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Abstract

Poisoning is considered a significant health problem among elderly people in Poland. This report refers to patients treated for poisonings at the Toxicology Unit, Lodz, Poland, during the period 2008–2012. The data to be analyzed were obtained from medical records of elderly people. A group of 1167 patients aged 60+ was selected. The number of intentional poisonings in the group of patients was 417, which accounted for 35.7% of all poisonings among the elderly people. Patients attempting intentional poisonings included 301 (72.2%) women and 116 (27.8%) men. The most common cause of intentional poisonings were drugs—96.6% (n = 403). Benzodiazepines (46.9%) dominated among the intentional poisoning by drugs. During the analyzed 5 years, 80.3% (n = 335) were suicidal poisonings and 19.7% (n = 82) were demonstrative poisonings. Cardiovascular disease, which was diagnosed among 53.5% of the patients, was the most common physical illness. In conclusion, drugs are the most frequent type of the toxic agent responsible for poisoning cases among the elderly people. In this situation, the role of family doctors is very important: they should prescribe medicines in amounts not greater than absolutely necessary and maybe more often recommend psychiatric care for the elderly patients.

Keywords

Epidemiology poisonings human toxicology

Introduction

The growing number of poisonings by xenobiotics is an important issue of public health at the present stage of civilization development in many societies. Acute poisonings by drugs, alcohol, solvents, pesticides, psychoactive substances, plant toxins and animal venoms are an important and difficult problem, both for medical and social reasons. The effects of poisonings, and intentional ones in particular, affect not only the person attempting suicide but also his/her family and friends. In many countries, the number of suicide attempts continues to increase, and they occur among different social groups, including very young children. The increasing number of intentional poisonings among the elderly is another major source of concern.

The development of civilization and continuing progress in medicine results in aging population. Longer average human life, reduced premature mortality and declining birth rates are responsible for the growing proportion of elderly people worldwide.¹ Demographers forecast that the aging process of humanity in the coming years will continue to intensify.

People over 60 years of age represent a steadily increasing proportion of the population, also in Poland. According to data by the Central Statistical Office, in 2008, in Poland, the proportion of people 60 or older was 18.6% of the general Polish population. In 2012, the proportion increased to 20.9%.²

Comparing the 2008–2012 demographic data for Lodz, which is the third most populated city in Poland, we can see that the aging process at the local level is even more evident. The proportion of people 60 and older, living in Lodz in 2008, was 23.7%, whereas in 2012 it increased to 27.0%.²

Old age is a universal phenomenon, it is also encumbered with many handicaps. Elderly people are exposed to numerous somatic diseases, and the incidence of those diseases increases with age. They are also faced with loneliness, poverty, social isolation, unfriendly, and sometimes even hostile attitudes of young people.³ Advanced age is also associated with various deficits not only in health but also in social status, autonomy, and so on.⁴ That is why suicide rates, including suicide by autointoxication, among the elderly are higher than in other age groups.^3,5,6

Suicide attempts during early and late old age are an ever-growing phenomenon. However, cases when they have become the subject of research and scientific publications continue to be extremely rare. Studies on suicide among the elderly are published most frequently in the context of psychiatric research regarding depression and suicide attempted during the critical period, the depressed mood.

Therefore, the main aim of this study was to analyze the incidence of intentional poisonings among the elderly and old people living in a large urban agglomeration in Poland. An attempt was also made to examine how the characteristics of poisonings are related to the age and sex of the victims.

Methods

This retrospective study was conducted by the team from the Poison Information Centre (PIC), which is an integral part of the Department of Occupational Diseases and Toxicology at the Nofer Institute of Occupational Medicine (NIOM) in Lodz. All adults (18 and older) residing in Lodz and surrounding area, with suspected or diagnosed acute poisoning, are referred for treatment in the Toxicology Unit (TU NIOM). In 2012, the last year of the analyzed period, the population of residents of the area served by the TU comprised 1,106,579 people, of whom 937,654 were adults. The poisoning rate (number of poisonings per 1000 adult inhabitants) was 1.94.

Medical documentation of TU NIOM patients in Lodz, hospitalized in the period from 1 January 2008 to 31 December 2012, was used as the material for the study. Pre-admission diagnoses of poisoning are confirmed or rejected at the TU by a professional team of employees. Toxicologists (based on physical examination, an interview with the patient and/or witnesses to the event, anamnesis of the history of pre-existing illnesses and events of similar type and the results of laboratory tests) assess a patient’s condition and the severity of poisoning according to the three-point Poisoning Severity Score.

Data on people 60 or older were extracted from medical records of all patients in which the occurrence of acute poisoning was confirmed during the period 2008–2012. Then the material was divided into three age groups: 60–65, 66–75, and >75. Data analysis was conducted methodically and in accordance with the checklist developed specifically for the needs of the present study.

Variables collected in a specially developed database included sociodemographic data (gender, age, place of residence, and marital status), type of poisoning, information about previous suicide attempts, name of the toxic agent(s) responsible for the poisoning, the time of admission to the TU (at 4-h intervals), somatic diseases occurring before the poisoning, patient’s condition at admission, duration of hospitalization, and treatment outcome. Type of poisoning, according to the information specified in the patient’s medical history as “the final clinical diagnosis”, was included into one of three groups: intentional poisoning, unintentional (accidental) poisoning, and abuse. The intentional poisoning category was divided into two subgroups: suicidal poisoning (where the intention of the patient was to die, as disclosed during the psychiatric and/or psychological consultation) and demonstrative poisoning (where the intention of the patient was to call for help or exert pressure on the social environment, etc.). The categorization of toxic agents had been made during the study using the International Statistical Classification of Diseases and Related Health Problems, ICD-10. Poisoning by drugs, pharmacological and biological substances was coded using T36–T50 codes. Codes T51–T65 were used to encode intoxication by non-pharmacological substances (alcohols, solvents, caustics, detergents, metals, gases, pesticides, plants, and animal venoms).

The procedure of the study was approved by the Bioethics Committee at NIOM in Lodz, Poland.

Statistical analysis

STATISTICA (StatSoft, Inc.), version 14.0 software, was used for the statistical analysis of the results. Due to the qualitative nature of the analyzed nominal variables, χ², Pearson’s test of linear correlation, and Fisher exact tests were used. A p value less than the adopted level of significance (α = 0.05) was considered statistically significant.

Results

In the years covered by the study, a total of 11,010 people with confirmed diagnosis of acute poisoning were hospitalized at the TU in Lodz. A separate group of 1167 patients aged 60+ was selected. The number of intentional poisonings in this group of patients was 417, which accounted for 35.7% of all poisonings among elderly people. The number of poisonings among elderly people in the particular years of study, in absolute terms, showed an upward tendency (Figure 1).

Figure 1.

Number of the 60+ patients treated at the TU in 2008–2012. TU: Toxicology Unit.

Altogether, during the analyzed 5 years, 80.3% (n = 335) were suicidal poisonings and 19.7% (n = 82) were demonstrative poisonings. The most common cause of intentional poisonings was drugs in 96.6% (n = 403). The remaining relatively small proportion (3.4%) was due to agents such as pesticides, corrosives or irritants, gases (carbon monoxide), alcohols, and metals. Benzodiazepines (46.9%) dominated among the intentional poisoning by drugs (Table 1). Single drug poisoning was reported for 247 (61.3%) patients, the remaining patients were poisoned by two or more drugs. Mixed intoxications (drugs and ethanol) were found in 21.8% (n = 88) patients in the 60+ age group.

Table 1.

Frequency of intentional poisonings and drug category (N = 403).

	Women (n = 295)		Men (n = 108)		Total (N = 403)
Drug category	n	%n	n	%n	N	%N
Benzodiazepines	139	47.1	50	46.3	189	46.9
Other sleep-inducing drugs and sedatives	49	16.6	11	10.2	60	14.9
Cardiovascular	42	14.2	11	10.2	53	13.2
Analgesics	41	13.9	10	9.3	51	12.7
Other drugs	32	10.8	14	13.0	46	11.4
Phenotiazine derivative	30	10.2	12	11.1	42	10.4
Anti-epileptics	23	7.8	16	14.8	39	9.7
Tricyclic antidepressants	26	8.8	9	8.3	35	8.7
Typical neuroleptics	16	5.4	7	6.5	23	5.7
Atypical neuroleptics	13	4.4	6	5.6	19	4.7
Opioid analgesics	11	3.7	5	4.6	16	4.0
Selective serotonin re-uptake inhibitors	7	2.4	2	1.9	9	2.2
Cough medicines	6	2.0	2	1.9	8	2.0
Oral antihyperglycemic drugs	2	0.7	4	3.7	6	1.5
Total	437		159		596^a

^aThe number of patients poisoned by drugs is smaller than the number of drug categories because 38.7% of the patients were poisoned by drugs belonging to more than one category.

Assessment by seasons showed that most intentional suicides were attempted in the third quarter of each year, an average of 27.3% (n = 114), while lowest numbers, 21.3% (n = 89), were noted in the first quarter.

Cardiovascular disease, which was diagnosed among 53.5% of patients, was the most common physical illness coexisting in the elderly patients diagnosed with suicidal poisoning (Table 2). For the elderly people, hospitalized for demonstration poisoning, the corresponding proportion was slightly higher (54.9%).

Table 2.

Frequency of somatic diseases in patients after intentional poisoning (%, N = 417).

Somatic disease	Age group						Total
	60–65		66–75		>75		Total
	n	%	n	%	n	%	N	%
Arterial hypertension	53	29.28	59	42.45	37	38.14	149	35.73
Ischemic heart disease	22	12.15	12	8.63	22	22.68	56	13.43
Sclerosis	1	0.55	1	0.72	1	1.03	3	0.72
Myocardial infarction	1	0.55	1	0.72	1	1.03	3	0.72
Stroke	6	3.31	4	2.88	2	2.06	12	2.88
Gastrointestinal diseases	1	0.55	3	2.16	1	1.03	5	1.20
Cancer	5	2.76	3	2.16	3	3.09	11	2.64
Diabetes	13	7.18	12	8.63	7	7.22	32	7.67
Asthma and other respiratory diseases	7	3.87	6	4.32	4	4.12	17	4.08
Other somatic disease^a	34	18.78	17	12.23	10	10.31	61	14.63
NA	38	20.99	21	15.11	9	9.28	68	16.31
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	ns

NA: no available (no information in patient’s medical history); ns: non-significant

^aIncludes osteo-arthral diseases, vision and hearing disorders, polineuropathies, Parkinson disease, and so on.

Data collected in patients’ medical records show that in 77.0% (n = 321) of the patients, the current attempt of autointoxication was the first one requiring hospitalization. In 96 (23.0%) patients, the current suicide attempt was the second, or another one of a series of suicide attempts.

The majority of patients (23.5%) were admitted to the TU between 12.00 p.m. and 4.00 p.m. The lowest percentages of admissions (5.0%) were recorded at 4.00–8.00 a.m.

More than half (56.6%) of those patients poisoned intentionally were admitted to the TU in good general condition. On average, one in five (21.3%) admitted patients was in a severe condition. In the analyzed group of intentional poisonings in the 5-year period, 13 (3.1%) patients died.

More than half of the patients (53.9%, n = 225) hospitalized at TU NIOM were referred for further treatment in a psychiatric hospital. Twenty per cent (n = 82) of the patients were referred for treatment in the psychiatric outpatient clinic. Only 7.4% of patients leaving the TU were in good condition and did not require further treatment.

The frequency of poisonings versus age and gender

The highest percentages of intentional poisonings were noted for patients aged 60–65. In the consecutive years of the study this percentage increased: in 2008 it was 32.1% and in 2012 it was 45.7% (with a 5-year mean of 42.9%). Patients aged 66–75 accounted for one-third (33.5%) of the study group and their percentage in the analyzed period decreased from 44.6% in 2008 to 35.1% in 2012. The oldest patients represented the smallest proportion (23.6%) of the study group and their proportion relative to the total study population also continued to decrease throughout the study period.

The frequency of suicidal poisonings increased with age: 76.8% in the 60–65 group and 80.6% and 86.6% in the next two age groups, respectively, while the proportion of demonstrative poisonings decreased. However, the differences observed in the frequency between individual age groups were not statistically significant (p = 0.146). The weak statistical relationship became apparent only in the results of the linear test (p = 0.052).

Table 3 shows the results of analysis of the frequency of intentional poisonings in age groups versus sociodemographic characteristics. Women dominated in the three groups were compared in our study; their proportion increased with advancing age. Analysis of the frequency of poisonings versus age and gender showed significant statistical differences (p < 0.01).

Table 3.

Selected sociodemographic characteristics and intentional poisoning frequency in age groups (%, N = 417).

	Age group						Total
	60–65		66–75		>75		Total
Analyzed characteristic	n	%	n	%	n	%	N	%
Gender
Women	120	66.30	100	71.94	81	83.51	301	72.18
Men	61	33.70	39	28.06	16	16.49	116	27.82
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	p < 0.01
Marital status
Single	34	18.78	31	22.30	20	20.62	85	20.38
Married	98	54.14	64	46.04	24	24.74	186	44.60
Widowed	14	7.73	27	19.42	48	49.48	89	21.34
Divorced	19	10.50	8	5.75	0	0.00	27	6.47
NA	16	8.84	9	6.47	5	5.15	30	7.19
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	p < 0.001
Residence
Lodz	123	67.96	118	84.89	80	82.47	321	76.98
Lodz province	52	28.73	20	14.39	17	17.53	89	21.34
Other province	2	1.10	0	0.00	0	0.00	2	0.48
Homeless	3	1.66	1	0.72	0	0.00	4	0.96
Foreigner	1	0.55	0	0.00	0	0.00	1	0.24
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	p < 0.01

NA: no available (no information in patient’s medical history).

The study has also confirmed a strong correlation of the frequency of intentional poisonings with marital status and age of the hospitalized patients (p < 0.001). Cardiovascular diseases were diagnosed as the most common disorder in the hospitalized elderly people and their frequency becomes higher with age: 44.9% in the 60–65 group; 54.4% in the 66–75 group, and 65.5% in the >75 group (Table 2). It is interesting to note the high proportion of patients diagnosed with diabetes.

Data on the course of treatment: patient’s condition at the time of admission to the TU, time of stay in the hospital ward, and the final effect of the treatment are summarized in Table 4. Most patients of every age at admission were in moderate to severe condition. The largest group of patients admitted to the TU in the severe condition were the oldest, over 75 years. Those patients were also hospitalized for the longest time. In the analyzed period in the TU, as a result of intentional poisoning, 3 people died in the 60–65 group and 2 patients died in the 66–75 group. The highest number (8 of fatal cases) was noted among the oldest patients.

Table 4.

Hospitalization course of patients with intentional poisonings (%, N = 417).

	Age group						Total
	60–65		66–75		>75		Total
	n	%	n	%	n	%	N	%
Patient’s general condition at the time of admission to TU
Good	38	20.99	35	25.18	19	19.59	92	22.06
Average	109	60.22	80	57.55	47	48.45	236	56.59
Grave	34	18.78	24	17.27	31	31.96	89	21.34
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	ns
Time of patient stay at TU
1 day	26	14.36	21	15.11	7	7.22	54	12.95
3 days	64	35.36	41	29.50	32	32.99	137	32.85
4–7 days	85	46.96	70	50.36	49	50.52	204	48.92
Longer than 1 week	6	3.31	7	5.04	9	9.28	22	5.28
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	ns
Patient condition and effect of treatment at TU
Good, no recommendation	13	7.18	12	8.63	6	6.19	31	7.43
Released at her/his own request	12	6.63	7	5.04	0	0.00	19	4.56
Referred to
Specialist outpatient clinic	9	4.97	11	7.91	8	8.25	28	6.71
Psychiatric outpatient clinic	45	24.86	23	16.55	14	14.43	82	19.66
Psychiatric hospital	91	50.28	80	57.55	54	55.67	225	53.96
Other hospital	8	4.42	4	2.88	7	7.22	19	4.56
Death	3	1.66	2	1.44	8	8.25	13	3.12
Total	181	100	139	100	97	100	417	100
p in frequency comparison test	p < 0.01

ns: non-significant; TU: Toxicology Unit.

The frequency of first-time intentional poisonings increased with age and the relationship was statistically significant (p < 0.05). The first-time suicide was attempted by 71.3% of patients aged 60–65 years; in the following age groups the corresponding values were 80.6% and 82.5%, respectively. There were no statistically significant differences in age groups in the incidence of repeated intentional suicidal attempts; second suicide was attempted by 17.1%, 16.6%, and 17.5% of patients in different age ranges; the third suicide was attempted by 7.7% and 2.9% of patients in the first and second age group, respectively. Patients in the oldest age group did not attempt suicide more than twice.

Discussion

PIC in Lodz for many years has already published reports on epidemiology of acute poisoning, including many aspects of this issue. Until 2002, the information collected in PIC (in the form of questionnaire sheets received from toxicology centers throughout Poland) allowed publication of materials covering various aspects of acute poisoning in the whole of Poland. Due to a change in legal regulations, this information is now no longer received, and PIC in Lodz systematically produce statistics valid only for Lodz agglomeration. There is currently no center in Poland responsible for recording and storing the information on cases of suicidal attempts, while results of research on intentional poisoning among older people inhabiting the area of operation of one of the national centers of toxicology were published longer than a decade ago.^7
–9 It is, therefore, advisable to undertake current research in order to obtain knowledge on intentional poisonings in the population, particularly to elucidate the nature of this phenomenon among the elderly people. The results of the study confirmed that older women are more likely than men to attempt suicide. The ratio of suicidal attempts among women to men was 2.6:1; similar data were obtained in studies performed in 2004 in Krakow, Poland.^7,8

According to a study launched by the World Health Organization (WHO START Study) spanning over different parts of the world, women are more likely to attempt suicide than men.¹⁰ The exception is the Philippines, where the ratio of nonfatal suicidal attempts among women in relation to men was 1:1.7.

With the aging of the population living in the agglomeration of Lodz, the proportion of older people treated for acute poisoning at the toxicology ward has increased. Test results published in earlier PIC publications^11,12 as well as information presented in this work confirm this observation. The importance of the problem of deteriorating mental health of the Polish population has been highlighted by a report prepared in April 2015 by the Bureau of Research of the Polish Parliament.¹³ The authors of that report state that one of the major indicators of mental health, namely mortality rate due to suicide among men in Poland is higher by nearly 68% than the average for EU countries. According to data from the General Headquarters of Police,¹⁴ the total number of suicidal attempts and suicides committed by older people in 2008–2014 has dramatically increased. The largest increase was recorded in the age range 60–65, as confirmed by the results of our research.

In our studies of suicidal poisonings among the elderly people, we have found that the percentage of widowed people grows, while the proportion of married people decreases with age. Many studies have shown that death of one’s spouse is one of the major reasons to attempt suicide.^15
–17 The first year after the death of a loved one is critical the number of suicidal deaths is twice higher than in later years.¹⁶ Relevant literature data also show that the frequent reason to attempt suicide among widowers and divorced men is the loss of their life partner and the accompanying depression.^18,19 It seems that with men, marriage is a factor that protects from suicide, while among women this relationship is not statistically significant.²⁰

Evaluation of data on seasonality of suicidal attempts, collected from thirteen European centers in a study conducted by WHO, showed that the largest number of such attempts was noted in May.²¹ This relationship was valid in particular for women.²¹ Different results on suicidal attempts of women were obtained by R. Mergl et al.²² in a study performed in Northern Bavaria, Germany. Fewest suicidal attempts were recorded among women during the spring months, while the frequency of attempts by men in individual months did not differ significantly. The results of the analysis in this article are different from those quoted above. Most suicides in the Lodz agglomeration among the elderly people were attempted in the period from July to September, and the fewest from January to March.

In their suicidal attempts, elderly people most often used prescription drugs.^7,9,18 This is confirmed by our findings: drug intoxication was the method of choice by older people attempting suicide. The most commonly used drugs to attempt suicide were benzodiazepines, responsible for the largest proportion of poisonings, which is also confirmed by other studies.^23
–25 Our data also show that single-drug intoxication accounted for the highest proportion of the poisonings. Drug poisoning accompanied by ethanol intoxication accounted for more than 21%. The results are consistent with the literature data, in which single-drug poisoning prevailed, followed by poisoning with several drugs, and drugs in combination with alcohol.²⁴ Accessible information indicates that women most often choose drugs to commit suicide.^15,24 Men, on the other hand, more often than women choose poisoning by drugs in combination with alcohol.^15,24

In our study, substances other than drugs (e.g., corrosive agents, pesticides, and gases) accounted for a small percentage of cases. The corresponding data for industrialized countries are similar.^6,26

The coexistence of somatic diseases, especially cardiovascular disease, associated with the severity of the symptoms and often poor prognosis, may be one of the reasons to attempt suicide. In the study population of Lodz agglomeration, we found that in elderly patients the cardiovascular disease was most common. Most authors confirm this relationship and specify cardiac and circulatory disease as a factor that may contribute to attempt suicide. The risk is elevated in patients who are chronically ill and have been diagnosed with more than one somatic disease.^27
–29 According to some authors, the risk of suicidal attempt increases not as a result of diagnosed disease itself, but rather as a result of the accompanying factors, such as the experience of physical pain and suffering, subjective feelings of hopelessness, uncertainty associated with the disease, loss of independence, and the need to use other people’s care.^29,30

In our study, more than half of patients over 60 were admitted to the TU in moderate to severe condition. In a study by Polewka et al.⁷ on the elderly people after intentional poisoning, in most patients the degree of poisoning was mild. We have also found that in the majority of people diagnosed with acute poisoning, hospitalization began in the afternoon. Similar data on suicidal attempts were obtained in a study of older people in Tehran; 42.5% of patients were brought to the hospital between 7 p.m. and midnight.²³ Data on that issue in the relevant literature are not consistent. Some authors^15,19,31 claim, for example, that suicides committed by the elderly people occur in the morning, but the time of day with the highest number of suicidal attempts was late in the evening or the first half of the night.

Those discrepancies in the description of the nature of suicidal attempts by autointoxication among the elderly people result from the character of this social phenomenon, that is, intentional poisoning. They also stem from the differences in the applied diagnostic procedures.

In reporting results of our present study, we are aware that our data are probably underestimated due to limited reliability of the data that may result from subjects’ reluctance to admit that the poisoning was intentional for fear of stigmatization, and so on. The heterogeneous system of recording information on poisoning by multiple diagnostic and therapeutic teams employed in the TU may also adversely affect the reliability.

In conclusion, drugs are the most frequent type of the toxic agent responsible for all poisoning cases among the elderly people. In this situation, the role of family doctors is very important: they should prescribe medicines in amounts not greater than absolutely necessary and maybe more often recommend psychiatric care for the elderly patients.

When assessing the frequency of individual types of poisonings, it can be seen that in the intentional poisoning category, the frequency of the suicidal poisoning increases, while the proportion of the demonstrative poisonings decreases with age.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Intentional poisoning among elderly people—residents of a large urban agglomeration in Poland

Abstract

Keywords

Introduction

Methods

Statistical analysis

Results

The frequency of poisonings versus age and gender

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

References