Assessing the needs of Older People in Worcestershire who misuse alcohol

August 2010

By

Kate Ray DAAT Programme Lead for Alcohol

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Contents

1. Introduction 2-3

2. Demographics 4-8

3. Methodology 9

4. National Picture 10-12

5. Local Picture (a) Data analysis; 13-19 (b) Community Consultation; 19-20 (c) Questionnaires; 21-25 (d) Interviews. 25-26 6. Conclusions 27 7. Recommendations 28-31

8. Appendix 1 32-33 9. Appendix 2 34-37

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1. Introduction: For some time, alcohol misuse among older people (defined as over-65s in this report) has become an increasing concern for care workers, health services and alcohol services. The proportion of older people within the population has grown – in 2001, people over 65 made up 16% of England's population and this is forecast to rise to 21% by 20261. In Worcestershire, the most noticeable population increase will be amongst the older age groups, with the 65+ age group expected to increase by over 60%. At the same time, alcohol is the most commonly misused substance in the world and is associated with serious social, economic and health costs for the individual and society.

Data produced by Office for National Statistics indicates that alcohol use and misuse decreases with age2, there is increasing evidence being uncovered which suggests that the problem of older people misusing alcohol is underrecognised. Kar (2006)

carried out a piece of research which has shown that alcohol misuse problems in this group are difficult to identify due to a number of reasons – atypical symptoms presented by older people often mimic other geriatric illnesses, i.e. anxiety, depression, memory loss etc; older people tend to be less accurate in self-reporting on their alcohol consumption; family members, health professionals and care workers often ignore problems due to a feeling that 'this is all that's left' for the drinker.3

However, alcohol puts older people's health and well-being at risk. There is a need to assess the scale and nature of alcohol misuse amongst older people for the following reasons:

Almost half of all alcohol related hospital admissions are for individuals over the age of 65. Failure to tackle alcohol misuse in older people may result in an increase in alcohol related hospital admissions;

Approximately 85% of people admitted to hospital for hypertensive diseases and cardiac arrhythmia (conditions strongly associated with alcohol misuse) are over 60. Failure to tackle alcohol misuse in older people could result in an increase in alcohol related conditions inducing hypertension, coronary heart disease and strokes, placing strain on acute services, primary care and social care services;

Alcohol Concern identified several 'triggers' of problematic drinking including bereavement, mental stress such as depression, loneliness and loss.4 There is a need to address these underlying causes of alcohol misuse to improve the quality of life of older people in Worcestershire.

1 Flalaschetti, E. Et all. (2002). The general health of older people and their use of health services (in: Health Survey in England for England 2000). The Stationery Office, London. 2 Office for National Statistics (2001) Living in Britain. Results from the 2000 General Household

Survey. The Stationary Office, London. 3 Dar, K. (2006) Alcohol use disorders in elderly people: fact or fiction? Advances in Psychiatric Treatment, vol. 12, 173-181. 4 Alcohol Concern (2002) Alcohol Misuse among older people. Acquire, Autumn.

http://alcoholconcern.org.uk/servlets/doc/50.

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A study was undertaken in Worcestershire to determine the needs of older people who misuse alcohol. The information gathered attempts to answer the following research questions:

What is the prevalence of alcohol misuse in older people in Worcestershire?

Are there any variations within the county?

Are their drinking habits/patterns different to those of other ages?

What are the reasons why older people misuse alcohol?

How can be we support this group of people?

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2. Demographics Worcestershire is located in the West Midlands region, to the south-west of Birmingham. The county consists of six Local Authorities: Bromsgrove, Malvern Hills, Redditch, Worcester City, Wychavon and Wyre Forest. Worcestershire is a diverse area, with a rural landscape interspersed with towns and villages. Despite this, 60% of the county's population resides in more urban areas, with the remaining 40% dispersed across an area of 670 square miles. Associated with this, some areas of Worcestershire experience geographical barriers to services and facilities. According to the Indices of Deprivation (2007), 23% of lower super output areas in the county fall in the top 20% most deprived nationally in terms of access to housing and services, including the areas of Teme Valley (Malvern Hills) and Eckington (Wychavon), which fall in the top 1%. Population In 2008, Worcestershire had a population of 557,600.5 Across the county, 20.9% of the population were aged 0-17 and 57.4% were of working age. Additionally, Worcestershire had a higher than average population aged 65 and over (18.1% compared to the national average of 16.2%). The proportion of the population aged 75 and over was also higher than the national average (8.6% compared to 7.8%). It should be noted that females accounted for over half (55.4%) of the population aged 65 and over, which may be reflective of higher life expectancy and lower mortality rates amongst females compared to males. Figure 1: Proportion of Population in 65-plus age groups within Worcestershire

Source: Mid 2008 Population Estimates, Office for National Statistics (2009)

5 Mid-2008 population estimates, Office for National Statistics (2009)

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Figure 1 shows:

Malvern Hills has the highest proportion of people aged 65 and over (22.4%) and more specifically, those aged 85 and over (3.4%).

Redditch has a much lower proportion of people aged 65 and over (13.5%) compared to the other districts.

In addition, Figure 2 suggests that the more urban areas of the county (Worcester City and Redditch) have a higher prevalence of younger age groups, whilst older age groups (those aged 65 and over) are more likely to reside in more rural areas such as Great Hampton, Broadway and Wickhampton (Wychavon), and the area near North Bromsgrove High in Bromsgrove. Figure 2: Proportion of the total population aged 65 and over, by lower super output area

Source: Mid 2008 Population Estimates, Office for National Statistics (2009)

The Office for National Statistics projects that in the next two-decades, there will be significant changes to Worcestershire's population. Figures from the 2008 based population projections suggests that the number of people in Worcestershire will increase by approximately 8.2% (45,300) between 2008 and 2028.6 The most notable population increase will be amongst the older age groups, with the 65+ age group expected to increase by over 60%. Specifically, the 80-84 age group is projected to almost double during this period (an increase of 98.6%, from 14,400 to 28,600), whilst the 90 and over age group is expected to triple (increasing from 4,400 to 13,400).

6 2008 Subnational Population Projections, Office for National Statistics (2010)

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Ethnicity Within Worcestershire, 4.7% of the total population are from a Black or Minority Ethnic (BME) group, which increases to 6.5% if the group White Other is included.7 Since 2001, the White Other group has experienced the greatest growth within the county, which is reflective of an increased level of migration from Eastern European countries following the EU Accession in 2004. Within Worcestershire, Redditch has the highest proportion of residents of BME or White Other ethnicity (8.5%), followed by Bromsgrove (7.5%). The lowest proportions are in Wychavon and Wyre Forest (5.2% of the population). With the exception of the White Other group, the largest BME groups within Worcestershire are Pakistani (1%) and Indian (0.7%). Within Worcestershire, Black or Minority Ethnic groups make up a greater proportion of younger age groups (7% of persons aged 0-15 are from a non-White ethnic group) compared to older age groups (1.3% of persons of pensionable age and over are from a BME group). More specifically, less than 1% of the 75 and over age group are from a BME group. Economy and Benefits The economic downturn over the last couple of years has led to a significant rise in the number of people claiming unemployment benefits. Information for September 2009, showed that the total claimant count for Worcestershire was 4% of the working age population, compared to 4.2% nationally. However, Worcestershire's claimant count has increased by 2.4 times since January 2008, compared to the slightly slower increase nationally of 1.9 times. The proportion of persons aged 65 and over in Worcestershire claiming Attendance Allowance is lower than the corresponding figure regionally, and similar to that nationally. In May 2009, 16.7% of Worcestershire residents aged 65 and over were claiming Attendance Allowance, compared to 18.3% across the West Midlands, and 16% nationally.8 Within Worcestershire, Redditch had the highest proportion of persons aged 65 and over claiming this allowance (18.9%), and Wychavon the lowest (15.4%). Attendance Allowance is a tax free benefit for those that need help with personal care due to physical or mental disabilities. Indices of Deprivation (2007) Based on the Indices of Multiple Deprivation (2007) 16% (56) of Worcestershire lower super output areas (LSOAs) are in the 30% most deprived areas within England, including 7 LSOAs that are in the top 10%. Many of the most deprived areas in the county can be found in the urban areas of Worcester City, Redditch and Kidderminster, as well as a small area in Malvern (Pickersleigh). As a whole, Redditch is the most deprived district in the county.

7 Mid-2007 Population Estimates by Ethnic Group, Office for National Statistics (2009) 8 Claimants of non-income related benefits May 2009, Department of Work and Pensions (2009)

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Figure 3: Areas of Multiple Deprivation, 2007

Source: Department of Communities and Local Government (2007)

Specific areas of deprivation include Warndon and Gorse Hill in Worcester City, Oldington and Foley Park and Broadwaters in Wyre Forest, and Winyates and Church Hill in Redditch. Specific domains are negatively affecting Worcestershire's levels of deprivation. These include the 'Barriers to Housing and Services' domain, mentioned previously, and the 'Education and Skills' domain where 14% of areas fall in the top 20% (including 3 in the top 1%). Health The Old Warndon area of Worcester City, parts of Church Hill, Greenlands, Winyates and Abbey in Redditch, and the Oldington area of Wyre Forest are in the top 10% most deprived areas nationally using the Health Deprivation and Disability domain of the Indices of Multiple Deprivation (2007). Findings from the 2001 Census showed that a greater proportion of older age groups had a Limiting Long Term Illness (LLTI), defined as any long-term illness, health problem or disability that limits daily activities. Specifically, it found that 48% of Worcestershire residents aged 65 and over had a LLTI, including 75% of those aged 85 and over. Other key findings from Worcestershire's Joint Strategic Needs Assessment (2009-10) include:

Between 9,600 and 14,500 persons aged 65 and over in Worcestershire are experiencing depression

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In 2009, it was estimated that 7,240 persons aged 65 and over were suffering from late onset dementia

81% of those receiving home care in March 2009 were aged 65 and over. 9 Health ACORN is a classification of health at output area. It is designed to incorporate a range of factors relating to current and future health, including indicators of existing health and lifestyle issues. The classification is divided into 4 major groups, Existing Problems, Future Problems, Possible Future Concerns, and Healthy. Figure 4: Health ACORN by Output Area, 2009

Source: CACI, 2009

Urban areas, including neighbourhoods within Worcester City, Redditch, Kidderminster, Droitwich, Evesham and Malvern, as well as areas that are located on the Birmingham border, are more likely to have either Existing Problems or Future Concerns. Rural, more affluent areas, including parts of Wychavon, Malvern and Feckenham, are identified as having Potential Future Concerns.

9 Worcestershire Joint Strategic Needs Assessment For Adult Health and Well-being 2009/10, WCC (2010)

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3. Methodology The following section details the steps taken to gather and analyse information and data relating to alcohol misuse amongst older people. The key research question is:

What is the prevalence and nature of alcohol misuse amongst older people in Worcestershire and what interventions are needed to address issues? 1. Literature Review: A literature review was carried out to look at the prevalence and nature of alcohol misuse amongst older people on a national and international level. It should be noted that much of the research originates from the USA so not all findings can be generalised for the UK. The following papers were reviewed:

Alcohol use disorders in elderly people: fact or fiction? By Karim Dar (2006);

Alcohol use disorders in elderly people – redefining an age old

problem in old age – By O'Connell, Ai-Vyrn Chin, Cunningham and Lawlor (2003);

Alcohol Misuse among older people. Alcohol Concern (2002);

Older People & Alcohol Misuse: Setting the Agenda. Age Concern and Wandsworth Alcohol Misuse Older People Project (2002).

2. Data Collection: The following data was collected and analysed:

Alcohol related hospital admissions data for over 65s – Worcestershire PCT;

Specialist alcohol treatment data – Worcestershire Community Alcohol Team;

Alcohol related crime data – West Mercia Police. 3. Community Consultation Events: 6 local consultation events were held to gain stakeholder views on a wide range of issues relating to drugs and alcohol, including alcohol misuse amongst older people. The events were held in each district across Worcestershire. 4. Professional Viewpoints:

Questionnaires were sent to wide range of professionals working across health and social care; voluntary sector; housing and homelessness sector.

One-to-one interviews were held with Dr Karim Dar, Consultant Psychiatrist in substance misuse and Mark Vardy, Alcohol Liaison Nurse, Worcester Royal Hospital.

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4. National Picture Alcohol misuse amongst older people is often described as a 'hidden' or 'neglected' area of research in the UK. This is because estimating the true size of the problem is difficult for a number of reasons:

Many older people do not disclose information about their drinking because they are ashamed;

Many are isolated, meaning that any problems can be difficult to detect due to the lack of social contact;

Naik and Jones (1994) suggest that older people may significantly under-report their drinking – they will often 'miss out' alcoholic drinks(when calculating how much they have had) regarding them as 'medicinal'10;

There is also a view that professionals who come into contact with older people seem to be reluctant to ask them about their drinking, either because it makes them feel awkward or because they have a stereotypical image that only younger people use alcohol (Deblinger, 2000)11;

Finally, alcohol problems often present in a large number of non-specific ways such as accidents, depression, insomnia, confused states, and self-neglect, many of which are linked to the ageing process (Dar, 2006)12.

Current research has looked at prevalence problematic drinking, patterns of alcohol use, key causes and triggers associated with heavy drinking, assessment and screening, treatment and interventions. In the General Household Survey (2007)13, it was reported that:

Those people in the youngest and oldest age groups (16 to 24 and 65 and over) were less likely than those in the other age groups (25 to 44 and 45 to 64) to report drinking alcohol during the previous week.

Less than half (46%) of women aged 65 and over reported drinking alcohol in the previous week.

However, those aged 65 and over were also more likely than any other age group to have drunk on everyday of the previous week; 22% of men and 12% of women aged 65 and over had drunk every day during the previous week, compared to 3% of men and 2% of women aged 16 to 24.

Also, both men and women in the 65 and over age group were the least likely to drink over 50/35 units a week (5% of men and 2% of women), compared to other ages groups.

Dar (2006) identified 2 patterns of alcohol use within older people – early onset and late onset. Older people who fall into the early onset category have had a lifelong pattern of problem drinking and have probably been alcoholics for most of their

10 Naik, P. & Jones, R.G. (1994) Alcohol histories taken from elderly people on admission. BMJ, 308, 248. 11 Deblinger, L. (2000) Alcohol Problems in the elderly. Patient care, 34, 70. 12 Dar, K. (2006) Alcohol use disorders in elderly people: fact or fiction? Advances in Psychiatric Treatment, vol. 12, 173-181. 13 Office for National Statistics (2009) Results from the 2007 General Household Survey. London: TSO (The Stationary Office).

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lives. Those that fall into the late-onset drinking category have developed the drink problem later in life. Research suggests that two thirds of older people who drink problematically fall into the early onset category and about one-third fall into the late-onset category.14 Schutte et al (1994) carried out a longitudinal study to look at the remission rates of individuals who fell into the two categories mentioned above. It was found that older alcoholics (dependant drinkers) found an overall stable remission of 21% in late-life drinking at 4 years, with late-onset alcoholics almost twice as likely as those with early onset alcoholism to have stable remission with treatment.15 Cooper et al (1999) identified factors associated with problematic drinking, for example,

Older men are more likely to drink than older women;

Higher levels of drinking are more prevalent among higher social classes and the most affluent;

Older married men are the least likely to drink heavily;

Older widowed or divorced men are more likely to engage in health damaging behaviour such as smoking or excessive drinking;

Older married women have the highest level of alcohol consumption;

Drinking patterns vary considerably across different ethnic groups.16 However, these factors do not explain the reasons why older people drink. Alcohol Concern (2002)17 has identified a list of factors that commonly lead to problematic drinking in older people. Emotional and social problems

Bereavement;

Loss of friends and social status;

Loss of occupation;

Impaired ability to function;

Family conflict;

Reduced self-esteem. Medical Problems

Physical disabilities;

Chronic pain;

Insomnia;

Sensory deficits;

14 Dar, K. (2006) Alcohol use disorders in elderly people: fact or fiction? Advances in Psychiatric Treatment, vol. 12, 173-181. 15

Schutte, K. K., Brennan, L. & Moos, R. H. (1994). Remission of late-life drinking problems: a 4-year follow up. Journal of Geriatric Psychiatry and Neurology, 13, 124-129. 16 Cooper, H. et al. (1999). The influence of social capital and social support on health: a review and analysis of British data. Health Authority, London. 17 Alcohol Concern (2002) Alcohol Misuse among older people. Acquire, Autumn. http://alcoholconcern.org.uk/servlets/doc/50.

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Reduce mobility;

Cognitive impairment. Practical problems

Impaired self-care;

Reduced coping skills;

Altered financial circumstances;

Dislocation from previous accommodation. As previously mentioned, identifying alcohol issues in older people is difficult because many of the symptoms are similar to those associated with the ageing process. Also, some health professionals working with older people may hold the mistaken perception that older problem drinkers are too old to change their habits. (Willenbring, 1990). Dar suggests that older people should be routinely screened for alcohol misuse. According to Dar, "The aim of proactive screening of elderly people is to identify the presence and severity of alcohol problems that might otherwise be overlooked and to determine the need for further assessment." 18 Most standard screening tools have not been designed for use with older people. However, there are some tools which are more appropriate than others. The geriatric version of the Michigan Alcohol Screening Test (MAST-G) has high sensitivity with older people in a wide range of settings, including primary care clinics and nursing homes. Also, although the Alcohol Use Disorders Identification Test (AUDIT) has not been evaluated for use with older people, it has been validated cross-culturally. Dar believes that it may therefore be useful for screening older people from minority ethnic groups.19 (See Appendix 1 for examples of screening tools.) As Willenbring discovered in 1990, many health professionals believe that older problem drinkers are too old to help.20 However, this is a misconception – research has shown that older people are just as likely to benefit from treatment as the younger age groups. It has been shown that older people can benefit from:

Brief Interventions;

Specialist treatments e.g. community alcohol treatment, inpatient detox, self-help;

Psychological treatments e.g. Cognitive Behaviour Therapy, Motivational Interviewing etc.

18

Dar, K. (2006) Alcohol use disorders in elderly people: fact or fiction? Advances in Psychiatric Treatment, vol. 12, 173-181. 19 Dar, K. (2006) Alcohol use disorders in elderly people: fact or fiction? Advances in Psychiatric Treatment, vol. 12, 173-181. 20 Willenbring, M. (1990) Evaluating alcohol use in elders. Aging, 361, 22-27,

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5. Local Picture (a) Data Analysis: Alcohol-related hospital admissions During 2008-09, there were a total of 11,023 alcohol-related hospital admissions in Worcestershire, which is a rate of 1,576 per 100,000 population.21 Between 2005-06 and 2008-09, Worcestershire was subject to a greater rate of increase (42.9%) in the rate of alcohol-related admissions, compared to that regionally (30.4%) and nationally (22.7%). More specifically, within Worcestershire the volume of admissions for individuals aged 55 and over increased by approximately 82% during the same period.22 These admissions were for both conditions that were wholly attributable to alcohol, as well as conditions that that were caused by alcohol in some, but not all, cases (i.e. hypertension, fall injuries). The likelihood of being admitted to hospital for an alcohol-related condition increases with age, as shown in Figure 1. Specifically 10% (n = 1,123) of alcohol-related admissions were for individuals aged between 55 and 64, and just under half (46% or 5,052 admissions) were for individuals aged 65 or over. Figure 5: Local crude rates of alcohol-related admissions by 5-year age bands, 2008/09

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1000

2000

3000

4000

5000

6000

7000

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Source: NHS Worcestershire Public Health Intelligence Team (2009)

21 Alcohol-related hospital admissions: 2002-03 to 2008-09, North West Public Health Observatory (2009) 22 Alcohol-specific and alcohol-related hospital admissions, NHS Worcestershire Public Health Intelligence Team (2010)

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Based on local crude rates of admissions during 2008-09, individuals aged 70 or over were 2.9 times more likely to be admitted to hospital for an alcohol-related condition compared to the population as a whole. Moreover, it should be noted that whilst the prevalence of alcohol-related conditions increase with age, the opposite is true of alcohol-specific conditions, which were more prevalent amongst younger age groups. Alcohol-related admissions for diseases of the circulatory system were most prevalent amongst individuals aged 65 and over (3.7 times more likely than the population as a whole). Specific conditions contributing to this included hypertension (46% of admissions were for those aged 60-74 year olds) and cardiac arrhythmias (42% amongst those aged 80 and over). Conversely, the 65 and over age group were amongst the least likely to be admitted for mental and behavioural disorders due to alcohol use (rate of 249 per 100,000 compared to an average of 279). Figure 6: Local rate of alcohol-related hospital admissions (per 100,000) by broad age group and district, 2008-09

District 0-19 20-24 25-34 35-44 45-54 55-64 65+

Bromsgrove 199.3 796.5 732.5 931.4 1260.0 2418.2 4687.9

Malvern Hills 147.2 1230.0 989.6 1042.7 1548.7 2191.4 4492.5

Redditch 330.3 923.7 1189.0 1518.6 1951.7 3175.7 6240.4

Worcester 271.0 1353.3 1163.5 1365.9 2807.1 3498.4 5505.2

Wychavon 167.5 632.0 985.5 975.3 1919.2 2996.8 5357.9

Wyre Forest 188.2 876.6 856.9 1129.3 1998.9 3026.0 4905.1

Worcestershire 216.6 961.3 1001.6 1153.1 1911.0 2886.3 5134.0

Source: NHS Worcestershire Public Health Intelligence Team (2009)

Figure 2 indicates that all districts had higher rates of admissions for those aged 65 and over compared to the other age groups. It should also be noted that districts where individuals aged 65 and over constitute a greater proportion of the overall population (Bromsgrove, Malvern and Wyre Forest) have lower rates of alcohol-related admissions amongst that age group compared to other areas. Redditch was subject to the highest rate of admissions amongst the 65 and over age group, which makes up just 13% of the total population. Compared to the age profile of alcohol-related admissions across the West Midlands during 2008-09, Worcestershire had a similar profile, with a couple of exceptions. Within the county, there was a lower rate of admissions for persons aged 55-64 (2886.3 per 100,000 compared to 3169.9 regionally). Moreover, Worcestershire

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experienced a higher rate of admissions for the 65 and over age group (5134 per 100,000) compared to the corresponding rate regionally (4984.1). Whilst it was not possible within the data to map the concentration of admissions for individuals aged 55 and over specifically, Figure 3 provides an indication of where alcohol-related admissions are highest as a whole. It is evident from Figure 3 that a noticeable proportion of admissions originate from the more urban parts of the county. However, it should also be noted that there are a number of rural areas that also experience a high rate of alcohol-related admissions. Figure 7: Local estimates of alcohol-related hospital admissions in Worcestershire, pooled DSR for 2006-07 to 2008-09

Source: NHS Worcestershire Public Health Intelligence Team (2009)

The age profile outlined above is in part reflective of the calculation underlying NI 39: alcohol-related hospital admissions. NI 39 is based on analysis of the first 14 diagnosis codes on a patient's record when admitted to hospital. The primary diagnosis code refers to the condition/symptoms that directly contributed to the admission. The remaining 13 codes can include pre-existing conditions that require on-going treatment in addition to symptoms that directly contributed to the hospital admission. If any one of these codes are related to alcohol, then they are included in the calculation of NI39. Where a patient has one or more diagnosis code linked to alcohol, the code that has the highest likelihood of being related to alcohol is included in the calculation of the indicator. As a result of the process above, the calculation and analysis of alcohol-related hospital admissions is not always reflective of the primary condition that brought a

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person into hospital. For example, only 1.25% of admissions coded as hypertension under NI39, actually had a primary diagnosis of hypertension. This means that the targeting of alcohol-related conditions is more difficult. It is also this factor in the calculation of NI 39 that may explain the high rates of admissions amongst older age groups, who are more likely to suffer from chronic conditions, such as hypertension, which are thought to be linked to alcohol in some, but not all cases. Consequently, in order to reduce the incidence of alcohol-related conditions amongst older age groups, attention needs to be paid to the wider health needs/risks of individuals, alongside a consideration of the role alcohol has to play in these conditions. Alcohol-related offending According to the 2008-09 British Crime Survey (BCS), 47% of violent crime victims believed the offender to be under the influence of alcohol at the time of the offence, most commonly when the offence was committed by a stranger.23 In addition, a Home Office study during 2003 looking at the characteristics of domestic abuse perpetrators found that alcohol was a feature in 62% of offences and that almost half of the perpetrators were alcohol dependent.24 During 2008-09 there were a total of 4,569 alcohol-related offences in Worcestershire.25 These constituted 12.4% of the total offences in the county; a proportion that has been relatively consistent since 2006-07, with only slight fluctuations. Figure 8: Alcohol-related offences and offenders, 2006-07 to 2008-09

Number of alcohol-related

offences

% of total crime

Number of known alcohol-

related offenders

% of alcohol-related

offenders aged 55 & over

2006-07 5,139 13.1% 3,984 1.4%

2007-08 4,856 13.1% 3,491 2.6%

2008-09 4,569 12.4% 2,284 2.2%

Source: West Mercia Police, 2010

Alcohol-related offences as a proportion of the total volume of offences during 2008-09, were highest in Worcester (16.2%) and Redditch (15.1%), and lowest in Wychavon (8.8%). This may partially be reflective of the concentration of licensed premises and the night-time economy in Worcester and Redditch, and the higher level of policing in these areas as a result.

23 Crime in England and Wales 2008/09, Home Office (2009) 24

Domestic Violence Offenders: characteristics and offending related needs, Home Office (2003) 25 Based on offences where an alcohol interest marker was included in the initial record.

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There were 2,284 individuals known to have committed an alcohol-related offence during 2008-09. These individuals were primarily male (83%) and more likely to be amongst the younger age groups (54% under the age of 25). Specifically, 2% (n=51) of the known alcohol-related offenders were aged 55 or over, and were responsible for 78 offences during 2008-09. The majority of these offenders were male (86%) and 45% were between the ages 55 and 59. Individuals aged 55 and over were known to be responsible for 2.8% of the total alcohol-related offences in Wychavon (the highest proportion), and 1.1% in Redditch and Wyre Forest (the lowest proportions). Figure 9: Offences known to have been committed by individuals aged 55 and over, 2008-09

56%

12%

10%

9%

7%5%

1%

Violent Crime

ASBO

Public Order

Theft

Possession Weapon

Criminal Damage

Burglary

Source: West Mercia Police, 2010

Over half of the offences known to have been committed by individuals aged 55 or over were violent crimes (n=44). Specifically, 20 of these alcohol-related violent offences were also linked to domestic abuse. It should also be noted that of the 9 breaches of anti-social behaviour orders, five were for the same individual. Seven of the 51 individuals committed more than one offence during the 12 month period. Of these, one committed eight offences (including four offences on the same night and 5 breaches of an ASBO), one committed seven offences and the other six committed between 2 and 6 offences each.

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Figure 10: Alcohol-related offences committed by individuals aged 55 and over by time of the day, 2008-09

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4

6

8

10

12

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5

# o

f o

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Source: West Mercia Police, 2010

There was a noticeable concentration of offences during the early evening (31 offences between 16:00 and 19:59). This would not suggest a strong link to the night time economy. However, recent evidence has suggested that people in the middle to older age groups are drinking more at home which could suggest that they are drinking earlier in the day, and then committing offences during early evening. During 2008-09, there was a concentration of offences during the weekend period (39% of offences occurred between 18:00 on Friday and 05:59 on Monday). Saturday experienced the largest volume of offences (21 offences or 27%), whilst Wednesday was subject to the lowest volume of offences (3 offences or 4%). It should be noted that the inclusion of an alcohol interest marker on the crime record is likely to underestimate the true proportion of offences linked to alcohol. This is because the interest markers are dependent on alcohol being mentioned during the initial '999' call, and the operator logging this on the crime record. Alcohol Treatment During 2008-09, 935 individuals accessed structured Tier 3 or 4 treatment, or alcohol brief interventions in Worcestershire.26 A significant proportion of these individuals were male (67% or 622 clients). Moreover, as can be seen from Figure 7, the 35-44 age group constituted the largest proportion of clients accessing support (205 clients), whilst those under the age of 25 constituted a third of clients. One in ten clients accessing alcohol treatment in 2008-09 were aged 55 or over. This statistic could suggest that older people aren't accessing specialist treatment. There could be a number of reasons for this including:

Professionals aren't referring older people to specialist treatment;

26 These figures include clients who attended the brief intervention sessions offered through the Alcohol Criminal Justice Interventions Team (ACJIT).

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Specialist treatment is not marketed widely enough.

Figure 11: Clients in treatment by age group, 2008-09

14%

19%

18%

22%

17%

8%

2%

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Source: Quarter 4 Alcohol PCT Information Report, NDTMS (2009)

There were 686 referrals to the Alcohol Criminal Justice Interventions Team (ACJIT) during 2008-09, which provides two sessions of brief interventions to individuals who have been arrested for an alcohol-related offence. Of these referrals, 6% (n=93) were for individuals aged 55 and over. It should be noted that the likelihood of an individual attending both sessions offered increased with age. Whilst a third of 18-24 year olds attended both sessions, 67% of those aged 65 or over. Similarly, whilst 22% of individuals aged 65 or over did not attend either session, this was true of 57% of 18-24 year olds referred to the scheme. (b) Community Consultation: During October and November 2009 a number of consultation events were held throughout the county with service users, carers and a wide range of stakeholders. Stakeholders were asked a selection of questions about older people's drinking:

1. What evidence of alcohol misuse in older people (65+) are you encountering in your service, and does it appear to be increasing?

2. What appears to be the main patterns of drinking for older people, (e.g., lone, social, self-medicating) and does this appear to be changing?

3. What do you think is the best way to approach this group regarding their drinking, e.g. health visitors, specialist workers, home visits or other venues?

The following are some common points raised at these events:

It is difficult to get older people to acknowledge that they have a problem with alcohol. They are often in denial and will go to great lengths to hide the alcohol and the problem;

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The majority of older people drink alone, in their homes;

There are issues with falls, personal hygiene and people struggling to feed themselves properly;

Queries regarding how older people obtain alcohol, especially those who live in sheltered accommodation;

There is a perception by professionals that services will only help younger people;

For older people, the first port of call is often the GP;

Older people often use alcohol in a medicinal way to self prescribe for a traumatic event;

Cider, Sherry, Brandy were popular choices, often mixed in with tea/coffee;

There is no recognition amongst professionals, including GPs, that older people misusing alcohol is an issue,;

Advice is not targeted at older people – there is just generic advice which talks a lot about units, which is not understood by older people;

All of the media attention seems to be about young people and binge drinking – you don't see any advertisements about older people drinking at home;

Older people need diversionary activities to reduce their need to drink through loneliness;

Single, older males seem to drink more than any other older population group;

Young people are often drinking with older people and this can lead to vulnerability issues e.g. younger people using older people's homes as 'drink dens';

Services to support older people with drink problems are being contacted too late;

Many older people are drinking to cope with debt problems resulting from loss of income (through retirement or redundancy);

Drinking often starts as a social activity but develops into drinking at more dangerous levels at home;

Older people aren't aware of how much they are drinking because they don't use standard measures e.g. they may pour themselves a 'glass' of sherry but the glass may be a tumbler;

Reduction in homecare visits and day care has contributed to the social isolation of older people;

There is a need for more outreach with older people – a lot of older people will not attend a clinic or A&E;

Partners of the drinker often end up being the carer;

Falls are a big problem with older people but they are not always identified as alcohol related;

Would 'befriending' be a good approach to tackle loneliness?

There are many dual diagnosis cases i.e. alcohol misuse and mental health problems;

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(c) Questionnaires A questionnaire (see appendix 2) was sent out to the following professionals:

- Older People's Social Workers; - Older People's Health Visitors; - Older People's Community Mental Health Teams - Health Trainers; - Volunteers/Be-frienders; - Home care services; - Housing officers; - Acute nurses; - Homelessness Workers.

A total of 47 questionnaires were returned, from the following organisations:

Age Concern Hereford & Worcester;

Dial (Disability Advice Network);

Hereford & Worcester Fire & Rescue Service;

Redditch Borough Council;

Rooftop Housing Group;

Worcestershire Acute Hospitals Trust;

Worcestershire Community Alcohol Team;

Worcestershire County Council;

Worcestershire Mental Health Partnership Trust;

Worcestershire PCT;

Wyre Forest Community Housing. Questionnaires were received from the following range of professionals:

Social Workers;

Mental Health Nurses;

Community Psychiatric Nurses;

Alcohol Counsellors;

Clinical Psychologists;

Community Liaison Coordinators;

Old Age Psychiatrists;

Community Safety Advisors;

A&E Consultants;

Hospital Discharge Liaison Nurses;

District Nurses;

Gypsy Services Manager;

Home Support Officers;

Nurse Advisors to Older People;

Occupational Therapists;

Older Person's Health Visitors;

Welfare Benefits Advisors;

Rapid Response Nurse.

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The majority of respondents worked solely with clients who were over 65 (some worked with clients of all ages, which included older people). Most respondents worked with any adult or older person. However, a small number of respondents worked with a specialist client group such as older disabled people, older people with dementia, older vulnerable adults etc. Results Question 1 - In your role, how often do you come into contact with older people who are misusing alcohol? (Rarely; Occasionally; Frequently; Everyday) 30% (n=14) of respondents frequently come into contact with older people

misusing alcohol. 40% (n=19) of respondents occasionally come into contact with older people

misusing alcohol. 30% (n=14) of respondents rarely come into contact with older people misusing

alcohol. Figure 12: The frequency of which professionals come into contact older people who misuse alcohol

Question 2 - Please state which kind of alcohol related injuries/illnesses and behaviours you see? (Physical Injuries; Ongoing health conditions; General drunken behaviour; Mental Health Problems; General Poor Hygiene) 81% (n=38) of respondents had witnessed physical injuries, the most common

injury being falls, broken bones, cuts and bruises; 85% (n=40) of respondents had witnessed ongoing health conditions related to

alcohol misuse. The most common reported conditions included hypertension, stroke, memory loss, heart, liver and kidney problems;

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70% (n=33) of respondents had witnessed general drunken behaviour, the most common behaviour being slurring of words, difficulty standing or keeping balance and aggression. Many respondents commented that their clients tried to deny that they had been drinking;

74% (n=35) of respondents had witnessed mental health problems, the most common problem being depression and anxiety;

79% (n=37) of respondents had witnessed general poor hygiene, the most common behaviour being neglect of personal hygiene and incontinence.

Figure 13: Alcohol related injuries/illnesses and behaviours in older people which are witnessed by professionals

Question 3 – In your experience, are older people's drinking habits any different from other clients that you engage with? Could you explain how they are different (e.g. frequency, type of alcohol, amount)? 19% (n=9) of respondents felt that older people's drinking habits were no

different to younger people; However, the most common response that came from respondents was that

older people are drinking alone, in their homes; Older people are more likely to drink sherry, wine and spirits rather than beer; Older people are less likely to binge – they are more likely to drink smaller

amounts throughout the day. Question 4 - Do you have any idea about the reasons why older people may misuse alcohol? 72% (n=34) of respondents felt that older people are drinking due to

loneliness/social isolation; A further 28% (n=13) of respondents felt that older people are drinking due to

bereavement;

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Other reasons cited were depression, stress, pain relief, to help them sleep, loss of role, boredom, and pleasure.

Question 5 - What kinds of interventions/services are you aware of that could support older people who misuse alcohol? 26% (n=12) of respondents had heard of Alcoholics Anonymous; 21% (n=10) of respondents had heard of Worcestershire Community Alcohol

Team; 15% (n=7) of respondents felt that a GP was the best person to support an older

person with alcohol problems; 21% (n=10) of respondents didn't know of any interventions/services available to

support older people who misuse alcohol. Figure 14: Type of alcohol related intervention/service that professional is aware of

Question 6 - What interventions/services do you think are needed to address alcohol misuse in older people? 28% (n=13) of respondents felt that professionals need more education and

training on the issues associated with older people who misuse alcohol and guidance on how to raise awareness with their clients and advise them on safe limits;

21% (n=10) of respondents felt that older people need better day care facilities and activities in the community to prevent social isolation and alcohol misuse;

19% (n=9) of respondents felt that older people would benefit from counselling from a specialist.

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Questions 7 - Do you think that professionals are sufficiently aware of alcohol issues in Older People? 55% (n=26) of respondents did not believe that professionals were sufficiently

aware of alcohol issues in older people; Many respondents requested further training.

Question 8 – What further support would you like to see to support older people who are misusing? A range of responses were provided in this section including further funding, a

specialist alcohol worker to work with the older people; a walk-in clinic; better counselling; support groups specifically for the older people; more joint working by professionals.

(d) Findings from Professional Interviews Two interviews were held with professionals who come into contact with older people who misuse alcohol on a daily basis – an Alcohol Liaison Nurse based in the Accident & Emergency Department at Worcester Royal Hospital and a Consultant Psychiatrist in Substance Misuse at St Bernard's Hospital in Middlesex whose special interests include substance misuse problems in special populations and the economics of service provision. Interview 1 – Alcohol Liaison Nurse, Worcester Royal Hospital – 25th February 2010

The Alcohol Liaison Nurse reported that he came into contact with older people who are misusing alcohol every day.

He mainly sees head injuries due to falls but he also sees fractures and many cases of self neglect.

He sees many different types of drinking behaviours: - Older people tend to drink in 'tots'; - Many patients drink wine – they start off drinking with a meal then it

continues; - Many older people still use pubs and drink in rounds with their friends; - Street drinkers tend to drink cider, particularly White Lightening; - Older females tend to drink Sherry or Cider; - Some have had problems with alcohol all of their life.

The Alcohol Liaison Nurse believes that some of the reasons why older people drink problematically include:

- Depression; - Bereavement; - Loneliness; - Trying to hold onto their youth; - They are housebound so they have no other pleasure; - Many drink to take away the stress involved in caring for a partner; - Many older people still drink socially, in the pub or at bingo for example.

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He believes that Brief Interventions would be an effective form of treatment for older people.

Also, as many older people are drinking because they are socially isolated, a specialist befriending service would be beneficial.

Improved transport for older people would enable them to get out and about more, which would prevent them from drinking through boredom and loneliness.

The Alcohol Liaison Nurse also felt that some healthcare professionals held a distorted view – he has heard professionals say "It's too late for them to change now".

He recommended that some events to raise awareness are held for professionals, especially older people's services.

Interview 2 – Consultant Psychiatrist in Substance Misuse at St Bernard's Hospital in Middlesex – 17th March 2010

The Consultant Psychiatrist stressed the importance of bringing services together to address the attitudes that exist around older people and alcohol misuse.

Like the Alcohol Liaison Nurse, he also recommended holding sessions to raise awareness with relevant older people's workers and services.

He believes that older people that misuse alcohol can be screened and then a stepped care model can be implemented, starting with a Brief Intervention and then gaining agreement on what stage the patient should be referred onto the next stage e.g. specialist treatment, psychiatric services.

The Consultant Psychiatrist recommended the use of the MAST-G Screening Tool (see Appendix 1). However, he maintains that the screening tool should be incorporated into routine assessments for older people, for example, when seeing their GP.

He recommended developing a process of training and awareness for staff on how to use the screening tool and deliver Brief Interventions.

Finally, the Consultant Psychiatrist recognises that older people often misuse alcohol because of bereavement, loneliness and depression. He recommends setting up age specific support groups, similar to Alcoholics Anonymous. Also, we need more adequate day care to help alleviate depression.

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6. Conclusions As can be seen from the results of this study, although alcohol issues in older people may be underrecognised, they are certainly present. Although a small sample of professionals were surveyed, 70% of respondents either frequently or occasionally witnessed alcohol issues in older people that they work with. Professionals are witnessing not only drunken behaviour but illnesses and health conditions linked to alcohol misuse. The difficulty with identifying the need for support amongst older people who misuse alcohol is that often they will go to great lengths to disguise their use. Also, some older people may not realise how much alcohol they are consuming so will underreport their usage to professionals. Furthermore, many symptoms of alcohol misuse present in similar ways to those of the ageing process, for example, accidents, memory loss and self neglect. Professionals need to always be mindful that alcohol issues may be exaggerating health concerns for their clients and it is never too late to intervene. The most common reason given for why older people misuse alcohol is loneliness. Although there are many treatments which could help treat alcohol problems in the older people, it seems that many older people would drink less if they had more social contact, became more involved in community based activities and had somebody to chat to on a regular basis. Professionals admit that they need more education and training on the issues associated with older people misusing alcohol – this needs to be more than basic alcohol awareness. Experts in the field suggest that frontline workers and professionals are trained to screen for alcohol misuse – preferably using a screening tool designed for geriatric use such as the Michigan Alcoholism Screening Test (MAST-G). Finally, if professionals are being trained to screen for alcohol misuse, there must be services available for them to refer to when appropriate. Research has shown that older people are just as likely to benefit from treatment as younger people. However, many older people would not feel comfortable accessing a Community Alcohol Team so thought needs to be given to more outreach focussed specialist work. Also, older people who are dependent on alcohol could require a detox; however, a community detox may not be suitable (especially if the client lives alone). Consideration needs to be given to a developing a detox facility that will suit older people, such as a specialist bed in a nursing home or making funding available for inpatient detox for older people. Consideration must also be given to mutual aid support. Groups such as Alcoholics Anonymous and SMART Recovery have a high success rate but often groups like these are daunting to someone who is not used to social contact. Age specific groups could be trialled to see if there is a need for this type of intervention

7. Recommendations As a result of this study, there are a number of key recommendations that should be considered and investigated:

No. Recommendation Theme Current Position Actions Required Costs Risks of no action

1. All frontline professionals working with the older people should be trained in alcohol awareness, screening and Brief Interventions. This training should be specialist training focusing on alcohol problems in the older people and using tools designed for geriatric use, such as the Michigan Alcohol Screening Tool.

Diagnosis General IBA training exists and is provided through MerciaNet Training. No specialist training in place. MAST Screening tool not currently used.

Training programme developed and disseminated to OP professionals

Nil Worker time to attend training

Alcohol Misuse in older people will continue to go undetected. Alcohol related health harms will continue to increase in older people

2. Appropriate care pathways should be developed and disseminated widely so professionals are aware of referral routes into support and treatment and are clear at what point a patient should be referred on.

Diagnosis No care pathway exists

Care Pathway developed Care Pathway agreed and disseminated

Nil OP professionals will be unclear of process and will be reluctant to make referrals.

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No. Recommendation Theme Current Position Actions Required Costs Risks of no action

3. Consideration should be given to developing a specialist outreach treatment worker to support older people who find it difficult to get out of their house.

Treatment Current alcohol treatment provision does not have capacity to do this type of work

Ensure that new drug and alcohol service has capacity to do outreach work with hard to reach clients

This could be managed within capacity of the new drug and alcohol service

Alcohol Misuse in older people will continue to go undetected and untreated. Alcohol related health harms will continue to increase in older people

4. Consideration should be given to having workers with a special interest (alcohol misuse in this case) based within teams that visit older people e.g. social workers, health visitors etc.

Treatment There are no workers with a special interest in alcohol misuse

Liaison with senior managers within Adult and Community Services and NHS Worcestershire to gain approval to train members of staff to specifically work with older people who are misusing alcohol. Train members of staff.

Staff Time Alcohol Misuse in older people will continue to go undetected and untreated. Alcohol related health harms will continue to increase in older people

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No. Recommendation Theme Current Position Actions Required Costs Risks of no action

5. According to respondents who completed the questionnaire, loneliness is the most common reason for older people misusing alcohol. Consideration should be given to developing a specialist befriending scheme or recruiting volunteers with a special interest in alcohol misuse.

Prevention The current befriending scheme in Worcestershire has a shortage of volunteers

Liaison with "Onside" regarding holding a recruitment drive to attract more volunteers with an interest in alcohol misuse

Minimal admin costs Staff time

Loneliness will continue to affect older people and problematic drinking will continue to increase

6. Bereavement is cited as one of the main reasons for alcohol misuse in the older people, so more counselling should be made available for individuals should they become bereaved.

Prevention Unknown Scope Bereavement Counselling services across the County Raise awareness of the links between bereavement and alcohol misuse and encourage professionals to refer to appropriate services

Staff time

Bereavement will continue to affect older people and problematic drinking will continue to increase

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No. Recommendation Theme Current Position Actions Required Costs Risks of no action

7. An age-specific support group could be trialled to see if the success of AA and SMART Recovery can be replicated with older people.

Treatment No age-specific support groups exist

Liaise with AA Coordinator regarding the trialling of a specialist group Set up and monitor group

Room hire and refreshments Volunteer and staff time

This action may not be effective so no risks can be identified at this point

8. Community activities/forums that already exist for older people should be used to deliver messages about safer drinking and the dangers involved with excess drinking.

Prevention These forums are not currently used to deliver messages about safer drinking

Map older people community forums across the County and make contact Deliver awareness sessions

Staff time

Older people will not be aware of risks of excess alcohol consumption

9. A social marketing campaign should be developed to raise awareness of the dangers associated with alcohol misuse and to encourage responsible and safer drinking.

Prevention Marketing is currently generic

Scope views from older people regarding alcohol misuse Implement social marketing techniques to devise an effective awareness campaign

£10,000 Older people will not be aware of risks of excess alcohol consumption

1. Appendix 1

Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)

Question Yes No

1. After drinking have you ever noticed an increase in your heart rate or beating in your chest?

2. When talking with others, do you ever underestimate how

much you actually drink?

3. Does alcohol make you sleepy so that you often fall asleep in

your chair?

4. After a few drinks, have you sometimes not eaten or been able

to skip a meal because you didn't feel hungry?

5. Does having a few drinks help decrease your shakiness or tremors?

6. Does alcohol sometimes make it hard for you to remember

parts of the day or night?

7. Do you have rules for yourself that you won't drink before a

certain time of the day?

8. Have you lost interest in hobbies or activities you used to

enjoy?

9. When you wake up in the morning, do you ever have trouble

remembering part of the night before?

10. Does having a drink help you sleep?

11. Do you hide your alcohol bottles from family members?

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Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)

Question Yes No

12. After a social gathering, have you ever felt embarrassed

because you drank too much?

13. Have you ever been concerned that drinking might be harmful

to your health?

14. Do you like to end an evening with a nightcap?

15. Did you find your drinking increased after someone close to you died?

16. In general, would you prefer to have a few drinks at home rather than go out to social events?

17. Are you drinking more now than in the past?

18. Do you usually take a drink to relax or calm your nerves?

19. Do you drink to take your mind off your problems?

20. Have you ever increased your drinking after experiencing a loss in your life?

21. Do you sometimes drive when you have had too much to drink?

22. Has a doctor or nurse ever said they were worried or concerned about your drinking?

23. Have you ever made rules to manage your drinking?

24. When you feel lonely, does having a drink help?

Five or more "yes" responses are indicative of an alcohol problem.

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Alcohol use disorders in older people are a common but under recognised problem associated with major physical and psychological health problems. Worcestershire DAAT is currently conducting a Needs Assessment of Older People (over 65s) and their alcohol use. This piece of work seeks to highlight issues and concerns about alcohol misuse in older people and look at possible ways of meeting the alcohol related needs of older people. As part of this work, it would be really helpful if you could complete the following questionnaire. Please could you return the questionnaire by Friday 19th March 2010 to

kray@worcestershire.gov.uk or post to Kate Ray, Worcestershire DAAT, County Hall, Worcester. WR5 2NP Name: Job Title: Organisation: Client Group: Age of Client Group you work with:

1. In your role, how often do you come into contact with older people who are misusing

alcohol? Rarely Frequently Occasionally Everyday 2. Please state which kind of alcohol related injuries/illnesses and behaviours you see? Physical Injuries (Falls, broken bones, cuts, bruises etc)

Ongoing health conditions (High or Low Blood Pressure, heart problems, liver and kidney problems, stroke, cancer, memory loss, insomnia etc)

QUESTIONNAIRE: Alcohol & Older People

8. Appendix 2

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General drunken behaviour (Slurring of words, unable to stand, unconsciousness etc) Mental Health Problems (Depression, anxiety etc) General poor hygiene (Incontinence, poor cleanliness etc)

3. In your experience, are older people's drinking habits any different from other clients

that you engage with? Could you explain how they are different (e.g. frequency, type of alcohol, amount)?

4. Do you have any ideas about the reasons why older people may misuse alcohol?

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5. What kinds of interventions/services are you aware of that could support older people

who misuse alcohol?

6. What interventions/services do you think are needed to address alcohol misuse in

older people?

7. Do you think that professionals are sufficiently aware of alcohol issues in Older People?

8. What further support would you like to see to support older people who are misusing?

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If you want to add any further comments, please do so in the box provided. If you would like to have an informal conversation about anything related to this subject area, please contact Kate Ray, Alcohol Lead for Worcestershire Drug & Alcohol Action Team on (01905) 766661.