What to Do if Parkinson Patient Talks of Wanting Suicide

• Journal List
• Mov Disord Clin Pract
• v.5(2); Mar-Apr 2018
• PMC6174449

Mov Disord Clin Pract. 2018 Mar-Apr; 5(2): 177–182.

Suicide in Parkinson'southward Disease

Wei Li, RN, MSc, ^{ane , ii} Masoom M. Abbas, Medico, DM, ^{1 , 2} Sanchalika Acharyya, PhD, ⁱⁱⁱ Hwee Lan Ng, RN, BSc, ^{1 , 2} Kay Yaw Tay, MD, MRCP, ^{i , 2 , 3} Wing Lok Au, Dr., FRCP, ^{1 , two , 3} and Louis C. S. Tan, MD, FRCP ^{ane , ii , iii}

Wei Li

^ane Department of Neurology, National Neuroscience Institute, Singapore,

ⁱⁱ Parkinson's Affliction and Move Disorders Center, National Neuroscience Institute, Singapore,

Masoom Grand. Abbas

¹ Department of Neurology, National Neuroscience Found, Singapore,

² Parkinson's Illness and Movement Disorders Middle, National Neuroscience Found, Singapore,

Sanchalika Acharyya

³ Duke‐NUS Graduate Medical School, Singapore,

Hwee Lan Ng

¹ Department of Neurology, National Neuroscience Institute, Singapore,

² Parkinson's Disease and Movement Disorders Centre, National Neuroscience Institute, Singapore,

Kay Yaw Tay

¹ Department of Neurology, National Neuroscience Institute, Singapore,

^two Parkinson's Affliction and Motion Disorders Center, National Neuroscience Plant, Singapore,

^three Duke‐NUS Graduate Medical School, Singapore,

Wing Lok Au

¹ Section of Neurology, National Neuroscience Constitute, Singapore,

² Parkinson'due south Disease and Move Disorders Heart, National Neuroscience Institute, Singapore,

³ Duke‐NUS Graduate Medical School, Singapore,

Louis C. S. Tan

^one Department of Neurology, National Neuroscience Constitute, Singapore,

² Parkinson's Illness and Motility Disorders Center, National Neuroscience Institute, Singapore,

³ Knuckles‐NUS Graduate Medical School, Singapore,

Received 2017 Oct 2; Revised 2017 December nineteen; Accepted 2018 Jan xviii.

Abstruse

Background

Suicide is a potentially preventable event. Suicidal ideation is mutual in Parkinson'due south disease (PD), but literature on completed suicides is deficient. In this example‐control study, we compared the clinical characteristics of PD subjects who completed suicide (case) with those who died from natural causes (control).

Methods

PD patients from the National Neurosciences Institute'due south motility disorders database from 2002 till 2012 were identified. The database was linked to the Singapore National Registry of Disease Office for bloodshed data, and suicide deaths were confirmed with the coroner'due south function. The demographic and clinical variables were compared between the cases and controls and the meaning factors were further analyzed using logistic regression assay.

Results

During the study period, 366 deaths were recorded and suicide accounted for 11 deaths. 10 subjects with suicide deaths with consummate clinical information were compared with randomly selected 30 PD subjects who had died from natural causes. PD suicide patients were younger (65.9 vs. 74.48 years), had less comorbidities (CWI: 2.6 vs. 4.63), better cognition (MMSE: 25.75 vs. 21.36), lower 'ON' UPDRS motor scores (20.83 vs. 41.63), lower H &Y stage (2.16 vs. 3.86), and higher utilize of Entacapone than the PD non‐suicide group.

Decision

Suicide is potentially preventable tragedy. PD patients with the identified clinical characteristics should exist closely monitored for suicide ideations. Motor fluctuation is a treatable factor in such patients and should be aggressively managed.

Keywords: Parkinson's disease, suicide

Introduction

Parkinson'due south disease (PD) is a chronic, progressive, and debilitating neurodegenerative disorder. In add-on to the motor symptoms and physical disability, PD is associated with a range of not‐motor features contributing significantly to the overall quality of life^ane. Suicide is defined as expiry caused by self‐directed injurious behavior with whatever intent to die equally a result of the behavior.² Old historic period, male person gender, multiple comorbidities, depression, and cognitive decline are the recognized hazard factors for suicide in general populations.ⁱⁱⁱ These risk factors are also prevalent in PD. There have been, to our best knowledge, only v studies on suicide in PD. A summary of their findings may exist institute in Table ​ 1.⁴, ^v, ⁶, ⁷, ⁸ The initial studies noted suicide to exist ten times less common in PD compared to general population,⁵ while in the after studies, the suicide run a risk was 2‐5 times increased.^vii, ^eight Suicide is a potentially avoidable tragedy and analysis of the predisposing factors can help in formulating better preventive strategies. In this regard, we undertook a instance control study to ascertain the clinical profile of completed suicide patients and compared them with PD patients succumbing to the natural causes.

Tabular array 1

Summary of Previous Studies on Suicide in PD

Writer	Year of publication	Country	Title	Population	Result
Stenager EN, et al. 4	1994	Kingdom of denmark	Suicide in patients with Parkinson's illness‐ An epidemiological study	458 PD patients followed‐upwardly over mean period of 5.7 years (0 to 17 years), 254 deaths with 2 suicides. Local catchment population used equally reference 435,000; suicide rate = 30/100,000.	The number of expected suicide was i.06 for men and 0.55 for women. The expected and observed suicide rates were not statistically significant for either gender.
Myslobodsky M, et al.v	2001	USA	Are patients with Parkinson'due south disease suicidal?	Total number of deaths was 12,430,473 from 1991 to 1996. Of these, 99,109 committed suicide, 144,364 of deaths were Parkinson patients of 40 years former and above. of these, 122 committed suicide	Merely 0.08% (122) persons with PD died by suicide, as compared with 0.viii% (99,109) in the reference population. People who committed suicide were younger than people who died from other causes (72.ii vs 81.two years for patients with PD, t = 13.iii, P < .001; 59.6 vs 74.9 years for the referent population, t = 335.ix, P < .0001). PD suicide deaths were significantly older than suicide deaths in the reference population (72.ii vs 59.6 years, t = 9.7, P < .001). The rate of suicide amid married patients with PD was higher than amid single patients with PD.
Mainio A et al.6	2009	Finland	Parkinson's disease and suicide: a profile of suicide victims with Parkinson'south illness in a population‐based study during the years 1988–2002 in Northern Finland	546 suicide victims anile 50 and above without PD vs 9 Suicide victims with PD	Suicide occurred in ane.six% of hospital‐treated Parkinson's disease patients, indicating a rather low prevalence of suicide in this grouping of patients. The profile of PD persons who completed suicide was as follows: male person subject with recently diagnosed disease, living in rural surface area, having multiple physical illnesses, and having attempted suicide before.
Kostić et al.7	2010	Serbia	Suicide and suicidal ideation in Parkinson's disease	Suicide as outcome in PD patients 102 PD patients, followed upwardly for 8 years, 2 patients committed suicide	The suicide‐specific mortality was 5.iii (95% CI 2.one–12.vii) times higher than expected. Both patient who committed suicide had major low
Lee T et al.viii	2016	Korea	Increased Suicide risk and clinical correlates of suicide amongst patients with Parkinson disease	4362 Parkinson patients (from 1996 to 2012) 29 PD suicides matched with 116 non‐suicide controls	Standardised Mortality ratio for PD patients was i.99 (95% CI ane.33 to 2.85) which was 2 times college than the general population. Risk factors: male person gender; upper extremity or generalised onset of motor symptoms; history of depressive disorder, delusion or whatsoever psychiatric disorder; and higher Fifty‐dopa dosage.

Methods

Data Source

The report population was selected from the National Neuroscience Institute movement disorders database during the catamenia 2002 to 2012. Parkinson's affliction was diagnosed by a movement disorders specialist co-ordinate to the National Found of Neurological Disorders and Stroke (NINDS) diagnostic criteria.^nine These patients were linked to the Singapore National Registry of Disease role to obtain data on decease information from January one, 2002 to December 31, 2012. The cause of death for suicide was confirmed by coroner'southward certificate from the coroner's court in Singapore. The Centralized Institution Review Board of the Singapore Health Services approved the written report.

Case and Control Choice

The report population comprised of PD patients with completed suicide and randomly selected PD patients with non‐suicide deaths as controls. The suicide patients were included in the study after the verification of Coroner's certificate. In both groups, clinical information obtained from the terminal clinic visit within ii years from the date of death was included for analysis. In order to obtain reliable data on vital status, simply Singaporean citizens and permanent residents were included. Command subjects were selected randomly from pool patients who had a non‐suicide death in a 1:3 case‐to‐control using the following web‐help: http://www.uwec.edu/help/excel107/randamizationdata.htm/.

Data Drove

The demographic and clinical characteristics were reviewed past the authors (LW, AMM) from medical records. Demographic variables, such every bit historic period, gender, ethnicity, education, employment, and marital status were recorded. The clinical data comprised the presence of other comorbidities, date of PD diagnosis, Hoehn and Yahr stage, part 3 (motor component) Unified Parkinson's Disease Rating Scale (UPDRS) during the "ON" country, and Mini‐Mental State Exam (MMSE). Depression and hallucinations were determined by the reviewers based on the clinical history and use of antidepressants and antipsychotics, respectively, in the clinical record besides as a score of 2 and above in UPDRS part I (ane.2 and 1.iii). Clinical history and UPDRS part IV were utilized to appraise motor fluctuations and wearing‐off phenomenon. The total levodopa dose and the anti‐Parkinson's medications during the last visit were noted; the levodopa equivalent dose was calculated. The Charlson Weighted Index (CWI) score was utilized as a measure of co‐morbidities.¹⁰ CWI is a method of classifying comorbidities and provides an estimate of the take chances of death from comorbid diseases for a patient who may accept a range of comorbid weather condition, such as center disease, AIDS, or cancer. Each condition is assigned a score of ane, ii, 3, or 6 depending on the run a risk of dying from each condition. In addition, a gene for age is included by assigning 1 point for each decade in a higher place 40 years (40 years taken equally 0 rank for age). These scores are added together to compute a total score that ranges from 0 to 41, with higher scores indicating greater comorbidity.

Statistical Analysis

SPSS version 22 was used for the data assay. Distribution of demographic and clinical characteristics of the written report population was summarized. Categorical variables were presented with simple frequency, along with percentages, and were compared between cases and control subjects using Fisher's verbal tests. Continuous variables were summarized using mean ± SD and compared using non‐parametric Mann‐Whitney U exam. Statistical significance was ready at five%. Univariate logistic regression was used to estimate the odds ratios (OR) along with 95% confidence interval (CI) to study the private issue of the demographic and clinical characteristics. The variables associated with nature of expiry in the univariate analysis at 10% statistical significance level were further included in a multivariable logistic regression model and backward variable selection procedure was applied.

Results

The total cohort comprised of 2012 PD subjects during the 11‐year written report period; 366 (18.1%) deaths were observed and suicide was the cause of death in 11 (3%) of deceased patients (cases). One patient was excluded from analysis due to insufficient data and the remaining x PD suicide patients were analyzed. Thirty non‐suicide deceased PD subjects served as controls.

The demographic and clinical profiles of cases and controls are summarized in Tabular array ​ 2. The demographic features were similar in both the groups, except the cases were more likely to be younger (hateful age: 65.9 ± thirteen.12 years). The cases had a higher mean MMSE and a lower hateful Charlson's weighted index score compared to control subjects. The other significant clinical differences were a lower mean UPDRS motor score, lower Hoehn & Yahr phase, and more frequent use of Entacapone. Depression (40%) and motor fluctuations (67%) were frequent and the mean levodopa equivalent dose (820.88mg) was higher in the cases than the command subjects, although these did not accomplish statistical significance (Table ​ 2).

Table 2

Demographic and Clinical Contour of PD Suicide Cases and Not‐Suicide Controls

Variables	PD Controls (northward = 30)	N* = 30	PD Suicide (north = 10)	North* = 10	p Value
Historic period (years)	74.48 (+7.xvi)	30	65.9 (+13.12)	ten	0.015
Gender (male)	xiv (47%)	30	vii (70%)	ten	0.281
Race (Chinese)	24 (lxxx%)	30	ten (100%)	10	0.307
Married	27 (96%)	28	8 (100%)	8	one
Didactics (years)	5.23 (+four.33)	26	6.88 (+4.39)	viii	0.413
Employed	1 (4%)	25	2 (25%)	8	0.139
CWI	4.63 (+one.54)	xxx	2.6 (+1.43)	10	0.001
Duration of disease (years)	6.81 (+4.56)	30	6.82 (+iv.13)	ten	0.842
MMSE	21.36 (+4.41)	22	25.75 (+3.28)	8	0.012
Hallucinations	eleven (37%)	30	1 (11%)	9	0.228
Low	4 (13%)	thirty	four (40%)	ten	0.089
UPDRS Three (motor score)	41.63 (+17.7)	30	20.83 (+8.28)	ix	0.002
Hoehn & Yahr phase	3.86 (+1.09)	30	two.sixteen (+0.35)	ix	0.000
Motor fluctuation	eleven (37%)	30	half dozen (67%)	9	0.142
Dyskinesia	5 (60%)	30	two (22%)	ix	0.653
Levodopa equivalent dose (mg)	631.65 (+355.46)	30	820.88 (+425.86)	10	0.173
Entacapone	1 (iii%)	xxx	4 (40%)	10	0.01
Trihexyphenidyl	2 (six%)	30	2 (20%)	x	0.256
Selegiline	1 (3%)	30	2 (20%)	10	0.149
Dopamine agonists	4 (thirteen%)	30	four (40%)	ten	0.089
Antidepressants	3 (10%)	xxx	one (10%)	10	1
Antipsychotics	iv (13%)	xxx	0 (0%)	10	0.556

In the univariate regression analysis, age (OR 0.90; 95% CI: 0.81‐0.98), CWI score (OR 0.39; 95% CI: 0.18‐0.69), MMSE (OR one.38; 95% CI: 1.08‐i.92), UPDRS motor score (OR 0.89; 95% CI: 0.80‐0.96), H &Y staging (OR 0.06; 95% CI: 0.01‐ 0.34), and Entacapone use (OR 19.33; 95% CI: 2.37‐417.05) were significantly associated with nature of expiry (Table ​ iii). Still, nothing remained statistically significant in the multivariable model.

Table iii

Univariate Logistic Regression Analysis Results

Variables	Odds ratio (95% CI)	P value
Age	0.90 (0.81, 0.98)	0.024
Gender	2.67 (0.61, 14.26)	0.209
Education	1.09 (0.91, 1.34)	0.348
Employed	8.0 (0.66, 190.36)	0.112
CWI	0.39 (0.18, 0.69)	0.005
Disease elapsing	1.02 (0.85, one.21)	0.839
MMSE	1.38 (1.08, 1.92)	0.025
Hallucination	0.22 (0.01, one.41)	0.174
Depression	4.33 (0.82, 23.86)	0.081
UPDRS Motor Score	0.89 (0.lxxx, 0.96)	0.011
Hoehn &Yahr stage	0.06 (0.01, 0.34)	0.021
Motor fluctuation	3.45 (0.75, xix.09)	0.122
Dyskinesia	1.43 (0.eighteen, eight.40)	0.704
Levodopa equivalent dose	1.00 (0.99, i.00)	0.181
Entacapone	xix.33 (2.37, 417.05)	0.014
Trihexyphenidyl	three.5 (0.37, 33.23)	0.245
Selegiline	7.25 (0.62, 168.38)	0.124
Dopamine agonists	4.33 (0.82, 23.86)	0.081
Antidepressants	ane.00 (0.05, 9.01)	0.999

Word

In the present study, we reviewed the clinical profile of PD patients who committed suicide and compared them with randomly selected PD subjects who died from natural causes. In our present cohort, 3% of all deaths in PD were due to suicide. These patients were younger, had less comorbidities (lower CWI score), better cognition, lower motor scores, and more frequent apply of Entacapone than non‐suicide controls. Male person gender, depression, motor fluctuations were frequent and levodopa equivalent dose was higher in the PD suicide patients; but, these did not reach statistical significance. Our results are in contrast to the clinical correlates of suicide in normal population; wherein quondam age, cerebral decline, presence of multiple comorbidities, and depression play a major part.³, ^xi

We observed that PD suicide cases accounted for three% of PD deaths in our study. The suicide rate of the Singapore resident population over the aforementioned period equally our report was 2.3% (4332 suicide cases/185,905 number of deaths).¹², ¹³ Statistically, they were not significantly different. Although the PD suicide charge per unit in our report was similar to the Singapore resident population, suicide is an important preventable cause of death in Parkinson's disease. A recent American study observed PD as one of the major health conditions amongst 2,674 individuals committing suicide (historic period and gender adjusted OR: 1.87; 1.20‐ 2.91).¹⁴ Suicidal ideation is common in PD patients and occurs in 17‐30% of patients;⁷, ^xv however, the literature on completed suicides is scarce. Our written report is only the second to clarify the clinical profile of these subjects. In a previous study of clinical correlates in 29 PD suicide patients, the presence of psychiatric disorders and a higher levodopa utilize, but not PD related variables similar motor scores, were significantly associated with suicides in PD patients.⁸ However, motor fluctuations were non analyzed in that study and the motor scores were noted during the entry into the PD registry, only not at the concluding visit every bit in our study.

PD patients with younger age (Mean 65.9 ± 13.12, median 63.8) were noted to be more than probable to commit suicide in our study. The mean age is like to a previous population‐based report on profile of PD suicide victims in Northern Finland.^{half dozen}

In the present study, the PD suicide grouping had lower motor scores compared to controls, more frequent motor fluctuations, and pregnant Entacapone utilize. Entacapone is the merely COMT inhibitor in Singapore and is indicated for utilise in patients with motor fluctuations. Our findings suggest that it is the motor fluctuations that occur more ofttimes amongst younger PD patients,¹⁶ that has such an adverse impact that information technology drives these relatively young, cognitively well patients with few comorbidities towards suicide. A previous multi‐heart written report noted that motor complications, primarily on/off fluctuations significantly touch on the quality of life in PD patients.¹⁷ Our findings highlight the importance of ameliorate management of motor fluctuations to avert this disastrous outcome. In addition to the medical management of motor fluctuations, deep brain stimulation should be considered in PD patients with early motor fluctuations.¹⁸, ¹⁹

Our findings, that PD patients who committed suicide had better motor function, contrasts with the suicidal behavior in older adults and other neurological illnesses where physical disability is a pregnant risk factor.³, ²⁰ In a study on handling preferences at the end‐of‐life in PD patients, we observed that PD patients were more tolerant of greater motor impairment in regards to finish‐of‐life treatment preferences. Patients with greater motor impairment were more likely to have care that would result in further physical disability rather than face death.²¹

Dementia is associated with a higher suicide gamble in the elderly;²² nonetheless, at that place are no studies on the cognitive profile of PD suicide patients. Like to our study, better cognitive scores were observed in PD patients with suicidal ideation in previous studies.⁷, ¹⁵ Suicide is a heterogeneous behavior, with coaction of private vulnerability, state related brain changes, and environmental factors playing a role. The predisposing factors might differ across the lifespan. The poor decision‐making abilities due to cerebral refuse in sometime age might be contributory.^xi

In our present study, depression was more frequent in the suicide grouping, although the difference did not achieve statistical significance. Depression was a significant determinant of both suicidal ideation and completed suicide in the previous studies.⁸, ¹⁵ In another study, suicidal thoughts were noted in more than two‐thirds of depressed PD and major depression patients. Yet, very few PD depressed (4%) patients made suicidal attempts compared to major depression (42%) subjects.²³

The strengths of our study is the uniformity of data, with each patient in the two groups regularly reviewed by the move disorders specialists, and suicide cases were only included after proper verification with coroner's certificates. Our study also had several limitations. The major limitation was the pocket-sized sample size of the PD suicide group. This is a retrospective report and the number of suicides was express. As such, no statistically meaning relationship with the suicide condition could be established in the multivariable setting. The other limitations were the absenteeism of detailed neuropsychological evaluation and history of previous suicidal ideation or attempts.

In decision, suicide is a potentially preventable cause of expiry amidst PD patients. These subjects are significantly younger with fewer comorbidities, better knowledge, lower motor scores, and meaning motor fluctuations equally demonstrated by their more than frequent Entacapone use. These results advise that motor fluctuations, rather than affliction severity, is an of import contributor to suicide deaths. Motor fluctuations should therefore be more aggressively managed with medical and surgical therapies. Future studies with larger pooled patient groups volition exist helpful to further validate these findings in the promise of preventing such catastrophic deaths.

Writer Roles

(1) Inquiry Projection: A. Conception, B. Arrangement, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the First Typhoon, B. Review and Critique.

L.W.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B

A.K.Thousand.: 1C, 2A, 2C, 3A, 3B

A.S.: 2B, 2C, 3A, 3B

N.H.50.: 1A, 2C, 3B

T.K.Y: 1A, 2C, 3B

A.Due west.L.: 1A, 2C, 3B

L.C.Southward.T.: 1A, 1B, 1C, 2A, 2C, 3B

Disclosures

Ethical Compliance Statement: We ostend that we accept read the Journal's position on issues involved in upstanding publication and affirm that this work is consistent with those guidelines.

Conflicts of Involvement related to this enquiry: All authors have no disharmonize of interest to declare.

Full financial disclosure for the previous 12 months: All authors report no disclosures.

Acknowledgements

This research is supported by the Singapore National Inquiry Foundation under its Translational and Clinical Research Flagship Plan (TCR12dec010) and administered past the Singapore Ministry of Health's National Medical Research Council

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