45 Important Considerations for Older Adults

Abuse of Older People (Commonly called “Elder Abuse”)

Current research indicates that at least 1 in 10, or approximately 4.3 million, older Americans are affected by at least one form of abuse per year (Roberto, 2016). Those between 60 and 69 years of age are more susceptible than those older. This may be because younger older adults more often live with adult children or a spouse, two groups with the most likely abusers. Cognitive impairment, including confusion and communication deficits, is the greatest risk factor for elder abuse, while a decline in overall health resulting in greater dependency on others is another.  Having a disability also places an older person at a higher risk for abuse (Youdin, 2016). Definitions of abuse of older people typically recognize five types of abuse as shown in Table 6.45.1.

Consequences of abuse of older people are significant and include injuries, new or exacerbated health conditions, hospitalizations, premature institutionalization, and early death (Roberto, 2016). Psychological and emotional abuse is considered the most common form, even though it is underreported and may go unrecognized by the older person. Continual emotional mistreatment is very damaging as it becomes internalized and results in late-life emotional problems and impairment. Financial abuse and exploitation is increasing and costs older people nearly 3 billion dollars per year (Lichtenberg, 2016).  Financial abuse is the second most common form after emotional abuse, and affects approximately 5% of elders.  Abuse and neglect occurring in a nursing home is estimated to be 25%-30% (Youdin, 2016). Abuse of nursing home residents is more often found in facilities that are run down and understaffed.

Older women are more likely to be victims than men, and one reason is due to women living longer.  Additionally, a family history of violence makes older women more vulnerable, especially for physical and sexual abuse (Acierno et al., 2010).  However, Kosberg (2014) found that men were less likely to report abuse.  Recent research indicated no differences among ethnic groups in abuse prevalence, however, cultural norms regarding what constitutes abuse differ based on ethnicity.  For example, Dakin and Pearlmutter found that working class White women did not consider verbal abuse to be abusive, and higher socioeconomic status African American and White women did not consider financial abuse to be abusive (as cited in Roberto, 2016, p. 304).

Perpetrators of abuse are typically family members and include spouses/partners and older children (Roberto, 2016). Children who are abusive tend to be dependent on their parents for financial, housing, and emotional support.  Substance use, mental illness, and chronic unemployment increase dependency on parents, which can then increase the possibility of abuse.  Prosecuting a family member who has financially abused a parent is very difficult. The victim may be reluctant to press charges and the court dockets are often very full resulting in long waits before a case is heard. According to Tanne, family members abandoning older family members with severe disabilities in emergency rooms is a growing problem as an estimated 100,000 are dumped each year (as cited in Berk, 2007). Paid caregivers and professionals trusted to make decisions on behalf of an older person, such as guardians and lawyers, also perpetuate abuse. When older people have social support and are engaged with others, they are less likely to suffer abuse. In other words it is the marginalization that older people experience that makes them vulnerable to abuse, and it is our responsibility as members of a just society to create policies that keep us all as full participants in society through education, work, recreation, healthcare throughout life.

Substance  Use in Older People

Alcohol and drug problems, particularly prescription drug use disorders, have become a serious health concern among older adults.  Although people 65 years of age and older make up only 13% of the population, they account for almost 30% of all medications prescribed in the United States. According to the National Council on Alcoholism and Drug Dependence (NCADD) (2015), the following statistics illustrate the significance of substance use disorders for older people in the U.S.:

• There are 2.5 million older adults with an alcohol or drug problem.
• Six to eleven percent of  hospital admissions of older people, 14 percent of emergency room admissions of older people,  and 20 percent of psychiatric hospital admissions of older people are a result of alcohol or drug problems.
• Widowers over the age of 75 have the highest rate of alcoholism in the U.S.
• Nearly 50 percent of nursing home residents have alcohol related problems.
• Older adults are hospitalized as often for alcoholic related problems as for heart attacks.
• Nearly 17 million prescriptions for tranquilizers are prescribed for older adults each year. Benzodiazepines, a type of tranquilizing drug, are the most commonly misused and abused prescription medications.

Substance use disorders also occur relatively frequently in older Canadians, according to Patten (2018).  Those currently  65 to 74 years old are most likely to say that they drink alcohol daily or nearly daily. This rate is nearly three times higher than the rate of 4% observed in people from 15 to 54 years of age.

Risk factors for psychoactivesubstanceuse disordersin older adults includesocial isolation, which can lead to depression (Youdin, 2016).  This can becaused bythedeath ofaspouse/partner,family members and/or friends,retirement, moving, and reducedactivitylevels. Additionally, medical conditions, chronicpain,anxiety,and stress can all lead to substance use disorders.

Diagnosis Difficulties

Using criteria from the Diagnostic and Statistical Manual of Disorder-5th Edition (American Psychiatric Association, 2013), diagnosing older adults with a substance use disorder can be difficult (Youdin, 2016).  For example, compared to adolescents and younger adults, older adults are not looking to get high, but rather become dependent by accident. Additionally, stereotypes of older adults, which include memory deficits, confusion, depression, agitation, motor problems, and hostility, can result in a diagnosis of cognitive impairment instead of a substance use disorder. Further, a diagnosis of a substance use disorder involves impairment in work, school, or home obligations, and because older adults are not typically working, in school or caring for children, these impairments would not be exhibited.  Stigma and shame about use, as well as the belief that one’s use is a private matter, may keep older adults from seeking assistance.  Lastly, physicians may be biased against asking those in older adulthood if they have a problem with drugs or alcohol (NCADD, 2015).

Abused Substances

Drugs of choice for older adults include alcohol, benzodiazepines, opioid prescription medications and marijuana. The abuse of prescription medications is expected to increase significantly. Siriwardena, Qureshi, Gibson, Collier, and Lathamn (2006) found that family physicians prescribe benzodiazepines and opioids to older adults to deal with psychosocial and pain problems rather than prescribe alternatives to medication such as therapy. Those in older adulthood are also more sensitive to the effects of alcohol than those younger because of an age-related decrease in the ratio between lean body mass and fat (Erber & Szuchman, 2015). Additionally, “liver enzymes that metabolize alcohol become less efficient with age and central nervous system sensitivity to drugs increase with age” (p.134).  Older people are also more likely to be taking other medications, and this can result in unpredictable interactions with the psychoactive substances (Youdin, 2016).

Cannabis Use

Blazer and Wu (2009) found that adults aged 50-64 were more likely to use cannabis than older adults. These “baby boomers” with the highest cannabis use included men, those unmarried/unpartnered, and those with depression.  In contrast to the negative effects of cannabis, which include panic reactions, anxiety, perceptual distortions and exacerbation of mood and psychotic disorders, cannabis can provide benefit to the older adult with medical conditions (Youdin, 2016).  For example, cannabis can be used in the treatment for multiple sclerosis, Parkinson’s disease, chronic pain, and the fatigue and nausea from the effects of chemotherapy (Williamson & Evans, 2000).

Future Concerns about Substance Use Disorders

There is expected to be an increase in the number of older people abusing substances in the future because the baby boomer generation has a history of having been exposed to, and having experienced, psychoactive substance use over their adult life. This is a significant difference from the current and previous generations of older adults (National Institutes of Health, 2014c). Efforts will be needed to adequately address these future substance use issues for older people due to both the health risks for them and the resulting challenges for society to use healthcare resources in a creative and just way.

The Notion of  Successful Aging

Rowe and Kahn (1997) defined three criteria of successful aging that are useful for research and behavioral interventions.  They include:

• Relative avoidance of disease, disability, and risk factors, like high blood pressure, smoking, or obesity
• Maintenance of high physical and cognitive functioning
• Active engagement in social and productive activities

For example, research has demonstrated that age-related declines in cognitive functioning across the adult life span may be slowed for some of us through physical exercise and lifestyle interventions (Kramer & Erickson, 2007).

Another way that we can respond to the challenges of fluctuating abilities throughout life, including as older people,  is through compensation. Specifically, selective optimization with compensation is used when a person  makes adjustments, as needed, in order to continue living as independently and actively as possible (Baltes & Dickson, 2001). When we lose functioning, referred to as loss-based selection, we may first use new resources/technologies or continually practice tasks to maintain their skills.  However, when tasks become too difficult, we may compensate by choosing other ways to achieve their goals.   For example, a person who can no longer drive needs to find alternative transportation, or a person who is compensating for having less energy, learns how to reorganize the daily routine to avoid over-exertion .