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Original Investigation
March 24, 2021

Risk of Suicide Attempt in Patients With Recent Diagnosis of Mild Cognitive Impairment or Dementia

Author Affiliations
  • 1Department of Clinical Psychology, Leiden University, Leiden, the Netherlands
  • 2Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
  • 3San Francisco Veterans Affairs Health Care System, San Francisco, California
  • 4Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 5Department of Neurology, University of California, San Francisco
  • 6Northern California Institute for Research and Education, The Veterans Health Research Institute, San Francisco, California
  • 7Department of Medicine, Division of Geriatrics, University of California, San Francisco
JAMA Psychiatry. 2021;78(6):659-666. doi:10.1001/jamapsychiatry.2021.0150
Key Points

Questions  Is the risk of suicide attempt increased in patients diagnosed with mild cognitive impairment (MCI) or dementia, and does the recency of diagnosis matter?

Findings  In this propensity-matched cohort study of 147 595 older adults, the risk of suicide attempt was higher in patients with recently diagnosed MCI and those with recently diagnosed dementia compared with those without MCI or dementia, after adjusting for demographic characteristics and medical and psychiatric comorbidities.

Meaning  The finding of increased risk of suicide attempt in individuals with recent diagnosis of MCI or dementia suggests the importance of supportive services soon after diagnosis.

Abstract

Importance  Little is known about the association between mild cognitive impairment (MCI) and suicide. Most studies have focused on dementia and suicidal behavior, with inconsistent results.

Objectives  To examine the association between diagnoses of MCI and dementia and suicide attempt and explore potential psychiatric moderators and to assess whether the association differs based on recency of diagnosis.

Design, Setting, and Participants  This nationwide cohort study integrated 5 national databases from the Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services and included all VA medical centers in the US. US veterans 50 years or older with MCI diagnoses at baseline (October 1, 2011, to September 30, 2013) or earlier (October 1, 2007, to September 30, 2011) were propensity matched 1:3 with (1) patients with dementia diagnoses and (2) patients without either diagnosis based on demographic characteristics and the Charlson Comorbidity Index. Diagnoses of MCI or dementia were defined as recent if there were no diagnosis codes before baseline. Data were analyzed from March 16, 2020, to January 15, 2021.

Main Outcomes and Measures  Information on suicide attempts through December 31, 2016, provided by the National Suicide Prevention Applications Network (nonfatal) and Mortality Data Repository (fatal).

Results  The study population of 147 595 participants included 21 085 patients with MCI, 63 255 with dementia, and 63 255 in the propensity-matched comparison group. Participants had a mean (SD) age of 74.7 (10.3) years, 143 353 (97.1%) were men, 4242 (2.9%) were women, and 127 065 (86.1%) were non-Hispanic White. A total of 138 patients with MCI (0.7%) and 400 patients with dementia (0.6%) attempted suicide during follow-up, compared with 253 patients without MCI or dementia (0.4%). Exploratory analyses revealed that no psychiatric comorbidity moderated the association between MCI or dementia and suicide attempt. After adjustment for demographic details and medical and psychiatric comorbidities, risk of suicide attempt was consistently highest for patients with a recent MCI or dementia diagnosis, with adjusted hazard ratios (HRs) of 1.73 (95% CI, 1.34-2.22; P < .001) for recent MCI and 1.44 (95% CI, 1.17-1.77; P = .001) for recent dementia. Risk associated with prior diagnosis was not significant (HR for prior MCI, 1.03 [95% CI, 0.78-1.36; P = .84]; HR for prior dementia, 1.14 [95% CI, 0.95-1.36; P = .15]).

Conclusions and Relevance  This study found that older adults with recent MCI or dementia diagnoses were at increased risk of attempting suicide. These findings suggest that involvement of supportive services at the time of or soon after diagnoses of MCI or dementia may help mitigate risk of suicide attempts.

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    1 Comment for this article
    EXPAND ALL
    Risk of suicide attempt in patients with mild cognitive impairment or dementia
    Tomoyuki Kawada, MD | Nippon Medical School
    Günak et al. reported the association between mild cognitive impairment (MCI) and suicide in the elderly (1). The adjusted hazard ratios (95% confidence intervals [CIs]) of recent MCI and recent dementia for suicide attempt were 1.73 (1.34-2.22) and 1.44 (1.17-1.77), respectively. In contrast, prior diagnosis of MCI and dementia were not significantly associated with suicide attempt. The authors concluded that rapid responses after recent MCI or dementia diagnoses were important for preventing suicide attempt. I have some comments about their study.

    First, An et al. reported that old patients with cognitive impairment did not present the risk of death
    by suicide (2), which was in concordance with past reports regarding the risk of suicide and attempted suicide (3,4). The risk of suicide in elderly patients with cognitive impairment or dementia might also be related to some other physical and/or mental comorbidities. Further studies are needed to verify the association.

    Second, Álvarez Muñoz et al. conducted a meta-analysis on the association between dementia in the elderly and the subsequent development of suicide ideation, attempts and/or completed suicides (5). Pooled odds ratio (95% CI) of dementia for suicidal ideation, suicide attempt, and completed suicide were 1.37 (0.78-2.39), 2.24 (1.01-4.97), and 1.28 (0.77-2.14), respectively. They emphasized that attention should be paid to recent diagnosis of dementia and comorbidities, which could influence the occurrence and outcome of suicidal events. In any case, dementia was significantly associated with suicide attempt, not with suicidal ideation nor completed suicide.

    Additionally, Günak et al. reported that the risk of suicide attempt did not increase in patients with dementia, compared with patients with MCI (1). I suspect that risk of suicidal attempt might not only be explained by the progression of cognitive impairment, which should be specified by further studies.


    References
    1. Günak MM, Barnes DE, Yaffe K, Li Y, Byers AL. Risk of suicide attempt in patients with recent diagnosis of mild cognitive impairment or dementia. JAMA Psychiatry 2021 Mar 24. doi: 10.1001/jamapsychiatry.2021.0150
    2. An JH, Lee KE, Jeon HJ, Son SJ, Kim SY, Hong JP. Risk of suicide and accidental deaths among elderly patients with cognitive impairment. Alzheimers Res Ther 2019;11(1):32.
    3. Purandare N, Voshaar RC, Rodway C, Bickley H, Burns A, Kapur N. Suicide in dementia: 9-year national clinical survey in England and Wales. Br J Psychiatry 2009;194(2):175-80.
    4. Wiktorsson S, Runeson B, Skoog I, Ostling S, Waern M. Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. Am J Geriatr Psychiatry 2010;18(1):57-67.
    5. Álvarez Muñoz FJ, Rubio-Aparicio M, Gurillo Muñoz P, García Herrero AM, Sánchez-Meca J, Navarro-Mateu F. Suicide and dementia: Systematic review and meta-analysis. Rev Psiquiatr Salud Ment 2020;13(4):213-227.
    CONFLICT OF INTEREST: None Reported
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