B. When the Senior has a Substance Use Problem

There are many misconceptions about seniors and substance use problems. First, it is commonly believed that older people do not drink, and that people with alcohol problems simply die off before they reach old age. (11) In reality, drinking is a common social behaviour among older adults. Approximately three quarters of people aged 65 and over drink occasionally or regularly, as do approximately one half of adults aged 75 and over. Drinking is more common among older men than older women.

Between 270,000 and 405,000 seniors in Canada experience problems in daily living as a result of alcohol use. (12) Studies typically indicate that between 6 and 10% of the general senior population have alcohol use problems. Among certain groups of seniors, the percentage of problem use is significantly higher. Rates are higher among widowers, individuals with medical problems and people in difficulty with the police. (13) For example, it has been estimated that 10-18% of general medical inpatients and 44% of psychiatric inpatients misuse alcohol.(14) A 1988 study, based on Winnipeg hospital statistics, indicated that 27% of seniors were admitted to acute care hospitals because of alcohol abuse, and the figure would  have been higher if medications were included. (15)

Older adults experiencing difficulties with alcohol are not easily noticed and therefore can escape detection when traditional clinical indicators of alcohol use problems are used. Some substance use/ senior abuse cases may come to the attention of the police. Most of these cases are not because of illegal behaviour on their part, as is the case for younger adults, but more often as a result of "unusual occurrence" calls where neighbours report not seeing them recently.

Understanding Alcohol Use Problems among Seniors

Seniors who have drinking problems are commonly divided into two distinct groups:

1) Early onset problem drinkers: These are individuals who began drinking relatively early in life and continue drinking into old age. Medical advances and the availability of detoxification and treatment, as well as genetic good luck, have allowed them to beat the odds of early mortality that many people who have alcohol problems face.

2) Late onset problem drinkers: These are individuals who began using alcohol late in adult life and show little if any evidence of any previous alcohol or drug use problems. Late onset problem drinking appears to be limited to situations where the person has been facing several major life crises that act as a "trigger" for the increased alcohol or drug use.

A third category is sometimes used for individuals who intermittently experienced problems with alcohol use throughout their lives, but in who develop a pattern of misuse in old age. They may have had several periods in their lives when they drink less or not at all. The drinking may increase or resume during periods of stress or crisis. In later life, these crises come closer together, or the person may become less successful at controlling his or her alcohol use.

Beatrice

Beatrice is a widow in her mid 70s. She is well off and lives in an affluent part of town. She has long-standing prescription drug and alcohol problems, but she denies that she is anything but a "social drinker".

She has two sons. The eldest lives in another province. He is considered a responsible family man. He does not get along with Beatrice's younger son, who is in his mid 30s. The younger son spends considerable time at his mother's home, but does not live there. Over the years he has been in trouble at work, and with friends and neighbours. In each instance, his mother has bailed him out.

Beatrice recently came to the attention of psycho-geriatric staff for assessment of her ability to function when her physician noticed that she had some memory problems (especially regarding financial matters). The assessment indicated that Beatrice is quite cognitively impaired. It was felt that this may be the result of a series of mini-strokes, her long standing alcohol consumption, prescription drugs, or some combination of these issues. As Beatrice's health deteriorates, her son's ability to provide care has become marginal.

There is some evidence that this son has been taking financial advantage of his mother. Money seems to be missing from her account. As well there are months of unpaid bills. Beatrice's car has been impounded when police stopped the son for a traffic violation and discovered that the car was not insured.

When social services became aware that there might be a problem, the situation escalated. While at the day care centre, Beatrice mentioned that the night before her son was acting very erratically, throwing chairs and other pieces of furniture around. When the police and social services investigated the matter later that day, the son stated "I'm insulted that you came here. You do not appreciate all the work I have done caring for her, and all the worry".

The son has threatened social services staff with statements such as "My father was a lawyer. I'll get his lawyer friends to take care of you guys". Her son also openly encourages his mother's drinking, by buying alcohol for her. Although Beatrice excuses her son's behaviour, she is unhappy with her relationship with him as it presently exists. However she still wants to maintain contact with him.

Harms: Financial abuse, psychological abuse, potential for neglect, potential to escalate to physical abuse. Risks: Isolation, physical injury and mental health deterioration, property (car) in jeopardy, unpaid bills.

Important Points

Older Women Who Have Alcohol or Drug Problems

Older women are less likely than older men to be recognized as having alcohol problems, partly because of stereotypes that professionals and other service providers, as well as family members have about what an older person who has an alcohol problem might look like. For example, in one study of women who attended Alcoholics Anonymous support groups, over 50% of them had approached their physician about their drinking, only to be told "you couldn't possibly have an alcohol problem". This may reflect the fact that many women who have alcohol problems are able to portray an image of calm and well-being to the world. They may hide feelings of low self esteem, doubt and pain. (16) At the same time, some health care providers draw conclusions about alcohol problems based on their personal alcohol use, as opposed  to focussing on the effect that the alcohol use is having for this specific older adult.

Older adults may not be aware that they even have a drug use problem, particularly where the drugs have been prescribed to them by their physician. Some drugs become problematic for older adults because the drug was only intended for short time use (e.g. benzodiazepines); it is too high a dose;  it is the wrong drug for the mental health condition; or the drug is interacting with alcohol or other drugs the person is taking, leading to mental confusion or other problems.

Alcohol use and other drug use problems are among much more common among women who have experienced abuse earlier in life, including childhood physical or sexual abuse, or domestic violence, than among women who have not experienced abuse. (17)

Research also indicates that physicians tend to prescribe mood altering drugs to women with symptoms of depression or anxiety rather than confront an obvious drinking problem they see in their patients. Older women appear to be at greater risk for physician-perpetrated drug abuse involving psychoactive medications than any other age or gender group. The women have become psychologically or physically dependent on the medication over time, using it even if it is causing harms in their lives. (18, 19) The unfortunate result is that older women may end up with two chemical dependencies, not one.

Alcohol Abuse and Cognitive Impairment

Long standing alcohol problems can leave the senior with some degree of cognitive impairment. Either the cognitive impairment or heavy alcohol use make it easier for the person to be financially abused by others, often without others experiencing any repercussions. (20, 21) Where the senior has a substance use problem, the abuser may easily deny or try to discredit  the senior's version of events or their financial situation -- "Oh, she can never remember how much she had in the bank; anyhow, she could have easily drank or given it away". Unless there are other sources of information, it becomes difficult to tell where the truth lies.

Service providers sometimes express frustration when the older adult appears to agree with a plan of service, but does not follow through. The person may be ambivalent or resistant to services offered. It is important to understand  that in some instances,  this  is not resistance. Long term, heavy alcohol consumption can cause damage to the frontal lobe, an important area of the brain for executive functioning (in other words, making and carrying out decisions). As a result of this brain damage, the person may have the desire to make changes in his or her life, but may lack the capacity to carry out those decisions.

Misidentification

The presence of an alcohol problem often confounds the identification of potential abuse cases. For example, when an abused senior goes to an emergency room with a fracture from a fall,  this may be erroneously attributed to drinking, when it was actually the result of being thrown down stairs.

In many instances both the alcohol problem and the senior abuse problem are overlooked by families and service providers. Sometimes this results from stereotypes about aging. People may misinterpret memory problems, problems with sleep, or seclusion as stereotypical behaviours of older adults, not an indication of an alcohol abuse or family violence problem.

Personal Values

Beatrice may need some assistance in order to remain relatively independent. However, health care and other service providers may view Beatrice's alcohol use problem as a moral issue, or believe her inability to stop drinking is simply a matter of "not having enough willpower." Health care providers may worry that in providing assistance and services, they may be enabling the person with the alcohol problem to continue drinking. This is a common misconception. It is important to distinguish between 

a) meeting the person's needs and helping them regain strength and confidence, and 

b) not meeting needs which the person could take care of themselves, if they were not drinking.

By way of contrast, the son's behaviour (buying the alcohol for his mother who has a substance use problem) is promoting harm.

Neutral Parties

In the example above, Beatrice may need assistance in managing her financial affairs. Although in many cases it may be preferable to have family or friends help her, the existing family conflict (mother- son; son-son) suggests that the involvement of a perceived neutral and trusted party such as the bank or an outside agency might be advisable.

Alcohol and Drug Treatment

Although the situation is gradually improving, older adults with alcohol use problems often find themselves in a "Catch 22" situation. Some are excluded from alcohol treatment services because of age and excluded from geriatric services because of alcohol problems. (20) The problem drinker may be known to many different agencies and may receive fragmented, ineffective and even contradictory advice, assistance or support.

In many instances, an agency may assume (or require) the older person must become abstinent at the onset of services. If so, this requirement will effectively exclude many older adults. However, older adults who are unwilling or unable to stop drinking or using the prescription drugs that may be causing problems in their lives can be helped by service providers using harm reduction approaches. 

Harm reduction refers to approaches that do not necessarily require the person to stop drinking to receive help.  The goal is to work towards less problematic alcohol use or abstinence. It is a non-confrontational and non-judgmental approach.  It also  focuses on helping the person to reduce some of the other problems that she or he may be experiencing, such as depression, housing problems, financial difficulties, health problems, or social isolation.

Service providers have also noted that there are certain points where an offer of assistance is more willingly accepted by a senior with an alcohol problem. For example, the older person's concern for physical problems as a result of hospitalization may be a starting point for providing service which can be expanded to include other services, such as dealing with alcohol use or the abusive situation.

Isolation

Both abusers and abused persons are often very isolated, which means the problem may be hidden for considerable time. Alcohol problems or abusive behaviour may remove possible "social checks" that would bring the abuse situation to light before the problem became life threatening.(21) This may prevent people from accurately detecting how dangerous the situation is until it becomes extreme and involves involuntary intervention by legal or other authorities.

Carlos

Carlos is 61. He has been married twice and is presently estranged from his second wife. He was divorced from his first wife because he was physically, psychologically, and sexually abusive, at first towards his children and later towards her. Although he states that he has mellowed with time, his second wife apparently left him because he would go on drinking binges and become very threatening.

Carlos's health has significantly deteriorated over the last six months. He recently was hospitalized for surgery for ulcerated colitis. Although he has a good pension, he has lost most of the money to drinking or "drinking buddies". He is at risk of losing his house because he is behind on paying his taxes.

He has four children, three of whom refuse to have anything to do with him. The eldest, however, lives in the same city, and has maintained minimal contact over the years. She explains "you cannot let your childhood feelings poison your life". Because of his poor health, including a recent stroke, Carlos will need ongoing help.

His daughter has agreed to do this "for the meantime" but would prefer some other arrangement. She visits him every day, helping with grocery shopping and driving. On several occasions she has discovered that he has had the local "runner" delivering alcohol to his home. During these times, the father and daughter have very violent arguments. Although Carlos is not cognitively impaired, his daughter has been making inquiries with authorities to see if his pension cheques can be signed over to her so that he does not use the money to buy alcohol. She has not asked for his consent.

Harms: Violation of rights (pension cheques), financial abuse (buddies). Risks: Isolation, health deterioration, property (house) in jeopardy, unmet care needs, physical injury.

This example illustrates some of the other problems commonly associated with early onset alcohol problems, and highlights the potential for abuse or violation of the older adult's rights. 

Where there is a history of heavy drinking, many family members may have distanced themselves from the person. The senior's physical health may significantly deteriorate over time. At that point, a particular family member may be expected by service providers to assume the task of providing care to a parent who has an alcohol problem. Often this is not by personal choice. The person can end up with the responsibility of providing care by virtue of 

Adult offspring who have survived abuse from a parent earlier in life, particular if it involved sexual abuse, will use a variety of "caregiving avoidance" strategies to balance the opposing needs of their parents and their own recovery process. These can include a) determined avoidance, b) remote caregiving, c) restrained support, d) no touch caregiving, and e) disengaged caregiving. (22)

The violent arguments between daughter and father in this case scenario may reflect a potential for abuse or neglect. The addictions literature suggests that some children of substance abusers (COSAs) may have a specific temperamental vulnerability. While there is wide diversity in this group, they are often described as having less ability to recover from emotional distress and are more likely to have rapid moods swings. (23) 

Most grown offspring of substance abusers do not abuse their parents. For some, this reflects the fact they have learned other coping styles as they've grown up and have had positive models in their lives. Others may have cut off any contact with the parent, eliminating the potential for abuse or neglect to occur. The question remains: What happens if these offspring in later life are thrown back in close contact with their substance abusing parents?

Dieter

Dieter is 67 year old. He retired from a large pulp and paper company two years ago where he worked for 45 years. He is married to Alice and has three sons. All of his life he has been described as a "go getter" and a perfectionist. He has always been moody and rigidly demanding in his home life and marriage.

Dieter has a history of drinking for most of his adult years, though when he was working he limited his drinking to weekends so that it never interfered with his work. Now that he is not working there does not seem to be any restraint on where, when or how often he drinks. Over time he has become increasingly paranoid and fearful, hostile and belligerent. At home, because he and Alice are alone much of the time, she faces much of his wrath. Alice has become increasingly depressed.

Dieter has refused any outside help, stating "That is my wife's responsibility. I brought home the bread all my life. She is supposed to take care of me and the house." He has threatened to kill himself on more than one occasion. The most recent occurrence was when he learned that one of his co-workers killed himself using a shotgun.

Harms: Psychological abuse of Alice, potential to escalate to physical abuse. Risks: Isolation, mental health deterioration (for both), potential for suicide/ homicide.

This example illustrates:

Depression is common among people who have alcohol use problems, affecting at least one in four. Alcohol use problems are also more common among people who have major mental disorders. Alcohol use can be a coping strategy for them. It may relieve some of the symptoms temporarily, but tends to cause other problems in the longer term. Whether the mental health problem is caused by the drinking or whether it functions independent of the drinking, both these issues must be addressed concurrently.

For more detailed information on how to help when the person has an alcohol use problem and depression, see the publication "Older Adults, Alcohol and Depression". (24)

There is also a risk for homicide-suicide, with Dieter killing his wife and himself.

Important Points

Each of these vignettes illustrates an important facet of the overlap between substance abuse and senior abuse cases:

Guiding Principles for Helping Older Adults Experiencing Substance Use Problems

The national project "Seeking Solutions: Canadian Community Action on Seniors and Alcohol Use Issues" has developed a number of best practice information sheets for working with older adults, including some guiding principle. (25) These principles include:

-    the need to respect the person. This is a person first, and secondly, a senior with a specific problem (in this case, an alcohol or another drug misuse or dependence problem).

-    the need to see the person behind the presenting problem. There is a need to deal with problems holistically. An alcohol problem is often only part of the senior's problems.

-    the importance of understanding that problems that developed over a long time are unlikely to get fixed overnight. It is important to take the needed time when providing assistance.

-   the need to respect the senior’s right to live at risk of different kinds of harm and the senior's right to make choices that you may disagree with. It is important to understand the nature of alcohol dependency, and how it can affect a senior's choices. Recognize the role that alcohol is playing in this person's life. Don't take away one coping mechanism (alcohol) without making sure there is a better coping mechanism in place.

-    avoid waiting for a crisis before responding and offering help. An older adult may not survive the crisis.

Summary

Many service providers, friends and neighbours are in an excellent position to help abused seniors whose lives are affected by alcohol problems. Older adults may be trying to deal with their own problems or they may be affected by the alcohol problems of others.

If we are to play this role effectively, however, several things must occur. First, we need to recognize the nature and extent of alcohol and other drug use problems in abusive situations. Second, we must combine the knowledge and skills we have in our own area of expertise with the specialized knowledge and skills of others who are well informed about the complexities of growing old, abuse, and substance abuse.

Effective assistance is dependent on recognizing the diversity of what constitute abuse or neglect for older persons, understanding the role that problem drinking or other substance abuse takes in abuse and neglect cases, adopting goals that reflect this range of problems, and implementing assistance or intervention techniques suited to the specific problem and goals.

References

1.     Bradshaw, D. & Spencer, C. “The Role of Alcohol in Elder Abuse Cases”. (1999) Elder Abuse Work: Best Practice in Britain and Canada (ed. by J. Pritchard) (London, Eng.: Kingsley Publishing) .

2.      Pittaway, E. & Gallagher, E. (1995). A Guide to Enhancing Services for Abused Older Canadians. Victoria, B.C.: Office for Seniors & Interministry Committee on Elder Abuse.

3.      Hayes, H.R. & Emshoff, J. G. (1993). "Substance abuse and family violence" in R. G. Hampton, T. P. Gullota et al. (eds.) Family Violence: Prevention and Treatment Newbury Park, Calif: Sage, pp. 281-310 at 282.

4.      M.D. Pagelow (1984). Family Violence. New York: Praeger, 87-97; see also Walker, L. W, (1984). The Battered Woman Syndrome. New York: Springer.

5.      Hayes, supra, n. 3 at 282.

6.      For arguments on both sides of the debate, see J.P. Flanzer (1993). "Alcohol and other drugs are key causal agents of violence", p.171-182 and Gelles, R.J. (1993). "Alcohol and other drugs are associated with violence- they are not its cause", both in R.J. Gelles & D.L. Loeske (eds.) Current Controversies on Family Violence. (Newbury Park, Calif.: Sage) 182-196.

7.      Hayes, supra, n. 3 at 286.

8.      Hayes, supra, n. 3 at 282.

9.      Hayes, supra, n. 3 at 300.

10.    Pittaway, supra, n. 2-- 43.9% of cases reflected the abuser being very controlling of the client.

11.    Ibid. at 68.

12.    Ministry of Health and Ministry Responsible for Seniors (June, 1994) Report on Older Adults and Alcohol Misuse. Victoria, B.C.

13.    National Advisory Council on Aging (1989) 1989 and Beyond: Challenges of an Aging Canadian Society. Ottawa.

14.    Schuckit, M.A. (1977). "Geriatric alcoholism and drug abuse." Gerontologist, 17: 168-174.

15.    Grymonpre, R., Mitenko, P. Sitar, D., Aoki, F. & Montgomery, P. (1988) " Drug associated hospital admissions in older medical patients. Journal of the American Geriatrics Society 36, 1092-1098.

16.    Glantz, M. & Backenheimer, M. (1988). "Substance abuse among elderly women" Clinical Gerontologist, 8, 3-26.

17.    See for example, Brems C, Namyniuk L: The relationship of childhood abuse history and substance use in an Alaska sample. Substance Use and Misuse, 2002, 37(4):473-494. Freeman RC, Collier K, Parillo KM: Early life sexual abuse as a risk factor for crack cocaine use in a sample of community recruited women at high risk for illicit drug use. American Journal of Drug and Alcohol Abuse, 2002, 28(1):109-131. Ouimette PC, Kimerling R, Shaw J, Moos RH: Physical and sexual abuse among women and men with substance use disorders. Alcoholism Treatment Quarterly 2000, 18(3):7-17. Simpson TL, Miller WR: Concomitance between childhood sexual and physical abuse and substance use problems: a review. Clinical Psychology Review, 2002, 22(1):27-77.

18.     Hubbard, R-W; Santos, J-F & Santos, M.A. (1979). Alcohol and older adults: Overt and covert influences. Social Casework: Journal of Contemporary Social Work, 60(3):166- 170, at 167.

19.    Hayes, supra, n. 3 at 295; also Tarter, R.E., Alterman, A. E., & Edwards, K. L. (1985) "Vulnerability to alcoholism in men: a behavioural-genetic perspective." Journal of Studies on Alcoholism, 46, 329-356.

20.    Ibid at 140.

21.    Gulino, C. & Kadin, M. (1986) "Aging and reactive alcoholism", Geriatric Nursing, 7 (3) 140-151 at 151.

22.    Joseph, C.J. & Rose, M.R. (1994). Female incest survivors: caregiving for aging parents. Journal of Women and Aging. 6 (3): p. 53-68.

23.   Hayes, supra, n.3.

24. Older  Adults, Alcohol and Depression. May 2003. Seeking Solutions: Canadian Community Action on Seniors and Alcohol Use Issues

25. Seeking Solutions: Canadian Community Action on Seniors and Alcohol Use Issues, Guiding principles for services  providers helping older adults who have substance use problems.  See also the Best Practices sheet on Guiding Principles.

Additional Resources and Readings

If you are looking for a good article that helps explain the lives and circumstances of older women who have experienced abuse in their lives, see: "Unmet Needs of Older Women in a Clinic Population: The Discovery of Possible Long-Term Sequelae of Domestic Violence" written by B. Wolkenstein and L. Sterman, Professional Psychology: Research and Practice (1998), Vol. 29, No. 4, 341-348.

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