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This dissertation considers the rationale for positive nurse-based intervention in consideration of issues relating to suicide in the elderly. The introduction sets the context, including the historical context, of the issues and discusses the negative effects of ageism on issues relating to suicide in the elderly.
The literature review considers selected texts which have been chosen for their specific relevance to the issue and particularly those that espouse the view that ageism is counter productive to a satisfactory quality of life outcome for the elderly person.
Conclusions are drawn and discussed with specific emphasis on those
measures that are of particular relevance to the nursing profession
whether it is in a secondary care facility, a residential home setting
or in the primary healthcare team and the community.
Introduction
We can observe, from a recent paper (O’Connell H et al. 2004), the
comments that, although there is no doubt that the elderly present a
higher risk of completed suicide than any other age group, this fact
receives comparatively little attention with factors such as media
interest, medical research and public health measures being
disproportionately focused on the younger age groups (Uncapher H et al.
2000).
Perhaps we should not be surprised at the fact that both suicidal
feelings and thoughts of hopelessness have been considered part of the
social context of growing old and becoming progressively less capable.
This is not a phenomenon that is just confined to our society. We know
that the Ancient Greeks tolerated these feelings in their society and
actively condoned the option of assisted suicide if the person involved
had come to the conclusion that they had no more useful role to play in
society (Carrick P 2000). Society largely took the view that once an
individual had reached old age they no longer had a purpose in life and
would be better off dead. In a more modern context, we note the
writings of Sigmund Freud who observed (while he was suffering from an
incurable malignancy of the palate:
It may be that the gods are merciful when they make our lives more
unpleasant as we grow old. In the end, death seems less intolerable
than the many burdens we have to bear.
(cited in McClain et al. 2003)
We would suggest that one of the explanations of this apparent
phenomenon of comparative indifference to the plight of the elderly in
this regard is due to the fact that the social burden of suicide is
often refered to in purely economic terms, specifically relating to
loss of social contribution and loss of productivity. (Brechin A et al.
2000).
This purely economic assessment would have to observe that the young
are much more likely to be in employment and less likely to be a burden
on the economic status of the country whereas with the elderly exactly
the converse is likely to be true. This results in economic prominence
being give to the death of a younger person in many reviews. (Alcock P,
2003). There is also the fact that, despite the fact that we have
already highlighted the increase in relative frequency of suicide in
the elderly, because of the demographic distributions of the population
in the UK, the absolute numbers of both attempted suicides and actual
suicides are greater in the younger age ranges and therefore more
readily apparent and obvious.
The elderly are a particularly vulnerable group from the risk of
suicide. In the industrialised world males over the age of 75 represent
the single largest demographic group in terms of suicide attempts.
Interestingly (and for reasons that we shall shortly discuss) although
there is a general trend of increasing suicide rate with age the
excess rates associated with the elderly are slowly declining in the
recent past (Cattell 2000).
We can quantify this statement by considering the statistics. If we
consider the period 1983 to 1995 in the UK then we can show that:
The suicide rates for men reduced by between 30% and 40% in the age groups 55–64, 65–74 and 75–84
The rates for the most elderly men (males over 85 years) remained
fairly static, this group still having the highest rates of any group
By way of contrast, the 25- to 34-year-old male group exhibited a 30%
increase in suicide rate during the same period, this group are
becoming the group with the second highest rate, while the 15- to
24-year-old male group demonstrated a 55% increase in suicide rates.
(WHO 2001)
Female suicide rates have shown a similar overall decrease, reducing by between 45 and 60% in the 45–84 age group.
Elderly women, however, retain the highest rates throughout the life span (Cattell 2000)
The ratio of male to female elderly suicide deaths remains approximately 3:1 (Fischer L R et al. 2003)
We can suggest that these trends in reduction of suicide, particularly
in the elderly are likely to be due, amongst other things, to:
The improved detection of those at risk together with the advent of
aggressive treatment policies relating to mental illness in the
elderly. (Waern M et al. 2003)
One of the main reasons, we would suggest, for this obviously
changing pattern and the discrepancies in the suicide rates between the
age ranges, is the fact that, in direct consideration of the context of
our topic, the elderly are more likely to be both amenable to
professional help and also, by virtue that a higher proportion are
likely to be in direct contact with healthcare professionals either
through failing health or nursing homes and hospitals, (Suominen K et
al. 2003), have the warning signs of impending suicide recognised and
acted upon more promptly than the younger, arguably more independent
age group.
In specific consideration of the elderly group we should also note
that attempted suicide is more likely to be a failed suicide attempt
rather than a parasuicide. (Rubenowitz E et al. 2001).
There is considerable evidence that the incidence of depression is
increased in the presence of a concurrent physical illness (Conwell Y
et al. 2002) and clearly this is going to be more likely in the elderly
age group. Some sources have cited association rates of between 60-70%
of major depression with physical illness in the over 70yr olds.
(Conwell Y et al. 2000).
Another significant factor is that it is commonly accepted that an
attempted suicide is a strong independent risk factor in the aetiology
of further suicide attempts. (Conwell Y et al. 1996) This trend is much
more marked in the elderly group with a ratio of about 4:1 which
compares very badly with the ratios in the younger age groups of
between 8:1 and 200:1 (depending on age range, definition and study).
(Hepple J et al. 1997)
Aims and objectives
In this dissertation it is intended to gain evidence based knowledge of
the scope and significance of the phenomenon of attempted suicide in
the elderly. In addition it is intended to gain evidence based
knowledge in the use of strategies to ameliorate attempted suicide in
the elderly to highlight gaps in the literature available and to
suggest recommendations for change in nursing practice It is hoped to
be able to suggest areas for research into the phenomenon of attempted
suicide in the elderly.
Methodology
The initial strategy was to undertake a library search at the local
post graduate library and the local university library (Client: you
might like to personalise this) on the key words “suicide, elderly,
prevention strategies, industrialised societies”. This presented a
great many papers. About 40 were selected and read to provide an
overview of the literature in this area. During this phase, references
were noted and followed up and key literary works were assimilated. The
bulk of the papers accessed and read were published within the last
decade, however a number of significant older references were also
accessed if they had a specific bearing on a particular issue. The most
significant references were accessed and digested. The dissertation was
written referencing a selected sub-set of these works.
Rationale for proposal
To increase nurses knowledge and understanding of attempted suicide in
the older age group and to highlight through the literature review,
evidence based strategies that an be employed to ameliorate attempted
suicide amongst the elderly.
Literature review
Before commencing the literature review, it is acknowledged that the
literature on this subject is huge. The parameters of the initial
search have been defined above. In addition it should be noted that
there is a considerable literature on the subject of assisted suicide
which has been specifically excluded from these considerations
The literature base for suicide in the elderly is quite extensive and
provides a good evidence base for understanding, appropriate action and
treatment. (Berwick D 2005)
One of the landmark papers in this area is by Hepple and Quinton
(Hepple J et al. 1997) which provided a benchmark, not only on the
aetiology of the subject, but also in the long term outcomes, which, in
terms of potential nursing care input, is extremely important. The
paper points to the fact that there is a good understanding of the
absolute risk factors for suicide in the elderly but a comparative lack
of good quality follow up studies in the area. It set out to identify
100 cases of attempted suicide in the elderly and then follow them up
over a period of years. The study was a retrospective examination of
100 consecutive cases of attempted suicide that were referred to the
psychiatric services over a four year period. The authors were able to
make a detailed investigation (including an interview of many of the
survivors), about four years later. Their findings have been widely
quoted in the literature.
Of particular relevance to our considerations here we note that they
found that of the 100 cases identified, 42 were dead at the time of
follow up. Of these, 12 were suspected suicides and five more had died
as a result of complications of their initial attempt. There were 17
further attempts at suicide in the remaining group. Significantly, the
twelve women in the group all made non-lethal attempts whereas all five
of the men made successful attempts. The authors were able to establish
that the risk of further attempts at suicide (having made one attempt)
was in excess of 5% per year and the “success” rate was 1.5% per year
in this group. From this study we can also conclude that the risk of
successful repeat attempted suicide is very much greater if the subject
is male. The authors were also able to establish that, because of
their initial attempt, those at risk of self harm were likely to be in
contact with the Psychiatric services and also suffering from
persistent severe depression.
We can examine the paper by Dennis (M et al. 2005) for a further
insight into the risk factors that are identifiable in the at risk
groups. This paper is not so detailed as the Hepple paper, but it
differs in its construction as it is a control matched study which
specifically considered the non-fatal self harm scenario. The study
compared two groups of age matched elderly people both groups had a
history of depression but the active study group had, in addition, a
history of self harm. The significant differences highlighted by this
study were that those in the self harm group were characterised by a
poorly integrated social network and had a significantly more hopeless
ideation. This clearly has implications for intervention as, in the
context of a care home or warden assisted setting, there is scope for
improving the social integration of the isolated elderly, and in the
domestic setting community support can provide a number of options to
remove factors that mitigate towards social isolation. This would
appear to be a positive step towards reducing the risk of further self
harm.
The O’Connell paper (O’Connell et al. 2004) is effectively a tour de
force on the pertinent issues. It is a review paper that cherry-picks
the important information from other, quite disparate, studies and
combines them into a coherent whole. It is extremely well written, very
detailed, quite long and extremely informative. While it is not
appropriate to consider the paper in its entirety, there are a number
of factors that are directly relevant to our considerations here and we
shall restrict our comments to this aspect of the paper.
In terms of the identification of the risk factors associated with
attempted suicide in the elderly, it highlights psychiatric illnesses,
most notably depression, and certain personality traits, together with
physical factors which include neurological illnesses and malignancies.
The social risk factors identified in the Dennis paper are expanded to
include “social isolation, being divorced, widowed, or long term
single”.
The authors point to the fact that many of the papers refered to
tend to treat the fact of suicide in reductionist terms, analysing it
to its basic fundamentals. They suggest that the actual burden of
suicide should also be considered in more human terms with
consideration of the consequences for the family and community being
understood and assessed. (Mason T et al. 2003)
In terms of nursing intervention for suicide prevention, we note that
the authors express the hypothesis that suicidality exists along a
continuum from suicidal ideation, through attempted suicide, to
completed suicide. It follows from this that a nurse, picking up the
possibility of suicidal ideation, should consider and act on this as a
significant warning sign of possible impending action on the part of
the patient.
The authors point to the fact that the estimation of the actual
significance of the various prevalences of suicide varies depending
on the study (and therefore the definition) (Kirby M et al. 1997). In
this context we should note that the findings do not support the ageist
assumptions expounded earlier, on the grounds that the prevalence of
either hopelessness or suicidal ideation in the elderly is reported as
up to 17% (Kirby M et al. 1997), and there was a universal association
with psychiatric illness, especially depressive illness.
If we consider the prevalence of suicidal feelings in those elderly
people who have no evidence of mental disorder, then it is as low as
4%. It therefore seems clear that hopelessness and suicidality are not
the natural and understandable consequences of the ageing process as
Freud and others would have us believe. This has obvious repercussions
as far as nursing (and other healthcare) professionals are concerned,
as it appears to be clearly inappropriate to assume that suicidality
is, in most cases, anything other than one of many manifestations of a
mental illness. It also follows from this, and this again has distinct
nursing implications, that suicidal ideation and intent is only the tip
of the iceberg when one considers the weight of psychological, physical
and social health problems for the older person. (Waern M et al. 2002)
If one considers evidence from studies that involve psychological
autopsies, there is further evidence that psychopathology is involved.
Depressive disorders were found in 95% in one study. (Duberstein P R et
al. 1994) Psychotic disorders and anxiety states were found to be
poorly correlated with suicidal completion.
Further evidence for this viewpoint comes from the only study to
date which is a prospective cohort study in which completed suicide was
the outcome measure. (Ross R K et al. 1990). This shows that the most
reliable predictor of suicide was the self-rated severity of depressive
symptoms. This particular study showed that those clients with the
highest ratings were 23 times more likely to die as the result of
suicide than those with the lowest ratings. It also noted that other
independent risk factors (although not as strong), were drinking more
than 3 units of alcohol per day and sleeping more than 9 hours a night.
One further relevant point that comes from the O’Connell paper is
the fact that expression of suicidal intent should never be taken
lightly in the older age group. The authors cite evidence to show that
this has a completely different pattern in the elderly when compared to
the younger age groups. (Beautrais A L 2002).
The figures quoted show that if an elderly person undertakes a suicide
attempt they are very much more likely to be successful than a younger
one. The ratio of parasuicides to completed suicides in the adolescent
age range is 200:1, in the general population it is between 8:1 and
33:1 and in the elderly it is about 4:1. (Waern M et al. 2003). It
follows that suicidal behaviour in the elderly carries a much higher
degree of intent. This finding correlates with other findings of
preferential methods of suicide in the elderly that have a much higher
degree of lethality such as firearms and the use of hanging. (Jorm A F
et al. 1995).
The paper by Cornwell (Y et al. 2001) considers preventative
measures that can be put in place and suggests that independent risk
factors commonly associated with suicide in the elderly can be expanded
to include psychiatric and physical illnesses, functional impairment,
personality traits of neuroticism and low openness to experience, and
social isolation. And of these, t is affective illness that has the
strongest correlation with suicide attempts. We have discussed
(elsewhere) the correlation between impending suicide and contact with
the primary care providers. Cornwell cites the fact that 70% of elderly
suicides have seen a member of the primary healthcare team within 30
days of their death and therefore proposes that the primary healthcare
setting is an important venue for screening and intervention. It is
suggested that mood disorders are commonplace in primary healthcare
practice but, because they are comparatively common, are underdiagnosed
and often inadequately treated (ageism again).
The authors suggest that this fact alone points to the fact that one
of the suicide prevention strategies that can be adopted by the primary
healthcare team. they suggest that clinicians, whether they are
medically qualified or nursing qualified, should be trained to identify
this group and mobilise appropriate intervention accordingly. Obviously
the community nurses can help in this regard as they are ideally placed
to maximise their contact with vulnerable and high risk groups.
We have identified the role of a major depressive illness in the
aetiology of suicide in the elderly. Bruce (M L et al. 2002) considered
the role of both reactive and idiopathic major depression in the
population of the elderly in a nursing home setting. This has
particular relevance to our considerations as firstly, on an intuitive
level, one can possibly empathise with the reactive depressive elements
of the elderly person finding themselves without independence in a
residential or nursing home and secondly, this is perhaps the prime
setting where the nurse is optimally placed to monitor the mood and
other risk factors of the patient and continual close quarters. The
salient facts that we can take from this study are that there was a
substantial burden of major depressive symptomatology in this study
group (13.5%). The majority (84%) were experiencing their first major
depressive episode and therefore were at greatest risk of suicide. The
depression was associated with comorbidity in the majority of cases
including “medical morbidity, instrumental activities of daily living
disability, reported pain, and a past history of depression but not
with cognitive function or sociodemographic factors.” All of these
positive associations which could have been recognised as significant
risk factors of suicide in the elderly.
Significantly, in this study, only 22% of all of the seriously
depressed patients were receiving antidepressant therapy and none were
receiving any sort of psychotherapy. In addition to this the authors
point to the fact that 31% of the patients who were put on
antidepressants were taking a subtherapeutic dose (18% because they
were purposely not complying with the dosage instructions). The
conclusions that the authors were able to draw from this study were
that major depression in the elderly was twice as common in the
residential setting as opposed to those elderly patients still in the
community. The majority of these depressed patients were effectively
left untreated and therefore at significant risk of suicide. There was
the obvious conclusion that a great deal more could be done for this
study population in terms of relieving their social isolation and
depressive illnesses. And, by extrapolation, for their risk of suicide.
Ethical considerations.
In consideration of the issue of suicide in the elderly we note that
there are a number of ethical considerations but these are primarily in
the field of assisted suicide which we have specifically excluded from
this study. (Pabst Battin, M 1996)
Evidence for positive nursing interventions
Having established the evidence base in the literature that defines
the risk factors that are known to be particularly associated with
suicide in the elderly, we take it as read that this will form part of
the knowledge base for the nurse to be alert to, and to identify those
patients who are at particular risk of suicide. It is equally
important to be aware of those factors that appear to confer a degree
of protection against suicide. This will clearly also help to inform
strategies of intervention for the nurse.
Studies such as that by Gunnell (D et al. 1994) point to the fact
that religiosity and life satisfaction were independent protective
factors against suicidal ideation, and this factor was particularly
noted in another study involving the terminally ill elderly where the
authors noted that higher degrees of spiritual well-being and life
satisfaction scores both independently predicted lower suicidal
feelings. (McClain et al. 2003).
The presence of a spouse or significant friend is a major protective
factor against suicide. Although clearly it may not be an appropriate
intervention for nursing care to facilitate the presence of a spouse
(!) it may well be appropriate, particularly in residential settings,
to facilitate social interactions and the setting up of possible
friendships within that setting (Bertolote J M et al. 2003)
Conclusions and discussion
This Dissertation has considered the rationale behind the evidence base
for nursing intervention and strategies to prevent or minimise suicide
attempts in the elderly age group. We have outlined the literature
which is directed at identification of the greatest “at risk” groups
and this highlights the importance of the detection and treatment of
both psychiatric disorders (especially major depression), and physical
disorders (especially Diabetes Mellitus and gastric ulceration).
(Thomas A J et al. 2004)
Although we have been at pains to point out the relatively high and
disproportionate incidence of suicide in the elderly, we should not
loose sight of the fact that it is not a common event. One should not
take the comments and evidence presented in this dissertation as being
of sufficient severity to merit screening the entire elderly
population. (Erlangsen A et al. 2003) The thrust of the findings in
this dissertation are that the screening should be entirely
opportunistic. The evidence base that we have defined should be
utilised to identify those who are in high risk groups, for example,
those with overt depressive illnesses, significant psychological and
social factors, especially those who have a history of previous
attempted suicide. The healthcare professional should not necessarily
expect the elderly person to volunteer such information and if the
person concerned is naturally withdrawn or reserved, minor degrees of
depressive symptoms may not be immediately obvious. (Callahan C M et
al. 1996).
In terms of direct nursing intervention, this must translate into the
need to be aware of such eventualities and the need to enquire directly
about them. The nurse should also be aware that the presence of
suicidal feelings in a patient with any degree of depression is
associated with a lower response rate to treatment and also an increase
in the need for augmentation strategies. The nurse should also be aware
of the fact that these factors may indicate the need for secondary
referral. (Gunnell D et al. 1994).
If we accept the findings of Conwell (Y et al. 1991), then the
estimated population at risk from significant mood disorder and
therefore the possibility of attempted suicide in the elderly, is 74%.
This can be extrapolated to suggest that if mood disorders were
eliminated from the population then 74% of suicides would be prevented
in the elderly age group. Clearly this is a theoretical viewpoint and
has to be weighed against the facts that firstly “elimination” of mood
disorders (even if it were possible), would only be achieved by
treatment of all existing cases as well as prevention of new cases, and
the secondary prevention of sub-clinical cases.
We know, from other work, that the detection and treatment of
depression in all age ranges is low, and even so only 52% of cases that
reach medical attention make a significant response to treatment
(Bertolote J M et al. 2003). These statistics reflect findings from the
whole population and the detection rates and response rates are likely
to lower in the elderly. (Wei F et al. 2003).
It follows that although treatment of depressive illness is still the
mainstay of treatment intervention as far as suicide prevention is
concerned, preventative measures and vigilance at an individual level
are also essential. Nursing interventions can include measures aimed at
improving physical and emotional health together with improved social
integration. Sometimes modification of lifestyle can also promote
successful ageing and lead to an overall decrease in the likelihood of
suicidal feelings. (Fischer L R et al. 2003)
On a population level, public health measures designed to promote
social contact, support where necessary, and integration into the
community are likely to help reduce the incidence of suicide in the
elderly, particularly if we consider the study by Cornwell (Y et al.
1991) which estimated the independent risk factor for low levels of
social contact in the elderly population as being 27%. Some communities
have provided telephone lines and this has been associated with a
significant reduction in the completed suicide in the elderly (Fischer
L R et al. 2003)
To return to specific nursing interventions, one can also suggest
measures aimed at reducing access to, or availability of the means for
suicide such as restricting access to over the counter medicines.
(Skoog I et al. 1996),
Some sources (Cattell H 2000) point to the possibility of introducing
opportunistic screening in the primary healthcare setting. The
rationale behind this suggestion is the realisation that there is a
high level of contact between the suicidal elderly person and their
primary healthcare team in the week before suicide (20-50%) and in the
month before suicide (40-70% make contact). This is particularly
appropriate to our considerations here because of the progressively
increasing significance of the role of the nurse within the primary
healthcare team particularly at the first point of contact. (Hogston, R
et al. 2002)
The evidence base for this point of view is strengthened by
reference to the landmark Gotland study (Rutz W et al. 1989) which
examined the effect of specific training in suicide awareness and
prevention in the primary healthcare team by providing extensive
suicide awareness training and measures to increase the facilitation of
opportunistic screening of the population. Prior to the intervention,
the authors noted that, when compared to young adults, the elderly were
only 6% as likely to be asked about suicide and 20% as likely to be
asked if they felt depressed and 25% as likely to be refered to a
mental health specialist. This balance was restored almost to normality
after the intervention.
Suicide in the elderly is a multifaceted and complex phenomenon. It
appears to be the case that the elderly tend to be treated with
different guidelines from the young suicidal patient insofar as the
increased risk is not met with increased assistance. (Lykouras L et al.
2002). We have presented evidence that the factors included in this
discrepancy may include the higher overall number of young suicides,
the higher economic burden that society appears to carry for each young
suicide together with ageist beliefs about the factors concerning
suicide in the elderly.
From the point of view of nursing intervention, both in a hospital
and in a community setting, there should be greater emphasis placed on
measures such as screening and prevention programmes targeted at the at
risk elderly. There is equally a need for aggressive intervention if
depression or suicidal feelings are overtly expressed, particularly in
the relevant subgroups where additional risk factors may be active, for
example those with comorbid medical conditions or social isolation or
recent bereavement. (Harwood D et al. 2001),
Many of the elderly spend their last years in some form of sheltered
accommodation, whether this is a nursing home, a hospital, warden
assisted housing or being cared for by the family. (Haupt B J et al.
1999) In the vast majority of cases this is associated with a loss of
independence, increasing frailty and an increasing predisposition to
illness that comes with increasing age. (Juurlink D N et al. 2004).
This loss of independence and increasing predisposition to illness is
also associated with depressive illnesses of varying degrees. (Bruce M
L et al. 2002). These patients are arguably, by a large, more likely to
come into contact with the nurses in the community. (Munson M L 1999)
The comments that we have made elsewhere relating to the nurse’s role
in being aware of the implications for the depressed elderly patient
are particularly appropriate in this demographic subgroup. As a general
rule, it may be easier to keep a watchful eye on patients who are
exhibiting early signs of depressive illness or mood disorder in this
situation by making arrangements to visit on a regular basis or on
“significant anniversaries” such as the death of a spouse or a wedding
anniversary. (Nagatomo I et al. 1998) when the risk factors for suicide
increase dramatically (Schulberg H C et al. 1998)
The literature in this area is quite extensive and covers many of the
aspects of suicide in the elderly. It is noticeable however, that there
is a great deal of literature on the subject of risk factors and
associations of suicide together with plenty of papers which quote
statistics that relate the various trends and incidences. There are, by
comparison, only a few papers which emphasise and reflect on the
positive aspects of nursing care. The positive steps that can be taken
by the nursing profession specifically to help to minimise the burden
of suicidal morbidity. There is clearly scope for studies in areas such
as the impact that a dedicated community nurse might have on the levels
of depression in the community if regular visits were timetabled. It is
fair to observe that the community mental health nurses fulfil this
role to a degree, but are severely hampered in most cases by sheer
weight of numbers in the caseload. (Mason T et al. 2003)
Having made these observations, we must conclude that there appears to
be an overwhelming case for opportunistic screening of the at risk
elderly at any point of contact with a healthcare professional. It is
part of the professional remit of any nurse to disseminate their
specific professional learning with others. (Yura H et al. 1998). This
can either be done on an informal professional basis in terms of
mentorship or, if appropriate in a lecture or seminar situation.
(Hogston, R et al. 2002). There clearly is little merit in critically
evaluating the literature and creating one’s own evidence base if it
is not disseminated to one’s professional colleagues. (Hunt T 1994)
Reflections
John Dewey is generally credited with first propounding the concept of
reflective thinking in the early part of the 20th century. He initially
defined it as an “active, persistent and careful consideration of any
belief or supposed form of knowledge in the light of the grounds that
support it and the further conclusion to which it tends.” (Dewey J
1933). Over the passage of time this concept has been refined and
expanded by a number of educationalists and thinkers such as Taylor
(2000) who included the concept of not only considering the recall of
memories of events, but also constructing plans and strategies so as to
deal with similar situations, should they occur again, with the benefit
of the reflective experience. Palmer points to this concept as being a
dynamic process which allows the healthcare professional to build a
personal knowledge base to enhance their practice and therefore grow in
professional stature. (Palmer 2005)
Other academics have defined the process further and in different
directions. Boyd and Fales (1983) placed the emphasis on reflection as
a learning experience rather than simply a process and Schon (1987), in
the course of extensive writing on the subject sub-divided the
opportunities for reflection into “reflection in action” and
“reflection on action”, the former being the process whereby the
healthcare professional adapts their professional practice whilst
working and the latter is a process of quiet contemplation. It is this
latter process that is being adopted here.
It should be noted that the concept of reflection as being a useful
adjunct to the learning cycle Gibbs, G (1988) is not universally
accepted. James and Clarke (cited in Atkins, S. & Murphy, K. 1993)
suggest that asking some healthcare professional to engage in critical
analysis of their practice may actually result in some practitioners
not engaging at all. They point to the fact that some practitioners
seem incapable of accurate recall of a past situation indulging in what
the authors call hindsight bias. This effectively means that the
practitioner finds it difficult to consider the situation in any way
other than that which compliments the already known outcome. (Goodmann,
J. 1989). Quite clearly one must be prepared to take a completely
dispassionate look at any given situation if any significant learning
experience is to be gained from it.
Reflection on the learning experience that writing this literature
review has provided has proved to be very useful and educational
experience. Prior to writing, I had clearly appreciated that the
elderly had a greater tendency to appear to be depressed and in low
mood. On reflection I believe that I may well have subscribed to the
ageist ideas that have been outlined in the introduction of this piece
and considered that the fate of feeling of little value to society
together with the increased weight of probable morbidity, was part of
the natural scheme of reaching old age, and was a reasonable intuitive
explanation for feeling occasionally miserable or indeed becoming
depressed when the person concerned reflected upon their own situation.
I do not believe that I had actively considered this viewpoint before,
but that I had come to an unchallenged appreciation of the situation
from uncritical clinical experience.
Having gone through the process of the literature assimilation prior to
the preparation of the review, I realised that this assimilation proved
to be something of a catalyst and that the causes of depression in the
elderly may well be to a degree, reactive. This does not necessarily
mean that they are untreatable or unmodifiable. The comments made by a
number of authors quoted (and others that have been read but not
included in this piece), show that it is quite possible to take simple,
but effective, steps to reduce social isolation and to help lift
depression but the fact of the matter is that it needs to be clearly
identified first. In real terms, I believe that this can be most
effectively done by keeping the possibility firmly in mind when one is
dealing with an elderly person and opportunistically screening for it,
perhaps not formally, but certainly by asking relevant and probing
questions in an empathetic manner.
It is clear that depression in the elderly is a significant problem.
It clearly has a much greater impact on the incidence of suicide in the
elderly as a group than it does in the younger age ranges. I feel that
the knowledge that I have gained in preparing and producing this review
will help me to understand and empathise better with the situation that
many of the elderly find themselves in. I hope that such an
understanding will help to improve my professional behaviour in
approaching the clinical problems surrounding the elderly patient.
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