Understanding self-harm in the very old: A qualitative study with implications for clinical care and wider society.

Abstract

The population is ageing globally and the highest rate of suicide is in men aged 85 or more. The connection between suicide and self-harm in older people provides a window into understanding why older people die by suicide. Older people with cognitive impairment, advanced age, or from non-English speaking backgrounds are often excluded from research in this area, despite representing a significant proportion of the population. The aims of the thesis were to understand why very old people self-harm and to use the findings to inform and evaluate an educational intervention for clinicians. Study 1 qualitatively examined why a cognitively and culturally diverse cohort of very old (aged 80+) adults self-harmed by interviewing the person, their nominated relative/friend, and by questionnaire completion by their General Practitioner (GP). The older people reported a myriad of biopsychosocial factors contributing to the self-harm, including relational factors in his/her clinical and familial systems such as perceived rejection, burdensomeness and helplessness. The carer perspective echoed that of the older person, as well as highlighting their own distress. GPs reported helplessness, professional isolation and therapeutic nihilism. The implications for requests for voluntary assisted dying were explored. Study 2 followed-up the original cohort one year after the self-harm. Emergent themes from the three groups were triangulated. Patients and their relatives/friends described many contributing factors to self-harm persisting at follow-up, whereas GPs felt problems had been resolved and they understood the underlying reasons for self-harm. A conceptual framework for self-harm in late life, empirically derived, highlighted the relational context of the older adult with family, health professionals, and society, and opportunities for interventions to improve outcomes through prevention and aftercare. Study 3 combined the results of the two previous studies in the development and evaluation of an educational intervention for primary care and hospital-based clinicians focused on understanding, assessing and managing self-harm in older people. Multidisciplinary clinicians attended the brief educational intervention. Significant improvements in attitudes, knowledge and confidence regarding self-harm in late life were found post-intervention. In summary, this thesis presented novel insights into why the very old self-harm and the importance of relationships with family/friends and clinicians, which influence the decision to self-harm and outcomes. A brief educational intervention based upon this qualitative work had immediate impact on the knowledge and confidence of multidisciplinary clinicians.