Alcohol and Senior Abuse Cases
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The presence of alcohol problems is one of the most commonly listed risk indicators in abuse and neglect of older adults.
Two Different Roles
There are two main ways in which alcohol use problems may be part of abuse and neglect cases involving older adults.
The classic case is where the person committing the abuse or neglect has the substance use problem. A study examining "elder abuse" case files from agencies across Canada found that severe drinking bouts by the abuser lead up to the abuse in 14.6% of the cases. In another 18.7% of the client records, the clients indicated that the abuse was secondary to alcoholism. (1)
The second case (which is probably as common), is where the older adult has a substance abuse problem. For some, it is alcohol, and for others, it is medications. For many it is both.
For example, the Seniors Well Aware Program, an outreach program in Vancouver, British Columbia for seniors with substance abuse problems, reports that 15-20% of their clients also experience senior abuse from spouse, family, friends or neighbours. Many of these cases involve seniors whose memory is impaired or who are frail.
Both of these cases (abuser with substance abuse problem, and senior with substance abuse problem) have their own special features and there are undoubtedly many variations on these two types.
A. When the abuser has an alcohol or other substance problem:
A person with an alcohol or drug problem may abuse the senior, either physically, psychologically or financially. Sometimes a person who is responsible for giving care, fails to live up to that responsibility because he or she drinks heavily. Or the person has tried to give care, but the caregiving and stresses are too great for his or her abilities, and the person turns to alcohol as a coping strategy.
Physical Abuse (e.g. assault):
It is not surprising to find alcohol or drug abuse problems in many of abuse cases in later life. Younger people with alcohol problems tend to be more hostile, impulsive and aggressive than people who do not have a problem with alcohol, although it is unclear whether this aggressiveness also holds for older people who have alcohol problems or for both sexes.
Alcohol is consistently implicated in wife abuse by male batterers. (2) Research and clinical practice indicate that abuse is more likely to occur when intoxication is present. (3) The injuries, that substance abusers inflict while intoxicated are often more serious as well. (4) In cases of extreme violence (such as assaults with a weapon or murder), the abuser is frequently a chronic drinker or drug user.
At this point we know that there is a connection between family violence and alcohol, but the nature of the connection is unclear. (5) Abusers often use their inebriation as a way of rationalizing their behaviour ("I was drunk at the time, I didn't know what I was doing"). Alcohol use may lower inhibitions, but it has been suggested that some abusers get drunk in order to abuse.
Psychological Abuse (e.g. threats, intimidation):
Emotionally, people who have alcohol problems often experience low self esteem, loss of impulse control, lability ("hot tempers"), anger, guilt, anxiety and depression. (6, 8) Psychological abuse by a chemically dependent person often takes the form of degradation, humiliation, terrorizing and threatening, with the goal of destroying the other person's self worth. This abuse includes the following behaviours:
a) rejecting an individual by verbally degrading him or her;
b) terrorizing a person by having them witness violence, using verbal threats, intentionally creating a climate of intense fear and unpredictability;
c) ignoring the person, not protecting the person from dangerous situations; or
d) isolating the person from normal opportunities for social interaction and relationships.(7)
A person who has a substance abuse problem will sometimes go to extreme measures to ensure that he or she has a continuing supply of alcohol or drugs. That often means getting money from what source is the most readily and easily available. Theft or fraud of family members is quite common.
The Relationship Between Substance Abuse and Senior Abuse
Many elements that are commonly ascribed to senior abuse cases also apply to substance abuse. Both the abusive family and the family where there is chemical dependence are characterized by guilt, shame and denial. This makes it difficult for service providers to enter into either system and facilitate change. (8) Both types of problems can be challenging and resistant to offering assistance.
"Co-dependency" refers to a person who does not personally have the substance abuse problem, but instead is significantly affected by someone who has the problem. People who are in a relationship with an individual with a substance use problem may take on a lot of responsibility for that person's behaviour. They may rationalize or minimize the negative effects of the other person's behaviour.
Special Challenges to Providing Services
B. When the Senior has a Substance Abuse Problem:
There are many misconceptions about seniors and substance abuse problems. First, it is commonly believed that people with alcohol problems simply die off before they reach old age. (11) According to the National Advisory Council on Aging, there are between 270,000 and 405,000 seniors in Canada experience problems in living as a result of alcohol use. (12) Studies typically indicate that between 6 and 10% of the general senior population have alcohol problems.
However, among certain groups of seniors, the percentage is significantly higher. Rates are higher among widowers and individuals with medical problems and those 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 admitted to acute care hospitals because of alcohol abuse and the figures is higher if medications are included. (15)
Older adults experiencing difficulties with alcohol are not easily noticed and therefore can escape detection when traditional indicators are used. They may come to the attention of the police, not because of illegal behaviour, 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 Abuse 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 allow 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 no evidence of any previous problems. Late onset problem drinking appears to be limned to situations, with major life crises being more prevalent as "triggers".
A third category is sometimes used for individuals who intermittently experienced problems with alcohol use throughout their lives, but in old age developed a pattern of misuse. They may have had several periods in their lives when they are drinking less or not at all, and the drinking increases or resumes during periods of stress or crisis. In later life these crises come closer together, or in old age, they may have become less successful at controlling their alcohol use.
Beatrice is a widow in her mid 70s. She is well off and lives in an affluent part of town. She has long-standing 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 which may be the result of a series of mini-strokes, her long standing alcohol consumption, or some combination of the two. 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 and worry that I have done, caring for her".
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.
Older Women Who Have Alcohol Problems
Older women are the least likely group to be recognized as having alcohol problems, partly because of stereotypes that professionals, para-professionals, service providers, and 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, hiding feelings of low self esteem, doubt and pain. (16) At the same time, health care providers often make decisions based on their personal alcohol usage, as opposed to the effect alcohol is having on this specific older adult.
Research also indicates that physicians are quick 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. (17, 20) 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 someone to financially abuse the person. (18, 21) The senior's version of their financial situation may be more easily denied or discredited by the abuser- "Oh, she can never remember how much she had in the bank; anyhow, she could have easily drank or given it away". Unless there is another source of information, it becomes difficult to tell where the truth lies.
Long term alcohol use problems can also cause damage to the frontal lobe, an area of the brain responsible for making and carrying out decisions. Service providers sometimes express frustration when the older adult appears to agree with a plan , but does not follow though. In some instances, the damage to frontal lobe may mean the person has the desire, but lacks the capacity to carry out decisions.
The presence of alcohol problems often confounds the identification of potential abuse cases. For example, a senior falling might be attributed to alcohol problem, when it is actually the result of being thrown down stairs. In other instances both the alcohol problem and the abuse problem are overlooked. Sometimes this results from stereotyped views where memory problems, problems with sleep, or seclusion are misinterpreted by family or others as stereotypical behaviours of older persons, not an indication of an alcohol abuse problem.
Beatrice needs assistance in order to remain relatively independent. However, health care and other service providers often see alcohol problems as a moral issue, or consider the inability to stop drinking simply a matter of "not having enough willpower." Health care providers also often worry that in providing assistance and services, they may be enabling the person with the alcohol problem to continue drinking. 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, Beatrice's son's behaviour (buying alcohol) is certainly enabling behaviour.
In this example, Beatrice needs assistance in managing her financial affairs. Although in many cases it would be preferable to have family or friends help her, the existing family conflict suggests that the involvement of a perceived neutral party such as the bank or an outside agency might be advisable.
Although the situation is gradually improving, older adults with alcohol problems often find themselves in a "Catch 22" situation of being excluded from alcoholism services because of age and being excluded geriatric services because of alcohol problems. (19, 23) The problem drinker may be known to many different agencies and may receive fragmented, ineffective and even contradictory interventions. The extent to which the agency assumes or requires the older person must become abstinent, significantly affects whether they are able to help the older adult. See harm reduction (General Information), and Harm Reduction Best Practices.
Service providers have 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.
The isolation that frequently accompanies aging, alcohol problems or abusive behaviour removes possible social checks that would bring the abuse situation to light before the problem became life threatening.(20, 24) This may prevent detecting the dangerousness of the situation until it has advanced to extremes and involves involuntary intervention.
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 agreed to do this in the meantime. 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 quietly been making inquiries to see if his pension cheques could be signed over to her (without his consent) so that he does not use them to buy alcohol.
This example illustrates some of the other problems associated with early onset alcohol problems, and the potential for abuse or violation of rights.
Where there is a history of heavy drinking, many family members may have totally distanced themselves from the person. The senior's physical health significantly deteriorates 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
geography (being the closest relative),
cultural or familial expectations (being the youngest, the eldest, the woman, the one who is not working),
feelings of responsibility to the parent.
Adult offspring who have survived sexual abuse from a parent earlier in life 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. (21)
The violent arguments between daughter and father in this case scenario may reflect a potential for abuse or neglect from children of substance abusers (COSAs). The addictions literature suggests that COSAs have a specific temperamental vulnerability. As a group, they seem to have less ability to recover from emotional distress and are more likely to have "hot tempers" (increased emotional lability). (22)
Many grown offspring of substance abusers do not abuse their parents. For some, this reflects the fact that they have learned other coping styles as they've grown up. For some, there is no abuse because there is no contact-- they have cut off any contact with the parent. The question remains: What happens if these offspring in later life are thrown back in close contact with their substance abusing parents?
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. In his home life and marriage, he has always been moody and rigidly demanding.
Dieter has a history of drinking for most of his adult years, though when he was working he limited it 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, most recently upon learning that one of his co-workers killed himself using a shotgun.
This example illustrates:
Depression is common among people who have alcohol use problems. Alcohol use problems are also more common among people who have major mental disorders, and alcohol use is an important coping strategy for them. Whether the mental health problem is caused by the drinking or functions independent of the drinking, both issues must be addressed concurrently.
For more detailed information on how to help when the person has an alcohol use problem and depression, click here.
Each of these vignettes illustrates an important facet of the overlap between substance abuse and senior abuse cases:
- Alcohol abuse is often a long standing problem in family conflict and spousal abuse.
- Alcohol treatment, alone, seldom helps the victim in abuse cases unless the abuser learns to deal with problems in non-violent or non-threatening manner.
- The presence of alcohol problems can affect acceptance of services.
- Without careful planning, the strategy or intervention decided on in a substance or senior abuse case may exacerbate other problems.
- The alcohol problem, if left unaddressed, can lead to serious physical harm or suicide.
- Multidisciplinary approaches are needed in order to address both the alcohol problem and the abuse. The formal responses also need to be co-ordinated, with a range of services to meet the various needs of the person with the alcohol problem and/ or the abuser.
Many service providers, friends and neighbours are in an excellent position to help abused seniors whose lives are affected by alcohol problems. The older adult may be trying to deal with their own problems or she or he 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 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.
Senior Abuse Links and Resources
It is very important for anyone working in the addictions area to have a good sense what the resources are in the community to help older adults experiencing abuse. Click here for a few starting points.
- Fisher, P.E. (August, 1993). Dual Diagnosis and the Older Adult: The Challenges (Vancouver: Seniors Well Aware Program).
- 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.
- 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.
- M.D. Pagelow (1984). Family Violence. New York: Praeger, pp. 87-97; see also Walker, L.W, (1984). The Battered Woman Syndrome. New York: Springer.
- Hayes, supra, n. 3 at 282.
- 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.
- Hayes, supra, n. 3 at 282.
- Hayes, supra, n. 3 at 286.
- Hayes, supra, n. 3 at 300.
- Pittaway & Gallagher, supra, n. 2. A large proportion (43.9%) of cases reflected the abuser being very controlling of the client.
- Ibid. at 68.
- Ministry of Health and Ministry Responsible for Seniors (June, 1994) Report on Older Adults and Alcohol Misuse. Victoria, B.C.
- National Advisory Council on Aging (1989) 1989 and Beyond : Challenges of an Aging Canadian Society. Ottawa.
- Schuckit, M.A. (1977). "Geriatric alcoholism and drug abuse." Gerontologist, 17, 168-174.
- 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.
- Glantz, M. & Backenheimer, M. (1988). "Substance abuse among elderly women" Clinical Gerontologist, 8, 3-26.
- 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.
- Gulino, C. & Kadin, M. (1986) "Aging and reactive alcoholism", Geriatric Nursing, 7 (3), 140-151 at 151.
- Ibid at 140.
- 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.
- Joseph, C.J. & Rose, M.R. (1994). Female incest survivors: caregiving for aging parents. Journal of Women and Aging. 6 (3): p. 53-68.
- Hayes, supra, n.3.
Additional Resources and Readings
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)
If you are looking for a good article that helps explain about 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.
(c) Charmaine Spencer, Seeking Solutions
First Written: 1997 for the Health Canada, "Barriers to Treatment" project. Updated, 2002, 2005.
* I would like to thank Denise Bradshaw and the staff of the Senior Well Aware Program in Vancouver as well as other counsellors working with older adults who have alcohol problems for their many insights to help shape the ideas for this introductory text.
Page last updated Saturday May 28, 2005
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