Suicide Among Older Adults Living in or Transitioning to Residential Long-term Care, 2003 to 2015

Abstract

Importance: Almost 25% of Medicare beneficiaries live in residential long-term care (LTC) (eg, independent or assisted living facility or nursing home). There are few reliable statistics on completed suicide in LTC, in part because of data limitations.

Objectives: To estimate the number of suicides associated with residential LTC (ie, among persons in a facility, transitioning into or out of a facility, or otherwise associated with LTC) among adults 55 and older and, secondarily, to identify whether machine learning tools could improve the quality of suicide surveillance data.

Design, setting, and participants: Cross-sectional epidemiologic study (conducted in 2018) of restricted-access data from the National Violent Death Reporting System (NVDRS) (2003-2015) using restricted-access case narratives from suicides and undetermined deaths among adults 55 years and older in 27 states. Participants were all suicides and undetermined deaths (N = 47 759) among persons 55 years and older.

Exposure: Long-term care cited in the coroner/medical examiner case narrative, whether as a reason for self-harm or the injury location, identified using machine learning natural language processing (NLP) algorithms plus manual review of texts.

Main outcomes and measures: Number and characteristics (eg, demographics, health history, and means of injury) of suicides associated with LTC. The κ statistic was used to estimate the reliability of the existing NVDRS injury location codes relative to cases identified by the algorithm.

Results: Among 47 759 persons 55 years and older (median age, 64 years; 77.6% male; 90.0% non-Hispanic white), this study identified 1037 suicide deaths associated with LTC, including 428 among older adults living in LTC, 449 among older adults transitioning to LTC, and 160 otherwise associated with LTC. In contrast, there were only 263 cases coded with the existing NVDRS location code "supervised residential facility," which had poor agreement with cases that the algorithm identified as occurring in LTC (κ statistic, 0.30; 95% CI, 0.26-0.35).

Conclusions and relevance: Over a 13-year period, approximately 2.2% of suicides among adults 55 years and older were associated with LTC in some manner. Clinicians, administrators, and policy makers should consider ways to promote the mental health and well-being of older adults experiencing functioning limitations and their families. Natural language processing may be a useful way to improve abstraction of variables in the NVDRS.

Figure 1.. Flowchart of the Development and Training of the Natural Language Processing (NLP) Algorithm to Identify Cases Associated With Long-term Care (LTC), 2003 to 2015

Stepwise development and training used coroner/medical examiner narratives of decedents 55 years and older (N = 47 759) in the National Violent Death Reporting System.

Figure 2.. Annual Frequencies of Suicides Associated With Long-term Care (LTC) Among Adults 55 Years and Older, 2005 to 2015

Frequencies are stratified by 3 groups identified by the natural language processing algorithm. Frequencies are limited to the 13 states that began reporting valid data to the National Violent Death Reporting System in 2003 or 2004 (eTable 1 in the Supplement).