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Suicide and assisted dying in dementia: what we know and what we need to know. A narrative literature review

  • J. Diehl-Schmid (a1) (a2), R. Jox (a1) (a3) (a4), S. Gauthier (a1) (a5), S. Belleville (a1) (a6), E. Racine (a1) (a7), C. Schüle (a1) (a8), G. Turecki (a1) (a9) and S. Richard-Devantoy (a1) (a9) (a10)...



Evidence-based data on prevalence and risk factors of suicidal intentions and behavior in dementia are as scarce as the data on assisted dying. The present literature review aimed on summarizing the current knowledge and provides a critical discussion of the results.


A systematic narrative literature review was performed using Medline, Cochrane Library, EMBASE, PSYNDEX, PSYCINFO, Sowiport, and Social Sciences Citation Index literature.


Dementia as a whole does not appear to be a risk factor for suicide completion. Nonetheless some subgroups of patients with dementia apparently have an increased risk for suicidal behavior, such as patients with psychiatric comorbidities (particularly depression) and of younger age. Furthermore, a recent diagnosis of dementia, semantic dementia, and previous suicide attempts most probably elevate the risk for suicidal intentions and behavior. The impact of other potential risk factors, such as patient's cognitive impairment profile, behavioral disturbances, social isolation, or a biomarker based presymptomatic diagnosis has not yet been investigated. Assisted dying in dementia is rare but numbers seem to increase in regions where it is legally permitted.


Most studies that had investigated the prevalence and risk factors for suicide in dementia had significant methodological limitations. Large prospective studies need to be conducted in order to evaluate risk factors for suicide and assisted suicide in patients with dementia and persons with very early or presymptomatic diagnoses of dementia. In clinical practice, known risk factors for suicide should be assessed in a standardized way so that appropriate action can be taken when necessary.


Corresponding author

Correspondence should be addressed to: Prof. Dr. Janine Diehl-Schmid, Department of Psychiatry, Technische Universität München, Ismaninger Str.22, 81675 München, Germany. Phone: +49-89-41406488; Fax: +49-89-41404923. Email:


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Alberici, A., Cottini, E., Cossedu, M., Borroni, B. and Padovani, A. (2012). Suicide risk in frontotemporal lobe degeneration: to be considered, to be prevented. Alzheimer Disease & Associated Disorders, 26, 194196.
Ballard, C., Bannister, C., Solis, M., Oyebode, F. and Wilcock, G. (1996). The prevalence, associations and symptoms of depression amongst dementia sufferers. Journal of Affective Disorders, 36, 135144.
Bamford, C., Lamont, S., Eccles, M., Robinson, L., May, C. and Bond, J. (2004). Disclosing a diagnosis of dementia: a systematic review. International Journal of Geriatric Psychiatry, 19, 151169.
Barak, Y. and Aizenberg, D. (2002). Suicide amongst Alzheimer's disease patients: a 10-year survey. Dementia and Geriatric Cognitive Disorders, 14, 101103.
Beautrais, A. L. (2002). A case control study of suicide and attempted suicide in older adults. Suicide and Life-Threatening Behavior, 32, 19.
Benatar, M. et al. (2016). Presymptomatic ALS genetic counseling and testing: experience and recommendations. Neurology, 86, 22952302.
Birnbacher, D. and Dahl, D. (2008). Giving Death a Helping Hand. Physician-Assisted Suicide and Public Policy. An International Perspective. Heidelberg: Springer.
Bundesamt_fuer_Statistik (2012). Todesursachenstatisktik 2009. Sterbehilfe (assistierter Suizid) und Suizid in der Schweiz.
Carpenter, B. D. et al. (2008). Reaction to a dementia diagnosis in individuals with Alzheimer's disease and mild cognitive impairment. Journal of the American Geriatrics Society, 56, 405412.
Caselli, R.J., Coon, E.A. and Johansson, L. (2015). Midlife personality and risk of Alzheimer disease and distress: a 38-year follow-up. Neurology, 85, 298299
Catell, H. and Jolley, D. J. (1995). One hundred cases of suicide in elderly people. The British Journal of Psychiatry, 166, 451457.
Chan, J., Draper, B. and Banerjee, S. (2007). Deliberate self-harm in older adults: a review of the literature from 1995 to 2004. International Journal of Geriatric Psychiatry, 22, 720732.
Chao, S., Roberts, J. S., Marteau, T. M., Silliman, R., Cupples, L. A. and Green, R. C. (2008). Health behavior changes after genetic risk assessment for Alzheimer disease: the REVEAL study. Alzheimer Disease & Associated Disorders, 22, 9497.
Cipriani, B., Vedovello, M., Lucetti, C., Fiorino, A. D. and Nuti, A. (2013). Dementia and suicidal behavior. Aggression and Violent Behavior, 18, 256659.
Cohen-Almagor, R. (2016). First do no harm: euthanasia of patients with dementia in Belgium. Journal of Medicine and Philosophy, 41, 7489.
Davis, D. (2014). Alzheimer disease and pre-emptive suicide. Journal of Medical Ethics, 40, 543549.
Draper, B. (1996). Attempted suicide in old age. International Journal of Geriatric Psychiatry, 11, 577587.
Draper, B., Brodaty, H., Low, L. F., Richards, V., Paton, H. and Lie, D. (2002). Self-destructive behaviors in nursing home residents. Journal of the American Geriatrics Society, 50, 354358.
Draper, B., Maccuspie-Moore, C. and Brodaty, H. (1998). Suicidal ideation and the 'wish to die' in dementia patients: the role of depression. Age and Ageing, 27, 503507.
Draper, B., Peisah, C., Snowdon, J. and Brodaty, H. (2010). Early dementia diagnosis and the risk of suicide and euthanasia. Alzheimer's & Dementia, 6, 7582.
Emanuel, E., Onwuteaka-Philipsen, B., Urwin, J. and Cohen, J. (2016). Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA, 316, 7990.
Erlangen, A., Zarit, S. H. and Conwell, Y. (2008). Hospital-diagnosed dementia and suicide: a longitudinal study using prospective, nationwide register data. The American Journal of Geriatric Psychiatry, 16, 220–8.
Farrer, L. A. (1986). Suicide and attempted suicide in Huntington disease: implications for preclinical testing of persons at risk. American Journal of Medical Genetics, 24, 305311.
Fonseca, L. and Machado, A. (2014). Suicidal behaviour in frontotemporal dementia patients – a retrospective study. International Journal of Geriatric Psychiatry, 29, 217218.
Gallego, J. A., Rachmallu, V., Yuen, E. Y., Fink, S., Duque, L. M. and Kane, J. M. (2015). Predictors of suicide attempts in 3.322 patients with affective disorders and schizophrenia spectrum disorders. Psychiatry Research, 228, 791796.
Gather, J. and Vollmann, J. (2013). Physician-assisted suicide of patients with dementia. A medical ethical analysis with a special focus on patient autonomy. International Journal of Law and Psychiatry, 36, 444453.
Goldman, J. S. (2015). Genetic testing and counseling in the diagnosis and management of young-onset dementias. Psychiatric Clinics of North America, 38, 295308.
Hamann, J. et al. (2011). Patient participation in medical and social decisions in Alzheimer's disease. Journal of the American Geriatrics Society, 59, 20452052.
Harkins, K. et al. (2015). Development of a process to disclose amyloid imaging results to cognitively normal older adult research participants. Alzheimers Research & Therapy, 7, 26.
Haw, C. (2009). Dementia: suicide by drowning. The British Journal of Psychiatry, 194, 563564; author reply 564.
Haw, C., Harwood, D. and Hawton, K. (2009). Dementia and suicidal behavior: a review of the literature. International Psychogeriatrics, 21, 440453.
Heide, A. et al. (2007). End-of-life practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine, 356, 19571965.
Kim, J. P. and Hyun, M. Y. (2013). Depression and suicidal ideation in elders with dementia. Journal of Korean Academy of Nursing, 43, 296303.
Kim, S., Ha, J. H., Yu, J., Park, D. H. and Ryu, S. H. (2014). Path analysis of suicide ideation in older people. International Psychogeriatrics, 26, 509515.
Knapskog, A. B., Barca, M. L. and Engedal, K. (2014). Prevalence of depression among memory clinic patients as measured by the Cornell scale of depression in dementia. Aging and Mental Health, 18, 579587.
Lim, W. S., Rubin, E. H., Coats, M. and Morris, J. C. (2005). Early-stage Alzheimer disease represents increased suicidal risk in relation to later stages. Alzheimer Disease & Associated Disorders, 19, 214219.
Macleod, R. et al. (2013). Recommendations for the predictive genetic test in Huntington's disease. Clinical Genetics, 83, 221231.
Menzel, P. and Chandler-Cramer, M. (2014). Advance directives, dementia, and withholding food and water by mouth. Hastings Center Report, 44, 2337.
Moretti, R., Torre, P., Antonello, R. M. and Cazzato, G. (2006). Behavioral alterations and vascular dementia. The Neurologist, 12, 4347.
Mormont, E., Jamart, J. and Jacques, D. (2014). Symptoms of depression and anxiety after the disclosure of the diagnosis of Alzheimer disease. Journal of Geriatric Psychiatry and Neurology, 27, 231236.
Nunnemann, S., Last, D., Schuster, T., Foerstl, H., Kurz, A. and Diehl-Schmid, J. (2011). Survival in a German population with frontotemporal lobar degeneration. Neuroepidemiology, 37, 160165.
O'Dwyer, S. T., Moyle, W., Zimmer-Gembeck, M. and De Leo, D. (2016). Suicidal ideation in family carers of people with dementia. Aging & Mental Health, 20, 222230.
O'Dwyer, S., Moyle, W. and Van Wyk, S. (2013). Suicidal ideation and resilience in family carers of people with dementia: a pilot qualitative study. Aging & Mental Health, 17, 753760.
Oregon_Public_Health_Division (2014). Oregon's Death With Dignity Act – Annual Report. Available from:
Osvath, P., Kovacs, A., Voros, V. and Fekete, S. (2005). Risk factors of attempted suicide in the elderly: the role of cognitive impairment. International Journal of Psychiatry in Clinical Practice, 9, 221225.
Peisah, C., Snowdon, J., Kril, J. and Rodriguez, M. (2007). Clinicopathological findings of suicide in the elderly: three cases. Suicide and Life Threatening Behavior, 37, 648658.
Préville, M., Hébert, R., Boyer, R., Bravo, G. and Seguin, M. (2005). Physical health and mental disorder in elderly suicide: a case-control study. Aging & Mental Health, 9, 576584.
Purandare, N., Voshaar, R. C., Rodway, C., Bickley, H., Burns, A. and Kapur, N. (2009). Suicide in dementia: 9-year national clinical survey in England and Wales. The British Journal of Psychiatry, 194, 175180.
Qin, P. (2011). The impact of psychiatric illness on suicide: differences by diagnosis of disorders and by sex and age of subjects. Journal of Psychiatric Research, 45, 14451452.
Rao, R., Dening, T., Brayne, C. and Huppert, F. A. (1997). Suicidal thinking in community residents over eighty. International Journal of Geriatric Psychiatry, 12, 337343.
Regional_Euthanasia_Review_Committees (2014). Regional Euthanasia Review Committees: 2014 annual report [Online].
Richard-Devantoy, S., Berlim, M. T. and Jollant, F. (2014a). A meta-analysis of neuropsychological markers of vulnerability to suicidal behavior in mood disorders. Psychological Medicine, 44, 16631673.
Richard-Devantoy, S., Szanto, K., Butters, M. A., Kalkus, J. and Dobrovski, A. Y. (2014b). Cognitive inhibition in older high-lethality suicide attempters. International Journal of Geriatric Psychiatry, 46, 933944.
Rohde, K., Peskind, E. R. and Raskind, M. A. (1995). Suicide in two patients with Alzheimer's disease. Journal of the American Geriatrics Society, 43, 187189.
Rubio, A., Vestner, A. L., Stewart, J. M., Forbes, N. T., Conwell, Y. and Cox, C. (2001). Suicide and Alzheimer's pathology in the elderly: a case-control study. Biological Psychiatry, 49, 137145.
Sabodash, V., Mendez, M. F., Fong, S. and Hsiao, J. J. (2013). Suicidal behavior in dementia: a special risk in semantic dementia. American Journal of Alzheimer's Disease and Other Dementias, 28, 592599.
Schmid, M., Zellweger, U., Bosshard, G. and Bopp, M. (2016). Medical end-of-life decisions in Switzerland 2001 and 2013: who is involved and how does the decision-making capacity of the patient impact? Swiss Medical Weekly, 146, w14307.
Schneider, B., Maurer, K. and Froelich, L. (2001). Dementia and suicide. Fortschritte der Neurologie Psychiatrie, 69, 164169.
Seyfried, L. S., Kales, H. C., Ignacio, R. V., Conwell, Y. and Valenstein, M. (2011). Predictors of suicide in patients with dementia. Alzheimer's & Dementia, 7, 567573.
Silverman, M. M., Berman, A. L., Sanddal, N. D., O'Carroll, P. W. & Joiner, T. E. (2007). Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale, and methodology. Suicide and Life Threatening Behavior, 37, 248263.
Snijdewind, M. C., Willems, D. L., Deliens, L., Onwuteaka-Philipsen, B. D. and Chambaere, K. (2015). A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands. JAMA Internal Medicine, 175, 16331640.
Steinbart, E. J., Smith, C. O., Poorkaj, P. and Bird, T. D. (2001). Impact of DNA testing for early-onset familial Alzheimer disease and frontotemporal dementia. Archives of Neurology, 58, 18281831.
Surampalli, A. et al. (2015). Psychological impact of predictive genetic testing in VCP inclusion body myopathy, paget disease of bone and frontotemporal dementia. Journal of Genetic Counseling, 24, 842850.
Synofzik, M., Biskup, S., Leyhe, T., Reimold, M., Fallgatter, A. J. and Metzger, F. (2012). Suicide attempt as the presenting symptom of C9orf72 dementia. The American Journal of Psychiatry, 169, 12111213.
Tomlinson, E. and Stott, J. (2015). Assisted dying in dementia: a systematic review of the international literature on the attitudes of health professionals, patients, carers and the public, and the factors associated with these. International Journal of Geriatric Psychiatry, 30, 1020.
Tsai, C. F., Tsai, S. J., Yang, C. H. and Hwang, J. P. (2007). Chinese demented inpatients admitted following a suicide attempt: a case series. International Journal of Geriatric Psychiatry, 22, 11061109.
Upadhaya, A. K., Conwell, Y., Duberstein, P. R., Denning, D. and Cox, C. (1999). Attempted suicide in older depressed patients: effect of cognitive functioning. The American Journal of Geriatric Psychiatry, 7, 317320.
Van der Lee, J., Bakker, T. J., Duivenvoorden, H. J. and Droes, R. M. (2014). Multivariate models of subjective caregiver burden in dementia: a systematic review. Ageing Research Reviews, 15, 7693.
Van Orden, K. and Conwell, Y. (2011). Suicides in late life. Current Psychiatry Reports, 13, 234241.
Waern, M., Rubenowitz, E., Runeson, B., Skoog, I., Wilhelmson, K. and Allebeck, P. (2002). Burden of illness and suicide in elderly people: case-control study. British Medical Journal, 324, 13551359.
Waern, M., Rubenowitz, E. and Wilhelmson, K. (2003). Predictors of suicide in the old elderly. Gerontology, 49, 328343.
Wiktorsson, S., Runeson, B., Skoog, I., Ostling, S. and Waern, M. (2010). Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. The American Journal of Geriatric Psychiatry, 18, 5767.
Williams, N., Dunford, C., Knowles, A. and Warner, J. (2007). Public attitudes to life-sustaining treatments and euthanasia in dementia. International Journal of Geriatric Psychiatry, 22, 12291234.



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