Abstract

This is a study on scientific work on the ideation, suicide attempt and self-neglect of elderly residents in LTCEs from 2002 to 2017. Documents were retrieved from the following sources: BVS/SP, SciELO, Scopus, PubMed and Web of Science, with the following descriptors: suicide attempt, suicidal ideation, self-neglect, elderly, long-term care establishment, and their correspondents in Portuguese, Spanish and French. Twenty-six papers on the subject were found. There is a consensus among the authors, whose texts are analyzed here, concerning the factors that lead the elderly to suicidal behavior: depression, illness and pain, complicated and traumatic mourning, anxiety and despair after recovery from depressive episode, poor living conditions, death of close relatives, friends, family conflicts, family history of self-inflicted events. The protection factors found are religiosity, optimistic lifestyle, satisfaction with life and investment in the autonomy and power of relationships and communication and monitored drug therapy for mental disorders such as depression.

Suicidal behavior; The elderly; Long-term care establishments; Risk diagnosis; Protective factors and preventive measures

Introduction

This study aims to present national and international publications on suicidal ideation, suicide attempt and self-neglect in older adults living in Long-Term Care Establishments (LTCE). In his classic book, “Suicide”, Durkheim¹1. Durkheim E. O Suicídio. Lisboa: Editora Martins Fontes; 2004. states that the moral constitution of society determines the contingent of voluntary deaths. He adds that every people has a collective force of determined energy that drives people to kill themselves. The author focuses the social macrostructure within which the act of taking one’s life is inserted. After Durkheim, suicide has advanced, and sociological analyses of self-inflicted death have been added, as well as other, sometimes opposing, theories addressing this event as a complex and multiple causal phenomenon. In this text, the subject is addressed in its micro-social, interpersonal, psychological, environmental and health complexity, through the contribution of several authors, especially Shneidman²2. Shneidman ES. Comprehending suicide. Washington: American Psychological Association; 2001.; Joiner³3. Joiner T. Why people die by suicide. Cambridge: Harvard University Press; 2005.; Forsell et al.⁴4. Forsell Y, Jorm AF, Winblad B. Suicidal thoughts and associated factor in elderly population. Acta Psychiatr Scand 1997; 95(2):108-111.; Osgood and Thielmann⁵5. Osgood NJ, Thielman S. Geriatric suicidal behaviour: Assessment and treatement of suicidal patients. In: Blumenthal SJ, Kupter DJ, editors. Suicide over the life cycle: risk factors, assessment and treatment of suicidal patients. Washington: American Psychiatric Press; 1990. p. 341-379..

Based on the psychological needs of the human being, Shneidman²2. Shneidman ES. Comprehending suicide. Washington: American Psychological Association; 2001. considers suicide and suicidal behavior as the result of the confluence of maximum pain, disturbance and pressure, which is expressed in the way of life. Also, Joiner³3. Joiner T. Why people die by suicide. Cambridge: Harvard University Press; 2005. says that the desire to die is a function of three constructs: the feeling of non-belonging, the feeling of being a burden to the family or others, and the absence of the instinctive fear of death. Forsell et al.⁴4. Forsell Y, Jorm AF, Winblad B. Suicidal thoughts and associated factor in elderly population. Acta Psychiatr Scand 1997; 95(2):108-111. found a peculiar link between suicidal behavior, acts and thoughts with depression, and between ideation and multiple dependencies, institutionalization, severe visual problems and use of psychotropic drugs. Osgood and Thielmann⁵5. Osgood NJ, Thielman S. Geriatric suicidal behaviour: Assessment and treatement of suicidal patients. In: Blumenthal SJ, Kupter DJ, editors. Suicide over the life cycle: risk factors, assessment and treatment of suicidal patients. Washington: American Psychiatric Press; 1990. p. 341-379. recall that the relationship between suicidal ideation, attempted suicide and suicide is expressed in verbal communications, in behaviors and in a set of signs that can be detected, such as neglecting medication, organizing belongings, naming their future destination, not showing interest in the things of life, suddenly seeking some religion, visiting the doctor verbalizing vague symptoms, among others.

Attempted suicide, suicidal thoughts and self-neglect are analyzed here within public or private Long-Term Care Establishments for the Elderly (LTCE), which in Brazil aim to provide supervision and care to older adults in daily activities and nursing services when necessary. They are regulated by the National Health Surveillance Agency (ANVISA)⁶6. Agência Nacional de Vigilância Sanitária (Anvisa). Resolução nº 283, de 26 de setembro de 2005. Regulamento técnico para o funcionamento das instituições de longa permanência para idosos. Diário Oficial da União 2005; 27 set. and, to comply with the Statue of the Elderly, are included in the Social Assistance System (SUAS) in the category of highly complex social protection services. They are defined as “Institutional Reception Services” aimed at serving seniors with broken or weakened family ties and aim to give them full protection in facilities inserted in the community and with residential characteristics, welcoming environment and adequate physical structure. Regarding attempted suicides, the Resolution of ANVISA⁶6. Agência Nacional de Vigilância Sanitária (Anvisa). Resolução nº 283, de 26 de setembro de 2005. Regulamento técnico para o funcionamento das instituições de longa permanência para idosos. Diário Oficial da União 2005; 27 set. requires their immediate compulsory notification the local health authority.

Study design

This is one of an integrative review of the national and international literature on self-neglect, suicidal ideation and suicide attempt in seniors that reside in LTCEs. According to Souza et al.⁷7. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1 Pt.1):102-106., the integrative review is the most extensive methodological approach to revisions, allowing the inclusion of experimental and non-experimental studies for a comprehensive understanding of the analyzed event. We follow the following steps to perform this study⁸8. Whittemore R, Knafl K. The integrative review: update methodology. J Adv Nurs 2005; 52(5):546-553.^,99. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto - enferm 2008; 17(4):758-764.:

1. Elaboration of the guiding question, i.e. identification of the theme and selection of the hypothesis or research question. The motivation to carry out this study, in the Brazilian case, is because, together with the hospitals, the LTCEs are where 26.1% of the older adults’ suicides occur, right after their residences or surroundings¹⁰10. Pinto L, Pires TO, Silva CMFP, Assis, SG. Evolução temporal da mortalidade por suicídio em pessoas com 60 anos ou mais nos estados brasileiros, 1980 a 2009. Cien Saude Colet 2012; 17(8):1973-1981.^,1111. Minayo MCS, Cavalcanti FG. Suicide Attempts among Elderly People: literature review (2002/2013). Cien Saude Colet 2015; 20(6):1751-1762.. Generally, self-inflicted death is preceded by various types of suicidal behavior. However, even with such relevance, the number of studies on these institutions as a locus for both self-destructive behavior and self-inflicted death is low¹²12. MCS, Souza ER, Ribeiro AP, Figueiredo AEB. Lições aprendidas na avaliação de um programa brasileiro de atenção a idosas vítimas de violência. Interface Botucatu 2015; 19(52):171-182.. The guiding question of this search is that there rarely is an understanding among the employees and managers of senior residences about the relevance of the boarding environment, the process of separation of the elderly from their families and the institutional dynamics itself, of self-neglect, suicidal thoughts and suicide attempts, predictive elements of self-inflicted death. Thus, we understand that it is crucial to elucidate these issues to prevent such events.

2. Establishment of criteria for the inclusion and exclusion of studies, sampling and search in the literature. Texts were searched in the following data sources: BVS/SP, SciELO, Scopus, PubMed, and Web of Science, from 2002 to 2017. The following descriptors were used: “Asilo” OR “Instituição de Longa Permanência para Idosos” OR “Instituição Asilar” OR “Asilos para Idosos” OR “Ancianatos” OR “Instituições Geriátricas de Longa Permanência” OR “ILPI” OR “Casa de repouso” OR “Casa lar” OR “Abrigo”; “Idosos” OR “Pessoa Idosa” OR “Pessoa de Idade” OR “Pessoas de Idade” OR “Pessoas Idosas”; “Ideação suicida” OR “Ideações suicidas” OR “Tentativa de suicídio” OR “Autonegligência” and their equivalent in English, Spanish and French.

3. and 4. In literature sampling and data collection, including the definition of the information to be extracted from the selected studies and categorization, 205 papers were selected, all read as to their scope, keywords and abstracts. Of these, 179 were excluded through the following criteria: duplication in the databases and lack of relevance to the subject of suicidal behavior specifically in nursing homes, long-term care establishments, senior homes.

5. Critical review and evaluation of included studies returned, were only 26 studies fit the study object, which were thoroughly read and analyzed as to their understanding of the subject regarding the focus, the method, the results and the discussion raised.

The summary of this selection is shown in Figure 1.

The analysis of the selected papers followed a comprehensive perspective, seeking to study further: (a) the main risk factors related to the suicidal behavior of elderly people hospitalized in long-term care establishments; (b) the comparison between risk factors that specifically refer to hospitalized seniors and seniors in general; (c) protective factors and proposed prevention measures; (d) discussion and conclusions.

Discussion of results

Terms used in the characterization of LTCE and suicidal behavior

Regarding the analyzed literature, the first one to be observed is that the Brazilian term “ILPI” has different equivalents, as per the countries in which the studies were carried out: residence for the elderly; nursing homes; assisted nursing homes for the elderly; homes; rest homes; among others. For this study, all such denominations are referred to herein as LTCEs. Likewise, a varied terminology is noted to name the phenomenon studied here: suicidal behavior to refer to attempts, thoughts and self-harm; direct suicidal behavior to express, for example, voluntary drug poisoning and self-mutilation; passive suicide or indirect behavior to mean, for example, the refusal of food or medicines; self-destructive behavior, self-violence, among others.

(1) Characterization of the papers that underpin the review

In Chart 1, papers are organized by title, author, year, type of study, country of the primary author, publishing journal and principal diagnoses of suicidal behavior. Suicidal behavior is understood here as the individual’s way of acting that can lead to self-inflicted death and includes self-harm; persistent thoughts, planning to end life, and history of attempts to accomplish the act.

Although it is a relevant subject, since several authors mentioned¹⁷17. Anía BJ, Chinchillab E, Suárez-Almenarac JL, Iruritad J. Intentos de suicidio y suicidios consumados por los ancianos de una residencia. Revista Espanõla Geriatría Gerontología 2003; 38(3):170-174.^,2626. Scocco P, Rapattoni M, Fantoni G, Galuppo M, De Biasi F, de Girolamo G, Pavan L. Suicidal behaviour in nursing homes: a survey in a region of north-east Italy. Int J Geriatr Psychiatry 2006; 21(4):307-311.^,3030. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254.

35. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^-3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45. report that older adults in LTCEs proportionately show more suicidal behaviors than the general senior population, the subject has not received much attention of the scientific community. In the databases analyzed here, in the last 14 years, only 26 references were found. In them, many of the issues brought up refer to seniors in general. Only a few are peculiar to those living in institutions.

Four papers were found in 2002, namely, one theoretical essay¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24., two cross-sectional quantitative studies¹⁴14. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.^,1515. Draper B, Brodaty H, Low L F, Richards V. Self-destructive behaviors in nursing home residents. J Am Geriatr Soc 2002; 50(2):354-358. and one exploratory review¹⁶16. Ron P. Suicidal ideation and depression among institutionalized elderly: the influence of residency duration. Illn Crises Loss 2002; 10(4):334-343.. One retrospective longitudinal study¹⁷17. Anía BJ, Chinchillab E, Suárez-Almenarac JL, Iruritad J. Intentos de suicidio y suicidios consumados por los ancianos de una residencia. Revista Espanõla Geriatría Gerontología 2003; 38(3):170-174., one cross-sectional study¹⁸18. Draper B, Brodaty H, Low LF, Richards V, Paton H, Lie D. Prediction of Mortality in Nursing Home Residents: Impact of Passive Self-Harm Behaviors. Int Psychogeriatr 2003; 15(2):187-196. and one descriptive and comparative study¹⁶16. Ron P. Suicidal ideation and depression among institutionalized elderly: the influence of residency duration. Illn Crises Loss 2002; 10(4):334-343. were referenced in 2003. In 2004, one exploratory and comparative study²⁰20. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: A comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work 2004; 43(2-3):97-116., three descriptive cross-sectional studies²¹21. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2222. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.^,2424. Adams KB, Sanders S, Auth EA. Loneliness and depression in independent living retirement communities: Risk and resilience factors. Aging Ment Health 2004; 8(6):475-485. and one qualitative study²³23. Kao HF, Travis SS, Acton GJ. Relocation to a long-term care facility: Working with patients and families before, during, and after. J Psychosoc Nurs Ment Health Serv 2004; 42(3):10-16. were retrieved. Only one comparative quantitative study was shown²⁵25. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145. in 2005. The same occurs in 2006, although, in this one, the authors combine a descriptive epidemiological approach and a qualitative approach²⁷27. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315.. Once again, in 2007, only one study was mentioned, namely, a qualitative study²⁸28. Kaup BA, Loreck D, Gruber-Baldini AL, German P, Menon AS, Zimmerman S, Burton L, Magaziner J. Depression and its relationship to funciton and medical status, by dementia status, in nursing home admissions. Am J Geriatr Psychiatry 2007; 15(5):438-442.. In 2008, the literature showed one descriptive epidemiological study²⁹29. Mezuk B, Prescott MR, Tardiff K, Vlahov D, Galea S. Suicide in older adults in long-term care: 1990 to 2005. J Am Geriatr Soc 2008; 56(11):2107-2111. and one theoretical essay³⁰30. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.. In 2009, one descriptive epidemiological study³¹31. Scocco P, Fantoni G, Rapattoni M, Girolamo G, Pavan L. Death Ideas, Suicidal Thoughts, and Plans among Nursing Home Residents. J Geriatr Psychiatry Neurol 2009; 22(2):141-148. and two qualitative studies³²32. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.^,3333. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750. were identified. One theoretical essay³⁴34. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254. and one cross-sectional quantitative study³⁵35. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849. were referenced in 2010. In 2011, only one descriptive and prospective work was retrieved³⁶36. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340.. No papers on the subject are found in the searched databases in 2012 and 2013. One review text appeared in 2014³⁷37. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry 2014; 29(12):1198-1211.. Again, in 2015, no references on the subject were found, and only one text was identified in 2016, which is the only qualitative case study³⁸38. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45..

As of 2010, a decrease or even lack of scientific papers on the subject is observed. Only one text³⁸38. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45. was found in Brazil in 2016 throughout the studied period, which shows the early investment of the scientific community in the subject, despite its relevance in the national context. Most of the early authors are from the United States (11), followed by Australia (3), Israel (2), Italy (2), Spain (1), Hong Kong (1), Taiwan (1), South Korea (1), Austria (1), Greece (1), Romania (1) and Brazil (1).

Fourteen journals in which the analyzed papers circulate articulate suicidal behavior with medical, psychiatric, neurological and mental health issues, and they are: Drugs & Aging; Journal of the American Geriatrics Society; Revista Espanõla de Geriatría y Gerontología; International Psychogeriatrics; International Journal of Geriatric Psychiatry; Journal of Mental Health and Aging; Journal of Psychosocial Nursing and Mental Health Services; Aging & Mental Health Journal; The American Journal of Geriatric Psychiatry; Journal of Geriatric Psychiatry and Neurology; PLOS Medicine; Revista medico-chirurgicală̆ a Societă̆ţ̜ii de Medici ş̧i Naturaliş̧ti din Iaş̧i Societatea de Medici şi Naturalişti Iaşi; Journal of Korean Academy of Nursing; Illness Crisis & Loss Journal. Six journals have a broader scope and address psychological, social, human, and the circumstances that accompany suicide: The International Journal of Aging and Human Development; Journal of the American Geriatrics Society; Journal of Gerontological Social Work; The Gerontologist; Estudos de Psicologia; Professional Psychology: Research and Practice.

From the selection of vehicles for the dissemination of their work, we can conclude that most authors consider the suicidal behavior of seniors in LTCEs a medical and psychiatric problem. Even when it is known that social (conditions and situations of life), relational and microsocial issues are the ones that overly burden the states of sadness, feelings of abandonment, isolation, discouragement and maladaptation of older adults to boarding home, which can lead them to have persistent thoughts of death and commit suicide.

(2) Risks of suicidal behavior of the seniors in general and older adults in LTCEs

The main diagnoses of suicidal thoughts and suicide attempts for seniors in LTCEs, according to the relevance given by the authors studied, are:

• Physical and incapacitating problems (functional decline): physical disease¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,1717. Anía BJ, Chinchillab E, Suárez-Almenarac JL, Iruritad J. Intentos de suicidio y suicidios consumados por los ancianos de una residencia. Revista Espanõla Geriatría Gerontología 2003; 38(3):170-174.^,1919. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.; functional decline¹⁸18. Draper B, Brodaty H, Low LF, Richards V, Paton H, Lie D. Prediction of Mortality in Nursing Home Residents: Impact of Passive Self-Harm Behaviors. Int Psychogeriatr 2003; 15(2):187-196.^,1919. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2727. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315.^,2828. Kaup BA, Loreck D, Gruber-Baldini AL, German P, Menon AS, Zimmerman S, Burton L, Magaziner J. Depression and its relationship to funciton and medical status, by dementia status, in nursing home admissions. Am J Geriatr Psychiatry 2007; 15(5):438-442.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.; overmedication¹⁹19. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2727. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315..

• Psychiatric problems: depression¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,1919. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.

20. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: A comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work 2004; 43(2-3):97-116.^-2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2525. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145.^,2828. Kaup BA, Loreck D, Gruber-Baldini AL, German P, Menon AS, Zimmerman S, Burton L, Magaziner J. Depression and its relationship to funciton and medical status, by dementia status, in nursing home admissions. Am J Geriatr Psychiatry 2007; 15(5):438-442.^,3030. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.^,3737. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry 2014; 29(12):1198-1211.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45.; abuse of illicit substances¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45.; personality disorders¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,1414. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.; behavioral disorder¹⁴14. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.^,1818. Draper B, Brodaty H, Low LF, Richards V, Paton H, Lie D. Prediction of Mortality in Nursing Home Residents: Impact of Passive Self-Harm Behaviors. Int Psychogeriatr 2003; 15(2):187-196.^,3333. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750.; history of suicide attempts¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.; self-destructive indirect self-destructive behaviors¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.

14. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.^-1515. Draper B, Brodaty H, Low L F, Richards V. Self-destructive behaviors in nursing home residents. J Am Geriatr Soc 2002; 50(2):354-358.^,1818. Draper B, Brodaty H, Low LF, Richards V, Paton H, Lie D. Prediction of Mortality in Nursing Home Residents: Impact of Passive Self-Harm Behaviors. Int Psychogeriatr 2003; 15(2):187-196.^,2222. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.^,3030. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.^,3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340.; direct harmful behaviors¹⁴14. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.^,1515. Draper B, Brodaty H, Low L F, Richards V. Self-destructive behaviors in nursing home residents. J Am Geriatr Soc 2002; 50(2):354-358.^,2222. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.; cognitive impairment³⁰30. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.^,3333. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750.; previous psychiatric diagnosis¹⁷17. Anía BJ, Chinchillab E, Suárez-Almenarac JL, Iruritad J. Intentos de suicidio y suicidios consumados por los ancianos de una residencia. Revista Espanõla Geriatría Gerontología 2003; 38(3):170-174.^,2626. Scocco P, Rapattoni M, Fantoni G, Galuppo M, De Biasi F, de Girolamo G, Pavan L. Suicidal behaviour in nursing homes: a survey in a region of north-east Italy. Int J Geriatr Psychiatry 2006; 21(4):307-311.^,3333. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750.^,3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340.;

• Psychological and subjective problems: persistent or traumatic suffering¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.; feeling of loneliness, hopelessness and boredom¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,1919. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,2020. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: A comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work 2004; 43(2-3):97-116.^,3737. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry 2014; 29(12):1198-1211.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45.; frailty²²22. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.; feeling of loss of control over one’s life¹⁹19. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2727. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315.; negative perception of aging²⁷27. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45..

• Micro-social problems – being very old¹⁸18. Draper B, Brodaty H, Low LF, Richards V, Paton H, Lie D. Prediction of Mortality in Nursing Home Residents: Impact of Passive Self-Harm Behaviors. Int Psychogeriatr 2003; 15(2):187-196.^,2727. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315.^,3131. Scocco P, Fantoni G, Rapattoni M, Girolamo G, Pavan L. Death Ideas, Suicidal Thoughts, and Plans among Nursing Home Residents. J Geriatr Psychiatry Neurol 2009; 22(2):141-148., being male¹⁸18. Draper B, Brodaty H, Low LF, Richards V, Paton H, Lie D. Prediction of Mortality in Nursing Home Residents: Impact of Passive Self-Harm Behaviors. Int Psychogeriatr 2003; 15(2):187-196.; social isolation¹⁹19. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2424. Adams KB, Sanders S, Auth EA. Loneliness and depression in independent living retirement communities: Risk and resilience factors. Aging Ment Health 2004; 8(6):475-485.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254.^,3737. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry 2014; 29(12):1198-1211.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45.; living in family conflicts¹⁹19. Meeks S, Tennyson KB. Depression, hopelessness, and suicidal ideation in nursing home residents. Journal of Mental Health and Aging 2003; 9(2):85-86.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.^,3838. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45.; have a low schooling level²¹21. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2525. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145.; having experienced deaths and losses of close relatives or friends²⁴24. Adams KB, Sanders S, Auth EA. Loneliness and depression in independent living retirement communities: Risk and resilience factors. Aging Ment Health 2004; 8(6):475-485.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.; lack of religiosity²⁷27. Jang Y, Bergman E, Schonfeld L, Molinari V. Depressive symptoms among older residents in assisted living facilities. Int J Aging Hum Dev 2006; 63(4):299-315.; inflexibility and strictness concerning changes, particularly social ones³²32. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754..

• Economic problems – lack of autonomy to manage one’s money²¹21. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.; lack of security and social assistance²¹21. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740..

• Socio-environmental problems – involuntary abandonment of the family environment¹⁶16. Ron P. Suicidal ideation and depression among institutionalized elderly: the influence of residency duration. Illn Crises Loss 2002; 10(4):334-343.; difficulty adapting to the regulated and impersonal institutional environment²³23. Kao HF, Travis SS, Acton GJ. Relocation to a long-term care facility: Working with patients and families before, during, and after. J Psychosoc Nurs Ment Health Serv 2004; 42(3):10-16.^,2525. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145.^,2929. Mezuk B, Prescott MR, Tardiff K, Vlahov D, Galea S. Suicide in older adults in long-term care: 1990 to 2005. J Am Geriatr Soc 2008; 56(11):2107-2111.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.^,3535. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.; loss of old relationships and a problem of interaction with colleagues or managers of LTCEs³²32. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254..

• Organizational flaws and flaws in the professional training of caregivers – lack of customized care, lack of knowledge of how to provide care for the frail seniors³⁰30. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.; lack of mental health coverage³⁰30. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275..

Difficulties related to physical health, incapacitating diseases, psychiatric problems, subjective issues, flaws in caregivers’ professional and family-oriented training, and the massive and impersonal organizational environment lead the list of possible elements associated with suicidal thoughts and attempts and self-neglect. However, all authors are unanimous in recognizing that there is never only one cause for self-destructive behavior, but rather a confluence of adverse conditions. Some emphasize the burden of life histories, family relationships, and the lack of expectation for the future that accompanies hospitalizations, and emphasize the social isolation particularly found in depressive states³⁸38. Minayo MCS, Teixeira SMO, Martins JCO. Tédio enquanto circunstância potencializadora de tentativas de suicídio na velhice. Estudos de Psicologia (Natal) 2016; 21(1):36-45..

Of the 26 authors studied, ten compared the risks of suicidal behavior among older adults in LTCEs and those living in the community. Three of them¹⁶16. Ron P. Suicidal ideation and depression among institutionalized elderly: the influence of residency duration. Illn Crises Loss 2002; 10(4):334-343.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2929. Mezuk B, Prescott MR, Tardiff K, Vlahov D, Galea S. Suicide in older adults in long-term care: 1990 to 2005. J Am Geriatr Soc 2008; 56(11):2107-2111. consider that, proportionally, there are more people with depression and depressive symptoms in geriatric residences; five emphasize that there are more self-destructive problems among them¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,2222. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254. and suicidal ideation³⁵35. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^,3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340., and four emphasize that the process of institutionalization and living in an LTCE, which involves loss of family and community relationships and entering a regulated and often impersonal regimen, are destabilizing and a risk for suicide²⁵25. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145.^,3030. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.^,3535. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^,3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340..

Next, Tables 2 and 3 describe protection and prevention factors related to self-destructive behavior, as per the authors analyzed. It is observed that not all the studied authors emphasize these two aspects.

It is possible to have a protective look at older adults living in LTCEs so that they do not give up on life, as per some authors consulted¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,1414. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.^,2020. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: A comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work 2004; 43(2-3):97-116.^,2525. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145.^,3232. Ku YC, Tsai YF, Lin YC, Lin YP.Suicide experiences among institutionalized older veterans in Taiwan. Gerontologist 2009; 49(6):746-754.^,3535. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^,3737. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry 2014; 29(12):1198-1211.. In general, they emphasize the development of religiosity, drug therapy for cases of mental disorders such as severe depression; association of psychiatric care with psychological counseling, promotion of a positive institutional environment and satisfaction with life, and investment in feelings of autonomy, relationships and communication. The very fact of living in an LTCE has a contradictory meaning. While for some this means isolation, loneliness and loss of the meaning of life, for others, particularly the poorest and without family ties, being in a residence is a protective situation¹⁴14. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675..

The high frequency of disagreements and suicidal thoughts among older adults of LTCE should be carefully considered in the planning and implementation of programs aimed at preventing self-inflicted death¹⁷17. Anía BJ, Chinchillab E, Suárez-Almenarac JL, Iruritad J. Intentos de suicidio y suicidios consumados por los ancianos de una residencia. Revista Espanõla Geriatría Gerontología 2003; 38(3):170-174.^,2020. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: A comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work 2004; 43(2-3):97-116.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2929. Mezuk B, Prescott MR, Tardiff K, Vlahov D, Galea S. Suicide in older adults in long-term care: 1990 to 2005. J Am Geriatr Soc 2008; 56(11):2107-2111.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254.. According to these and other authors¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,3333. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750., suicide prevention must also be part of the training and work of the professionals working in the LTCE, since it is possible to act in primary, secondary and tertiary prevention, in some cases fostering group and social activities and interactions, in others with drug therapy or the addition of supportive psychotherapy and, in very complicated cases, using electroconvulsive therapy, when indicated.

Preventive measures should emphasize the following aspects: (a) Organizing the daily dynamics of LTCE in such a way that seniors have maximum autonomy over their lives, including the management of their financial resources³³33. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750.^,3737. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry 2014; 29(12):1198-1211.; (b) Providing continuous training to caregivers, including information on aspects of the culture experienced by older adults, on the characteristics of aging, even conversations about the viewpoint of inmates about their ideas of putting an end to life and how they plan to do it³¹31. Scocco P, Fantoni G, Rapattoni M, Girolamo G, Pavan L. Death Ideas, Suicidal Thoughts, and Plans among Nursing Home Residents. J Geriatr Psychiatry Neurol 2009; 22(2):141-148.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254.; (c) Being aware of the fact that suicidal behavior is influenced by physical (various types of diseases, pain and dependence), emotional (affective loss) and relational (changes in communication with family members, separation from of friends, adaptation to the institution) and cognitive-behavioral aspects²³23. Kao HF, Travis SS, Acton GJ. Relocation to a long-term care facility: Working with patients and families before, during, and after. J Psychosoc Nurs Ment Health Serv 2004; 42(3):10-16.^,3333. Kim HS, Jung YM, Lee HS. Cognitive impairment, behavioral problems, and mental health in institutionalized korean elders -an eligibility issue for care settings. J Korean Acad Nurs 2009; 39(5):741-750.. (d) Social and medical services must pay attention to signs of self-neglect (which suggest suicidal behavior), such as refusal of food, medication, and social isolation. It is up to the professionals to interact with people, to encourage their contact with colleagues and to avoid their marginalization. This requires a multidisciplinary approach that usually includes a geriatrician, psychologist, and social worker³⁶36. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340.. (e) It is essential that LTCE provides an individualized approach²²22. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.^,2929. Mezuk B, Prescott MR, Tardiff K, Vlahov D, Galea S. Suicide in older adults in long-term care: 1990 to 2005. J Am Geriatr Soc 2008; 56(11):2107-2111.^,3535. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^,3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340..

(3) Summary of knowledge

In many respects, the studies presented here coincide with the scientific literature on suicide attempts of seniors not residing in LTCEs³⁹39. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356.

40. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetitionofsuicidalbehaviour in elderlyEuropeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295.

41. Saraiva CB. De Durkheim a Shneidman. Do determinismo social à dor psicológica individual. Psiquiatria Clínica 2005; 31(3):185-205.

42. Conwel Y, Challenges to preventing suicide in later life. Cien Saude Colet 2015; 20(6):1652-1653.^-4343. Beeston D. Older People and Suicide. Centre for Ageing and Mental Health. Stanfordshire: Stanfordshire University; 2006., particularly concerning depression as a triggering factor of the desire to die and several other factors already pointed out. However, there are some specifics. Many of them¹⁶16. Ron P. Suicidal ideation and depression among institutionalized elderly: the influence of residency duration. Illn Crises Loss 2002; 10(4):334-343.^,2121. Chow ES, Kong BM, Wong MT, Draper B, Lin KL, Ho SK, Wong CP. The revalence of depressive symptoms among elderly Chinese private nursing home residents in Hong Kong. Int J Geriatr Psychiatry 2004; 19(8):734-740.^,2929. Mezuk B, Prescott MR, Tardiff K, Vlahov D, Galea S. Suicide in older adults in long-term care: 1990 to 2005. J Am Geriatr Soc 2008; 56(11):2107-2111. consider that, in geriatric residences, there are proportionately more people with depression, depressive symptoms and self-destructive behaviors¹³13. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002; 19(1):11-24.^,2222. Low LF, Draper B, Brodaty H. The relationship between self-destructive behaviour and nursing home environment. Aging Ment Health 2004; 8(1):29-23.^,3434. Podgorski CA, Langford L, Pearson JL, Conwell Y. Suicide Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLOS Med 2010; 7(5):e1000254.

35. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^-3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340.. Moreover, they point out that the very process of institutionalization and living in an LTCE with a regulated and impersonal arrangement is destabilizing for some, and a risk for suicide²⁵25. Arvaniti A, Livaditits M, Kanioti E, Davis E, Samokouri M, Xenitidis K. Mental health problems in the elderly in residential care in Greece - A pilot study. Aging and Mental Health 2005; 9(2):142-145.^,3030. Reiss NS, Tishler CL. Suicidality in nursing home residents: Part 2. Special issues. Professional Psychology: Research and Practice 2008; 39(3):271-275.^,3535. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry 2010; 25(8):843-849.^,3636. Alexa ID1, Ilie AC, Alexandroaie B, Costin G, Emmanouil-Stamos P, Räihä I. Self-neglect in the case of the elderly. Where are we now? Rev Med Chir Soc Med Nat Iasi 2011; 115(2):337-340..

However, in some circumstances, LTCE admission may be beneficial, because albeit in a more impersonal way than in families, ongoing surveillance and assurance of primary care are assured, as well as a lower probability of access to the means to commit suicide. In cases analyzed in a recent survey⁴⁴44. Minayo M, Figueiredo AEB, Mangas RMN.Relatos de vida de pessoas idosas institucionalizadas com comportamento suicida. In: Minayo MSC, Figueiredo AEB, Silva RM, organizadores. Comportamento suicida de Idosos. Fortaleza: Edições UFC; 2017. p. 385-414., particularly senior men living in the streets, separated from families and very poor can resume the course of their lives. Some of those had made several attempts to take their lives before admission.

The management of financial resources by older adults – when they have the physical and mental capacity to do so – is another relevant point brought by literature. The feeling that not being dispossessed, enjoying some autonomy and being able to make decisions reduces the feeling of helplessness and being protected by employees or relatives.

The organization of an LTCE must take into account the factors that cause destabilization in someone who is admitted, mainly aiming to preserve the maximum autonomy of the people, provide personalized care and have a cadre of professionals who can give support to the seniors.

The training of health professionals, support staff and administrative staff was highlighted as of great importance for the quality of life of the institutionalized older adults by all authors who referred to the prevention of suicidal behavior. This statement reinforces findings from studies⁴⁵45. AEB, Minayo MCS, Mangas RMN. Cuidar de si e cuidar do outro: a percepção dos profissionais das instituições de longa permanência. In: Minayo MSC, Figueiredo AEB, Silva RM, organizadores. Comportamento suicida de Idosos. Fortaleza: Edições UFC; 2017. p. 415-437. which show how people who work in LCTEs feel unprepared and face difficulties in dealing with cases of suicidal ideation and attempts, either through ignorance or lack of adequate training.

In this particular, it is understood that it is necessary to take care of professional caregivers since the relationship between them and seniors is an exchange that can enrich or sicken both. At the end of the nineteenth century, Durkheim²2. Shneidman ES. Comprehending suicide. Washington: American Psychological Association; 2001. already warned that an ignored, excluded and marginalized individual, from whom many duties are required and to whom few rights are given, feels outside of organic solidarity and social cohesion and, therefore, take their lives.

Although the scope of an LTCEs is social security and the protection of the health and human rights of older adults, because of their organizational structure and way of acting, many of them can pose risks to the quality of life of those who live there, for example, when they contribute to a reduction of their autonomy, the loss of family and community identity marks, and their removal from interaction with younger generations.

On the part of older adults, living in an LTCE requires the reorganization of their social and subjective lives and internalization of mechanisms that may facilitate their insertion in this form of social coexistence. Because of age-specific frailties or physical and mental health problems of the elderly, LTCEs can exacerbate the effects of a regulated and segregated life of the family and community environment, representing a factor of exacerbation of suicidal behavior. However, it should be pointed out that in some instances, for example, when seniors traverse multiple dependencies, admission can have positive effects, bringing more protection and better care¹⁴14. Draper B, Brodaty H, Low LF. Types of nursing home residents with self-destructive behaviours: Analysis of the harmful behaviours scale. Int J Geriatr Psychiatry 2002; 17(7):670-675.^,1515. Draper B, Brodaty H, Low L F, Richards V. Self-destructive behaviors in nursing home residents. J Am Geriatr Soc 2002; 50(2):354-358..

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