A scoping review exploring the ‘grey area’ of suicide-related expression in later life: Developing a conceptual framework for professional engagement

Abstract

As the body of research on suicide in later life has developed, so has its vocabulary. This has generated a high level of overlap in concepts and terminology used to articulate suicide and how it might present, as well as ‘grey area’ behavioural terms that are both specific to older adults and less well-defined (e.g. ‘hastening of death’ or ‘completed life’). A better understanding of individual experiences and pathways to suicide can help to inform assessment and interventions, and increase the potential to relate any theoretical concepts to the implementation of such. Here, we adopted a scoping review to search systematically literature on specific presentation, features, circumstances and outcomes of these grey areas of suicide in later life. Fifty-three articles (quantitative, qualitative and theoretical) were reviewed. A narrative approach was used to merge and translate this body of knowledge into a new conceptual framework based on four key themes: (a) a sense of completed life or existential loneliness; (b) death thoughts, wishes and ideation; (c) death-hastening behaviour and advanced directives; and (d) self-destructive or self-injurious behaviour. We discuss the importance of integrating this understanding into current knowledge and suicide prevention strategies for older adults. Recommendations are made for unifying research with policy themes on healthy ageing, person-centredness within service provision and citizen participation.

“It’s a Living Experience”: Bereavement by Suicide in Later Life

“…Participants in our study demonstrated a greater awareness of their own end of life, associated with later life and possibly with a reduced fear of death or wish to die made more explicit in relation to their loss and potential losses. A scoping review of suicide and suicide-related concepts in older people [ 21 ] included a range of “grey area” behaviours (for lack of a better term) that are either less common, or present differently than they are in younger population groups. These include terms and behaviours such as “completed life”, “hastening of death” and “self-chosen death” [ 37 , 38 ].…”

“…There may be a need to unify research from different disciplines, with policy themes on ageing such as healthy ageing, concepts of promoting person-centredness within service provision and giving greater emphasis to participation which enables peer support. Being able to understand the individual experiences and pathways within suicide research can help inform and enrich assessment and evidence-based interventions [ 21 ].…”

“…This included providing formal training on qualitative interviewing and data analysis and opportunities for both verbal and written structured dialogue to facilitate mutual and reciprocal learning. The topic guide (see Table 1 ) was informed by a literature review and scoping of current suicide prevention strategies for potential domains and constructs [ 21 ]. While the topic guide had a strong focus on support after loss, it sought to gain broader insights into participants’ lived experiences of their loss(es) and their specific relationship to their experiences of ageing.…”

Talking really does matter: Lay perspectives from older people on talking about suicide in later life

“…One key message is that recognizing triggers that cause older people to “give up” on life can be difficult (Azulai and Walsh, 2015 ; Hafford-Letchfield et al, 2020 ). A recent conceptual model described several (so-called “gray area”) suicidal behaviors that might be considered unique to suicide expression in later life (Hafford-Letchfield et al, 2022a ). Yet, these expressions are viewed by many as “normal” part of aging, with such behaviors often described as a “rational” response to an age-related decline in physical or mental function (De Leo, 2022 ).…”

“…Yet, these expressions are viewed by many as “normal” part of aging, with such behaviors often described as a “rational” response to an age-related decline in physical or mental function (De Leo, 2022 ). The conceptual model presented by Hafford-Letchfield et al ( 2022a ) described how an older adult viewing their life as “completed” could lead to the development of a wish to die and subsequently motivate engagement with a range of behaviors that either are self-destructive (e.g., self-neglect and problematic substance use) or hasten death (e.g., voluntary stopping of eating or drinking and refusing necessary medication).…”