Aging , mental health , and suicide . An integrative review

1 Centro de Ensino Superior de Catalão, Programa de graduação em Psicologia. Catalão, Goiás, Brasil. 2 Universidade Federal de Goiás, Regional Catalão, Instituto de Biotecnologia, Programa de Pós-Graduação em Gestão Organizacional. Curso de Enfermagem. Catalão, Goiás, Brasil. 3 Universidade Federal de Goiás, Regional Catalão, Programa de Pós-Graduação em Gestão Organizacional. Catalão, Goiás, Brasil.


INTRODUCTION
In the twenty-first century population aging is resulting in almost 58 million new sexagenarians every year, making it clear that the phenomenon cannot be ignored.Furthermore, for every 84 male sexagenarians, there are 100 women of the same age, confirming the feminization of old age.This situation brings many challenges: social, economic and cultural, both individually and collectively (society), and above all within the family 1 .
From the individual perspective, which reflects on the collective and familiar scenario, one can cite the changes brought about by aging itself, inherent phenomena and important fields of investigation and research.These modifications are not limited to biological aspects as a consequence of lifelong wear and tear, but also include psychosocial factors involving personality, life history, gender and socioeconomic context 2,3 .
Physiologically, aging has a direct relationship with the incidence of chronic noncommunicable diseases (CNCD), such as cardiovascular and respiratory diseases, neoplasia and diabetes mellitus, resulting in functional disability and considerable changes in the habits and quality of life of the individual 3 .
Researchers 4 have identified an association between chronic pathologies and their negative impact on the quality of life of the elderly.Depression is a risk factor for a poor prognosis of chronic diseases, affecting the individual's functional capacity and quality of life 4 .The presence of a physical illness may contribute to the worsening of depression, through its effect on direct brain function, or psychological and psychosocial effects.Thus, just as depression anticipates chronic diseases, so these pathologies accentuate depressive symptoms 4 .
In relation to the contemporary events of old age, it has been seen that the more advanced the age, the greater the mortality rate in relation to attempts of suicide 5 .In its criteria for depressive states the Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition (DSM-V) includes factors such as recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan to commit suicide 6 .Suicidal ideation is understood as all the expressions, desires, thoughts and behaviors aimed at ending one's own life without the effectuation of the act.Self-extermination practices that do not achieve their goal are called suicide attempts 7 .
Faced with such challenges and manifestations of aging, it is necessary to assess the means of research and investigation into the subject in order to allow a better analysis and understanding of those who face such events.The research question posed was: which aspects influence suicidal ideation in the elderly?In this way we tried to systematize the knowledge produced about the suicidal ideation of elderly persons.

METHOD
An integrative literature review was used as a research method.This methodology allows the synthesizing of the state of the art of knowledge about the subject of interest, following the steps: identification of the theme, selection of the hypothesis or research question; establishing of criteria for inclusion and exclusion of studies/ sampling; definition of the information to be extracted from the selected studies; evaluation of included studies; interpretation of results; and presentation of knowledge review/synthesis 8 .
In order to carry out this integrative review, the following databases were selected: Latin American and Caribbean Health Sciences Literature (LILACS), MEDical Literature Analysis and Retrieval System (MEDLINE) and PubMed.The research was carried out between October and November 2017, and the collection was carried out simultaneously by two researchers.The following controlled descriptors in health were used: "Aging" and "Mental Heath" and "Suicide".
We included only original, complete articles with an exclusively epidemiological methodology, which were available free online, published between the years 2007 and 2017, and in English, Portuguese and Spanish.In order to increase the reliability of the information from the databases, a manual search of available articles (search by hand) was carried out, based on the references of the articles already collected.
To analyze the data, the articles were translated and read, followed by the systematization and transcription of the extracted information, allowing the publications that met the inclusion criteria to be organized.The following information of interest was extracted: authors, article title, year of publication, country of origin, database, sample, study design, level of evidence, instruments and indexes used by researchers in the original study, results and synthesis of conclusions.
With the aim of analyzing the level of evidence, the following hierarchical classification was used: level I -evidence of results of meta-analysis from controlled clinical trials with randomization; level II -evidence of experimental design studies; level III -evidence of quasi-experimental studies; level IV for evidence obtained from non-experimental, descriptive or qualitative methodological approaches; level V for evidence of case or experience reports; and level VI for evidence based on expert opinions or standards or legislation 9 .

RESULTS
The sample of this integrative review resulted in one article in the LILACS database (5.2%), one in PubMed (5.2%) and 17 in MEDLINE (89.4%) being found.From these texts, through a search by hand, five articles indexed in LILACS and ten in MEDLINE were also included.As four productions were repeated across the platforms, the search resulted in a total of 34 articles for final analysis, 27 from MEDLINE (79.4%), six from LILACS (17.6%) and one from PubMed (2.9%).
Figure 1 shows the steps of this integrative review.
In terms of the origin of the studies, 76.4% were from North America, 17.6% from Latin America and 5.8% from Europe.The English language was most prevalent (85.2%), followed by Portuguese (8.8%) and Spanish (5.8%).There was a considerable number of studies with a descriptive approach (88.2%), followed by those with a qualitative approach (11.7%), characterized as level IV in the hierarchical classification 9 .
The analysis of selected articles showed that the 2013 was the year with the greatest number of publications (20.5%), followed by 2014 (17.6%); 2015 and 2010 (14.7%); 2007, 2009, 2011, 2012 and 2016 (5.8% each); and 2008 (2.9%).No article was found that met the criteria for inclusion in 2017.Table 1 presents a brief description of the articles selected for this integrative review, together with the synthesis of the results of the selected texts.Descriptive, BSRS-%, GDS-15, MOS, SF-12.The data revealed a significant relationship between quality of life and suicidal ideation.
The proposed model has the potential to help health professionals effectively design and implement their suicide prevention programs.
Conte et al. 16 2015, Brazil, LILACS, 9, Descriptive, semistructured interview The study, through three brief stories, questions the biomedical model in terms of treatment of at-risk situations and emphasizes, in integral health care is to be achieved, the importance of the concept of the Expanded Clinic.
Highlights the need to construct a line of care for the elderly population.Descriptive structured interview Age-adjusted mortality rates in five years were 44.3 and 23.9 per 1,000 person/year for those who felt "useless" and those who did not, respectively.
Uselessness can be independently associated with all-cause mortality in elderly Chinese men.
Yan Ho et al. 43 2013, England, MEDLINE, 16 Qualitative, qualitative interview.The three main categories of themes of the Dignity Model were widely supported.
These findings highlight both a cultural dimension and a family dimension in the construct of dignity.

DISCUSSION
The majority of the articles found were from the MEDLINE database.The largest number of publications were published in 2013, followed by 2014, a fact that may be explained by the publication of the Good Health Adds Life To Years: Global Brief for World Health report by the World Health Organization (WHO) in 2012, which encouraged discussions on the phenomenon of aging and its impact on various sectors of society.The report presented data on the state of old age in the world, the demography and epidemiology of population aging, and possible actions on aging and health 44 .
The investigation pointed out that 28 articles (82.3%) used the application of questionnaires and interviews, with the aim of investigating the aspects involved in aging and suicidal ideation.Instruments such as scales are useful for the detection of depressive symptoms self-reported by the elderly 45 .In addition, actions that require on-site examination of the relationships, interactions and lifestyles of the elderly are fundamental for establishing a relationship between aging and possible suicidal behavior.It is important to harmonize clinical and social evidence, as well as epidemiological data, with reports of the elderly themselves about their life trajectory and their reasons for giving up on living 46 .
An association between suicide or suicidal ideation in the elderly and factors such as anxiety 34 , depressive symptoms and depression 14,20,23,26,36,37 , physical and chronic diseases 16,25,31,34 , low schooling 20 , low socioeconomic status 19 and ill-treatment 25 was found.The studies indicate a relationship between physical health status, the absence of leisure activities and less social support and a greater possibility of suicide attempts 16,18,34 .Thus, higher levels of social and physical activity confer benefits to the health of the elderly, reducing daily disability and depressive symptoms that can lead to suicide 25 .
It is known that elderly people with depression may have considerable cognitive and functional disorders, and that the changes due to aging may lead to certain alterations.It is observed that both cognitive impairment and mental suffering among the elderly increase the probability of suicidal ideation 10 .The most recurrent cognitive variations in depressed elderly persons are executive functions, attention deficit, and the slowing of processing 47 .
As a multifactorial process, aging causes anatomical and functional changes in the body.Such alterations may result in the appearance of chronic and degenerative diseases 16,25,31,34 , such as pulmonary diseases, arterial hypertension, osteoporosis, arthritis, dementias or mental disorders, heart diseases, arthrosis, rheumatism, stroke and cancer, reducing the functional capacity and quality of life of the elderly person 48 .All these factors increase the chances of suicidal ideation and suicide itself in the elderly 31 .
Another finding observed in the analysis of the articles was the need to invest in reception, therapies, discussion circles, groups, forums and health conferences as health care strategies 16 .The absence of a space for listening and reception in the health and social services, as well as the lack of a health professional who can support elderly individuals, can increase their vulnerability to the risk of suicide 16 , with such measures an effective protection against suicide.
There is a need for strategies that favor the prevention of mental disorders, the treatment of diseases with the inclusion of diagnostic procedures, early detection, correct medication, psychotherapy and the training of professionals and other persons involved with this population group 49 .The understanding of care in the quality of life as encompassing physical, psychological and social aspects allows the involvement of health professionals in the construction and effective implementation of suicide prevention programs in addition to potentializing opportunities of detection of the mental health needs of the elderly 15,36 .
Limitations of the present study include the methodology used, considering its level of scientific evidence compared to other methodologies such as systematic reviews or a meta-analysis.However, through the hierarchical level of methodological classification, the present study identified a predominance of level IV studies, which suggests that new studies on suicide among the elderly employ more robust methodologies and designs that produce consistent evidence.

CONCLUSION
The aspects related to suicidal ideation in the elderly were a low socioeconomic level, the presence of anxiety, depressive symptoms and depression, physical illnesses and chronic diseases.A multidimensional look at the phenomenon of suicide in the elderly is required, based on economic, psychological, physical and social factors, both by professionals who work in the field of aging and by the state, with public policies that support this population.Although the growth of the elderly population is an indisputable reality, the support given to such individuals has not advanced with the same speed.In this way, living spaces that offer physical and leisure activities, access to health care of all levels of complexity, social and family support avoiding isolation and solitude, can be considered actions that minimize or avoid suicidal ideation.
The reading of the original texts made it possible to understand the way aging, suicide and mental health issues have been treated in the scientific milieu.Nevertheless, the works studied addressed a relevant and complex topic of study, representing a significant source of knowledge for future research.The results of this review are relevant because, besides evidencing the associations between several factors found in literature and suicide, they also point out ways to promote physical and mental health among the elderly, thus reducing the risk of suicide among this population.
At the same time, the need for greater investment in the area of health is emphasized, strengthening existing public policies through intersectoral collaboration in the health care of the elderly.