Development of a Decision Aid to Prevent Firearm Suicide Among Older Adults with Mild Cognitive Impairment/early Dementia

Considered a national epidemic, suicide is the 10th leading cause of death in the United States. In the decade for which data are most recently available (2008-2018) 60,342 older adults died from firearm injuries, with 93% attributable to suicide. The risk of firearm suicide is highest for people over the age of 55 and has increased by 23% since 2000. Suicide is not only a problem among older adults, but also among those with cognitive impairment. One study reported that those with dementia were 3 times more likely to die by suicide compared to those without dementia after accounting for psychiatric diagnoses. The diagnosis of a medical illness represents a period of especially high suicide risk. The Interpersonal Theory of Suicide identifies thwarted belongingness and feelings of being a burden as key mechanisms through which suicidal desire arises. pwMCI/early dementia face a diagnosis of physical illness, which may increase perceptions of being a burden, potentially increasing the occurrence of suicidal desire and behavior. Dementia is fundamentally different than most other physical illnesses because it involves the gradual loss of cognitive functioning and can make activities of daily life much more challenging. The connection between perceived burdensomeness and risk of suicidal desire/behaviors has not been explored among pwMCI/early dementia; it is critical to understand this potential pathway so we can better assess risk among this vulnerable group. Prevention activities may also need to be tailored for pwMCI/early dementia, as it is unclear how they wish to be involved about decisions regarding firearm access, a major risk factor for suicide. To fill these gaps in the literature, we are proposing two achievable aims to develop formative data on the problem and to develop a decision aid to address the problem of suicide risk among pwMCI/early dementia. In Aim 1, we will conduct qualitative interviews of decision-making triads - patients, caregivers/family members, and physicians - to explore decision-making processes among such triads. We will also explore components of the Interpersonal Theory of Suicide to explore how constructs manifest for pwMCI/early dementia. In Aim 2 we will use this data to adapt components of the Ottawa Decision Support Framework into a prototype of a decision aid to address firearm storage tailored to the pwMCI/early dementia. Work from these Aims will form a foundation of evidence for the development of a tool to be implemented in outpatient settings to help prevent firearm suicide among older adults with a diagnosis of MCI/early dementia. The long-term goal of this program of research is to widely implement a decision aid in a network of clinics to make a marked reduction in firearm suicide among older adults, particularly those with cognitive decline.