MDS Alert

Tap these interview techniques and tools to do an accurate assessment.

Picture this: A resident attempts suicide by taking a hoarded stash of pills several days after admission to the nursing facility. And no one on staff had performed a suicide screen on the person or on any of the facility's residents.

Talk about an immediate jeopardy citation potentially in the offing, not to mention a quality improvement opportunity for avoiding this potentially preventable event.

A risk management must-do: Perform and document a suicide assessment at admission. And do one in conjunction with the MDS, suggests Natalie Statts Reiss, PhD, a clinical geropsychologist with CenterSite in Columbus, OH, who has done research on suicide in nursing homes.

Also look for these red flags which may signal the need for additional assessment of suicidality, which Reiss identified in her research:

• Any sort of mood change/exacerbation (up or down);

• Sudden isolating behavior or withdrawing and not wanting to engage in usual activities;

• Complaints of pain;

• A sudden interest or disinterest in religious issues;

• Giving away possessions or behavior indicating that the person may be tying up loose ends;

• Any sort of new loss. This doesn't have to be a death, Reiss points out. It could be someone not coming to visit anymore or a physical decline, such as worsening vision, particularly if someone enjoys reading, she says.

Watch out: Simply hearing the initial diagnosis of dementia can lead some people, especially those ages 50 to 69, to commit suicide, according to "Hospital-Diagnosed Dementia and Suicide," published in the March 2008 American Journal of Geriatric Psychiatry. Taking into account depression, the researchers linked a dementia diagnosis to a three to 10 times higher risk of suicide among elderly with dementia. The study also suggests that even patients with advanced stages of dementia may be sufficiently suicidal to plan and carry out suicide.

Also: Keep in mind that refusing care, such as medications or declining to move, can be a passive suicide attempt, cautions Sherry Cummings, PhD, associate dean of the College of Social Work at the University of Tennessee in Nashville.

Use a conversational technique to tap into a resident's feelings of depression or not wanting to live anymore. For example, Campbell suggests developing rapport by asking some general questions first. Then move into assessing the person for signs of depression, such as: "How is your energy level? What do you enjoy doing? How is your appetite? How are you sleeping and how many hours a night?"

"If the person reports lack of energy, has no joy at all, doesn't enjoy doing things, has a change in appetite, sleeps poorly or too much, ask her if she's feeling blue or down in the dumps. People usually will admit to that," says Campbell. Next, move to questioning about suicidal thoughts.

More tips: Keep in mind that as a topic, suicide is taboo for a lot of people in the older age group, Reiss cautions. She thus recommends framing questions about suicide by saying, "[Coming into a nursing facility] is a really big change for most people. How does this make you feel?" If the person admits to feeling sad, then get into more direct questioning, such as "Have you had thoughts that you don't want to be here anymore or that life isn't worth living?"

Questions like that can elicit a lot of information without turning someone off, Reiss says. If the person starts indicating that she might be suicidal, then you have to get direct and ask if the person has a plan and so forth, Reiss says.

Choose a tool based on a resident's cognitive status: Standard- ized instruments can also help you nail down whether someone is depressed and/or suicidal. Reiss recommends using the short form Geriatric Depression Scale for people who are cognitively intact. If the person has cognitive impairment, the Cornell Scale for Depression in Dementia is a good scale, Reiss adds. She thus recommends doing a standard cognitive screen, such as the mini-mental status exam, before the depression scale, so you'll know which depression scale to choose.

Resource: Read about the Cornell scale at http://siq.air.org/Resource_Detail.aspx?source=CMS&ResourceID=349.

Tip: Reiss thinks it's a good idea to involve the family in a suicide assessment. If the resident has cognitive impairment, the family can provide information about the person's past mood disorders, depression and suicide attempts, if any. Also the resident may not appear depressed to his family or the person may have, in their view, changed dramatically in terms of his mood and/or behavior, she notes.

If you're looking for a specific suicide assessment tool for the nursing home population, researchers have validated the Geriatric Suicide Ideation Scale for assessing older adults, including those in nursing homes. The scale has subscales that look at (1) suicide ideation; (2) death ideation; (3) loss of personal and social worth; (4) perceived meaning in life. The GSIS scale can be useful to get a sense of an incoming resident's issues, including suicidal thoughts, a wish to die, and/or perceived worthlessness or being a burden on others, says Marnin J. Heisel, PhD, CPsych, co-developer of the tool.

The GSIS scale can also identify potential resilience in terms of the person's perceived meaning in life, says Heisel, who is with the Department of Psychiatry and Department of Epidemiology and Biostatistics at the University of Western Ontario. And it can identify residents who might benefit from referral to a mental health provider for more in-depth psychological assessment and intervention, he says. But make sure those who use the GSIS have professional competency and experience in assessing mental health difficulties and addressing the issues that may come up during the interview, Heisel advises.

Editor's note: For a copy of the GSIS tool, e-mail Dr. Heisel at Marnin.heisel@lhsc.on.ca. For a free copy of a Long-Term Care Survey Alert article on clinical strategies for managing suicidal residents, e-mail the editor at KarenL@Eliresearch.com.