suicide such data may differ from community samples in Korea, where the
in studies using non-representative convenience samples.21 The average household income was less than the OECD average2 and
findings of the present study, conducted with nationally repre- the samples consisted of individuals who might not be actively
sentative data, add to the evidence on suicide prevention by seeking treatment for their disease. Given that arthritis is the
examining the critical impact of chronic illnesses, independent of second most prevalent chronic disease (40%) in older Korean adults,
depression, on suicidal behavior in older adults. the impact of arthritis on suicidal risk in this population requires
The risk of suicide was highest for individuals with renal failure. particular attention from health care providers. Often easily over-
In fact, the probability of attempting suicide was four times as high looked and neglected as a common disease that accompanies aging,
in individuals with renal failure compared to those without it. This life with arthritis is not only physically exhausting, but also
finding is in agreement with that of a previous study wherein mentally overwhelming, and ineffective coping with the resulting
people in the U.S. general population who had end-stage renal stress could lead to an increased risk of suicide.
disease were significantly more likely to commit suicide.22 In the The strong associations found between functional limitations in
current study, the significant association between renal failure and usual activities and severe pain and suicidal behavior were
suicide attempts remained after controlling for functional consistent with previous studies.9,19 The probability of attempting
4 S.H. Kim / Geriatric Nursing xx (2015) 1e4
suicide was two times as high for older adults with difficulties in
usual activities and almost four times as high for those with
extreme pain, after controlling for a range of chronic diseases and
depression. It is possible that older adults with severe pain or
functional limitations feel helpless about their ability to cope and
unsure about the possibility of future relief.24 Thus, they may view
suicide as a means of escape from suffering.9
In the multivariate analysis of suicidal ideation, functional limi-
tations and pain were more robust indicators than the range of
chronic illnesses studied. This finding suggests that suicidal ideation,
having thought about committing suicide before progressing to
attempting suicide, can be successfully diminished with nurses’
careful consideration of the patient’s functional ability and pain
status. In terms of older Korean adults, they are at high risk of losing
functional ability at an earlier age due to the high prevalence of
multiple chronic illnesses and chronic pain.25 Thus, the imple-
mentation of selective suicide prevention targeting older Korean
adults with chronic diseases that limit functioning with accompanied
pain could be one of the key actions in the guidelines for health care
providers. Nurses who care for older adults with severe pain or who
have functional limitations need to be attentive to the potential for
suicide and must develop psychological interventions accordingly.
The present study has several limitations. The data were based
on self-reports of illnesses and suicidal behaviors, which may have
led to underreporting and the possible introduction of some bias.
However, retrospectively reported events that were clearly oper-
ationalized have been demonstrated to be sufficiently valid to
warrant their use in research26 and to have reliable agreement with
medical records.27 In addition, the current study did not have ac-
cess to cases of completed suicide. Interpretation of the findings in
the present study should be made with caution because, although
there may be overlap between individuals who complete suicide
and those who experience suicidal ideation and suicide attempts,
these groups are not entirely identical.28 Future studies should
examine the complex characteristics of suicidal behaviors,
including associated risk factors and underlying mechanisms.
Conclusion
In sum, the present study demonstrated a strong association
between suicide attempts and the presence of renal failure and
arthritis in older Korean adults. Nurses need to be attentive to the
potential for suicide in older adults with renal failure and arthritis.
Systematic functional and pain assessments and interventions are
critical for preventing suicide in this population.
References
1. World Health Organization. Global Status Report on Noncommunicable Diseases
2010. Geneva, Switzerland: World Health Organization; 2011.
2. OECD. Society at a Glance 2014 Highlights: Korea. Available from: http://www.
oecd.org/korea/OECD-SocietyAtaGlance2014-Highlights-Korea.pdf; 2014.
3. OECD. OECD Factbook 2013: Economic, Environmental and Social Statistics.
Available from: http://www.oecd-ilibrary.org/sites/factbook-2013-en/12/01/
03/index.html?itemId¼/content/chapter/factbook-2013-97-en; 2013.
4. Organization WH. Suicide Data. Available from: http://www.who.int/
mental_health/prevention/suicide/suicideprevent/en/; 2015.
5. Conwell Y, Van Orden K, Caine ED. Suicide in older adults. Psychiatr Clin North
Am. 2011;34(2):451e468. ix.
6. Korea Centers for Disease Control and Prevention. Progress Report on the Korea
National Health and Nutrition Examination Survey. Seoul, Korea: Korea Center
for Disease Control & Prevention; 2008.
7. Centers for Disease Control and Prevention. The State of Aging and Health in
America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US
Department of Health and Human Services; 2013.
8. Juurlink DN, Herrmann N, Szalai JP, Kopp A, Redelmeier DA. Medical illness
and the risk of suicide in the elderly. Arch Intern Med. 2004;164(11):1179e
1184.
9. National Council on Aging. Older Americans Behavioral Health Issue Brief 4:
Preventing Suicide in Older Adults. Substance Abuse and Mental Health Services
Administration; 2012.
10. Sanna L, Stuart AL, Pasco JA, et al. Suicidal ideation and physical illness: does
the link lie with depression? J Affect Disord. 2014;152-154:422e426.
11. Scott KM, Hwang I, Chiu WT, et al. Chronic physical conditions and their as-
sociation with first onset of suicidal behavior in the world mental health
surveys. Psychosom Med. 2010;72(7):712e719.
12. Choi R, Moon HJ, Hwang BD. The influence of chronic disease on the stress
cognition, depression experience and suicidal thoughts of the elderly. KJ-HSM.
2010;4(2):73e84.
13. Conwell Y, Duberstein PR, Hirsch JK, Conner KR, Eberly S, Caine ED. Health
status and suicide in the second half of life. Int J Geriatr Psychiatry. 2010;25(4):
371e379.
14. Korea Centers for Disease Control and Prevention. Fifth Korea National Health
and Nutrition Examination Survey. 2010-2012; 2014. Seoul, Korea.
15. Korea National Statistical Office. Annual Report on the Cause of Death Statistics
2013. Daejeon: Korea National Statistical Office; 2013.
16. OECD. OECD Better Life Index: Korea. Paris, France. Available from:, http://www.
oecdbetterlifeindex.org/countries/korea/; 2015.
17. Kim SW, Yoon JS. Suicide, an urgent health issue in Korea. Med Gen Soc Med.
2013;28:345e347.
18. Chan HL, Liu CY, Chau YL, Chang CM. Prevalence and association of suicide
ideation among Taiwanese elderlyea population-based cross-sectional study.
Chang Gung Med J. 2011;34(2):197e204.
19. Sun WD, kim HR, Lee SY, et al. Strategies for Public Health Program According to
the Span of Health Status Among Older Adults. Sejong, Korea: Korea Institute for
Health and Social Affaits; 2014.
20. Kim YA, Bogner HR, Brown GK, Gallo JJ. Chronic medical conditions and wishes
to die among older primary care patients. Int J Psychiatry Med. 2006;36(2):
183e198.
21. Kim MH, Kim HS. A review on the risk factors for suicidal ideation among the
Korean elderly (2000-2010). Korean J Public Health. 2011;48(1):23e34.
22. Kurella M, Kimmel PL, Young BS, Chertow GM. Suicide in the United
States end-stage renal disease program. J Am Soc Nephrol. 2005;16(3):774e
781.
23. Webb RT, Kontopantelis E, Doran T, Qin P, Creed F, Kapur N. Suicide risk in
primary care patients with major physical diseases: a case-control study. Arch
Gen Psychiatry. 2012;69(3):256e264.
24. Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk
factors and psychological links. Psychol Med. 2006;36(5):575e586.
25. Korea Ministry of Health and Welfare. 2011 Annual Report of Status of the
Elderly; 2011. Seoul, Korea.
26. Hardt J, Rutter M. Validity of adult retrospective reports of adverse childhood
experiences: review of the evidence. J Child Psychol Psychiatry. 2004;45(2):
260e273.
27. Baumeister H, Kriston L, Bengel J, Harter M. High agreement of self-report and
physician-diagnosed somatic conditions yields limited bias in examining
mental-physical comorbidity. J Clin Epidemiol. 2010;63(5):558e565.
28. Linehan MM. Suicidal people. One population or two? Ann N Y Acad Sci.
1986;487:16e33.