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RESEARCH ARTICLE

Death wishes among older people assessed for home


support and long-term aged residential care
Gary Cheung1, Siobhan Edwards2 and Frederick Sundram1
1
Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
2
School of Medicine, University of Auckland, Auckland, New Zealand
Correspondence to: Dr Gary Cheung, E-mail: g.cheung@auckland.ac.nz

Objective: Death wishes in older people are common and may progress to suicidal ideation and
attempts. This study used routinely collected data from the interRAI Home Care assessment to examine
the prevalence and clinical predictors of death wishes in older New Zealanders assessed for home
support and long-term aged residential care.
Methods: Data were collected from 35 734 people aged over 65 during 2012–2014. Chi-squared analyses
were used to determine significant relationships between the presence of death wishes and demographic
factors, health and functional status, and emotional and psychosocial well-being. A three-step hierarchi-
cal logistic regression model was used to determine the predictive variables of death wishes, and odds
ratios were calculated.
Results: Death wishes were present in 9.5% of the sample. The following factors were significantly as-
sociated with death wishes: physical health (poor self-reported health, recurrent falls, severe fatigue
and inadequate pain control), psychological factors (depression, major stressors and anxiety), social fac-
tors (loneliness and decline in social activities) and impaired cognition. Depression (odds ratio = 2.54,
95% confidence interval = 2.29–2.81), loneliness (odds ratio = 2.40, 95% confidence
interval = 2.20–2.63) and poor self-reported health (odds ratio = 2.34, 95% confidence
interval = 1.78–3.07) had the greatest odds ratios in the full model.
Conclusions: Clinically significant depression alone cannot fully account for the development of death
wishes in the elderly, and several factors are independently associated with death wishes. This knowl-
edge can help clinicians caring for older persons to identify people who are most at risk of developing
death wishes. Copyright # 2016 John Wiley & Sons, Ltd.
Key words: death wishes; depression; loneliness; self-rated health; older people
History: Received 08 July 2016; Accepted 19 October 2016; Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/gps.4624

Introduction while a number of longitudinal studies have found


older people with death wishes also had a higher
The phenomenon of suicidality can be considered as mortality rate from all causes (MacDonald and Dunn,
a continuum, with death wishes (e.g.‘weariness of life’ 1982; Dewey et al., 1993; Skoog et al., 1996; Raue
and ‘life is not worth living’) on one end and fatal et al., 2010). For example, in one of the earliest stud-
suicidal behaviour on the opposite end (Paykel ies, MacDonald and Dunn (1982) found 31.7% of
et al., 1974; Skoog et al., 1996; O’Connell et al., older people (age 75–89) who reported a wish to
2004). Suicidal ideation is one of the strongest pre- die passed away within a year, as compared with
dictors of suicidal behaviour and increases the risk 16.7% of those who did not report a wish to die;
of eventual death by suicide (Brown et al., 2000; and the association was independent of disability,
Kuo et al., 2001; Nock et al., 2008). Older people depression and age.
with suicidal ideation are more likely to die by suicide Internationally, the prevalence of death wishes
than the general population (Conwell et al., 1988); among older people has been investigated, and it

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
2 G. Cheung et al.

ranges from 2% to 15.9% (Barnow et al., 2004; Dewey et al., 1995; Kirby et al., 1997; Barnow et al., 2004;
et al., 1993; Fässberg et al., 2013; Fässberg et al., 2014; Ladwig et al., 2008; Lapierre et al., 2012; Saïas et al.,
Forsell, 2000; Handley et al., 2014; Jorm et al., 1995; 2012; Vasiliadis et al., 2012; Fässberg et al., 2014;
Kirby et al., 1997; Lapierre et al., 2012; Lapierre Handley et al., 2014; Bonnewyn et al., 2016).
et al., 2015; Rurup et al., 2011a; Saïas et al., 2012; The methodological differences in studies might
Scocco and De Leo, 2002; Skoog et al., 1996; Yip have contributed to these inconsistent findings in the
et al., 2003). However, direct comparison between literature. Variations in socioeconomic environment,
these studies is not possible because of differences in culture, attitude towards ageing/death and healthcare
methodology. While the majority of these studies have provision in different parts of the world might also
used age 65+ to define older people, some studies be relevant in explaining these inconsistencies. There-
used age 55+ and others used age 60+. Various fore, local research is needed to understand the phe-
instruments/questions were used to screen for death nomenon of death wishes, and knowledge gained
wishes, for example items from the Patient Health from this process can directly inform clinical practice
Questionnaire (PHQ9), Geriatric Mental State, Ham- and benefit the local population. In New Zealand
ilton Depression Rating Scale and Beck Scale of Sui- (NZ), there has been no previous research on death
cide Ideation. The duration used for estimating the wishes among older people. The aims of this study
period prevalence of death wishes also varied greatly are to (i) determine the prevalence of death wishes
in these studies, ranging from 1 week, 2 weeks, among older people living at home who were assessed
1 month, 12 months to life-time. for home-based support services or level of care prior
A recent literature review found age-related losses to entering long-term aged residential care (nursing
(e.g. control, connectedness, meaning and self) played home) facilities and (ii) assess the contribution of de-
a crucial role in older people developing a wish to die mographic, emotional, psychosocial and functional
(Van Wijngaarden et al., 2014). Rurup et al. (2011b) factors to the development of these wishes. By identi-
studied the development of a wish to die in older peo- fying the characteristics of older people at greatest
ple and identified themes of being widowed, a victim, risk of presenting with death wishes, clinicians may
dependent and feeling lonely or not being able to be be better able to detect these individuals and intervene
useful. However, Barnow et al. (2004) argued that a early. This is an important area in public health con-
wish to die in older people is a symptom of a psychi- sidering the high global suicide rate amongst older
atric disorder, rather than a reaction to the person’s people (Shah et al., 2016). Results gained from this
living conditions and physical health. Indeed, the pres- research could also potentially benefit other countries.
ence of clinically significant depressive symptoms is
consistently reported as a predictor of death wishes
Method
among older people (Jorm et al., 1995; Skoog et al.,
1996; Forsell, 2000; Barnow et al., 2004; Rurup et al.,
(i) Sample and setting
2011a; Saïas et al., 2012; Vasiliadis et al., 2012;
Fässberg et al., 2013; Fässberg et al., 2014; Bonnewyn The sample analysed in this study included all older
et al., 2016). In addition, a multitude of biological people (age ≥ 65) who had received their first interRAI
and psychosocial factors are found to be associated Home Care Assessment (version 9.1) between 1 July
with death wishes among older people. These factors 2012 and 30 June 2014. Following approval from the
include an older age, female gender, being NZ Health and Disability Ethics Committee (Refer-
unmarried/divorced/widowed, lower income/ ence 14/STH/74), the NZ International Resident As-
financial problems, higher number of chronic ill- sessment Instrument (interRAI) Governance Group
nesses, poor subjective physical health, disability, sleep at the Ministry of Health was approached to provide
problems, higher level of stress/psychological distress, the interRAI data routinely collected by all of the Dis-
reduced social network/satisfaction with social sup- trict Health Boards (n = 20) in NZ. NZ has an ethni-
port and loneliness (Jorm et al., 1995; Skoog et al., cally diverse population (Europeans, Maori, Pacific
1996; Forsell, 2000; Barnow et al., 2004; Ladwig Islanders and Asians) of approximately 4.5 million
et al., 2008; Rurup et al., 2011a; Lapierre et al., 2012; people (14.3%, age ≥ 65).
Saïas et al., 2012; Vasiliadis et al., 2012; Fässberg The interRAI was developed by a network of health
et al., 2014; Handley et al., 2014; Bonnewyn et al., researchers in over 30 countries (interRAI, 2016). There
2016). However, no association was found between are several versions of interRAI, including a ‘Home
death wishes among older people and age, gender, Care’ version developed in 1994 for needs assessment
marital status and income in some studies (Jorm of older people requiring home-based support services

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
Death wishes among older people 3

(interRAI, 2016). The ‘Home Care’ (version 9.1) has variables were chosen and minor adjustments of the
been used for older people assessed for home support response codes were performed to allow meaningful
and entry to long-term aged residential care in NZ since clinical interpretation of the variables.
2012 (interRAI Home Care (HC), 2016). The purpose
of the interRAI is to provide a comprehensive and struc- Demographic variables. Age, gender, ethnicity, marital
tured multidisciplinary geriatric assessment. The assess- status and whether the person lived alone.
ment can then be used to determine needs and inform
planning of daily care and services for older people Health and functional status variables. Self-reported
in order to improve their outcomes and maximise health, activity level (total hours of physical activity
functioning in the community setting. or exercise in the last 3 days), self-reported physical
All interRAI data were collected by trained interRAI function improvement potential (person believes
assessors and interRAI assessments are usually com- he/she is capable of improved performance in physical
pleted using a laptop, providing immediate outcomes function), change in activity of daily living status, falls,
at the time of assessment. There is a national compe- fatigue, cognitive skills for daily decision-making, pain
tency framework that supports interRAI assessment frequency and pain control.
and provides quality assurance for interRAI assess-
ment. interRAI assessors must be clinically registered Emotional and psychosocial variables. Depression and
and signed off as competent to use the instruments anxiety diagnoses, loneliness, major life stressors in
by an interRAI Lead Practitioner in each District the last 90 days, strong and supportive family relation-
Health Board. interRAI assessment competency is ships, length of time spent alone during the day and
achieved by attending a 3-day interRAI training pro- change in social activities in the last 90 days.
gramme which involves completing 10 assessments
and care plans, passing an evaluation and achieving (iii) Statistical Analysis
an acceptable quality review outcome. One of the Data were analysed using IBM Statistical Package
competency standards is to ‘Accurately record assess- for the Social Sciences (SPSS) Version 22. Descriptive
ment information’ whereby an interRAI assessor uses statistics for demographic variables were obtained. Bi-
multiple sources of information for example referral variate analysis with Chi-squared tests was used to in-
note, person interview, observation, discussion with vestigate the significance of the relationships between
family or carers or health professionals to gain accu- the predictor variables and the presence of death
rate information. The item domains of the interRAI wishes. Next, a three-step hierarchical logistic regres-
Home Care version have been shown to have good sion analysis was performed with death wishes as the
inter-rater reliability (Hirdes et al., 2008). dependent variable. Age, ethnicity and marital status
(ii) Measures was entered at step one to control for these demo-
graphic variables. Depression was entered at step
two, because this variable is considered to be an im-
Outcome variable: death wishes portant predictor for wishes to die. All characteristics
relating to health and functional status, and emotional
The interRAI item on ‘Made negative statements’ (e.g. and psychosocial well-being that proved to be signifi-
‘Nothing matters’, ‘Would rather be dead’, ‘What’s the cantly (p < 0.01) related to the presence of death
use’, ‘Regret having lived so long’ and ‘Let me die’) wishes in the bivariate analysis were entered in step
was used to represent death wishes expressed by older three. Results are presented as odds ratios (OR, with
people. The four responses are 1. Not present; 2. Pres- 95% confidence intervals, CI) which should be
ent but not in the last 3 days; 3. Exhibited on 1–2 days interpreted as the effect that a predictor variable has
of the last 3 days; and 4. Exhibited daily in last 3 days. on the odds of presenting with death wishes.
For this analysis, death wishes were categorised as a
binary outcome: Present (responses 2, 3 and 4) or
Absent (response 1). Results

A total of 35 734 older people aged between 65 and


Predictor variables 109 received their first interRAI assessment in the
study period. 40.1% of participants were aged between
There are 236 variables routinely recorded as part of 65 and 80, while 59.9% were over 80 years old (mean
an individual interRAI assessment. The following age = 81.9, SD = 7.5). A majority (60.7%) of the sample

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
4 G. Cheung et al.

were female, and a majority (86.9%) were NZ decision-making, loneliness, major life stressors in
European, while the remainder were 5.3% Maori, the last 90 days, person distressed by their decline in so-
4.1% Pacific, 2.7% Asian and 1.0% other. The sample cial activities in the last 90 days and an anxiety diagno-
was representative of the 2013 NZ elderly population sis. The variables with the largest OR in the full model
(Statistics New Zealand, 2013). Almost half (48.1%) were depression, perceived loneliness and poor self-
of the sample were widowed and 39.0% were married reported health (OR = 2.54, 2.40, 2.34, respectively).
or in civil union/de facto relationships.
Death wishes were present for 9.5% of the sample.
Table 1 illustrates how demographic variables influ- Discussion
ence the presence of death wishes. Tables 2 and 3 illus-
trate the effect of health and functional status and Death wishes were present in 9.5% of this clinical
emotional and psychosocial well-being on the pres- sample of older people assessed for home support
ence of death wishes. The results of the three-step hi- and long-term aged residential care who were likely
erarchical logistic regression analyses are shown in to have more physical comorbidities and functional
Table 4. The two-step model, including only age, eth- impairment than the general community dwelling
nicity, marital status and depression, was significant elderly population. Older people who were most likely
(X2 = 811.02, p < 0.000 with degrees of freedom = 11) to wish they were dead were those who felt lonely, had
and explained 5.6% of the variance in the presence a clinical diagnosis of depression and rated their
or absence of death wishes (R2 Nagelkerke). The full general health as poor. Although the regression model
three-step model explained 17.4% of the variance in is statistically significant, only 17.4% of the variance
the presence or absence of negative statements and in presentation of death wishes is explained. This
was statistically significant (X2 = 2586.30, p < 0.000 suggests that determining the contributors to death
with degrees of freedom= 38). The following factors wishes in older people is complex, and multiple factors
entered in the third step were significantly associated are likely to be involved. Indeed, other factors that are
with death wishes: poor self-reported health, two or significantly associated with death wishes in this
more falls in last 30 days, severe fatigue, inadequate regression model include physical health (recurrent
pain control, impaired cognitive skills for daily falls, severe fatigue and inadequate pain control),

Table 1 Prevalence of death wishes by demographic characteristics

Death wishes

Present (N = 3 395) Absent (N = 32 339) Chi- p-value


Characteristic n (%) n (%) Total square (d.f.)

Age
65–80 years 1451 (42.7) 12 864 (39.8) 14 315 (40.1) 11.22 0.001 (1)
>80 years 1944 (57.3) 19 475 (60.2) 21 419 (59.9)
Gender
Male 1370 (40.4) 12 661 (39.2) 14 031 (39.3) 1.86 0.173 (1)
Female 2025 (59.6) 19 676 (60.8) 21 701 (60.7)
Ethnicity
European 3034 (89.4) 28 003 (86.6) 31 037 (86.9) 47.07 0.000 (4)
Maori 153 (4.5) 1 755 (5.4) 1 908 (5.3)
Pacific Island 70 (2.1) 1391 (4.3) 1 461 (4.1)
Asian 98 (2.9) 879 (2.7) 977 (2.7)
Others 40 (1.2) 311 (1.0) 351 (1.0)
Living arrangements
Living alone 1533 (45.2) 14 752 (45.6) 16 285 (45.6) 0.25 0.615 (1)
Living with another 1861 (54.8) 17 585 (54.4) 19 446 (54.4)
Marital Status
Never married 137 (4.0) 1541 (4.8) 1678 (4.7) 25.71 0.000 (5)
Married/civil union/de facto 1296 (38.2) 12 643 (39.1) 13 939 (39.0)
Widowed 1625 (47.9) 15 580 (48.2) 17 205 (48.1)
Separated 102 (3.0) 665 (2.1) 767 (2.1)
Divorced 208 (6.1) 1609 (5.0) 1817 (5.1)
Others 27 (0.8) 301 (0.9) 328 (0.9)

d.f., degrees of freedom.

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
Death wishes among older people 5

Table 2 Prevalence of death wishes by health and functional status

Death wishes

Present (N = 3,395) Absent (N = 32,339) Chi- p-value


Characteristic n (%) n (%) Total square (d.f.)

Self-reported health
Excellent 69 (2.3) 1096 (3.8) 1165 (3.7) 753.01 0.000 (3)
Good 914 (31.0) 13 351 (46.2) 14 265 (44.8)
Fair 1138 (38.6) 11 235 (38.8) 12 373 (38.8)
Poor 830 (28.1) 3243 (11.2) 4073 (12.8)
Total hours of physical activity in the last 3 days
None 738 (21.7) 6011 (18.6) 6749 (18.9) 76.15 0.000 (4)
<1 h 1171 (34.5) 9711 (30.0) 10 882 (30.5)
1–2 h 950 (28.0) 10 114 (31.3) 11 064 (31.0)
3–4 h 344 (10.1) 4,146 (12.8) 4490 (12.6)
>4 h 192 (5.7) 2357 (7.3) 2549 (7.1)
Self-reported potential for physical
function improvement
No 2518 (74.2) 23 506 (72.7) 26 024 (72.8) 3.41 0.065 (1)
Yes 877 (25.8) 8833 (27.3) 9710 (27.2)
Change in ADL status
Improved 107 (3.2) 1460 (4.7) 1567 (4.5) 215.10 0.000 (3)
No change 1281 (38.9) 15 872 (50.8) 17 153 (49.7)
Declined 1905 (57.8) 13 920 (44.5) 15 825 (45.8)
Falls
None in the last 90 days 1823 (53.7) 20 397 (63.1) 22 220 (62.2) 166.04 0.000 (3)
Fell 31–90 days ago 408 (12.0) 3378 (10.4) 3786 (10.6)
One fall in the last 30 days 602 (17.7) 5236 (16.2) 5838 (16.3)
Two or more falls in the last 30 days 562 (16.6) 3326 (10.3) 3888 (10.9)
Fatigue (inability to complete normal daily activities)
None 728 (21.4) 10 229 (31.6) 10 957 (30.7) 417.46 0.000 (4)
Minimal 984 (29.0) 10 715 (33.1) 11 699 (32.7)
Moderate 907 (26.7) 7529 (23.3) 8436 (23.6)
Severe 590 (17.4) 2905 (9.0) 3495 (9.8)
Unable to commence any normal daily activities 186 (5.5) 959 (3.0) 1145 (3.2)
Cognitive skills for daily decision-making
Independent 1204 (35.5) 16 080 (49.7) 17 284 (48.4) 250.15 0.000 (1)
Shows impairment 2191 (64.5) 16 259 (50.3) 18 450 (51.6)
Pain frequency
No pain 1204 (35.5) 14 089 (43.6) 15 293 (42.8) 167.54 0.000 (3)
Present but not exhibited in the last 3 days 708 (20.9) 6726 (20.8) 7434 (20.8)
Exhibited on 1–2 of the last 3 days 863 (25.4) 7824 (24.2) 8687 (24.3)
Exhibited daily in the last 3 days 620 (18.3) 3698 (11.4) 4318 (12.1)
Pain Control
Pain adequately controlled/no issue with pain 2835 (83.5) 29 419 (91.0) 32 254 (90.3) 195.19 0.000 (1)
Pain is not adequately controlled 560 (16.5) 2918 (9.0) 3478 (9.7)

ADL, activity of daily living; d.f., degrees of freedom.

psychological factors (recent major life stressors and that were independently associated with suicidal idea-
anxiety), social factors (loneliness and recent decline tion. Sirey et al. (2008) found 13.4% of older people in
in social activities) and impaired cognition. The results a home delivered meal programme had suicidal
of this study suggest each factor has a potentially small, thoughts (being ‘better off dead, or of hurting yourself
additive effect on the development of death wishes. in some way’) on several days in the prior 2 weeks; and
When considering an international context, the re- among men (not women), suicidal thoughts were
sults of our study are similar to previous studies in the associated with chronic pain and greater depression
USA. Raue et al. (2007) found 10.6% of older people severity. O’Riley et al. (2014) found 14.3% of older
newly admitted to visiting nurse home care had pas- people who sought social services had experienced
sive suicidal ideation (thoughts that life is not worth thoughts of death or of harming themselves in the
living or that one would be better off dead) in the past previous 2 weeks; and 19.4% reported that they had
month; and higher depression severity, greater medi- either felt that their lives were not worth living or that
cal comorbidity and lower subjective social support they had wished they were dead in the previous year.

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
6 G. Cheung et al.

Table 3 Prevalence of death wishes by emotional and psychosocial well-being

Death wishes

Present (N = 3395) Absent (N = 32 339) Chi- p-value


Characteristic n (%) n (%) Total square (d.f.)

Depression
Diagnosis present 1067 (31.4) 3421 (10.6) 4488 (12.6) 1,216.15 0.000 (1)
Diagnosis not present 2328 (68.6) 28 917 (89.4) 31 245 (87.4)
Anxiety
Diagnosis present 761 (22.4) 2886 (8.9) 3647 (10.2) 610.13 0.000 (1)
Diagnosis not present 2634 (77.6) 29 451 (91.1) 32 085 (89.8)
Loneliness
No 2084 (61.4) 26 727 (82.7) 28 811 (80.6) 889.78 0.000 (1)
Yes 1311 (38.6) 5610 (17.3) 6921 (19.4)
Major life stressors in the last 90 days
No 1518 (44.7) 20 038 (62.0) 21 556 (60.3) 382.05 0.000 (1)
Yes 1877 (55.3) 12 300 (38.0) 14 177 (39.7)
Strong, supportive family relationships
No 503 (14.8) 3623 (11.2) 4126 (11.5) 39.25 0.000 (1)
Yes 2892 (85.2) 28 714 (88.8) 31 606 (88.5)
Time alone during the day
<1 h 1097 (32.3) 10 761 (33.3) 11 858 (33.2) 5.93 0.115 (3)
1–2 h 476 (14.0) 4142 (12.8) 4618 (12.9)
>2 h but <8 h 709 (20.9) 7049 (21.8) 7758 (21.7)
>8 h 1112 (32.8) 10 384 (32.1) 11 496 (32.2)
Change in social activities in the last 90 days
No decline 1419 (41.8) 18 990 (58.7) 20 409 (57.1) 820.14 0.000 (2)
Decline, no distress 1281 (37.7) 11 049 (34.2) 12 330 (34.5)
Decline, distress 695 (20.5) 2299 (7.1) 2994 (8.4)

d.f., degrees of freedom.

They also found death ideation was associated with physical functioning (Coulehan et al., 1997; Callahan
higher level of depressive symptoms, more medical et al., 2005). Collaborative care is usually delivered
conditions and lower social support. by a team involving a depression care manager, the pa-
tient’s primary care doctor and a consulting psychia-
trist. Mitchell and Harvey (2014) suggested that
Depression collaborative care models are well suited to medically
unwell older people and may provide more general-
Approximately 12.6% of this sample of older people ised benefits across both mental and physical health
had a diagnosis of depression. This rate is much higher measures. Promising results using new technology in
than the 12-month prevalence of major depressive dis- delivering treatment for depressed older people are
order (1.7%) and any mood disorder (2.0%) previ- emerging. For example, a study using problem-solving
ously found in community-dwelling older people as therapy delivered via Skype video calls on a laptop
part of a NZ epidemiological study (Wells et al., found that problem-solving therapy delivered in-
2006). The higher rate of depression found in this person and via Skype were both efficacious in treating
study is not surprising given functional impairment, depression (Choi et al., 2014). In addition, older peo-
a significant risk factor for depression (Zeiss et al., ple treated via Skype had lower suicidal ideation and
1996), was very likely to be present in our sample of hopelessness across the follow-up period (Choi et al.,
people who were assessed for home support and 2015).
long-term aged residential care. Our finding is very
similar to previous studies of home care patients or
home-delivered meal recipients where 8.5–13.5% of Loneliness
their sample had a diagnosis of major depressive disor-
der or clinically significant depressive symptoms Loneliness is a subjective, unwelcome feeling resulting
(Bruce et al., 2002; Ell et al., 2006; Sirey et al., 2008). from a perceievd absence or loss of companionship
Treatment of late-life depression using the collabo- (Routasalo et al., 2009). Loneliness is a risk factor for
rative care model can result in improvement in depression in older people, and people who are lonely

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
Death wishes among older people 7

Table 4 Multivariate model using functional, emotional and psychosocial status to show odds ratios of presenting with death wishes

Characteristic OR (95% CI) Wald p-value

Age (65–80) 0.97 (0.89–1.07) 0.33 0.569


Marital status (Married/civil union/de facto) REF 9.04 0.108
Never married 0.78 (0.63–0.98)
Widowed 1.01 (0.92–1.11)
Separated 1.19 (0.92–1.54)
Divorced 0.99 (0.83–1.20)
Other 0.72 (0.44–1.17)
Ethnicity (European) REF 13.00 0.011
Maori 0.88 (0.73–1.07)
Asian 0.89 (0.68–1.17)
Pacific 0.61 (0.46–0.81)
Other 1.01 (0.67–1.07)
Depression 2.54 (2.29–2.81) 317.03 0.000
Self-reported health (Excellent) REF 192.77 0.000
Good 1.00 (0.77–1.27)
Fair 1.23 (0.95–1.60)
Poor 2.34 (1.78–3.07)
Falls (None in the last 90 days) REF 18.42 0.000
Fell 31–90 days ago 1.13 (0.99–1.29)
One fall in the last 30 days 1.06 (0.95–1.19)
Two or more falls in the last 30 days 1.30 (1.15–1.47)
Fatigue (None) REF 34.79 0.000
Minimal 1.10 (0.99–1.24)
Moderate 1.18 (1.05–1.34)
Severe 1.51 (1.30–1.76)
Unable to commence any normal daily activities 1.58 (1.24–2.01)
Pain frequency (no pain) REF 9.20 0.027
Present but not exhibited in the last 3 days 1.15 (1.03–1.29)
Exhibited on 1–2 of the last 3 days 1.09 (0.98–1.22)
Exhibited daily in the last 3 days 1.20 (1.04–1.39)
Inadequate pain control 1.35 (1.19–1.54) 20.09 0.000
Total hours of physical activity in the last 3 days (>4 h) REF 9.32 0.054
None 1.06 (0.87–1.29)
<1 h 1.11 (0.92–1.33)
1–2 h 0.97 (0.80–1.16)
2–4 h 0.93 (0.76–1.15)
Change in ADL status (no change) REF 3.47 0.176
Improved 0.81 (0.65–1.01)
Declined 0.97 (0.88–1.07)
Impaired cognitive skills for daily decision-making 1.93 (1.77–2.10) 219.41 0.000
Loneliness 2.40 (2.20–2.63) 372.45 0.000
Major life stressors in the last 90 days 1.41 (1.29–1.54) 59.90 0.000
Lack of strong, supportive family relationships 1.18 (1.04–1.33) 6.70 0.010
Change in social activities in the last 90 days (no decline) REF 121.75 0.000
Decline, not distressed 1.14 (1.04–1.26)
Decline, distressed 1.99 (1.76–2.26)
Anxiety 1.43 (1.27–1.60) 36.62 0.000

OR, odds ratio; CI, confidence interval; ADL, activity of daily living; REF, Reference.

or depressed are more likely to experience a decline in Smart technologies (e.g. internet-based support
health status (Wenger et al., 1996; Alpass and Neville, groups, computer use and training, web-based discus-
2003). A systematic review concluded that effective in- sion groups and web-based self-help interventions)
terventions targeting social isolation in older people have been used to improve social connectedness in
were those offering social activity and/or support and older people (Morris et al., 2014). It has been sug-
at a group level (Dickens et al., 2011), whereas one- gested that smart technologies with electronic access
to-one support in people’s own homes was found to to clinicians and relevant websites may help older peo-
be ineffective (Cattan et al., 2005). Dickens et al. ple to better manage and understand various health
(2011) also found interventions that included older conditions and improve their depression, which is
people as active participants were more effective. correlated with factors of social connectedness. In

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
8 G. Cheung et al.

addition, a positive experience from learning and New Zealanders living in the community who were
using new technology and a perception of it being in- accessing home support services and aged residential
novative can contribute to better treatment outcomes care. Secondly, the interRAI item on ‘Made negative
in older people. (Choi et al., 2015). statements’ includes a range of responses (e.g. ‘Noth-
ing matters’, ‘Would rather be dead’, ‘What’s the
use’, ‘Regret having lived so long’ and ‘Let me
Self-rated health
die’). Some of these responses have a more passive
nature, while some may have indicated imminent
Self-rated health represents the perception individuals
suicide risk (e.g. ‘Let me die.’). The heterogeneity
have of the various dimensions of their state of health
of this item has important implications for interpre-
(Idler and Benyamini, 1997). A number of indepen-
tation of the findings and, eventually, design of pre-
dent biopsychosocial factors are integrated when mea-
ventive interventions. Thirdly, the interRAI
suring self-rated health, and it can be a useful
assessment item on negative statements is cross-
screening test. These factors include demographic
sectional and time-bound, referring typically to the
(age, gender, education level, social security and in-
last 3 days. Therefore, we must consider that an indi-
come), social (caregiver and family function), biologi-
vidual’s results may vary slightly if the assessment
cal (chronic disease, polypharmacy, smoking and
had been completed at a different time. The negative
alcohol abuse), mental health (dementia and depres-
statements item also includes a category of ‘Present
sion), and functional variables (instrumental/basic ac-
but not in the last 3 days’. The time frame referred
tivity of daily living deficits, walking speed, hand grip
to in this category is not clear, and it is impossible
strength, sedentary lifestyle and anergy) and geriatric
to know if it was present in the last few weeks or
syndromes (falls, frailty and faecal/urinary inconti-
even in the last year. This category could be im-
nence) (Lee, 2000; Ocampo, 2010).
proved in the interRAI assessment schedule and for
Self-rated health can predict health outcomes and is
future study. Lastly, while interRAI assessors use all
an independent predictor of mortality and suicide
available clinical infomation, rather than a structured
(Idler and Benyamini, 1997; Turvey et al., 2002;
diagnostic interview or validated rating scale, to
Blazer, 2008). In a meta-analysis, Chang-Quan et al.
reach the various diagnoses, some diagnoses such as
(2010) showed that poor self-rated health status was
depression and anxiety may be under-reported or
a stronger risk factor for depression in older people
diagnosed.
than the presence of chronic disease itself. Segal et al.
In conclusion, various physical health, psychosocial
(2008) found that global perceived health status had
and cognitive factors play a role in the development of
the strongest significant contribution to reasons for
death wishes among older New Zealanders, although
living among older people; while depressive symp-
some factors such as depression, loneliness and poor
toms, stressful experiences and optimism made mini-
self-reported health have stronger influence than
mal and non-significant contributions. They
others. Despite methodological differences, our results
recommended that attention to physical health status
(e.g. rates and predictors of death wishes) are in line
should be a standard part of suicide risk assessment
with the literature mainly from the USA. Comprehen-
in older people. Both loneliness and self-rated health
sive intervention programmes which aim to treat or
can influence an older person’s perception of their
improve depression, loneliness and physical health
quality of life and the possibility to realise meaningful
may contribute to reducing death wishes, suicidal ide-
activities. A quality of life measure is not included in
ation and suicide attempts in older people in NZ.
the interRAI assessment, and its relationship with
There is also emerging evidence for using smart tech-
death wishes should be studied in future research.
nologies to target depression, loneliness and health lit-
eracy in older people. More research is therefore
Strengths and limitations needed to prepare our baby boomers entering old
age, who are competent at using these smart technol-
There are limitations of this study that must be ac- ogies. Finally, international consensus on the defini-
knowledged. Firstly, the current study is a clinical tion of death wishes (and its look-back period)
sample, and the findings cannot be generalised to would allow direct comparision of findings between
the general older population in NZ. However, NZ studies. The interRAI is adopted in over 30 countries,
is one of a few countries in the world that has and it can be used as a tool to investigate death wishes
adopted the interRAI at a national level, and the nationally/regionally in the future, which may im-
present study represents a national sample of older prove our understanding of the phenomenon and

Copyright # 2016 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2016
Death wishes among older people 9

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