Rather death, reconsidered

Time and opportunity have allowed me to go carefully through the paper from Charles Marshall and others which I wrote about two weeks ago. Risk of Suicide After Dementia Diagnosis | Dementia and Cognitive Impairment | JAMA Neurology | JAMA Network


The important article from The Guardian People with recent dementia diagnosis found to have higher suicide risk | Dementia | The Guardian heightens concern that in addition to the impairments and other symptoms, a diagnosis of dementia leads some people to take their own lives.


The study is impressive, reviewing information held on three linked databases for a year or more relating to 594,674 individuals in England aged 15 or older January 2001 to December 2019. 14,515 were recorded as dying from suicide or with an open verdict.


Controls, up to 40 per case of suicide, were drawn from the same Primary Care source of data. 74.8% of suicides were male, whereas for controls, the genders were equal. Median age of death from suicide was 47.4 years, for controls it was 81.6 years. Thus suicide as a cause of death is skewed to younger age.


4940 patients had received a diagnosis of dementia. 95 (1.9%) of these had a recorded death of suicide or open verdict.


There was no statistically significant difference in the suicide rate between those with dementia and the whole sample. Differences only emerge when looking at people with diagnosis of dementia before the age of 65, and people with dementia in the three months after diagnosis. Living with dementia beyond a year of diagnosis is associated with a statistically significant reduction in suicide rate compared with controls.


Less than one in ten of the people with dementia were known to be taking one of the licensed anti-dementia medicines. Their suicide rate was much lower than that of controls but this is not celebrated as it is felt the data is ‘imprecise’.


There have been other studies into the relationship between a diagnosis of dementia and death by suicide. Fairly recent publications from cohort studies in Denmark and Korea have found increased rates or decreased rates.


Writing in 2009 Purandare et al reported on cases revealed to the National Suicide and Homicide Inquiry April 1996 – December 2004. These were all people known to mental health services during the 12 months before their deaths. Suicide in dementia: 9-year national clinical survey in England and Wales | The British Journal of Psychiatry | Cambridge Core


They noted that it was generally believed that suicide was uncommon amongst people with dementia but that where it occurred it was more common in the early stages of dementia, amongst men, people of higher education, professional occupation, the presence of insight, depression, the expression of suicidal ideas and having access to firearms.


Of the 45,012 suicides and open verdicts in those nine years, only 11,733 had been in contact with mental health services. Only 118 of these had a diagnosis of dementia. 26 were younger than 65 years and half had problems with alcohol. Death was caused by overdose of medication, especially analgesics in 30%, followed by drowning (19%) and hanging (17%). 35% had shared other psychiatric symptoms such as depression and/or anxiety. This paper gives some clinical colouring to the picture, but even here there is little depth to the stories available from each individual.

Perspective:

Standing back, we can see that suicide amongst people with a diagnosis of dementia is rare – The most recent study place it over all as the same rate as that found amongst controls – something less than 2% - 2 in 100.


There has been awareness for some years that people given a diagnosis of Early Onset Dementia are at the greatest risk. Giving the diagnosis to older people is followed by a short-lived increase in suicide risk, but after a while this settles to below that seen amongst controls. The presence of insight and additional psychiatric symptoms are also important. This raises the question of wrong diagnosis and of the possibility for effective treatment.

The suggestion that continued prescription of anti-dementia medicines is protective, is sure worthy of further investigation.


Reviewing these papers with colleagues with a combined clinical experience of over 60 years, none of us can remember a case of suicide amongst patients known to us.

We are encouraged to be aware, particularly amongst younger people with dementia, and the weeks immediately after diagnosis require special care and attention. Services at every stage and for people of all sorts of dementia and related conditions must be made as good and caring as possible.


But we would feel it is not appropriate to add the fear of suicide as a consequence of dementia to the spectrum of challenges to individuals or their families.

We would welcome reports of more detailed clinical and social description and analysis of cases.





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