drinking fluids; or have fatal "accidents," which are really suicidal acts. Many
of these deaths are certified as "natural or accidental." In addition, many of
the suicides in nursing homes and other long-term care facilities result from
intentional self-starvation and failure to take medications or follow prescribed
medical regimens. These passive suicidal behaviors often result in a debi-
litated physical condition, increasing the risk of death from pneumonia,
cardiac arrest, respiratory failure, and other physical disease conditions. Such
deaths are not certified as suicides and do not appear in reported suicide
statistics.

Compared to younger individuals, the old openly communicate their su-
icidal intent less frequently ( Jarvis & Boldt, 1980), use more violent and
lethal means ( McIntosh & Santos, 1985-86), and less often attempt suicide
as a means of gaining attention or to cry for help ( Pasquali & Bucher, 1981).
It is estimated that there are 10 to 20 suicidal attempts for every suicide
completion for the population as a whole. Ratios for the young are as high
as 200 to 1, while for the elderly the ratio is 4 to 1 ( McIntosh, 1985a). Social
isolation, lethality of method, greater effort to avoid discovery, delayed
medical interventions, and compromised physical conditions with poorer
recuperative powers all contribute to successful attempts among the elderly
( McIntosh & Santos, 1981).

Some older adults are considerably more vulnerable to suicide than are
others. Demographic characteristics associated with vulnerability to suicide
in late life include the age of the older adult, gender, race and ethnicity,
and marital status. In addition to these characteristics, physical illness and
such psychosocial factors as depression, alcoholism, social isolation and lone-
liness, and bereavement and widowhood, are related to vulnerability to
suicide and the increased risk of suicide in this population. Environmental
factors also play significant roles in suicide in older adults, particularly for
residents of long-term care facilities.

In this chapter, various factors related to suicide in the elderly are ex-
amined in detail. The chapter also includes an overview of the scientific
study of suicide in long-term care facilities.

Not only do suicide rates increase with age and peak past age 65, but
within the older population there is also differential vulnerability and higher
rates with increasing age. As J. McIntosh ( 1984) notes, rates are greater
among the old-old (75 years of age) compared to the high rates of the young-
old (65-74 years of age). If the old-old age group is considered in more detail,
suicide rates are usually highest for the 75-84 age group and slightly lower
for the oldest-old (85 years of age and older), although in the latter case

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