When older adults struggle with mental illness, families often turn to long-term care to keep them safe.
A jovial social worker who loved to dance, Ellen Karpas fell into a catatonic depression after losing her job at age 74 and was diagnosed with bipolar disorder. Concerned that she was “dwindling away” at home, losing weight and skipping medications, her children persuaded her to move to an assisted living facility in Minneapolis in 2017.
Karpas enjoyed watching the sunset from the large, fourth-story window of her room at Ebenezer Loren on Park. But she had trouble adjusting to the sterile environment, according to son Timothy Schultz, 52.
“I do not want to live here for the rest of my life,” she told him.
Ellen Karpas (second from left) and four of her five children attend a 2016 St. Patrick???s Day parade in 2016. The following year, the 79-year-old died by suicide at an assisted living facility in Minneapolis. (Courtesy of Timothy Schultz)
On Oct. 4, 2017, less than a month after she moved in, Karpas was unusually irritable during a visit, her daughter, Sandy Pahlen, 54, recalled. Pahlen and her husband left the room briefly. When they returned, Karpas was gone. Pahlen looked out an open window and saw her mother on the ground below.
Karpas, 79, was declared dead at the scene.
Schultz said he thinks the death was premeditated, because his mother took off her eyeglasses and pulled a stool next to the window. Escaping was easy: She just had to retract a screen that rolled up like a roller blind and open the window with a hand crank.
Pahlen said she believes medication mismanagement — the staff’s failure to give Karpas her regular mood stabilizer pills — contributed to her suicide. But a state health department investigation found staffers were not at fault in the death. Eric Schubert, a spokesman for Fairview Health Services, which owns the facility, called Karpas’ death “very tragic” but said he could not comment further because the family has hired a lawyer. Their lawyer, Joel Smith, said the family plans to sue the facility and may pursue state legislation to make windows suicide-proof at similar places.
“Where do I even begin to heal from something that is so painful, because it was so preventable?” said Raven Baker, Karpas’ 26-year-old granddaughter.
Nationwide, about half of people who die by suicide had a known mental health condition, according to the Centers for Disease Control and Prevention. Mental health is a significant concern in U.S. nursing homes: Nearly half of residents are diagnosed with depression, according to a 2013 CDC report
That often leads caregivers, families and patients themselves to believe that depression is inevitable, so they dismiss or ignore signs of suicide risk, said Conwell.
“Older adulthood is not a time when it’s normal to feel depressed. It’s not a time when it’s normal to feel as if your life has no meaning,” he said. “If those things are coming across, that should send up a red flag.”
Still, not everyone with depression is suicidal, and some who are suicidal don’t appear depressed, said Julie Rickard, a psychologist in Wenatchee, Wash., who founded a regional suicide prevention coalition in 2012. She’s launching one of the nation’s few pilot projects to train staff and engage fellow residents to address suicides in long-term care.
In the past 18 months, three suicides occurred at assisted living centers in the rural central Washington community of 50,000 people. That included Roland K. Tiedemann, 89, who jumped from the fourth-story window of a local center on Jan. 22, 2018.
“He was very methodical. He had it planned out,” Rickard said. “Had the staff been trained, they would have been able to prevent it. Because none of them had been trained, they missed all the signs.”
Tiedemann, known as “Dutch,” lived there with his wife, Mary, who has dementia. The couple had nearly exhausted resources to pay for their care and faced moving to a new center, said their daughter, Jane Davis, 45, of Steamboat Springs, Colo. Transitions into or out of long-term care can be a key time for suicide risk, data shows.
After Tiedemann’s death, Davis moved her mother to a different facility in a nearby city. Mary Tiedemann, whose dementia is worse, doesn’t understand that her husband died, Davis said. “At first I would tell her. And I was telling her over and over,” she said. “Now I just tell her he’s hiking.”
At the facility where Tiedemann died, Rickard met with the residents, including many who reported thoughts of suicide.
“The room was filled with people who wanted to die,” she said. “These people came to me to say: ‘Tell me why I should still live.’ “
Most suicide prevention funding targets young or middle-aged people, in part because those groups have so many years ahead of them. But it’s also because of ageist attitudes that suggest such investments and interventions are not as necessary for older adults, said Jerry Reed, a nationally recognized suicide expert
with the nonprofit Education Development Center.
“Life at 80 is just as possible as life at 18,” Reed said. “Our suicide prevention strategies need to evolve. If they don’t, we’re going to be losing people we don’t need to lose.”
Even when there are clear indications of risk, there’s no consensus on the most effective way to respond. The most common responses — checking patients every 15 minutes, close observation, referring patients to psychiatric hospitals — may not be effective and may even be harmful, research shows
But intervening can make a difference, said Eleanor Feldman Barbera, a New York psychologist who works in long-term care settings.
She recalled a 98-year-old woman who entered a local nursing home last year after suffering several falls. The transition from the home she shared with her elderly brother was difficult. When the woman developed a urinary tract infection, her condition worsened. Anxious and depressed, she told an aide she wanted to hurt herself with a knife. She was referred for psychological services and improved. Weeks later, after a transfer to a new unit, she was found in her room with the cord of a call bell around her neck.
After a brief hospitalization, she returned to the nursing home and was surrounded by increased care: a referral to a psychiatrist, extra oversight by aides and social workers, regular calls from her brother. During weekly counseling sessions, the woman now reports she feels better. Barbera considers it a victory.
“She enjoys the music. She hangs out with peers. She watches what’s going on,” Barbera said. “She’s 99 now — and she’s looking toward 100.”
Know What To Do
Families of people living in or transitioning to long-term care receive little advice about signs of suicide risk — or ways to prevent it. Here are steps to keep your loved one safe, based on interviews with suicide prevention researchers.
Know what’s normal. Depression and thoughts of suicide are not an inevitable part of aging or of living in long-term care. Consider treatment for depression if the person experiences trouble sleeping, muscle aches, headache, changes in appetite or weight, restlessness or agitation.
Don’t be afraid to ask about it. Asking someone about suicidal thoughts is unlikely to cause them to act on them. Start the conversation. Ask about the facilities, the activities, the food. Ask what would help them look forward to waking up or want to be alive.
If you have concerns, speak up. Let staff members know if your loved one talks about wanting to die, or about actual plans to end their lives. Work with the team collaboratively to discuss solutions.
Ask about suicide protocols. Facilities should have a plan for assessing, monitoring and preventing suicide risk. What’s the protocol if someone is actively or passively suicidal? Fifteen-minute checks? Close observation? Hospitalization? What’s the readmission policy?
Plan for safety. If suicide is a concern, restrict access to lethal means, including weapons, medications, chemicals, cords and plastic bags. Ensure that windows, stairwells and exits are secure.