Hostname: page-component-5db6c4db9b-5lzww Total loading time: 0 Render date: 2023-03-26T20:17:09.993Z Has data issue: true Feature Flags: { "useRatesEcommerce": false } hasContentIssue true

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

Published online by Cambridge University Press:  02 May 2017

J. Diehl-Schmid*
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada Department of Psychiatry, Technical University of Munich, Munich, Germany
R. Jox
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada Institute of Ethics, History and Theory of Medicine, Ludwig Maximilian University Munich, Munich, Germany Geriatric Palliative Care, Lausanne University Hospital, Lausanne, Switzerland
S. Gauthier
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Montréal, Québec, Canada
S. Belleville
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada Département de Psychologie, Université de Montréal & Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
E. Racine
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada Neuroethics Research Unit, Institut de Recherches Cliniques de Montréal (IRCM), Montréal, Canada & Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal; Departments of Neurology and Neurosurgery, Experimental Medicine & Biomedical Ethics Unit, McGill University, Montréal, Québec, Canada
C. Schüle
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada Department of Psychiatry, Ludwig Maximilians Universität München, Munich, Germany
G. Turecki
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada McGill University, Department of Psychiatry & Douglas Mental Health University Institute, McGill Group for Suicide Studies, Montréal, Québec, Canada
S. Richard-Devantoy
Munich-Montréal Working Group on Dementia and Suicide, Germany & Canada McGill University, Department of Psychiatry & Douglas Mental Health University Institute, McGill Group for Suicide Studies, Montréal, Québec, Canada Hôpital de Saint-Jérôme, CISSS des Laurentides, Saint-Jérôme (Quebec), Canada & Laboratoire de Psychologie des Pays de la Loire, Université d'Angers, Angers, France
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:



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.

Review Article
Copyright © International Psychogeriatric Association 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Barak, Y. and Aizenberg, D. (2002). Suicide amongst Alzheimer's disease patients: a 10-year survey. Dementia and Geriatric Cognitive Disorders, 14, 101103.CrossRefGoogle ScholarPubMed
Beautrais, A. L. (2002). A case control study of suicide and attempted suicide in older adults. Suicide and Life-Threatening Behavior, 32, 19.CrossRefGoogle ScholarPubMed
Benatar, M. et al. (2016). Presymptomatic ALS genetic counseling and testing: experience and recommendations. Neurology, 86, 22952302.CrossRefGoogle ScholarPubMed
Birnbacher, D. and Dahl, D. (2008). Giving Death a Helping Hand. Physician-Assisted Suicide and Public Policy. An International Perspective. Heidelberg: Springer.Google Scholar
Bundesamt_fuer_Statistik (2012). Todesursachenstatisktik 2009. Sterbehilfe (assistierter Suizid) und Suizid in der Schweiz.Google Scholar
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.CrossRefGoogle Scholar
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 CrossRefGoogle Scholar
Catell, H. and Jolley, D. J. (1995). One hundred cases of suicide in elderly people. The British Journal of Psychiatry, 166, 451457.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Cipriani, B., Vedovello, M., Lucetti, C., Fiorino, A. D. and Nuti, A. (2013). Dementia and suicidal behavior. Aggression and Violent Behavior, 18, 256659.CrossRefGoogle Scholar
Cohen-Almagor, R. (2016). First do no harm: euthanasia of patients with dementia in Belgium. Journal of Medicine and Philosophy, 41, 7489.Google ScholarPubMed
Davis, D. (2014). Alzheimer disease and pre-emptive suicide. Journal of Medical Ethics, 40, 543549.CrossRefGoogle ScholarPubMed
Draper, B. (1996). Attempted suicide in old age. International Journal of Geriatric Psychiatry, 11, 577587.3.0.CO;2-V>CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
Fonseca, L. and Machado, A. (2014). Suicidal behaviour in frontotemporal dementia patients – a retrospective study. International Journal of Geriatric Psychiatry, 29, 217218.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Goldman, J. S. (2015). Genetic testing and counseling in the diagnosis and management of young-onset dementias. Psychiatric Clinics of North America, 38, 295308.CrossRefGoogle Scholar
Hamann, J. et al. (2011). Patient participation in medical and social decisions in Alzheimer's disease. Journal of the American Geriatrics Society, 59, 20452052.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
Haw, C. (2009). Dementia: suicide by drowning. The British Journal of Psychiatry, 194, 563564; author reply 564.CrossRefGoogle ScholarPubMed
Haw, C., Harwood, D. and Hawton, K. (2009). Dementia and suicidal behavior: a review of the literature. International Psychogeriatrics, 21, 440453.CrossRefGoogle ScholarPubMed
Heide, A. et al. (2007). End-of-life practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine, 356, 19571965.CrossRefGoogle Scholar
Kim, J. P. and Hyun, M. Y. (2013). Depression and suicidal ideation in elders with dementia. Journal of Korean Academy of Nursing, 43, 296303.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Macleod, R. et al. (2013). Recommendations for the predictive genetic test in Huntington's disease. Clinical Genetics, 83, 221231.CrossRefGoogle ScholarPubMed
Menzel, P. and Chandler-Cramer, M. (2014). Advance directives, dementia, and withholding food and water by mouth. Hastings Center Report, 44, 2337.CrossRefGoogle Scholar
Moretti, R., Torre, P., Antonello, R. M. and Cazzato, G. (2006). Behavioral alterations and vascular dementia. The Neurologist, 12, 4347.CrossRefGoogle Scholar
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.CrossRefGoogle Scholar
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Oregon_Public_Health_Division (2014). Oregon's Death With Dignity Act – Annual Report. Available from: Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
Rao, R., Dening, T., Brayne, C. and Huppert, F. A. (1997). Suicidal thinking in community residents over eighty. International Journal of Geriatric Psychiatry, 12, 337343.3.0.CO;2-T>CrossRefGoogle ScholarPubMed
Regional_Euthanasia_Review_Committees (2014). Regional Euthanasia Review Committees: 2014 annual report [Online].Google Scholar
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.CrossRefGoogle Scholar
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.Google Scholar
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.Google ScholarPubMed
Schneider, B., Maurer, K. and Froelich, L. (2001). Dementia and suicide. Fortschritte der Neurologie Psychiatrie, 69, 164169.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle Scholar
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.Google Scholar
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.CrossRefGoogle ScholarPubMed
Van Orden, K. and Conwell, Y. (2011). Suicides in late life. Current Psychiatry Reports, 13, 234241.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
Waern, M., Rubenowitz, E. and Wilhelmson, K. (2003). Predictors of suicide in the old elderly. Gerontology, 49, 328343.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed