A potentially testable model with five sequential stages was proposed to explain these findings.

The overall global suicide rates for each of the eight five-year age-bands are sufficiently large for them to constitute a public health concern. This is especially important given the ongoing rise in the elderly population size and the paucity of data on risk and protective factors for suicide in the five-year age-bands after the age of 60 years.

Suicide rates generally increase with age. Examination of cross-national variations in elderly suicide rates may allow the generation of aetiological hypotheses. Suicide rates for males and females in the age-bands 65-74 years and 75+ years were ascertained from the World Health Organisation website for all the listed countries. Cross-national variations were examined by segregating different countries into four quartiles of elderly suicide rates. Suicide rates between males and females and between the two age-bands were compared across different countries. The main findings were: (i) there is wide cross-national variation in elderly suicide rates; (ii) elderly suicide rates were the lowest in Caribbean, central American and Arabic countries, and the highest in central and eastern European, some oriental and some west European countries; (iii) suicide rates were higher in men compared to women for both the age-bands; and, (iv) suicide rates were higher in the age-band 75+ years compared to the age-band 65-74 years for males and females. Potential explanations for regional and cross-national variations in elderly suicide rates include cross-national differences in genetic and environmental factors, prevalence of mental illness in the elderly, life expectancy, socio-economic deprivation, social fragmentation, cultural factors, the availability of appropriate healthcare services, and public health initiatives to improve the detection and treatment of mental illness, mental health and suicide prevention.

BackgroundHigh quality, contemporary data regarding patterns of chronic disease is essential for planning by health services, policy makers and local governments, but surprisingly scarce, including in rural Australia. This dearth of data occurs despite the recognition that rural Australians live with high rates of ill health, poor health behaviours and restricted access to health services. Crossroads-II is set in the Goulburn Valley, a rural region of Victoria, Australia 100–300 km north of metropolitan Melbourne. It is primarily an irrigated agricultural area.The aim of the study is to identify changes in the prevalence of key chronic health conditions including the extent of undiagnosed and undermanaged disease, and association with access to care, over a 15 year period.Methods/designThis study is a 15 year follow up from the 2000–2003 Crossroads-I study (2376 households participated). Crossroads-II includes a similar face to face household survey of 3600 randomly selected households across four towns of sizes 6300 to 49,800 (50% sampled in the larger town with the remainder sampled equally from the three smaller towns). Self-reported health, health behaviour and health service usage information is verified and supplemented in a nested sub-study of 900 randomly selected adult participants in ‘clinics’ involving a range of additional questionnaires and biophysical measurements. The study is expected to run from October 2016 to December 2018.DiscussionBesides providing epidemiological and health service utilisation information relating to different diseases and their risk factors in towns of different sizes, the results will be used to develop a composite measure of health service access. The importance of access to health services will be investigated by assessing the correlation of this measure with rates of undiagnosed and undermanaged disease at the mesh block level. Results will be shared with partner organisations to inform service planning and interventions to improve health outcomes for local people.

Cross-national ecological studies using national-level aggregate data are not helpful in establishing a causal relationship (and the direction of this relationship) between elderly suicide rates and mental health funding, service provision and national policies. The impact of introducing national policies on mental health, increasing funding for mental health services and increasing mental health service provision on elderly suicide rates requires further examination in longitudinal within-country studies.

Delirium is a common clinical phenomenon, often described as a disorder of consciousness. Delirium is commonly under recognised. The usual response to under recognition is to exhort practitioners to do a better job, but perhaps under recognition should instead be seen as a daily pragmatic challenge to how delirium is conceptualised. Here we retain the view that delirium is a disorder of consciousness, but propose a more multidimensional approach to this key feature. We argue that delirium can be recognised through evaluating arousal, attention and temporal orientation. We suggest that this approach can be validated by testing whether it leads to better delirium identification, accounts for the characteristic clinical disturbances, explains why delirium is common in the extreme age groups and why in later life its boundaries often blend with dementia.

Potential explanations for regional and cross-national variations in trends over time in elderly suicide rates include cross-national differences in trends over time in the prevalence of mental illness in the elderly, socioeconomic factors, cultural factors, the availability of appropriate healthcare services, and public health initiatives to improve the detection and treatment of mental illness, mental health and suicide prevention.

The direction of the causal relationship could be examined in longitudinal studies, after further improvement in levels of mental health service provision, in individual countries segregated by low and high levels of existing mental health service provision.