In general, people with dementia assume that it is difficult to attempt suicide due to cognitive impairment, but nonetheless, suicide of dementia patients often occur in many countries, including South Korea. Therefore, social problem of suicide among dementia patients should receive greater attention, and adequate assessment of suicidal ideation, attempts and psychological and physical support for patients with dementia are needed.
In South Korea, as the total older adults’ population increases, suicide is becoming a serious social concern that can no longer be overlooked because of worlds’ highest suicide rate in older population. However, there is still a lack of systematic research on suicide among older adults with dementia. Thus, this study evaluated whether the national intervention measure of LTCS has the effect of preventing suicide among older adults with dementia in the context of a continuously aging population and the rapidly increasing mortality rate of older adults with dementia. Despite Korea’s high and growing suicide rate among people with dementia, there is a lack of empirical research on the suicide. This study analyzed 558,147 older adults from the total population of individuals aged over 60 years in Korea through random sampling using the “Older Adults cohort DB” of 14 years from 2002 to 2015.
The study found that, first, at the individual level, men had a higher suicide rate than women, and the suicide rate among older adults with dementia was higher when their ADL and cognitive functioning were mild rather than severe. Additionally, the suicide rate was the highest if there were no caregivers to help them with daily living. The suicide rate was also higher if family members or acquaintances cared for them instead of professional caregivers.
Regarding ADL and cognitive functioning, the suicide rate among older adults with dementia was higher when their ADL and cognitive functioning were mild rather than severe. This is consistent with recent studies showing that older adults diagnosed with dementia most recently are more likely to attempt suicide [7, 12, 14-17]. In Korea, a study assessing the effects of “suicide prevention programs” on older adults with mild dementia showed positive effects as time changed due to perceived health conditions, social support, depression, and suicidal intentions [19]. A Canadian study reported that a positive social relationship alone could reduce the intentional self-harm among long-stay home care clients aged over 60 years [22]. Therefore, it is essential to provide interventions for older adults to prevent the risk of suicide among older adults with mild dementia or provide health education and rehabilitation programs for mental health management [23]. Also, to them, non-pharmacological strategy such as multicomponent training may be an important to enhance ADL's functionality on older adults with dementia [24]. Efforts should be aimed at providing customized services that can improve problem behavior to the extent that older adults can be active but without branding them as such. Recently, the Korean government is also making efforts to invest in the LTC facility resources and established a long-term care plan for placement of professionals for customized services.
Regarding the caregivers of older adults with dementia, the risk of suicide rate was lower when professional caregivers were used rather than family members or acquaintances. We can infer the reason for this from the literature that the burden and stress increases when taking care of family members or close neighbors. In Korea, there are several cases of older adults suffering from dementia committing suicide in the early stages because of the inability to overcome the mental distress of being a burden on the family [25]. Self-care needs and behaviors of caregivers including ample sleep, social engagement and support, and leisure activities are also essential for health care in patients with dementia [26, 27]. This can also have a positive effect on the formation of a relationship between the two groups. Systematic support for the formation of a relationship between dementia patients and family caregivers can have a positive effect not only on the patients but also on family caregivers [28]. It may also result from problems with the caregiver’s expertise as well as the burden of support for family or acquaintances. Therefore, it is essential to develop a “specialized curriculum” focused on staff delivery standards and mandatory training for unskilled nurses, as in Japan, to provide standardized services and establish infrastructure for ascertaining the role of caregivers [29, 30]. Besides, older adults with dementia and their caregivers can expect targeted improvements such as clinical knowledge of disease, better communication between dementia patients and service providers, and more proactive care plans through systematic counseling and education for an acknowledge cognitive decline [31].
Second, as a result of examining the effects of LTCS intervention at the national level, the suicide rate of non-users was higher than that of LTCS users. Among users, the suicide rate of home-service users was higher than that of facility service users. In other words, long-term care services provided by the government had a positive effect on the prevention of suicide among older adults with dementia. This is consistent with previous studies indicating that the effects of the national system or community program could contribute to the mental health of dementia patients [32, 33]. Older people also experience depression as they age and feel isolated, especially when they have feelings of perceived burdensomeness to others [10, 11]. Thus, they had a lower suicide rate when they were protected in a facility and served in a space where communication with people around them was relatively high.
Additionally, an analysis of the effects of the long-term care insurance system for older adults with dementia showed that the suicide rate among users was significantly lower than that of non-users, depending on the use of the service, while the suicide rate was higher after the expansion of the LTCS grade (after 2014) compared to before the expansion (before 2014). Therefore, the interaction between before and after the expansion of the grading and whether the LTCS was used showed no significant results.
In other words, the use of LTCS has a positive effect on lowering the suicide rate among older adults with dementia. Therefore, the country’s policy direction to increase access to long-term care services might be the precise direction. Furthermore, efforts are required to establish various programs and a care service culture within the LTCI system as well as quantitative increase in nursing facilities to prevent suicide among older adults with dementia. Additionally, it is necessary to develop measures to ensure continuous management and protection by recognizing problems with long-term care home service and establishing monitoring systems in-home by utilizing the apps and chatbots that have recently emerged. The LTCI system for older adults has increased the accessibility of services for older adults with dementia by implementing the expansion of the dementia grade since 2014; however, any change in the suicide rate was not observed in this study. This may be caused by an increase in the number of older patients with dementia who entered the system in the early stages of enhanced system security. Moreover, there may be limitations in observing the system for a short period of time; therefore, continuous monitoring and research is needed to develop measures to prevent and manage dementia patients in the future.
This study has several implications. First, this study is meaningful as it is the first empirical study on suicide among older adults with dementia in South Korea. Additionally, data from the NHIS’s representative “Older Adults cohort DB” were used for about 14 years from 2002 to 2015, enabling comparative analysis between before and after the extension of the dementia grade in 2014. Therefore, this study is advantageous as an observation of long-term changes as a longitudinal study and effective in identifying causal relationships between exposure and outcome in the empirical analysis. Second, the study recognized the importance of management at the national level for the prevention of suicide among older adults with dementia and makes effective policy suggestions such as linking the LTCI system with the suicide prevention program.
However, in this study, the effect of enhancing the coverage of “expanding the dementia grading” of LTCI was limited to a short-term observation of only two years. Further research should make a continuous assessment of the plan from a long-term perspective. Nevertheless, the LTCS strengthened the accessibility of the service to older adults with dementia and evaluated the effect of contributing to the prevention of suicide by providing care services, thereby identifying the direction of policy effects. Given that the current system has entered its sixth year since the expansion of the dementia grading, it is meaningful that the results of this study can be provided as basic data to establish a national long-term plan for LTCI, which legally establishes a basic plan for every five years.