Overview of Suicide Risk in Elderly at Nursing Home of Jember

ABSTRACT


INTRODUCTION
The hospital environment can cause healthcare-associated infections, and environmental infection management is important in preventing the spread of pathogens (Sehulster et al., 2003). Hospital room surfaces near patients are often touched, and commonly used medical devices are more frequently contaminated with microbes (Russotto et al., 2015;Saadi et al., 2021). By improving the cleaning processes and implementing various infection-control strategies, the rate of microbial contamination in the hospital environment has been reduced (Huang et al., 2020;Wong et al., 2018). In addition, multidrug-resistant bacterial infections (Anderson et al., 2017;Eichelberger & Zirges, 2019;Mitchell et al., 2019), implantable device-related infections (Ellingson et al., 2020), and intensive care infections (Nagaraja et al., 2015, Vianna et al., 2016 have decreased. "High-touch surfaces" that are frequently used by patients and healthcare workers in a healthcare environment as well as surfaces that are frequently contaminated, should be cleaned more often than other places to prevent the spread of infection (Sehulster et al., 2003;Ling et al., 2015;Government of South Australia, 2017; Korea Disease Control and Prevention Agency & Korean Society for Healthcare-associated Infection Control and Prevention, 2017). Previous studies have identified the most common high-touch surfaces in medical institutions (Cheng et al., 2015;Huslage et al., 2010;Jinadatha et al., 2017;Smith et al., 2012). However, the criteria for identifying these high-touch surfaces suggested in previous guidelines and studies are either abstract or vary widely (Table 1). Therefore, it was necessary to develop a standardized system to identify the high-touch surfaces in a hospital room.
The risk of suicide is a problem that is included in the nursing problem that cannot be taken lightly. According to the Indonesian Nursing Diagnosis Standards (SDKI), the risk of suicide is hurting oneself to end one's life. The existence of suicidal thoughts or ideas is one of the triggers for someone to commit suicide which can appear at any time to end life either with a plan or without a certain plan (Loora & Abidin, 2021). Elderly who have a suicide risk problem, one of which can be identified by the presence of suicidal ideation (Heisel & Flett, 2020).
Based on the Stress Adaptation Model theory developed by Gail W. Stuart that the problem of suicide risk occurs because of predisposing and precipitation factors (Stuart, 2013). Generally, the risk of suicide is influenced by factors of age, low socioeconomic status, living alone, loneliness, chronic illness, alcohol consumption, loss of a partner, drug abuse, family history of suicide, high dependency, loss of job, social isolation, depression, and widowed or never married (Meiner, 2015;Nie et al., 2020;Wand et al., 2020). The problem of suicide risk, if ignored and not prevented, will continue to suicidal behavior (Zalsman et al., 2020).
The incidence of death due to suicide in the world is as much as 14 per 100.000 population (CDC, 2020). A 2.5% increase in deaths from suicide from 2017 to 2018 (Heron, 2021). In China in 2018, out of 817 elderly with suicidal ideation (Nie et al., 2020). Currently, there is no data regarding the number of elderly people who have suicidal ideation or even have committed suicide in nursing homes in Indonesia. However, data on estimates of suicidal behavior from the World Health Organization (WHO) in 2019 in Indonesia is greater in the elderly aged 65 years and over. Most suicide victims are men in the late elderly stage (Nurtanti et al., 2020). Although there is still no data showing that there are suicides in nursing homes in Indonesia, many elderly people in nursing homes experience factors that trigger suicidal ideation, such as depression, social isolation, loneliness, and lack of family support, as well as a high level of dependence (Matillah et al., 2018;Sa'diyah, 2019;Indarti & Huroniyah, 2021;Nuraini et al., 2021).
The elderly, in the aging process, experience a decline in their physical, biological, and psychological conditions (Nugroho, 2008). The aging process makes the elderly susceptible to disease due to decreased physical capacity (Susanto & Widayati, 2018). The decrease in these conditions can affect the social contact of the elderly and cause a decrease in social interaction skills (Pambudi et al., 2017;Matillah el at., 2018). The decline in the elderly in interactions causes them to rarely or even never socialize with their friends and society, so it can cause the elderly to experience loneliness. Feelings of loneliness make the elderly feel bored with their lives, thus triggering them elderly to end their lives immediately (Matillah et al., 2018). In addition to various diseases experienced by the elderly, the loss of loved ones and the loss of positions are also causing the elderly to experience loneliness, which, if left unchecked, will trigger depression (Williams, 2016). Depression can occur when a person continuously feels sad, remembers bitter events, and is in a slump (Rachmawati & Suratmi, 2020).
According to Stuart (2013), the condition of the elderly who experience depression or stressors requires appropriate coping mechanisms to overcome them. If the coping mechanisms are not appropriate, it can trigger unwanted behaviors such as drug and alcohol abuse, mood swings, self-isolation, feeling worthless, and suicidal thoughts (Stuart, 2013;Williams, 2016). These conditions strongly encourage the emergence of suicidal ideation, which, if not noticed will continue to attempt suicide (Zalsman et al., 2020).
The elderly at the nursing home of Jember do not live with their families but with the elderly and nursing home officers. The elderly who live there experience psychological problems more easily because of the limited support and interaction from family and closest people (Pambudi et al., 2017). The elderly in nursing homes are very rarely visited by family or closest people (Adisiwi et al., 2021). In contrast to the elderly who live with their families, it is easier to interact and get support from their families. Whereas the role and support of the family can make the elderly more confident and maintain bio-psycho-social-spiritual health in achieving life satisfaction (Ningrum et al., 2017;. In addition, reduced social support for the elderly can cause them elderly to feel alienated from their social environment (Deviantony & Susanto, 2020). This allows the elderly to have suicidal thoughts or ideas at risk for suicidal behavior.
Based on the results of the literature study, there are differences in symptoms of depression in the elderly living in the nursing home of Jember and those living in the family. Elderly living in nursing homes dominant experience mild depression, while those living in dominant families do not experience depression (Sari et al., 2015). Research on elderly depression was conducted by Hartutik & Nurrohmah (2021), in the family community of Universitas Aisyiyah Surakarta, which found 31 elderly (52%) with mild depression. While the elderly in the nursing homes, according to research conducted by Sofiana et al. (2018), in the nursing home of Jember, found 17 elderly (89.5%) had moderate depression. Yunanto et al. (2019) found that 30 (71.4%) elderly experience moderate depression. Research by Indarti & Huroniyah (2021) at the nursing home of Jember, found that 34 elderly (63%) had moderate depression.
Research by Pambudi et al. (2017) showed that as many as 14 elderlies (73,7%) experienced low loneliness. Research by Matillah et al. (2018), at the nursing home of Jember, found that 52 elderly (57,1%) experienced mild loneliness. Sa'diyah's (2019) research, at a nursing home in Jember, in 103 elderly people, found 38 elderly (36,9%) with low loneliness. Sa'diyah's (2019) research regarding the level of dependence of the elderly at the nursing home of Jember found 6 elderly (5,8%) severely depending to the research of Nuraini et al. (2021), there is 73% of the elderly at the nursing home of Jember with widowed status.
There are 140 elderlies in nursing homes divided into 3 treatment criteria, including total care for 25 elderly, partial care for 36 elderly, and independent care for 79 elderly. These criteria are used to classify how dependent the elderly is so that they can impact the form and intensity of providing care. This phenomenon is important to study based on the description and data above. Hence, researchers need to research the description of the risk of suicide in the elderly at the nursing home of Jember.

METHOD
This research is quantitative research with a descriptive design. The population in this study were the elderly at the nursing home of Jember, as many as 140 elderly people. The sample used in this study was 76 elderly. The sampling technique in this study is total sampling. The researcher took data at the nursing home of Jember in July 2022. The step-in data collection begins with explaining the content and purpose of the study, then the elderly who are willing to become respondents sign the consent form. After the informed consent was carried out, it was followed by filling out the elderly characteristics sheet and the Geriatric Suicide Ideation Scale (GSIS) questionnaire, which the researcher read.
Data analysis in this study used univariate analysis. Suicide risk variables were tested using the one-sample Kolmogorov-Smirnov test to determine the significance of the risk of suicide in the elderly and the results of each indicator, including suicide ideation, death ideation, loss of personal and social worth, and perceived meaning in life. The significant risk of suicide has a significance value of 0.05. numerical data such as length of stay in the institution indicate that the data is not normally distributed, so it is displayed in the form of medians and 25-75 percentiles. Categorical data is presented in the form of numbers and percentages. This research has been ethically tested at the Faculty of Nursing Universitas Jember issued with No. 111/UN25.1.14/KEPK/2022.

Characteristics of the Elderly
The description of the characteristics of the elderly at the nursing home of Jember is shown in Table 1. The elderly in nursing homes in Jember have an age with a median value of 69 years. Most female respondents were 50 elderly (65.8%). The marital status of most widows/widowers is 36 elderly (47.4%). Long stay in the nursing homes majority is 1-5 years. Most elderly do not have chronic diseases, as many as 65 elderly (85.5%). Most respondents with a level of dependence on independent care are 52 elderly (68.4%). According to the results of statistical calculations in Table 2 using one sample, Kolmogorov-Smirnov, it was found that there was a significant risk of suicide in the elderly at the nursing home of Jember (Z= 0.151; p-value 0.000). This is indicated by the analysis result where the p-value ≤0.05. The elderly at the nursing home of Jember experienced significant suicide ideation (Z=0.341; p-value 0.000). Significant indicators of death ideation experienced by the elderly at the nursing home of Jember (Z=0.520; p-value 0.000). Indicators of loss of personal and social worth, which means experienced by the elderly (Z=0.172; p-value 0.000), and indicators of a perceived meaning in life are also meaningful for the elderly at the nursing home of Jember (Z=0.363; p-value 0.000).
The problem of suicide risk is categorized into two based on the mean value (mean= 53.11), namely low suicide risk and high suicide risk. The suicide risk category can be seen in Figure 1.  Based on Table 3, most of the elderly are 60-74 years old with a low risk of suicide (38.2%) and a Pearson chisquare value of 0.308 which means that age is not significantly related to the problem of suicide risk in the elderly at the nursing home of Jember. Most of the elderly are female with a low risk of suicide (35.5%) with a Pearson chi-square value of 0.759, which means that gender is not significantly related to the problem of suicide risk in the elderly at the nursing home of Jember. Most of the respondents were widowed/widowed, including low suicide risk (23.7%) and high suicide risk (23.7%) with a Pearson chi-square value of 0.412, which means that marital status is not significantly related to the problem of suicide risk in the elderly at the nursing home of Jember. Most of the elderly in the nursing home of Jember are 1-5 years with a low risk of suicide (38.2%) with a Pearson chi-square value of 0.464 which means that length of stay is not significantly related to the problem of suicide risk in the elderly at the nursing home of Jember. Most respondents do not have a chronic disease with low suicide risk (50.0%) and a Pearson chi-square value of 0.173. This means that the presence or absence of chronic disease is not significantly related to the problem of suicide risk in the elderly at the nursing home of Jember. Most respondents with independent care have a low risk of suicide (39.5%) and a Pearson chi-square value of 0.531. This means that the level of dependence is not significantly related to the problem of suicide risk in the elderly at the nursing home of Jember.

Characteristics of the Elderly 1. Age
The results showed that age was not significantly related to the problem of suicide risk, with a Pearson chi-square value of 0.308. the results also showed that most of the elderly were in the age group 60-74 years (73.7%) with a low risk of suicide. This is in line with Andari's (2017) research that the incidence of suicide in the 60-70 year age group is lower than in the 71-80 year age group. Stuart (2013) also states that in the United States, the highest suicide rate is in the elderly over 80. According to Meiner (2015), the elderly who are at risk of suicide are in the age range of 75-85 years. An elderly person experiences physical and psychological changes (Nugroho, 2008). The elderly in the 60-70year age group experienced less significant changes so the elderly in that group could still carry out their activity daily living (ADL). In contrast to the age group > 70 years, in meeting their needs, they may need the help of others; psychologically the elderly feel a burden to others in their living. Therefore, the elderly who can still be independent and not too dependent on others can increase their self-esteem and quality of life, so they are far from suicidal thoughts.

Gender
The result showed that gender was not significantly related to the problem of suicide risk with a Pearson chisquare value 0.759. The result also shows that most elderly are female (65.8%) with a low risk of suicide. In line with Field Saputri & Sutejo (2020) research, elderly women are more at risk of suicide. In contrast to the theory of Stuart (2013), males are more likely to commit suicide than women, but women are more likely to attempt suicide. This study is also inversely proportional to Andari (2017), which shows that more men commit suicide (57%) than women. The risk of suicide that occurs in elderly women is because women are more sensitive and they are closer to their families, especially children. When they live at the nursing home of Jember, they may feel more isolated because there is no close family. In addition, women are more likely to have unstable emotions and are more easily stressed (Yusriana et al., 2019).

Marital Status
The result showed that marital status was not significantly related to the problem of suicide risk, with a Pearson chi-square value of 0.412. The result also showed that most of the elderly were widowed/widowed (47.4%), with 50% of the elderly at high suicide risk and 50% at low suicide risk. Research by Harahap & Amalia (2021), shows that the elderly who live alone have higher suicidal ideation than those who live with their partner. Meiner (2015) also mentions the elderly at risk of suicide, namely the elderly with widow/widower status and the elderly who live alone. Elderly people who do not live with their families feel that there is no longer a support system. The existence of a good support system in the life of the elderly will bring up good coping mechanisms as well so that the elderly will avoid maladaptive behavior and are not at risk of suicide (Stuart, 2013).

Long Stay in the Nursing Home
The result showed that the length of stay was not significantly related to the problem of suicide risk with a Pearson chi-square value of 0.464. The study also showed that most of the time, the elderly were in the nursing home was in the range of 1-5 years (63.2%) with a low risk of suicide. In line with research by Devianto & Ulfameytalia Dewi (2020), most elderly live in a nursing home for 1-5 years, namely 62.7%. this study was supported by Mumulati et al. (2020); in their research, it was stated that the length of stay in nursing homes was not significantly associated with depression. Depression lowers the concentration of suicidal ideation (Mumulati et al., 2020). The elderly who have just lived in the nursing homes need time to adapt to the existing life.

Chronic Disease
The result showed that the presence or absence of chronic disease was not significantly related to the problem of suicide risk with a Pearson chi-square value of 0.173. The result also showed that the majority of the elderly in the nursing homes of Jember did not have a chronic disease as much as 63.2% with a low risk of suicide. In contrast to the theory put forward by Meiner (2015) that the risk factor for suicide in the elderly is the presence of chronic disease. Stuart (2013) also mentions that a chronic physical illness is a predisposing factor for self-harm. The majority of the elderly at the nursing home of Jember is in fairly good health condition, so they can participate in activities or activities recommended by the nursing home. This makes the elderly avoid the emergence of suicidal ideation. 6. Dependency Level The result showed that the level of dependence of the elderly was not significantly related to the problem of suicide risk with a Pearson chi-square value of 0.531. The result also shows that the majority of the elderly are included in the level of independence namely 68.4% with a low risk of suicide. According to Meiner (2015), the risk factor for suicide in the elderly is when the elderly experience a high level of dependence. The older a person is, the lower his physical abilities will be so it can lead to disturbances in fulfilling his life needs (Marlita et al., 2018). The elderly with independent dependency levels still have good physical and psychological health and can do their own daily living (ADL) activity and not depend on other people.

Suicide Risk in Elderly at Nursing Home of Jember
The results showed a low risk of suicide in the elderly at the nursing home of Jember (55.3%). This study agrees with Oon-arom et al (2019), in their research where most dangerous suicides are low (24,1%). This allows the elderly in the nursing home to interact with fellow elderly and officers. Suicide risk problems can help improve social relationships between individuals, families, peers, and health workers such as nurses to provide attention and support to the elderly and hope that the elderly can be grateful for their lives (Saputri dan Rahayu, 2020;Moutier, 2021). Therefore, good social interaction skills can eliminate boredom and emotional disturbances so that they are far from problems that threaten suicide.
Based on the suicide ideation indicator, shows that indicator has a significant significance value (p-value 0,000 (<0,05)). This value means that the elderly at the nursing home of Jember has significant suicidal ideation. This research is supported by research (Harahap & Amalia, 2021), that the elderly experience suicidal ideation but are in the low Volume 3, Number 2 (June 2023) e-ISSN: 2798-5067 p-ISSN: 2798 category. The risk of suicide is low in the elderly at the nursing home of Jember because the elderly can still interpret their lives. This is evidenced by the indicator of a perceived meaning in life in this study has a significant value (p-value 0,000 (<0,05)). The elderly there have scheduled various activities, but nursing home also provides free time for the elderly to do whatever they like. Based on information from nursing home officers, the majority of the elderly there actively participate in activities. The elderly who actively participate feel satisfaction in their lives and have a strong spirit of life (Monika et al., 2020). This makes the elderly's interpersonal relationships increase.
The results showed that the death ideation indicator had a significant value (p-value 0,000 (<0,05)). Research by Bernier et al (2020), shows that the majority of respondents have no idea of death. In contrast to research by Briggs et al (2018), the elderly have more than 3% death ideation. The elderly in nursing homes want to die in an honorable way and under proper conditions. The elderly at nursing homes consider death a destiny that has been arranged by God so many elderly people feel resigned if death comes. According to Stuart (2013), it s stated that the elderly who have extensive coping resources such as spiritual beliefs can deal with the stressors they experience. The researcher argues that the age of the elderly it is perceived to be an age that is close to death so the elderly think about wanting to be closer to God.
The results showed that the indicator of loss of personal and social worth or loss of personal and social values had a significant value (p-value 0,000 (<0,05)) which means that the elderly at the nursing home of Jember experienced a significant loss of personal and social values. Pirker dan Katzensclager's (2017) research, states that some elderly people feel a loss of personal value. Loss of personal and social value is caused because the elderly experience a decrease in a physical condition which increases their dependence on others to meet their needs, thus making them feel a burden for their powerlessness. In addition, the elderly in nursing homes do not have the support system that they might have had before living in a nursing homes. Elderly people who are not with their family or loved ones are at high risk of having poor self-perception and low self-esteem (Williams, 2016). When a person feels low self-esteem, feelings of hopelessness and helplessness will lead depression and lead to the risk of suicide.
The results showed that the indicator of a perceived meaning in life has a significant value (p-value 0,000 (<0,05)) which means that the elderly at the nursing home of Jember still feel a high sense of meaning in life. Research by (Sa'id & Djudiyah, 2019)), states that the majority of the elderly feel the meaning of life. The results of a qualitative study from (Ardhani & Kurniawan, 2020), stated that the elderly who live in nursing homes have a good meaning in life. This is possible with increasing age, the elderly are more able to interpret life by increasing the spirit and welfare of life for their happiness (Baris et al., 2019). The higher the meaning of life felt by the individual, the positive perception in his life will emerge, but on the contrary, if the individual cannot find meaning in his life it will cause negative perceptions such as anxiety, fear, boredom, will cause feelings of depression (Stuart, 2013). Researchers argue that the meaning of life that is felt by each elderly varies depending on the life experiences he has gone through. Elderly who have a high meaning in life because the elderly feel that all life must be very grateful and enjoyed, so whatever happens in their life is a gift from God.
The nursing home of Jember actively provides routine activities that must be followed for the elderly who can participate, so that the elderly in the nursing home can be distracted from suicidal thoughts. Activities held by the nursing home are such as elderly gymnastics, religious activities (recitation), community service, and creative activities. This is in line with research by (Kowel et al., 2016), which shows that activities such as elderly gymnastics can reduce the degree of depression in the elderly. The elderly who actively participate in nursing homes activities can fill their time so they don't have the opportunity to think about suicide. Researchers believe that the activities provided by nursing home can improve the quality of life of the elderly and distract the elderly from suicidal ideation.