Elder Abuse and Alcohol

ELDER ABUSE has been defined as a single or repeated act, or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person (1). Elder abuse can take many forms including physical, psychological and sexual abuse, financial exploitation, neglect and self-neglect¹, medication abuse, abandonment, scapegoating, and marginalisation of older people in institutions or social and economic policies (2). With the global population of older people (aged 60 and above) predicted to triple from 672 million in 2005 to almost 1.9 billion in 2050 (3), concerns around elder abuse are increasing. Preventing elder abuse means creating a greater understanding of its prevalence and identifying and removing risk factors. Harmful and hazardous² alcohol use have been identified as risk factors for elder abuse (4,5). This fact sheet therefore explores the links between alcohol and elder abuse and the role of public health in prevention.

BOX 1: International prevalence of elder abuse

Elder abuse

International prevalence estimates of elder abuse in community settings (including neglect by caregivers, physical, psychological and financial abuse) from Canada, Finland, the Netherlands, the United Kingdom and the United States of America range from 4−6% (2). A more recent study in the Republic of Korea found a corresponding figure of 6.3% (6), while in Israel an estimate of 18.4% has been reported with the majority of abuse involving neglect (7). A combination of cultural differences in attitudes towards older people and variations in perceptions and definitions of abuse make international comparisons difficult. Equally, prevalence of abuse in institutional settings is difficult to measure yet is thought to exceed that in community settings; in the US, 10% of nursing staff in institutional settings admitted committing physical and 40% psychological abuse against residents in the previous year (8).

Alcohol use

Across all age groups, prevalence of alcohol consumption varies widely between countries with the proportion of abstainers in the previous year ranging from 2.5% in Luxembourg to 99.5% in Egypt (9). Alcohol consumption is highest in high-income countries yet is steadily increasing in some low- to middle-income societies (e.g. South-East Asia). Studies in high-income countries show older people in general to be less likely than younger age groups to consume alcohol and also that they drink in lower quantities (e.g. United Kingdom [10], Canada [11]), Physiological changes that occur through ageing can reduce individual's tolerance to alcohol resulting in alcohol-related problems at lower levels of consumption (12). Furthermore effects of problem drinking among older people can be mistaken for symptoms associated with ageing (13).

Links between alcohol use and elder abuse

While there is a strong relationship between alcohol and interpersonal violence in general (14), specific links between alcohol and elder abuse include:

• Individuals with alcohol problems may be financially dependent on relatives (including older people). This reliance may include funding their alcohol use and financial or material coercion. (13).
• Some caregivers who drink excessively may neglect their respon sibilities to older people who depend on them (15).
• Impaired judgement and memory through harmful alcohol use by older people can leave them more vulnerable to abuse (13).
• Caregivers may encourage elders to drink in order to make them more compliant or exploit them financially (5).
• Abused elders may use alcohol as a means of coping with abuse or neglect (13).
• Hazardous and harmful levels of alcohol use are risk factors for intimate partner violence (16), which can feature in relationships between older people (17).

Magnitude of alcohol-related elder abuse

The majority of studies measuring the role of alcohol in elder abuse have been conducted in North America and the United Kingdom. Key findings include:

• In the United States, 44% of male and 14% of female abusers of parents (age 60 years and over) were dependent on alcohol or drugs, as were 7% of victims (18).
• In England, 45% of carers for older people receiving respite care admitted to committing some form of abuse, with harmful alcohol consumption by carers being the most significant risk factor for physical abuse (4).
• An outreach programme for older people with harmful alcohol or other substance use problems in Canada reported 15−20% of its clients to be suffering from psychological, physical or financial abuse (13).
• Also in Canada, a national study of elder abuse case files from agencies across the country found that severe drinking bouts by the abuser lead to harmful incidents in 14.6% of the elder abuse cases. In another 18.7% of the client records, the clients indicated that the abuse was secondary to the alcohol use problem (that is, they considered alcohol use as one of many contributing factors) (19).

In the United Kingdom, high and harmful levels of alcohol consumption by carers are more closely associated with physical abuse than neglect (20), while in the United States alcohol consumption by victims of elder abuse has been more closely associated with self-neglect than other forms of abuse (5). Despite a lack of studies from low- to middle-income countries that focus on harmful alcohol consumption and elder abuse, other information sources suggest strong links. For instance, a ministerial review in South Africa found alcohol to be an important contributor to elder abuse, reporting cases of adult offspring spending their parents' pensions on alcohol while leaving them without food, and of alcohol-related physical and sexual assault of older women (15).

Risk factors for alcohol-related elder abuse

Factors found to increase the risks of older people suffering elder abuse include cognitive or physical impairment and social isolation, while gender is also important in some regions where females are generally more at risk (e.g. Africa [21]). For perpetrators of elder abuse, risk factors include financial difficulties, dependence on the older person and mental health problems. Cultural risk factors include ageism, sexism and tolerance of violence, while in some transitional and low- to middle-income countries cultural change has increased the vulnerability of older members of society to abuse, through, for example, the loss of traditional roles for older people, erosion of family and community bonds and high unemployment (2).

For alcohol-related elder abuse in particular, alcohol dependence and harmful levels of alcohol consumption by older people increases the risk of self-neglect (5), and their vulnerability to abuse, while harmful levels of alcohol consumption by carers can increase their risk of perpetrating elder abuse (4). Thus, for older people, having an adult relative with a drinking problem is a risk for being a victim especially when the relative (often an offspring) is dependent on the elder for finance or accommodation. Further, older people are more likely to remain in an abusive relationship when their abuser is a highly dependent adult offspring or spouse (17).

Cultural expectations of the effects of alcohol can also be important. Thus, where the victim believes their abuser's alcohol consumption causes the abuse, a promise to stop drinking can mean the perpetrator is forgiven and the abuse not addressed (18). However, alcohol is often considered only an aggravating factor. In South Africa, elder abuse has been attributed to poverty, social disorder and a lack of policy to protect older people (21) who are viewed as easy targets for exploitation, with substance use regarded as one among other situational determinants of abuse (22).

Impact

The impacts on older people of elder abuse and harmful alcohol use can be similar. Both may lead to physical injury, financial problems, social withdrawal, malnourishment and emotional and psychological problems, including depression and cognitive and memory impairments (13). Older people are often physically weaker, meaning physical violence results in greater injury and convalescence takes longer (2). Moreover, alcohol-related violence has been associated with greater seriousness of injury (23). For victims of financial abuse, extortion of assets can have significant consequences as older people often have lower incomes and less opportunity to replace money (2). Elder abuse can reduce life expectancy (24), can lead to depression, and in some cases can lead to harmful alcohol use as a coping strategy (13). Harmful and hazardous alcohol use is also associated with a wide range of other health problems that can shorten life span, such as cardiovascular diseases, cancers and unintentional injuries (e.g. falls, burns [25]). As older people are less able to metabolise alcohol, the consequences of drinking can be more pronounced and alcohol problems can be experienced at lower levels of consumption (12). Wider impacts of alcohol use disorders in older people are substantial and include self-neglect, suicidal ideation and suicidal behaviour (26). While elder abuse frequently has significant economic consequences to the victim currently these are largely unmeasured.

Prevention

Prevention strategies to reduce elder abuse include protection and support services, educational programmes and mandatory reporting (i.e. a legal requirement for professionals and others in contact with older people to report suspected cases); although measures of their effectiveness are scarce (2). However, identification of victims and those at risk is a key factor in prevention.

Screening for both alcohol problems and elder abuse can be undertaken in a range of settings, including primary care, emergency departments and geriatric medicine services (27,28,29). Successful implementation of screening requires investment in training for practitioners to understand and recognise signs of abuse in later life. Both alcohol problems and elder abuse can be overlooked as a result of ageist beliefs that social withdrawal and memory problems are normal signs of ageing (13). In particular for older people with alcohol problems, signs of abuse can be mistaken for consequences of alcohol use and vice versa.

Knowledge of the victim's rights and support services are fundamental to advising those abused. Further, where victims or perpetrators have alcohol problems an understanding of the links between harmful alcohol use and violence and specialist support services mean both alcohol problems and related abuse can be addressed. Critically, alcohol services must cater for the needs of older individuals, while support services for older people should not exclude older people on the basis of their alcohol problems (13). Clarity is also required regarding effective methods of contacting perpetrators for treatment purposes, including involvement of health and judicial services.

In general, there is a dearth of information on effective primary prevention of alcohol-related elder abuse, and only a limited understanding of secondary prevention and treatment interventions. Interventions to reduce population and individual alcohol consumption levels have been shown to impact on interpersonal violence in general. Thus, evidence suggest that reductions in violence can be achieved through increased alcohol prices (e.g. the United States, intimate partner violence [30] and child abuse [31]) and implementation of closing times for licensed premises (e.g. Brazil, homicides [32]). However, the specific effects of reducing population consumption on elder abuse have not been measured. Consequently, there is an urgent need to better understand, measure and prevent alcohol-related elder abuse.

The role of public health

The public health approach to violence prevention uses a wide range of data and research to provide a better understanding of the extent, causes and risks of violence and to implement effective interventions through collective action. For alcohol-related abuse of the elderly, priorities for public health include:

• Collect and collate information on the prevalence of elder abuse, alcohol consumption levels, drinking patterns among older people and alcohol-related problems.
• Advocate for awareness raising and screening for elder abuse in geriatric services, social services and other health settings.
• Promote, conduct and evaluate research on the links between elder abuse and harmful alcohol consumption by both victims and perpetrators to improve understanding of the extent of the problem as well as of risk and protective factors.
• Measure and disseminate the health, economic and wider socio logical costs associated with alcohol-related elder abuse.
• Identify, evaluate and widely implement interventions that show promise in preventing and responding to alcohol-related elder abuse.
• Ensure that specialist services providing support for people with alcohol problems understand and meet the needs of older people, and that general health services can recognize alcohol- related problems in older people and understand their links with violence.
• Promote multi-agency partnerships to prevent elder abuse by raising awareness of the links between harmful alcohol use and elder abuse and the wider impacts on society.
• Advocate for policy to reduce hazardous and harmful drinking within populations and to discourage ageist attitudes, give older people the right to participate fully in society and ensure they are able to live in dignity.

Policy

Both the harmful and hazardous use of alcohol and elder abuse have been recognized internationally as key public health issues requiring urgent attention. At both national and international levels, health organizations have a key role in advocating for policies that address the relationships between alcohol use and elder abuse and in doing so promote prevention initiatives that will improve public health. The World Health Organization (WHO) runs comprehensive programmes on both issues to instigate and conduct research, identify effective prevention measures, and promote action by Member States to implement successful interventions and align policy towards reducing hazardous and harmful drinking and violence.

For alcohol, this includes collating and disseminating scientific information on alcohol consumption, developing global and regional research and policy initiatives on alcohol, supporting countries in increasing national capacity for monitoring alcohol consumption and related harm, and promoting prevention, early identification and management of harmful alcohol use disorders in primary health care (33). A World Health Assembly resolution on Public health problems caused by harmful use of alcohol (WHA58.26 [34]) of 2005 recognizes the health and social consequences associated with harmful alcohol use and request Member States to develop, implement and evaluate effective strategies for reducing such harms, while calling on WHO to provide support to Member States in monitoring alcohol-related harm, implementing and evaluating effective strategies and programmes, and to reinforce the scientific evidence on effectiveness of policies.

For violence, this includes the WHO Global Campaign for Violence Prevention. Launched in 2002, the Campaign aims to raise international awareness about the problem of interpersonal violence (including elder abuse), highlight the role of public health in its prevention, and increase violence prevention activities globally, regionally and nationally. The approach to preventing violence is set out in the WHO World report on violence and health (1). World Health Assembly resolution WHA56.24 (35) of 2003 encourages Member States to implement the recommendations set out in the report, and calls on the Secretariat to cooperate with Member States in establishing science-based public health policies and programmes for the implementation of measures to prevent violence and to mitigate its consequences. Complementary to this, the Violence Prevention Alliance has been established to provide a forum for the exchange of best practice information between governments and other agencies working to reduce violence around the world.

Specifically for elder abuse, the Madrid International Plan of Action on Ageing, adopted by UN countries in 2002, makes recommendations for action relating to the well-being of older people and their mainstreaming in the development process (www.un.org/esa/socdev/ageing). Subsequently, the Toronto Declaration on the Prevention of Elder Abuse (2002) called WHO Member States to action in raising awareness of the problem of elder abuse and implementing prevention measures. To assist the development of strategy to prevent elder abuse, the WHO Ageing and Life Course Unit conducted research in a range of countries to determine views and perceptions of elder abuse in different societies (36).

All references used in this document are available at:

• www.who.int/violence_injury_prevention/publications/violence/en/index.html

For further information please consult:

• www.who.int/violence_injury_prevention
• www.who.int/substance_abuse/en
• www.who.int/substance_abuse/terminology/who_lexicon/en
• www.who.int/topics/ageing/en/

Or contact:

• Department of Injuries and Violence Prevention
  Dr Alexander Butchart (butchart@who.int, fax + 41-22-791-4332, telephone + 41-22-791-4001)
• Department of Mental Health and Substance Abuse
  Dr Vladimir Poznyak, (poznyak@who.int, fax + 41-22-791-4160, telephone + 41-22-791-4307)
• Ageing and Life Course Unit
  Dr Alexandre Kalache (kalachea@who.int, fax + 41-22-791-4830, telephone + 41-22-791-3404)
• World Health Organization
  20 Avenue Appia
  CH-1211 Genève 27,
  Switzerland
  
• John Moore University, Centre for Public Health
  Prof Mark Bellis ((m.a.bellis@livjm.ac.uk, fax + 44-(0)-151-231-4515, telephone + 44-(0)-151-231-4511)
  Centre for Public Health
  Liverpool L3 2AV
  UK
  

Notes

1. 1 Although self-neglect through harmful alcohol use is a major concern among older people, this fact sheet deals specifically with interpersonal abuse of the elderly.
2. 2 Harmful use of alcohol is defined as a pattern of alcohol use that causes damage to health. Hazardous alcohol use is defined as a pattern of alcohol use that increases the risk of harmful consequences for the user (World Health Organization, www.who.int/substance_abuse/terminology/who_lexicon/en).