Suicidal ideation in older adults in nursing homes: impact of depression, perceived social support and cognitive impairment

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Suicide increases with age; the rate of death by suicide in people over 70 years of age is twice that of people aged 15-49. Currently 30.96% of the population over 64 years of age have functional limitations and perceived social support decreases significantly at this stage. Exposure to these factors appears to be exacerbated in people living in residential care, yet research remains scarce. We analysed suicidal ideation and associated factors such as depression, perceived social support, cognitive decline and functional limitations in older adults living in nursing homes. Methods. Multicentre study of 126 participants aged over 65 years, mean age is 81.35 years (SD= 9.31) and 65.6% are women. Results. Suicidal ideation was found in 57.1% of the participants. Depression, low social support and the presence of mild cognitive impairment were associated with the presence of suicidal ideation in older people living in nursing homes. Discussion. The results obtained highlight the need to focus the dynamics and interventions in nursing homes on emotional aspects, which can help prevent and even detect suicidal ideation and suicidal behaviour. Introduction In Spain, it is estimated that by 2035, the number of older people will reach 12.8 million, representing 26.5% of the total population. Currently, 30.96% of the population over 64 years of age live with functional limitations and more than 270,000 people receive care in nursing homes (68.6%, women) (National Institute of Statistics, 2021 ). 800,000 are diagnosed with Alzheimer disease (Spanish Society of Neurology-SEN). Cognition impairment have a deep impact on a person's overall health and well-being (social, emotional, physical). Cognitive impairment can range from mild cognitive impairment (MCI) to dementia, a form of impairment of various abilities severe enough to interfere with the performance of activities of daily living. Depression is the most costly mental disorder for public health systems. Depression affects approximately 121 million people worldwide (WHO, 2021). Depression is a risk factor for dementia, and it has high rates of comorbidity with other physical and mental illnesses, and mortality due to suicidal behaviour. Suicidal behaviour disorder is a public health problem worldwide with consequences that extend beyond the personal, family, social and economic dimensions (WHO, 2021). We do not have much data on the prevalence of suicidal ideation (SI) among older adults worldwide. Some researchers speak of a range of 3 to 25% (Kim, 2016 ; Conejero et al., 2018 ; Wei et al., 2018 ; Nie et al., 2020 ; Lu et al., 2020 ) and studies show that prevalence is particularly high among older adults (Shiraly et al., 2022 ). In the context of the multi-causality of suicide, age is a variable that should be highlighted (Chauliac et al., 2020 ). The rate of death by suicide in people over 70 years old is twice that of people aged 15 to 49 years (National Institute of Statistics, 2022). In 2021, Spain registered 999 cases of suicide among people aged over 70 (Spanish Foundation for Suicide Prevention, 2022 ). This situation becomes more complex when we talk about nursing homes, where data is difficult to obtain due to the different behaviours that may be associated with suicidal ideation (Pullen, 2016 ). Some research have found no differences by age (Mezuk et al., 2015 ), and other research has pointed out that suicides in nursing homes are often overlooked and under-reported (Menghini and Evans, 2000 ). SI is a significant predictor of suicidal actions and is considerably more prevalent in nursing homes compared to the general population (Barak and Gale, 2019 ). In this regard, Mezuk et al ( 2014 ), who reviewed a limited number of studies, found that the prevalence of SI in nursing homes ranged from 5–33%. Although SI in nursing homes is a growing international concern (Jain, 2020), research on the dynamics involved remains scarce (Joshaghani et al., 2022 ; Murphy et al., 2018 ). There is a need to increase research in this area in order to develop strategies aimed at suicide prevention. Risk factors for SI are factors that increase or decrease the likelihood that a person will eventually engage in suicidal behaviour, and are divided into biological, psychological, and social markers (Laflamme et al., 2022 ). Health-related stressors include the diagnosis of a mental disorder such as depression or anxiety, deterioration in physical health or a disabling medical condition (Murphy et al., 2018 ) that affects the person's independence or aspects related to cognitive abilities (Valera & Lucerón, 2021 ). A recent diagnosis of cognitive impairment or dementia is associated with an increased risk of completed suicide (Günak et al., 2021 ) and a positive association between biomarkers of Alzheimer's disease and SI has also been demonstrated (Ferrer-Cairols et al., 2022 ). On the other hand, physical limitations in carrying out basic activities of daily living contribute to suicidal behavior in aging (Erlangsen et al., 2020 ). At the psychosocial level, low perceived social support, loneliness, low levels of life satisfaction and hopelessness (Begui et al., 2021) are predictors of SI and tend to be underdiagnosed during this stage of life, as well as being increased in older adults living in nursing homes (Wand et al., 2020 ). This paper has two objectives: 1) to examine the prevalence of suicidal ideation in a sample of older adults living in nursing homes; 2) to analyze the relationship between perceived social support, depression, cognitive impairment and functional limitations, and suicidal ideation in older adults living in nursing homes. Method Participants The sample consisted of 126 older adults living in nursing homes. These are centres that provide long-term care and assistance to older people, usually in a situation of physical or cognitive dependence or in situations of social vulnerability. Where services arelimited and dementia may be almost widespread among older people. Out of 489 residents living in 5 nursing homes, 191 residents were eligible for inclusion in the trial. Of these, 70% were randomized and assessed for the study. In the end, 126 agreed to participate. Inclusion criteria were: being over 65 years of age and having no cognitive impairment according to diagnostic criteria of the Global Deterioration Scale (GDS) (1983), of 1–3 levels. The exclusion criteria for the study were: severe neurological disease, severe intellectual disability or having a significant hearing or visual disability that would make it difficult to complete the questionnaire. Instruments A questionnaire was administered to collect socio-demographic (age, sex, place of birth, educational level, occupation) and cognitive level, functional limitations, depression, perceived social support, suicidal ideation, using the following scales. Minimental State Examination (MMSE) (Folstein et al., 1975 ). The MMSE has been used in its adapted Spanish version (Lobo et al.,1999) which is a screening instrument for the assessment of the cognitive status. The maximum score is 35 points(obtained by adding the scores of each item and the items are grouped into 5 sections that test orientation, immediate memory, attention and calculation, delayed recall, language and construction). The cut-off point for dementia is usually set at 20 points; between 20–24 points, mild cognitive impairment;between 25–35 points indicate no cognitive impairment. The Barthel Index (Mahoney & Barthel, 1965 ). The Barthel Index assesses functional limitations or the level of independence of the person with respect to the performance of some basic activities of daily living (ADLs) such as eating, toileting, dressing or general mobility. It is easy to apply, has a high degree of reliability and validity and is sensitive to short-term changes. The scores range from 0 to 100 and its results categorize four levels of functional dependence in ADLs: 60 points, mild dependence in ADLs; 100 points, independent in ADLs. Geriatric Depression Scale (GDS) (Yesavage et al., 1988). GDS is a self-report instrument that measures the presence of depressive symptomatology by means of direct questions with dichotomous response (yes/no) and only considers cognitive aspects of depression such as pessimistic or disruptive thoughts. For this study we used the reduced version of 15 items [40]. The cut-off point of this scale is 5 points: a score of 5 or below is considered normal; a score of 6–10 points suggests mild depression; and a score of 11–15 points suggests severe depression. The reliability of the scale for the sample was .803 (Cronbach Alpha). Duke-UNK Functional Social Support Questionnaire (Duke-UNK-11 ) (Broadhead et al., 1988 ). This scale measures perceived functional social support. It explores the qualitative or functional aspects of social support by referring to four content areas: quantity of support, confidant support, affective support, and instrumental support items. The scale consists of 11 items scored from 1 ("much less than I want" to 5 "as much as I want", and its cut-off score is 34 points. In this case the reliability was .931 (Cronbach Alpha). Suicidal Ideation Scale (SSI) (Beck et al., 1979 ). The SSI is an instrument that quantifies and assesses the conscious ‘occurrence’ of suicidal thoughts; it weighs several dimensions of self-destructiveness: thoughts or desires. The SSI consists of 19 items. If the score of items (4) "desire to make active suicide attempt" and (5) "passive suicidal desire", is "0", the following sections are omitted and the questionnaire is discontinued, coded as: "Not applicable"; otherwise, it continues to be applied. For its interpretation, the researcher selects, for each item, the level of intensity/seriousness that best reflects the characteristics of the suicidal ideation. Each item is scored from 0–2 and the total score of the scale is the sum of the values assigned to the first 19 items, since items 20 and 21 have only descriptive value and are not taken into account for the total score. The range of the total score is 0–38. A score equal to or greater than 1 is considered to be indicative of suicide risk; higher values increase the risk of suicide. Two dimensions were calculated, following the approach of Beck et al. ( 1997 ): suicidal desire and suicidal active preparation. The reliability was .834 (Cronbach Alpha). Procedure A letter was sent to several nursing homes in Spain asking them to participate in the study. Participants who agreed to take part in the study and who met the inclusion criteria signed an informed consent form and agreed to undergo an assessment interview. The interviews took place in a separate room in the nursing home and were conducted by four psychologists who had been previously trained by the researchers in the application of the scales. The cognitive status (MMSE) and the functional level (BARTHEL) were obtained from the RESIPLUS software (an information management software). This is a computer tool that records the results of scales that the professionals apply to the patients through interviews and that are carried out periodically. The data extracted for the study were registered in the last 3 months. The 126 participants were assessed individually in a 60 minute session. The scales were checked by another psychologist and the data were analyzed anonymously and confidentially. This research had the approval of the ethics committee of the university institution, European University CIPI/23.245. Data Analysis All statistical analyses were performed with the SPSS 28 statistical program, and a significance level of p ≤ 0.05 was taken into account. Descriptive statistics were carried out on the sociodemographic and clinical data of the sample. Pearson correlations were also calculated to examine the relationships between the variables, and different multiple linear regression (MLR) models were calculated to predict the effect of the different independent variables (IV) (depression, perceived social support, and cognitive impairment) on the dependent variable (DV) “suicidal ideation”. Given that DV presents different levels: total suicidal ideation, suicidal desire/thoughts and suicidal active preparation, a model was made for each of them. The predictor variables were selected for each model based on the above correlations. In MLR, significant IVs behave as predictors of DV and the higher the beta value, the greater the predictive capacity of VI over DV. Results Related to sociodemographic variables, a mean age of 81.35 (SD = 9.31) years, 65.6% of the participants were women. In reference to the educational level, 36.3% were no schooling, 27.4% having basic educational level (until 12 years), 21.8% holding intermediate educational level (until 16–18 years) and 14.5% having high educational level (university studies). With regard to the first objective Table 1 shows mean and standard deviation of the variables examined. The results show a prevalence of suicidal ideation of 57.1% and 15.9% were actively preparing for suicide. Table 1 Variables: mean and standard deviation Range Mean Standard Deviation Depression (GDS) 0–15 4.78 3.55 Suicidal ideation, total (SSI) 0–38 2.62 3.77 Suicidal desire/thoughts (SSI) 0–18 2.16 2.930 Active preparation for suicide (SSI) 0–18 .38 1.134 Perceived Social Support (DUKE-UNK) 11–55 25.00 11.29 Functional limitations (BARTHEL) 10–100 68.37 25.80 Cognitive state (MMSE) 20–35 28.27 4.76 In relation to the second objective, to analyze the predictive effect of psychosocial and functional factors that may be associated as protectors against thoughts of suicide in older adults living in nursing homes, as shown in Table 2 , all variables, except the level of functional limitations and cognitive status, showed positive and significant relationships with total suicidal ideation, measured by Pearson correlation coefficient. Suicidal desire was positively related to suicidal active preparation, depression and perceived social support, and negatively related to cognitive level. Finally, suicidal active preparation was positively related to depression. Table 2 Correlations between variables. SII-T SSI-SD SSI-SAP GDS DUKE-UNK BARTHEL SII-T .942** SSI-SAP .687** .416** GDS .536** .581** .206* DUKE-UNK .416** .450** .167 .476** BARTHEL − .037 .-.098 .116 − .208* − .058 MMSE .146 .-220* − .076 − .234** − .242* − .136 Note: SII-T: suicidal ideation, total; SSI-SD: suicidal desire; SSI-SAP: suicidal active preparation; GDS: depression; DUKE-UNK: perceived social support; BARTHEL: functional limitations; MMSE: cognitive state. p < .05, *, ** p < .001 We then estimated an MLR model to predict the effect of depression and perceived social support on the total suicidal ideation variable. Regarding the regression equation (see Table 3 ), both variables were found to be predictors of total suicidal ideation with an R2 = .298 (f(2,117) = 26.218; MCE = 10.1; p < .001), with the level of depression being the variable with the greatest explanatory power. The MLR model was then run. DV was “suicidal desire” dimension, and it was significant. In Table 3 it can be seen that the variables depression and perceived social support were predictors (but not cognitive level) with an R2 = .354 (f(3,116) = 22.697; MCE = 5.627; p < .001). Once again, the depression variable appears to be the most explanatory, in this case, for suicidal ideation. Finally, a simple linear regression model was performed, with the DV in this case being the dimension “active preparation for suicide” and depression was IV. In this case, an R2 = .035 (f(1.120) = 5.334; MCE = 1.270; p = .023) was obtained. Table 3 also shows the standardized coefficients. Depression was not found to predict the presence of active preparation for suicide, but it was a predictor for total suicidal ideation and suicidal desire or suicidal thoughts. Table 3 Standardized coefficients of regression equations. Standardized coefficients DV Beta t Total Suicidal Ideation Depression .423 4.842** Perceived social support .212 2.428* Depression .457 5,386** Suicidal desire/thoughts Perceived social support .215 2.564* Cognitive impairment − .053 − .685 Active preparation for suicide Depression .206 2.310* *<.05; **<.001 Discussion This study shows how some factors such as depression, low social support and the presence of mild cognitive impairment can predict the presence of suicidal ideation in older adults living in nursing homes. With regard to suicide of adults in nursing homes, many studies argue that, although people living in nursing homes tend to have many chronic conditions and varying of functional dependence, they are at lower risk of suicidal behaviour than people living at home, because of the constant supervision of health professionals and the difficult access to dangerous elements (Joshaghani et al., 2022 ). It should be noted, however, that it is important to distinguish suicidal behaviour and attempts from suicidal ideation. In a study with patients with dementia (Chappell et al., 2016 ), the occurrence of suicidal behaviour was found to be lower than that of suicidal ideation. Therefore, the identification of suicidal ideation and related factors, is a necessary first step in the prevention of possible suicidal behaviour. Several studies showing that depression is a common illness among users of senior centers (Camacho-Conde & Galán-López, 2020 ; Simning & Simons, 2017 ). Depression is one of the most common health disorders, especially among older adults (Cho et al., 2021 ). In most cases depression remains undiagnosed or is detected late (Camacho-Conde & Galán-López, 2020 ) due to physical isolation or the development of cognitive disorders such as MCI and Alzheimer’s disease. This can be highlighted as a risk factor when reporting and diagnosing depression in older adults. It is common to find under-diagnosis of emotional disorders in nursing homes because they are not very disruptive to the environment, such as depression or apathy (De Sousa et al., 2020 ), and even more so when depression in older adults can manifest somatically (sleep problems, loss of appetite, fatigue...) (Cui & Fiske, 2022 ). In this study, the depressive symptomatology was a predictor of suicidal ideation. These results are similar to other results like Erlangsen et al. ( 2020 ) and Hernández et al. ( 2021 ) found. Valera and Lucerón ( 2021 ) and Silva and Bocchi ( 2020 ) support the idea that the presence of depression is one of the main factors related to suicide risk. Implementing intervention programs on the emotional states associated with depression is a key objective to reduce the risk of suicide in older people with depression (Kiosses et al., 2017 ). Older adults with depression experience high levels of sadness, anxiety, hopelessness, and guilt, symptoms that can precipitate suicidal ideation and accordingly, suicidal behavior (Conner et al., 2001 ). Some variables, such as social support, can be protective factors for mental health, such as depression (Seddigh et al., 2020 ). However, the social support received by older people living in a nursing home, and older people living at home, as well as the conditions under which they receive care, has always been the subject of consideration and debate among researchers in aging research. Alipour et al. ( 2009 ) demonstrated that social support is lower in nursing homes. However, some studies point to the benefits of living in nursing homes, such as relationships with peers, access to nursing care and health care facilities, and the reduction of loneliness and depression (Atadokht el al., 2015; Unsar et al., 2016 ). This research shows that low perceived social support may be a predictor of suicidal ideation. These results are consistent with other studies in older people show that social support is a protective factor against risk of suicidal behavior (Erlangsen et al., 2020 ) and depression (Kim & Kihl, 2021 ). Related to suicidal desire/thoughts and MCI, people with MCI presented greater suicidal ideation than people without cognitive decline. In this sense, and as indicated by Joshaghani et al. ( 2022 ), unlike people with severe dementia, whose cognitive abilities have declined considerably and thus decreases the ability to carry out a suicidal plan people with MCI, having better cognitive abilities and being aware of the disease, can perform suicide more easily (Moon et al, 2021 ; Cipriani et al., 2013 ). People with MCI or a diagnosis of recent dementia may have preserved disease consciousness, so they may anticipate the progressive cognitive and functional decline that the disease will lead to, fearing loss of autonomy and worrying about becoming a burden to family members (Günak et al., 2021 ). Impairment may play a key role in one of the current and most supported theories of suicide, the interpersonal-psychological theory of suicide (Van Orden et al., 2010 ). Among his factors, perceived burden, that contributes to suicidal ideation, is conceptualized as self-hatred and the belief that one's death is worth more to others than one's life. In this sense, older people may experience a perception of burden when there are physical illnesses, health problems and impaired functioning, such as mild cognitive impairment due to dementia (Beach et al., 2020). Therefore, it is necessary to carry out interventions to prevent or reduce suicidal desire/thoughts in MCI people which often tends to be neglected. Encouraging social stimulation of people with MCI, so as to decrease the social isolation they may present (Rodrigo-Claverol et al., 2020 ), may be an appropriate strategy to prevent suicide risk (Erlangsen et al., 2020 ). In addition, these findings may be related to the difficulties presented by people with MCI in communicating and relating to people in the environment (Rodrigo-Claverol et al., 2020 ). Cognitive decline in general and in executive control in particular make it difficult for people with MCI to implement strategies to manage, regulate and/or verbalize their distress or emotions (Kiosses et al., 2017 ; Richard-Devantoy et al., 2015 ). Regarding functional level, most of the participants (78.4%) have limited funcionality (moderate to severe level). Level of functional limitations not predicted suicide ideation. These results contrast with those obtained by other studies, which indicate that functional limitations can affect the emotional health, as well as being an indicator of their poor quality of life (Altieri et al., 2021 ) and a factor for suicide (Valera & Lucerón, 2021 ). Together with cognitive decline, limitation in activities of daily living is associated with a higher probability of admission to residential facilities (Toot et al., 2017 ). In this sense, in nursing homes there are support products in the environment that could compensate for dependence, making the person maintain maximum autonomy, for example, by having people to provide support in the tasks of daily living or making adaptations of space and environment. Cieza et al. ( 2018 ), indicate that nursing homes should be designed to promote personal assistance, build welcoming, accessible and appropriate environments that promote the autonomy of people. In conclusion, if the participants -despite the functional limitations they have-, have support from the environment, it is possible that the risk of suicidal ideation is reduced, as their quality of life increases. The results obtained highlight the need to focus the dynamics and interventions in nursing homes on psychological aspects, emotional and social care, and coping, acceptance of the diagnosis of the disease to prevent possible future suicidal behaviors (Gaugler et al., 2007 ; Joshaghani et al., 2022 ). Likewise, training of residential care professionals is necessary so that they can be trained in the detection and intervention of suicidal ideation and suicidal behavior (Holm et al., 2021 ). This work has limitations that shoud be taken into account in future research. One of the limitations of the study is the non-normal nature of the variables, especially the variable related to suicide. This fact is common in studies on suicide (Beck et al., 1997 ) where the variables usually have positive asymmetric and leptocurtic behaviour. Nevertheless, we consider the sample sufficient to use parametric tests or robust tests such as the MLR, taking into account the difficulty of access to this type of residential sample. Regarding the evaluation of the variables, it would have been interesting to analyse a larger number of variables such as loneliness, apathy or hopelessness and to have a bigger number of participants so that the results would have greater statistical power and allow better analyses. Declarations ETHICS STATEMENT The study was approved by the University of Valencia Ethics Committee (CIPI/23.245) and was conducted in accordance with the tenets of the Declaration of Helsinki. CONSENT TO PARTICIPATE Written informed consent was obtained from all participants or, if they were incompetent, from legal representatives. FUNDING. This work was supported by the Ministry of Innovation and Research under grant number PID2022-139404OA-I00. Author Contribution Rita Redondo, Conceptualization, Formal Analysis, Writing – original draft; Carolina Pinazo-Clapés Data curation, Investigation, resources; Carmen Lizandra García, Data curation, Investigation; Sacramento Pinazo-Hernandis Conceptualization, Supervision, Writing – review & editing; Teresa Mayordomo, Formal Analysis, Methodology, Writing – original draft; Alicia Sales, Conceptualization, Methodology, Writing – original draft. Acknowledgement We would like to thank a nursing homes, for their cooperation in carrying out this study and all older people for their participation in the survey. This work was supported by the Ministry of Innovation and Research under grant number PID2022-139404OA-I00. Data Availability Datasets generated and/or analysed during this study are available on request from the corresponding author. 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Suicide prevention strategies for older persons. An integrative review of empirical and theoretical papers. Nursing open, 8 (5), 2175-2193. https://doi.org/10.1002/nop2.789. Jain, B., Kennedy, B., Bugeja, L. C., Ibrahim, J. E. (2020). Suicide among nursing home residents: Development of recommendations for prevention using a nominal group technique. Journal of Aging & Social Policy, 32 (2), 157-171. https://doi.org/10.1080/08959420.2019.1652079. Joshaghani, N., Villa, N., Badla, O., Goit, R., Saddik, S. E., Dawood, S. N., Niaj, A. (2022). How residing in a long-term care facility affects suicidal risk in patients with dementia: A systematic review. Cureo, 14 (8), 23-38. https://doi.org/10.7759/cureus.27858. Kim, B. J., Kihl, T. (2021). Suicidal ideation associated with depression and social support: A survey-based analysis of older adults in South Korea. BMC Psychiatry , 21 (1), 1-9. https://doi.org/10.1186/s12888-021-03423-8. Kim, S. (2016). Suicidal ideation and suicide attempts in older adults: Influences of chronic illness, functional limitations, and pain. Geriatric Nursing , 37(1), 9-12. https://doi.org/10.1016/j.gerinurse.2015.07.006 Kiosses, D. N., Gross, J. J., Banerjee, S., Duberstein, P. R., Putrino, D., Alexopoulos, G. S. (2017). Negative emotions and suicidal ideation during psychosocial treatments in older adults with major depression and cognitive impairment. The American Journal of Geriatric Psychiatry , 25 (6), 620-629. https://doi.org/10.1016/j.jagp.2017.01.011. Laflamme, L., Vaez, M., Lundin, K., Sengoelge, M. (2022). Prevention of suicidal behavior in older people: a systematic review of reviews. PloS One , 17 (1), e0262889. https://doi.org/10.1371/journal.pone.0262889 Lobo, A., Saz, P., Marcos, G., Día, J. L., de la Cámara, C., Ventura, T., Morales, F., Pascual, L. F., Montañés, J.A., Aznar, S. Lacámara, C. (1999). Revalidation and standardization of the Mini-Cognitive Examination (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population.. Psychiatry, 112 (20), 767-774. Lu, L, Xu, L, Luan, X, Sun, L, Li, J, Qin, W, et al. (2020). Gender difference in suicidal ideation and related factors among rural elderly: a cross-sectional study in Shandong, China. Ann General Psychiatry, 19: 2. https://doi.org/10.1186/s12991-019-0256-0 Mahoney, F. I., Barthel, D. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal,14 , 56-61. Menghini VV, Evans JM. (2000). Suicide among nursing home residents: a population based study. J Am Med Dir Assoc 1 (2): 47–50. Mezuk, B., Lohman, M., Leslie, M., Powell, V. (2015). Suicide risk in nursing homes and assisted living facilities: 2003–2011. American Journal of Public Health, 105 (7), 1495-1502. https://doi.org/10.2105/AJPH.2015.302573 Mezuk, B., Rock, A., Lohman, M. C., Choi, M. (2014). Suicide risk in long‐term care facilities: A systematic review. International Journal of Geriatric Psychiatry, 29 (12), 1198-1211. https://doi.org/10.1002/gps.4142 Moon, S., Choi, M., Sohn, M. (2021). Suicide among older adults with dementia: effects of Korea's long-term care insurance system. International Journal of Environmental Research & Public Health, 18 (12), 65-82. https://doi.org/10.3390/ijerph18126582. Murphy, B. J., Bugeja, L. C., Pilgrim, J. L., Ibrahim, J. E. (2018). Suicide among nursing home residents in Australia: A national population‐based retrospective analysis of medico‐legal death investigation information. International Journal of Geriatric Psychiatry, 33 (5), 786-796. https://doi.org/10.1002/gps.4862. National Institute of Statistics (2021). Dependency rate of the population over 64 years of age. National Institute of Statistics National Institute of Statistics (2023). Population Structure Indicators. National Institute of Statistics. Nie, Y., Hu, Z., Zhu, T., Xu, H. (2020). A cross-sectional study of the prevalence of and risk factors for suicidal ideation among the elderly in nursing homes in Hunan Province, China. Front Psychiatry , 11, 339. https://doi.org/10.3389/fpsyt.2020.00339 Pullen, J. (2016). A Quality Improvement Project with the Aim of Improving Suicide Prevention in Long-Term Care. Annals of Long-Term Care, 6, 24-30 . Reisberg, B., Ferri, S.H., de Leon, M.J., Crook, T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am. J. Psychiatry 1982, 139, 1136–1139 Richard-Devantoy, S., Berlim, M. T., Jollant, F. (2015). Suicidal behaviour and memory: A systematic review and meta-analysis. The World Journal of Biological Psychiatry, 16 (8), 544-566. https://doi.org/10.3109/15622975.2014.925584. Rodrigo-Claverol, M., Malla-Clua, B., Marquilles-Bonet, C., Sol, J., Jové-Naval, J., Sole-Pujol, M., Ortega-Bravo, M. (2020). Animal-assisted therapy improves communication and mobility among institutionalized people with cognitive impairment. International Journal of Environmental Research and Public Health , 17 (16), 58-69. https://doi.org/10.3390/ijerph17165899. Seddigh, M., Hazrati, M., Jokar, M., Mansouri, A., Bazrafshan, M. R., Rasti, M., Kavi, E. (2020). A comparative study of perceived social support and depression among elderly members of senior day centers, elderly residents in nursing homes, and elderly living at home. Iranian Journal of Nursing and Midwifery Research, 25 (2), 160-165. https://doi.org/10.4103/ijnmr.IJNMR_109_18 Shiraly R, Mahdaviazad H, Zohrabi R, Griffiths MD. (2022). Suicidal ideation and its related factors among older adults: a population-based study in Southwestern Iran. BMC Geriatrics, 22(1): 371. https://doi.org/10.1186/s12877-022-03049-9 Silva, S. P. Z., Bocchi, S. C. M. (2020). Measuring suicide risk in the elderly with non-institutionalized depression: an integrative review. Revista Brasileira de Enfermagem, 73 (suppl 3), e20200106. https://doi.org/10.1590/0034-7167-2020-0106. Simning, A., Simons, K. V. (2017). Treatment of depression in nursing home residents without significant cognitive impairment: a systematic review. International psychogeriatrics , 29 (2), 209-226. https://doi.org/10.1017/S1041610216001733. Spanish Foundation for Suicide Prevention (2022). Suicides Spain 2021 . Spain: Suicide Observatory in Spain. Toot, S., Swinson, T., Devine, M., Challis, D., Orrell, M. (2017). Causes of nursing home placement for older people with dementia: a systematic review and meta-analysis. International Psychogeriatric, 29 , 195-208. https://doi.org/10.1017/S1041610216001654. Unsar, S., Erol, O., Sut, N. (2016). Social support and qualıty of life among older adults. International Journal of Caring Sciences , 9 (1), 249-257. Valera, J., & Lucerón, M. I. (2021). Suicide related factors in the elderly: a systematic review. Revista española de salud pública , 95 , e202110166. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., Joiner Jr, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117 (2), 575-600. https://doi.org/10.1037/a0018697 Wand, A. P. F., Zhong, B. L., Chiu, H. F. K., Draper, B., De Leo, D. (2020). COVID-19: the implications for suicide in older adults. International Psychogeriatrics , 32 (10), 1225-1230. https://doi.org/10.1017/S1041610220000770. Wei, J, Zhang, J, Deng, Y, Sun, L, Guo, P. (2018). Suicidal ideation among the Chinese elderly and its correlates: a comparison between the rural and urban populations. International Journal Environment Research Public Health., 15(3): 422-. https://doi.org/10.3390/ijerph15030422 World Health Organization (2021). Suicide worldwide in 2019. World Health Organization. Yesavage, J. A. (1988). Geriatric Depression scales. Psychopharmacol Bull, 24, 70-89. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5453374","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":380949656,"identity":"0e6da32d-9d9e-4c4f-bb9e-dd9737fd84cc","order_by":0,"name":"Rita Redondo","email":"","orcid":"","institution":"European University of Valencia","correspondingAuthor":false,"prefix":"","firstName":"Rita","middleName":"","lastName":"Redondo","suffix":""},{"id":380949659,"identity":"e0c4b49d-01d5-4a43-9079-b2ea39da1649","order_by":1,"name":"Carolina Pinazo-Clapés","email":"","orcid":"","institution":"European University of Valencia","correspondingAuthor":false,"prefix":"","firstName":"Carolina","middleName":"","lastName":"Pinazo-Clapés","suffix":""},{"id":380949660,"identity":"e4436a8a-400f-4c9c-99e5-4463de76a064","order_by":2,"name":"Carmen Lizandra García","email":"","orcid":"","institution":"European University of Valencia","correspondingAuthor":false,"prefix":"","firstName":"Carmen","middleName":"Lizandra","lastName":"García","suffix":""},{"id":380949661,"identity":"0f07619d-2eb6-4c96-b0bb-a675d8e116b2","order_by":3,"name":"Sacramento Pinazo-Hernandis","email":"","orcid":"","institution":"University of Valencia","correspondingAuthor":false,"prefix":"","firstName":"Sacramento","middleName":"","lastName":"Pinazo-Hernandis","suffix":""},{"id":380949662,"identity":"4fc638e2-e532-4174-8b7a-def131f7f7e5","order_by":4,"name":"Irene Checa","email":"","orcid":"","institution":"University of Valencia","correspondingAuthor":false,"prefix":"","firstName":"Irene","middleName":"","lastName":"Checa","suffix":""},{"id":380949665,"identity":"60730655-5070-44a7-bf4d-2140115042b5","order_by":5,"name":"Teresa Mayordomo","email":"","orcid":"","institution":"Valencia Catholic University Saint Vincent Martyr","correspondingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Mayordomo","suffix":""},{"id":380949667,"identity":"88861121-e2d1-4c51-b72b-16b3ccb55de5","order_by":6,"name":"Alicia Sales","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIie3RoQoCMQDG8W8MZhms7hB8hkuCcLJX2RWb1WQ4GcwiWq/5CvoGwsBrWo2KL3ByICbxULFu0bB/2RZ+8MGAWOwPYx1SQAMKnfZVhxBBPyQvKEDKEJKYz6nREspDSOrorD5PoYWhrhlaByF2PkKM1Hso6dioO25JUmovsdAMpHC8T8d2hPTkGabe5AmydqJpBi1RR/8wi9yCbBxHl9gMKfzDjMyXMt861k8Wh4zLk49U88vtcc9UrzLX+jGRPbHyDPsmf7egr4nFYrGYpxfMNz2pzIWNGgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Valencia","correspondingAuthor":true,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Sales","suffix":""}],"badges":[],"createdAt":"2024-11-14 11:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5453374/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5453374/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96604705,"identity":"69eeb1cc-1090-459f-a1c9-2bcd1212ef42","added_by":"auto","created_at":"2025-11-24 09:14:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":573156,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5453374/v1/062020a8-ebce-424d-9d50-54d8d7d08a24.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSuicidal ideation in older adults in nursing homes: impact of depression, perceived social support and cognitive impairment\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn Spain, it is estimated that by 2035, the number of older people will reach 12.8\u0026nbsp;million, representing 26.5% of the total population. Currently, 30.96% of the population over 64 years of age live with functional limitations and more than 270,000 people receive care in nursing homes (68.6%, women) (National Institute of Statistics, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). 800,000 are diagnosed with Alzheimer disease (Spanish Society of Neurology-SEN). Cognition impairment have a deep impact on a person's overall health and well-being (social, emotional, physical). Cognitive impairment can range from mild cognitive impairment (MCI) to dementia, a form of impairment of various abilities severe enough to interfere with the performance of activities of daily living.\u003c/p\u003e \u003cp\u003eDepression is the most costly mental disorder for public health systems. Depression affects approximately 121\u0026nbsp;million people worldwide (WHO, 2021). Depression is a risk factor for dementia, and it has high rates of comorbidity with other physical and mental illnesses, and mortality due to suicidal behaviour.\u003c/p\u003e \u003cp\u003eSuicidal behaviour disorder is a public health problem worldwide with consequences that extend beyond the personal, family, social and economic dimensions (WHO, 2021). We do not have much data on the prevalence of suicidal ideation (SI) among older adults worldwide. Some researchers speak of a range of 3 to 25% (Kim, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Conejero et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Wei et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Nie et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Lu et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and studies show that prevalence is particularly high among older adults (Shiraly et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the context of the multi-causality of suicide, age is a variable that should be highlighted (Chauliac et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The rate of death by suicide in people over 70 years old is twice that of people aged 15 to 49 years (National Institute of Statistics, 2022). In 2021, Spain registered 999 cases of suicide among people aged over 70 (Spanish Foundation for Suicide Prevention, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This situation becomes more complex when we talk about nursing homes, where data is difficult to obtain due to the different behaviours that may be associated with suicidal ideation (Pullen, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome research have found no differences by age (Mezuk et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), and other research has pointed out that suicides in nursing homes are often overlooked and under-reported (Menghini and Evans, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). SI is a significant predictor of suicidal actions and is considerably more prevalent in nursing homes compared to the general population (Barak and Gale, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In this regard, Mezuk et al (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), who reviewed a limited number of studies, found that the prevalence of SI in nursing homes ranged from 5\u0026ndash;33%.\u003c/p\u003e \u003cp\u003eAlthough SI in nursing homes is a growing international concern (Jain, 2020), research on the dynamics involved remains scarce (Joshaghani et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Murphy et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). There is a need to increase research in this area in order to develop strategies aimed at suicide prevention. Risk factors for SI are factors that increase or decrease the likelihood that a person will eventually engage in suicidal behaviour, and are divided into biological, psychological, and social markers (Laflamme et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth-related stressors include the diagnosis of a mental disorder such as depression or anxiety, deterioration in physical health or a disabling medical condition (Murphy et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) that affects the person's independence or aspects related to cognitive abilities (Valera \u0026amp; Lucer\u0026oacute;n, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A recent diagnosis of cognitive impairment or dementia is associated with an increased risk of completed suicide (G\u0026uuml;nak et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and a positive association between biomarkers of Alzheimer's disease and SI has also been demonstrated (Ferrer-Cairols et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). On the other hand, physical limitations in carrying out basic activities of daily living contribute to suicidal behavior in aging (Erlangsen et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). At the psychosocial level, low perceived social support, loneliness, low levels of life satisfaction and hopelessness (Begui et al., 2021) are predictors of SI and tend to be underdiagnosed during this stage of life, as well as being increased in older adults living in nursing homes (Wand et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis paper has two objectives: 1) to examine the prevalence of suicidal ideation in a sample of older adults living in nursing homes; 2) to analyze the relationship between perceived social support, depression, cognitive impairment and functional limitations, and suicidal ideation in older adults living in nursing homes.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe sample consisted of 126 older adults living in nursing homes. These are centres that provide long-term care and assistance to older people, usually in a situation of physical or cognitive dependence or in situations of social vulnerability. Where services arelimited and dementia may be almost widespread among older people. Out of 489 residents living in 5 nursing homes, 191 residents were eligible for inclusion in the trial. Of these, 70% were randomized and assessed for the study. In the end, 126 agreed to participate. Inclusion criteria were: being over 65 years of age and having no cognitive impairment according to diagnostic criteria of the Global Deterioration Scale (GDS) (1983), of 1\u0026ndash;3 levels. The exclusion criteria for the study were: severe neurological disease, severe intellectual disability or having a significant hearing or visual disability that would make it difficult to complete the questionnaire.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003eA questionnaire was administered to collect socio-demographic (age, sex, place of birth, educational level, occupation) and cognitive level, functional limitations, depression, perceived social support, suicidal ideation, using the following scales.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMinimental State Examination (MMSE)\u003c/em\u003e (Folstein et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1975\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe MMSE has been used in its adapted Spanish version (Lobo et al.,1999) which is a screening instrument for the assessment of the cognitive status. The maximum score is 35 points(obtained by adding the scores of each item and the items are grouped into 5 sections that test orientation, immediate memory, attention and calculation, delayed recall, language and construction). The cut-off point for dementia is usually set at 20 points; between 20\u0026ndash;24 points, mild cognitive impairment;between 25\u0026ndash;35 points indicate no cognitive impairment.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe Barthel Index\u003c/em\u003e (Mahoney \u0026amp; Barthel, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1965\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Barthel Index assesses functional limitations or the level of independence of the person with respect to the performance of some basic activities of daily living (ADLs) such as eating, toileting, dressing or general mobility. It is easy to apply, has a high degree of reliability and validity and is sensitive to short-term changes. The scores range from 0 to 100 and its results categorize four levels of functional dependence in ADLs: \u0026lt;20 points, total dependence in ADLs; 20\u0026ndash;35 points, severe dependence in ADLs; 40\u0026ndash;55 points, moderate dependence in ADLs; \u0026gt;60 points, mild dependence in ADLs; 100 points, independent in ADLs.\u003c/p\u003e \u003cp\u003e \u003cem\u003eGeriatric Depression Scale (GDS) (Yesavage et al., 1988).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eGDS is a self-report instrument that measures the presence of depressive symptomatology by means of direct questions with dichotomous response (yes/no) and only considers cognitive aspects of depression such as pessimistic or disruptive thoughts. For this study we used the reduced version of 15 items [40]. The cut-off point of this scale is 5 points: a score of 5 or below is considered normal; a score of 6\u0026ndash;10 points suggests mild depression; and a score of 11\u0026ndash;15 points suggests severe depression. The reliability of the scale for the sample was .803 (Cronbach Alpha).\u003c/p\u003e \u003cp\u003e \u003cem\u003eDuke-UNK Functional Social Support Questionnaire (Duke-UNK-11\u003c/em\u003e) (Broadhead et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1988\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis scale measures perceived functional social support. It explores the qualitative or functional aspects of social support by referring to four content areas: quantity of support, confidant support, affective support, and instrumental support items. The scale consists of 11 items scored from 1 (\"much less than I want\" to 5 \"as much as I want\", and its cut-off score is 34 points. In this case the reliability was .931 (Cronbach Alpha).\u003c/p\u003e \u003cp\u003e \u003cem\u003eSuicidal Ideation Scale (SSI)\u003c/em\u003e (Beck et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1979\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe SSI is an instrument that quantifies and assesses the conscious \u0026lsquo;occurrence\u0026rsquo; of suicidal thoughts; it weighs several dimensions of self-destructiveness: thoughts or desires. The SSI consists of 19 items. If the score of items (4) \"desire to make active suicide attempt\" and (5) \"passive suicidal desire\", is \"0\", the following sections are omitted and the questionnaire is discontinued, coded as: \"Not applicable\"; otherwise, it continues to be applied. For its interpretation, the researcher selects, for each item, the level of intensity/seriousness that best reflects the characteristics of the suicidal ideation. Each item is scored from 0\u0026ndash;2 and the total score of the scale is the sum of the values assigned to the first 19 items, since items 20 and 21 have only descriptive value and are not taken into account for the total score. The range of the total score is 0\u0026ndash;38. A score equal to or greater than 1 is considered to be indicative of suicide risk; higher values increase the risk of suicide. Two dimensions were calculated, following the approach of Beck et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1997\u003c/span\u003e): suicidal desire and suicidal active preparation. The reliability was .834 (Cronbach Alpha).\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eA letter was sent to several nursing homes in Spain asking them to participate in the study. Participants who agreed to take part in the study and who met the inclusion criteria signed an informed consent form and agreed to undergo an assessment interview. The interviews took place in a separate room in the nursing home and were conducted by four psychologists who had been previously trained by the researchers in the application of the scales. The cognitive status (MMSE) and the functional level (BARTHEL) were obtained from the RESIPLUS software (an information management software). This is a computer tool that records the results of scales that the professionals apply to the patients through interviews and that are carried out periodically. The data extracted for the study were registered in the last 3 months.\u003c/p\u003e \u003cp\u003eThe 126 participants were assessed individually in a 60 minute session. The scales were checked by another psychologist and the data were analyzed anonymously and confidentially. This research had the approval of the ethics committee of the university institution, European University CIPI/23.245.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed with the SPSS 28 statistical program, and a significance level of p\u0026thinsp;\u0026le;\u0026thinsp;0.05 was taken into account.\u003c/p\u003e \u003cp\u003eDescriptive statistics were carried out on the sociodemographic and clinical data of the sample. Pearson correlations were also calculated to examine the relationships between the variables, and different multiple linear regression (MLR) models were calculated to predict the effect of the different independent variables (IV) (depression, perceived social support, and cognitive impairment) on the dependent variable (DV) \u0026ldquo;suicidal ideation\u0026rdquo;.\u003c/p\u003e \u003cp\u003eGiven that DV presents different levels: total suicidal ideation, suicidal desire/thoughts and suicidal active preparation, a model was made for each of them. The predictor variables were selected for each model based on the above correlations. In MLR, significant IVs behave as predictors of DV and the higher the beta value, the greater the predictive capacity of VI over DV.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eRelated to sociodemographic variables, a mean age of 81.35 (SD\u0026thinsp;=\u0026thinsp;9.31) years, 65.6% of the participants were women. In reference to the educational level, 36.3% were no schooling, 27.4% having basic educational level (until 12 years), 21.8% holding intermediate educational level (until 16\u0026ndash;18 years) and 14.5% having high educational level (university studies).\u003c/p\u003e \u003cp\u003eWith regard to the first objective Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows mean and standard deviation of the variables examined. The results show a prevalence of suicidal ideation of 57.1% and 15.9% were actively preparing for suicide.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eVariables: mean and standard deviation\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression (GDS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuicidal ideation, total (SSI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuicidal desire/thoughts (SSI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.930\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive preparation for suicide (SSI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived Social Support (DUKE-UNK)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional limitations (BARTHEL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive state (MMSE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn relation to the second objective, to analyze the predictive effect of psychosocial and functional factors that may be associated as protectors against thoughts of suicide in older adults living in nursing homes, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, all variables, except the level of functional limitations and cognitive status, showed positive and significant relationships with total suicidal ideation, measured by Pearson correlation coefficient. Suicidal desire was positively related to suicidal active preparation, depression and perceived social support, and negatively related to cognitive level. Finally, suicidal active preparation was positively related to depression.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCorrelations between variables.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSII-T\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSSI-SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSSI-SAP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGDS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDUKE-UNK\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBARTHEL\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSII-T\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.942**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSI-SAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.687**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.416**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.536**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.581**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.206*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDUKE-UNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.416**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.450**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.476**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBARTHEL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.-.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.208*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.-220*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.234**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.242*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: SII-T: suicidal ideation, total; SSI-SD: suicidal desire; SSI-SAP: suicidal active preparation; GDS: depression; DUKE-UNK: perceived social support; BARTHEL: functional limitations; MMSE: cognitive state. p\u0026thinsp;\u0026lt;\u0026thinsp;.05, *, ** p\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe then estimated an MLR model to predict the effect of depression and perceived social support on the total suicidal ideation variable. Regarding the regression equation (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), both variables were found to be predictors of total suicidal ideation with an R2\u0026thinsp;=\u0026thinsp;.298 (f(2,117)\u0026thinsp;=\u0026thinsp;26.218; MCE\u0026thinsp;=\u0026thinsp;10.1; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), with the level of depression being the variable with the greatest explanatory power.\u003c/p\u003e \u003cp\u003eThe MLR model was then run. DV was \u0026ldquo;suicidal desire\u0026rdquo; dimension, and it was significant. In Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e it can be seen that the variables depression and perceived social support were predictors (but not cognitive level) with an R2\u0026thinsp;=\u0026thinsp;.354 (f(3,116)\u0026thinsp;=\u0026thinsp;22.697; MCE\u0026thinsp;=\u0026thinsp;5.627; p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Once again, the depression variable appears to be the most explanatory, in this case, for suicidal ideation.\u003c/p\u003e \u003cp\u003eFinally, a simple linear regression model was performed, with the DV in this case being the dimension \u0026ldquo;active preparation for suicide\u0026rdquo; and depression was IV. In this case, an R2\u0026thinsp;=\u0026thinsp;.035 (f(1.120)\u0026thinsp;=\u0026thinsp;5.334; MCE\u0026thinsp;=\u0026thinsp;1.270; p\u0026thinsp;=\u0026thinsp;.023) was obtained. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e also shows the standardized coefficients. Depression was not found to predict the presence of active preparation for suicide, but it was a predictor for total suicidal ideation and suicidal desire or suicidal thoughts.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eStandardized coefficients of regression equations.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eStandardized coefficients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTotal Suicidal Ideation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.423\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.842**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.428*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,386**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSuicidal desire/thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.564*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive preparation for suicide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.310*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003e*\u003c.05; **\u003c.001\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study shows how some factors such as depression, low social support and the presence of mild cognitive impairment can predict the presence of suicidal ideation in older adults living in nursing homes.\u003c/p\u003e \u003cp\u003eWith regard to suicide of adults in nursing homes, many studies argue that, although people living in nursing homes tend to have many chronic conditions and varying of functional dependence, they are at lower risk of suicidal behaviour than people living at home, because of the constant supervision of health professionals and the difficult access to dangerous elements (Joshaghani et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). It should be noted, however, that it is important to distinguish suicidal behaviour and attempts from suicidal ideation. In a study with patients with dementia (Chappell et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), the occurrence of suicidal behaviour was found to be lower than that of suicidal ideation. Therefore, the identification of suicidal ideation and related factors, is a necessary first step in the prevention of possible suicidal behaviour.\u003c/p\u003e \u003cp\u003eSeveral studies showing that depression is a common illness among users of senior centers (Camacho-Conde \u0026amp; Gal\u0026aacute;n-L\u0026oacute;pez, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Simning \u0026amp; Simons, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Depression is one of the most common health disorders, especially among older adults (Cho et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In most cases depression remains undiagnosed or is detected late (Camacho-Conde \u0026amp; Gal\u0026aacute;n-L\u0026oacute;pez, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) due to physical isolation or the development of cognitive disorders such as MCI and Alzheimer\u0026rsquo;s disease. This can be highlighted as a risk factor when reporting and diagnosing depression in older adults. It is common to find under-diagnosis of emotional disorders in nursing homes because they are not very disruptive to the environment, such as depression or apathy (De Sousa et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and even more so when depression in older adults can manifest somatically (sleep problems, loss of appetite, fatigue...) (Cui \u0026amp; Fiske, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the depressive symptomatology was a predictor of suicidal ideation. These results are similar to other results like Erlangsen et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Hern\u0026aacute;ndez et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) found. Valera and Lucer\u0026oacute;n (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and Silva and Bocchi (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) support the idea that the presence of depression is one of the main factors related to suicide risk. Implementing intervention programs on the emotional states associated with depression is a key objective to reduce the risk of suicide in older people with depression (Kiosses et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Older adults with depression experience high levels of sadness, anxiety, hopelessness, and guilt, symptoms that can precipitate suicidal ideation and accordingly, suicidal behavior (Conner et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome variables, such as social support, can be protective factors for mental health, such as depression (Seddigh et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, the social support received by older people living in a nursing home, and older people living at home, as well as the conditions under which they receive care, has always been the subject of consideration and debate among researchers in aging research. Alipour et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) demonstrated that social support is lower in nursing homes. However, some studies point to the benefits of living in nursing homes, such as relationships with peers, access to nursing care and health care facilities, and the reduction of loneliness and depression (Atadokht el al., 2015; Unsar et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis research shows that low perceived social support may be a predictor of suicidal ideation. These results are consistent with other studies in older people show that social support is a protective factor against risk of suicidal behavior (Erlangsen et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and depression (Kim \u0026amp; Kihl, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRelated to suicidal desire/thoughts and MCI, people with MCI presented greater suicidal ideation than people without cognitive decline. In this sense, and as indicated by Joshaghani et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), unlike people with severe dementia, whose cognitive abilities have declined considerably and thus decreases the ability to carry out a suicidal plan people with MCI, having better cognitive abilities and being aware of the disease, can perform suicide more easily (Moon et al, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Cipriani et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). People with MCI or a diagnosis of recent dementia may have preserved disease consciousness, so they may anticipate the progressive cognitive and functional decline that the disease will lead to, fearing loss of autonomy and worrying about becoming a burden to family members (G\u0026uuml;nak et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Impairment may play a key role in one of the current and most supported theories of suicide, the interpersonal-psychological theory of suicide (Van Orden et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Among his factors, perceived burden, that contributes to suicidal ideation, is conceptualized as self-hatred and the belief that one's death is worth more to others than one's life. In this sense, older people may experience a perception of burden when there are physical illnesses, health problems and impaired functioning, such as mild cognitive impairment due to dementia (Beach et al., 2020).\u003c/p\u003e \u003cp\u003eTherefore, it is necessary to carry out interventions to prevent or reduce suicidal desire/thoughts in MCI people which often tends to be neglected. Encouraging social stimulation of people with MCI, so as to decrease the social isolation they may present (Rodrigo-Claverol et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), may be an appropriate strategy to prevent suicide risk (Erlangsen et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, these findings may be related to the difficulties presented by people with MCI in communicating and relating to people in the environment (Rodrigo-Claverol et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Cognitive decline in general and in executive control in particular make it difficult for people with MCI to implement strategies to manage, regulate and/or verbalize their distress or emotions (Kiosses et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Richard-Devantoy et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding functional level, most of the participants (78.4%) have limited funcionality (moderate to severe level). Level of functional limitations not predicted suicide ideation. These results contrast with those obtained by other studies, which indicate that functional limitations can affect the emotional health, as well as being an indicator of their poor quality of life (Altieri et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and a factor for suicide (Valera \u0026amp; Lucer\u0026oacute;n, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Together with cognitive decline, limitation in activities of daily living is associated with a higher probability of admission to residential facilities (Toot et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In this sense, in nursing homes there are support products in the environment that could compensate for dependence, making the person maintain maximum autonomy, for example, by having people to provide support in the tasks of daily living or making adaptations of space and environment. Cieza et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), indicate that nursing homes should be designed to promote personal assistance, build welcoming, accessible and appropriate environments that promote the autonomy of people. In conclusion, if the participants -despite the functional limitations they have-, have support from the environment, it is possible that the risk of suicidal ideation is reduced, as their quality of life increases.\u003c/p\u003e \u003cp\u003eThe results obtained highlight the need to focus the dynamics and interventions in nursing homes on psychological aspects, emotional and social care, and coping, acceptance of the diagnosis of the disease to prevent possible future suicidal behaviors (Gaugler et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Joshaghani et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Likewise, training of residential care professionals is necessary so that they can be trained in the detection and intervention of suicidal ideation and suicidal behavior (Holm et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis work has limitations that shoud be taken into account in future research. One of the limitations of the study is the non-normal nature of the variables, especially the variable related to suicide. This fact is common in studies on suicide (Beck et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) where the variables usually have positive asymmetric and leptocurtic behaviour. Nevertheless, we consider the sample sufficient to use parametric tests or robust tests such as the MLR, taking into account the difficulty of access to this type of residential sample.\u003c/p\u003e \u003cp\u003eRegarding the evaluation of the variables, it would have been interesting to analyse a larger number of variables such as loneliness, apathy or hopelessness and to have a bigger number of participants so that the results would have greater statistical power and allow better analyses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eETHICS STATEMENT\u003c/h2\u003e \u003cp\u003e The study was approved by the University of Valencia Ethics Committee (CIPI/23.245) and was conducted in accordance with the tenets of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCONSENT TO PARTICIPATE\u003c/h2\u003e \u003cp\u003e Written informed consent was obtained from all participants or, if they were incompetent, from legal representatives.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING.\u003c/h2\u003e \u003cp\u003eThis work was supported by the Ministry of Innovation and Research under grant number PID2022-139404OA-I00.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRita Redondo, Conceptualization, Formal Analysis, Writing \u0026ndash; original draft; Carolina Pinazo-Clap\u0026eacute;s Data curation, Investigation, resources; Carmen Lizandra Garc\u0026iacute;a, Data curation, Investigation; Sacramento Pinazo-Hernandis Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing; Teresa Mayordomo, Formal Analysis, Methodology, Writing \u0026ndash; original draft; Alicia Sales, Conceptualization, Methodology, Writing \u0026ndash; original draft.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank a nursing homes, for their cooperation in carrying out this study and all older people for their participation in the survey. This work was supported by the Ministry of Innovation and Research under grant number PID2022-139404OA-I00.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDatasets generated and/or analysed during this study are available on request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlipour, F., Sajadi, H., Forouzan, A., Nabavi, H., Khedmati, E. (2009). The role of social support in the anxiety and depression of elderly. \u003cem\u003eIranian Journal of Ageing, 4(\u003c/em\u003e1), 1-9.\u003c/li\u003e\n\u003cli\u003eAltieri, M., Garramone, F., Santangelo, G. (2021). Functional autonomy in dementia of the Alzheimer\u0026rsquo;s type, mild cognitive impairment, and healthy aging: a meta-analysis. \u003cem\u003eNeurological Sciences\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e, 1773-1783. https://doi.org/10.1007/s10072-021-05142-0.\u003c/li\u003e\n\u003cli\u003eAtadokht, A., Zare, R., Karamati, N. (2015). The relationship between social interest and general health among elderly non-resident and resident at geriatric centers of Ardabil city. \u003cem\u003eIranian Journal of Health Education and Health Promotion\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(2), 141-149. \u003c/li\u003e\n\u003cli\u003eBarak, Y., Gale, C. (2019). Suicide in long-term care facilities\u0026mdash;the exception or the norm?. \u003cem\u003eJAMA Network Open,\u003c/em\u003e 2(6), e195634-e195634. https://doi.org/10.1001/jamanetworkopen.2019.5634.\u003c/li\u003e\n\u003cli\u003eBeck, A. T., Brown, G. K., Steer, R. A. (1997). Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients. \u003cem\u003eBehaviour Research and Therapy,\u003c/em\u003e 35(11), 1039-1046. https://doi.org/10.1016/S0005-7967(97)00073-9\u003c/li\u003e\n\u003cli\u003eBeck, A.T., Kovacs, M., Weissman, A. (1979). 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Geriatric Depression scales. \u003cem\u003ePsychopharmacol Bull, 24,\u003c/em\u003e 70-89.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5453374/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5453374/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction. Suicide increases with age; the rate of death by suicide in people over 70 years of age is twice that of people aged 15-49. Currently 30.96% of the population over 64 years of age have functional limitations and perceived social support decreases significantly at this stage. Exposure to these factors appears to be exacerbated in people living in residential care, yet research remains scarce. We analysed suicidal ideation and associated factors such as depression, perceived social support, cognitive decline and functional limitations in older adults living in nursing homes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods. Multicentre study of 126 participants aged over 65 years, mean age is 81.35 years (SD= 9.31) and 65.6% are women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults. Suicidal ideation was found in 57.1% of the participants. Depression, low social support and the presence of mild cognitive impairment were associated with the presence of suicidal ideation in older people living in nursing homes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiscussion. The results obtained highlight the need to focus the dynamics and interventions in nursing homes on emotional aspects, which can help prevent and even detect suicidal ideation and suicidal behaviour.\u003c/p\u003e","manuscriptTitle":"Suicidal ideation in older adults in nursing homes: impact of depression, perceived social support and cognitive impairment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-04 09:09:42","doi":"10.21203/rs.3.rs-5453374/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01efd6bf-7007-42d3-a01e-b2e26d8b38a2","owner":[],"postedDate":"December 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T23:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-04 09:09:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5453374","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5453374","identity":"rs-5453374","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}