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Suicide by drowning in dementia
- Emad Salib (25 February 2009)
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Suicide in dementia
- Camilla Haw (26 May 2009)
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Authors' reply
- Nitin B Purandare, Nitin Purandare N, Richard C. OudeVoshaar, Cathryn A. Rodway, and Navneet Kapur (4 June 2009)
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Emad Salib, Consultant in Old Age Psychiatry, Peasely Cross Hospital, St Helens Honorary Senior lecturer, Liverpool University
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esalib{at}hotmail.com Emad Salib
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Purandare et al (2009) paper on suicide in dementia is a valuable contribution to suicide research in the elderly, particularly in dementia sufferers. The authors have already dealt with number methodological limitations quite succinctly. One important limitation in particular is the choice of controls. As the authors rightly stated, a control group of patients with dementia who had not died by suicide would have been more appropriate. In the Methods section, the authors referred to ICD-10 only and not ICD-9. As far as I am aware from my own experience dealing with the Office of National Statistics (ONS), ICD-10 has only been used by ONS from 2001 and thereafter. Prior to this date and for the first 5 years of the study period (1996- 2000), the ONS used ICD-9. If the authors applied the same criteria in their selection of suicide and open verdicts in cases reported between April 1996 and December 2000, then I assume they would have selected: ICD-9 E950-E959 for suicide and E980-989 excluding E 988.8 for open verdicts respectively in a similar manner as they did with ICD-10 (page 175). However, this very relevant fact does not appear to have been mentioned or explained by the authors, and was quite possibly omitted from the manuscript in error. However, this omission, which covers 5 years of a 9 year study, ought to be acknowledged and duly corrected. I am grateful that the paper provides the opportunity to make one or two comments on some issues relating to drowning as method of suicide in the elderly. Drowning suicide accounted for 13.5% of total elderly suicide, being the third cause of death of total elderly suicide in England and Wales 1979-2001, 16% for women as the second cause of death after overdose in elderly female suicide and 12% for men, fourth cause of death in elderly male suicide (Salib 2005). Interestingly, Purandare et al (2009) findings clearly show that drowning suicide is in fact the second preferred method of choice by elderly psychiatric patients with or without a dementia diagnosis compared to the total elderly population. The diagnosis of drowning itself may be difficult as there are no specific features at autopsy (Lunetta et al 2003). In the investigation of a body found in water, a wide range of possibilities other than downing have to be considered; accident, suicide, misadventure or homicide. Even when the diagnosis of drowning is confirmed ( or excluded) the manner of death may remain undetermined (Lunetta et al 2003). It is also difficult to determine whether underlying natural diseases played a role in death by drowning, wrongly regarded as deliberate self harm (Byard et al 2000). There are some examples of this; 'Sudden Death in Bathroom' (SDB) has been reported (Yoshioka et al 2003) occurring mostly in winter and 80% of cases were elderly persons while bathing. Cardiac arrest and subsequent drowning in bathtubs were attributed to sudden reduction in blood pressure and cardiac arrhythmia and not due to fatal self harm (Yoshioka et al 2003). Drowning has also been attributed to Sudden Unexpected Death in Epilepsy (SUDEP) either subsequent to a seizure or occurring suddenly without explanation (Lathers and Schraeder 2002). It may be relevant to note that in a local study in Cheshire, UK (Salib et al 2003) bathroom drowning accounted for 7% of all elderly drowning, some of who may have died suddenly in water in a similar manner as in SDB. Niacin deficiency, similar to Pellagra has been reported in developed countries in alcohol dependent people with poor eating habits and self neglect malabsorption, malignancy and nutritional deficiencies (Kumar and Clark 1994). It may be reasonable to assume that some elderly people, with dementia, especially those who live alone develop mental and physical changes due to an easily overlooked nicotinamide deficiency which could result in accidental drowning, in an attempt to alleviate skin irritation as is the case in some Pellagra sufferers (Salib 2005). It is interesting to note that Lunetta et al (2003) reported that 2.6% of bodies found in water in their 25 review of drowning in Finland were found to have died of natural causes after an initially suspected suicide. A review of trends in elderly suicide by drowning in England and Wales 1979- 2001 revealed that drowning suicide in the elderly attracted only 38% verdicts of suicide but 62% open verdict (Salib 2005). The high rate of open verdicts in death by drowning compared to any other method of fatal self harm in England and Wales, simply confirms the difficulties in reaching a firm conclusion in drowning death. Combining suicide and all undetermined deaths in drowning suicide as a matter of course, especially in nationally collected statistics, and consequently in research, may result in grossly exaggerated rates and misleading trends in suicidal drowning. Suicide by drowning is probably not amenable to prevention and although the elderly are often thought to benefit from suicide prevention than younger adults, this is not likely to be the case in drowning, perhaps sadly more so in dementia sufferers. References: Byard R W, Houldsworth G, James R A. Gilbert J D. (2001) Characteristic features of suicidal drowning: a 20 year study. The American journal of forensic medicine and pathology VOL; 22 (2). P: 134-8. Kumar P., and Clark M. (1994) Clinical Medicine Bailliere Tindall London Chapter III, 163-164 Lathers CM. and Schraeder PL (2002): Clinical pharmacology: drugs as a benefit and/or risk in sudden unexpected death in epilepsy?. Journal of Clinical Pharmacology Vol 42 No 2 pp 123-136. Lunetta P., Smith G., Pentilla A., Sajanntila A (2003) Undetermined drowning. Med. Sci. Law (2003) Vol. 43, No. 3 Salib E., El Nimr G., Rahim S (2003) 200 cases of Elderly suicide Med Sci Law (in press) Salib E (2005) Trends in suicide by drowning in the elderly in England and Wales 1979-2001 Int J Geriatr Psychiatry 19: 175-181 Yoshioka N., Chiba T., Yamauchi M, Monma T., Yoshioki K (2003): Forensic consideration of death in the bathtub. Legal Medicine Vol 5, supp(1) 375-381. |
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Camilla Haw, Consultant Psychiatrist St Andrew's Healthcare
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chaw{at}standrew.co.uk Camilla Haw
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Purandare et al(ref.1) used National Confidential Inquiry data to compare the characteristics of dementia patients who died by suicide with those of age-matched suicides with other diagnoses. They say empirical data on suicide in dementia are scarce and largely based upon case reports. Although the literature in this area contains a number of interesting, albeit highly atypical, case reports of patients with less common sub-types of dementia who died by suicide, there are also a substantial number of reports on suicide in older adults with various psychiatric diagnoses. The real problem with this literature is the quality of the studies; the majority are methodologically flawed, for example not employing a sensitive method for detecting mild cognitive impairment or absence of a control group, also use of coroner?s records or death certificates to determine psychiatric diagnoses, sources known to under-report cases of dementia. The overall finding from this literature is that suicide appears to be uncommon in dementia, although the risk in Huntington?s Disease is in the region of three fold compared with the general population.(ref.2) However, in a recent cohort study based on Danish case registers, it was found that for younger patients (50-69 years) diagnosed with dementia during psychiatric hospitalisation the risk of suicide was over eight times that of the age-matched general population, and the risk was three-fold for patients aged over 70.(ref. 3) Purandare et al(ref.1) report suicide in dementia to be uncommon in the first year following diagnosis and highlight 1-5 years after first contact with services as the high risk period. The case-control design of their study used a convenient but not very informative control group, namely age and gender matched suicides with other psychiatric disorders and consequently the findings do not shed much new light on the association between suicide and dementia. No information is provided about severity of dementia or sub-type (dementia sub-type is of interest since fronto-temporal dementia would be expected to be associated with impulsive acts of suicide and self-harm as frontal lobe impairment is associated with impulsiveness). The finding that suicide is less common soon after diagnosis is counter-intuitive, and contrary to the findings of Erslangen et al 2008(ref.3) where suicide was most common in the first six months after diagnosis. There is also evidence that when attempted suicide occurs in dementia it is more common in early, mild disease and when accompanied by depression.(ref.4,5) References 1. Purandare N, Voshaar RCO, Rodway C, Bickley H, Burns A, Kapur N. Suicide in dementia: 9-year national clinical survey in England and Wales. Br J Psychiatry 2009; 194: 175-180. 2. Harris EC, Barraclough, BM. Suicide as an outcome for medical disorders. Medicine 1994; 73: 281-296. 3. Erlangsen A, Zarit SH, ConwellY. (2008). Hospital-diagnosed dementia and suicide: a longitudinal study using prospective, nationwide register data. Am J Geriatr Psychiatry 2008; 16: 220-228. 4. Tsai C F, Tsai S J, Yang C H, Hwang J P. Chinese demented inpatients admitted following a suicide attempt: A case series. Int J Geriatr Psychiatry 2007; 22: 1106-1109. 5. Osvath P, Kovacs A, Voros V., Fekete S. Risk factors of attempted suicide in the elderly: the role of cognitive impairment. Int J Psychiatry Clin Practice 2005; 9: 221-225. |
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Nitin B Purandare, Old Age Psychiatrist Senior Lecturer, University of Manchester, Nitin Purandare N, Richard C. OudeVoshaar, Cathryn A. Rodway, and Navneet Kapur
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nitin.purandare{at}manchester.ac.uk Nitin B Purandare, et al.
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Authors’ reply Re: Suicide in dementia: 9-year national clinical survey in England and Wales (Purandare et al, 2009) Nitin Purandare N*, Richard C. OudeVoshaar, Cathryn A. Rodway, and Navneet Kapur * Correspondence: Dr Nitin Purandare, Psychiatry Research Group, School of Community Based Medicine, The University of Manchester, Room 3.319, University Place (3rd Floor East), Oxford Road, Manchester, M13 9PL; Tel: 0161 3067941; Fax: 0161 3067945 We welcome the interest in our study of suicide in patients with dementia in England and Wales. We found relatively lower risk of suicide during the first year of illness in dementia. Haw says that our findings are contrary to findings by Erlangsen.1 However, such comparison is inaccurate. Erlangsen compared the risk of suicide in patients who were diagnosed to have dementia during hospitalisation for physical or psychiatric illness to the risk of suicide in general population. The authors point out that “the findings cannot be generalised to persons with dementia who have not received the diagnosis while hospitalised”. The risk of suicide is known to be increased around the time of psychiatric hospitalisation.2 Psychiatric inpatients would be expected to have more psychiatric disturbances. The study by Tsai,3 which Haw quote to support association with mild dementia, found that delusions were present in all 7 suicide cases. Haw also seems to confuse the literature on increased risk of attempted suicide in those with mild cognitive impairment to our study of completed suicide in patients with diagnosed dementia. One consideration during disclosure of the diagnosis of dementia is the potential for adverse reactions. Our findings suggest that unless the risk assessment, which should be done in any patient being given diagnosis of a major physical or mental illness, identifies a specific suicide risk the “fear of suicide” should not be a major factor in the decision to not disclose the diagnosis of dementia. We thank Salib who correctly points out that our Methods omitted ICD 9 which was indeed the classification system in use by Office of National Statistics in the earlier part of the study. The relevant ICD 9 codes were E950-E959 and E980-989 (excluding E 988.8). Our findings are based on National Confidential Inquiry data, so include individuals who die by suicide within 12 months of contact with specialist health services. When we examined general population deaths (suicide and undetermined verdicts) in older people during the period covered by this study, drowning was the 3rd most common method of suicide overall after hanging and self-poisoning (National Confidential Inquiry into Suicide and Homicide, personal communication). This is consistent with Salib’s findings. We agree that method of suicide may be an important determinant of verdict and there are difficulties in establishing suicide as a cause in drowning. However, this does not affect our main findings, which are based on the conventional definitions of suicide used in previous research and national statistics. Suicide prevention requires a variety of strategies.4 Whilst we agree restricting access to drowning as a method of suicide may not be feasible we do not agree that suicide prevention is futile in this group. Other strategies, for example the improved assessment and treatment of mental disorder are likely to be worthwhile. We do not accept that younger individuals may be less amenable to prevention. However, different age groups may require a different preventive emphasis.5 Declaration of interest All authors individually confirm that they do not have any conflict of interest to declare with regard to this manuscript. This includes fees and grants from, employment by, consultancy for, shared ownership in, or any close relationship with, an organisation whose interests, financial or otherwise, may be affected by the publication of this response. References 1. Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry; 62: 427-32. 2. Erlangsen A, Zarit SH, ConwellY. Hospital-diagnosed dementia and suicide: a longitudinal study using prospective, nationwide register data. Am J Geriatr Psychiatry 2008; 16: 220-8. 3. Tsai C F, Tsai S J, Yang C H, Hwang J P. Chinese demented inpatients admitted following a suicide attempt: A case series. Int J Geriatr Psychiatry 2007; 22: 1106-9. 4. Department of Health. National Suicide Prevention Strategy for England. DH 2002. 5. Hunt IM, Kapur N, Robinson J, Shaw J, Flynn S, Bailey H, et al. Suicide within 12 months of mental health service contact in different age and diagnostic groups: National clinical survey. Br J Psychiatry 2006; 188: 135-42. |
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