Elder Financial Abuse in PACE Programs: A Clinical Dialogue on Detection, Assessment,

and Intervention Strategies

Sheri Gibson, Ph.D. Behavioral Health

Rocky Mountain PACE 2015 NPA Annual Conference

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In 2000, A Fairly “Young” World . . .

Under 5% 5% to 12.4% 12.5% to 20% Above 20%

Source: U.S. Census Bureau

Percent of Population Age 60+ 2000

. . . An Aging World by 2025

Source: U.S. Census Bureau

Under 5% 5% to 12.4% 12.5% to 20% Above 20%

Percent of Population Age 60+ 2025

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Two sides of the Longevity Coin

• For many:

– Good health and independence

• For some:

– Chronic illness and increased medications

– Depression

– Dementia

– Change in quality/quantity of social support or

situation

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Cognitive Impairment

• Risk of cognitive impairment increases greatly with age.

• By 2030, 7.7 million adults in the U.S. over the age 65 will have dementia due to Alzheimer’s disease.

• By 2050, over 15 million affected.

• Dementia places individuals at risk for abuse and exploitation.

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Association between Dementia and Victimization

• Higher prevalence of elder abuse among

people with dementia (Cooper et al., 2008)

• Research findings:

– Nearly 50% of persons with dementia

experience some form of abuse (Cooper et al., 2009)

– 47% of persons with dementia had been

mistreated by their caregivers (Wiglesworth et al., 2010)

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Elder Financial Abuse

While my grandmother was emotionally and financially abused and isolated, her case is far from isolated.” –Philip Marshall.

“For years I suffered silently, unable to muster the courage to seek the help I knew I needed.” –Mickey Rooney

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Incidence Rates Unknown

• No national mechanism for recording or analyzing reporting data.

• Inconsistent definitions across states – Limits detection, investigative, and prosecution

processes

• Observational Research – Perpetrator and victim characteristics

– Develop theories of elder abuse

– Understand risk factors for abuse

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Elder Abuse: A fast-growing problem (NCEA, 2007)

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National Elder Mistreatment Study

Results: N = 5777 respondents Prevalence Rate Type of Abuse 5.2% Financial abuse by family member 5.1% Potential neglect 4.6% Emotional abuse 1.6% Physical abuse 0.6% Sexual abuse 1 in 10 respondents reported emotional , physical, or sexual mistreatment, or potential neglect in the past year. Most consistent correlates = low social support and previous traumatic event exposure

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Definition of Elder Financial Abuse (EFA) (www.NCEA.org)

• Illegal or improper use of an elder’s funds, property, or assets. Examples include:

– Cashing an elder’s check without permission

– Forging an elder’s signature

– Misusing or stealing money/possessions

– Using undue influence to coerce an elder into signing documents/contracts

– Improper use of conservatorship, guardianship, or power of attorney.

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Why exploit seniors?

• They have resources – Assets and income – Persons over 50 own 70% of nation’s wealth

• Some are physically dependent

• Some (not all) suffer from other vulnerabilities

– Dementia – Social isolation – Physical and psychological dependency

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Why is elder financial abuse a problem?

• Most common form of elder victimization (Acierno, 2010)

– Often occurs along with other forms of abuse

• Assumptions of researchers, APS caseworkers, and other experts for underreporting: – No physical mark

– Occurs over time with close interpersonal relationships

– Feelings of shame and embarrassment

– Fear of reprisal from perpetrator

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Societal Consequences of EFA

• Economic Costs

– MetLife Mature Market Institute (2009; 2011)

• Annual losses to victims calculated at $2.6 billion 2008 and increased to $2.9 billion in 2011.

• Almost 1 in 10 financial abuse victims will turn to Medicaid as a direct result of losing their assets and monies.

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Personal Consequences (NCEA website)

• Loss of trust in others

• Loss of security

• Depression

• Feelings of fear, shame, anger, self-doubt, remorse, worthlessness

• Financial destitution

• Inability to replace lost assets through employment

• Inability to obtain legal help or protection

• Inability to provide or obtain long term care needs

• Loss of primary residence

Perpetrator and Victim Risk Factors

Perpetrator: Victim:

• Demographic variables vary

• 60% of perpetrators are male and relatives of the victim (NCEA, 2008)

• Financially dependent on the elder

• Substance abuse, unemployment, poor health, mental illness

• Key psychological component: Undue Influence (Brandl, 2007;

Nerenberg, 1996, 200; Quinn 2000, 2002)

• Persons in a position of trust

• Widowed women (Hafemeister,

2003) • Age 75 or older • Geographically or socially

isolated • Presence of a functional or

cognitive disability (Acierno et al., 2009)

– Physical – Sensory deficit – Cognitive decline secondary

to dementia, depression, medication, or acute illness

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Psychological Component: Undue Influence

The misuse of one’s role and power to exploit the trust of another

UI plays a significant role in elder abuse

Risk factors for undue influence: Isolation, Cognitive deficits, Major life transition

Undue Influence is not an event –

it’s a process

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Psychological Component: Undue Influence

Create Fear

Create

Dependencies

Create Lack of

Faith in Own

Abilities

Induce Shame

and Secrecy

Perform

Intermittent

Acts of

Kindness

Keep Unaware

Isolate From

Others and

Information

Prey on

Vulnerabilities

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Common Patterns

• Gift-giving (not all gifting is suspect)

• New relationship/partners • Sweetheart scam; new best friends

• New caregivers • “She’s like a daughter to me”

• Change in wills, trusts, and powers of attorney

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Four Criteria for Undue Influence (Quinn, Goldman, Nerenberg, & Piazza, 2010)

1. Victim’s vulnerability: Illness, disability, injury, cognitive impairment, emotional distress, isolation, dependency;

2. Influencer’s power: Person in a position of trust, confidence, control, legal authority, or status. Examples: fiduciaries, caregivers, advisors, family members, health or legal professionals, spiritual leaders;

3. Unfair tactics or actions: Isolating victims, fostering false beliefs or perceptions, depriving them of information, basic necessities, sleep, or affection; using intimidation or coercion.

4. Outcomes, consequences, transactions, or exchanges divergent of accepted standards, including overprices sales, gifts that are incommensurate with the length of the relationship, elders’ actions that are inconsistent with their values/history/expressed wishes, or professionals’ violations of legal and ethical standards of conduct.

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Case Study “Mrs. G”

• Mrs. G is an 86 year old widow who lives alone, and has one son who handles her financial affairs.

• She is reported as mentally sound, but in the past year stopped driving due to vision impairment which increased her dependency on others for transportation to and from doctor’s appointments, grocery shopping, and attending Sunday church services.

• When Mrs. G bought a small condo, the son handled the paperwork regarding the sale of her larger residence and the purchase of the condo.

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“Mrs. G”

• Son placed the remainder of the proceeds not used to purchase the condo in an investment account.

• Mrs. G was surprised later to discover that neither the condo nor the investment account were titled in her name.

• She contacted a lawyer who had assisted with her deceased husband’s affairs and together, they sent her son a letter asking him to re-title both assets.

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“Mrs. G”

• The son called Mrs. G, and angrily responded by telling her that if she didn’t drop the matter he would sell the condo and place her into a nursing home.

• He also told her that if she persisted, when she died, he would not claim her body and bury her.

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Question:

• If Mrs. G did not lack capacity, is she still a victim of undue influence?

• How real is her fear that her son would place her in a nursing home and actually refuse to bury her?

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Mrs. G The Four Criteria:

• What are her vulnerabilities?

• How much power does the son control?

• What are the unfair tactics used by the son?

• What was the outcome of Mrs. G’s situation?

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Remember: Older Adults Can Make Poor Decisions!

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Family

• Family members – typical perpetrators of EFA – 60% of APS cases of EFA involve an adult child

– Grandchildren (9.2%) and other relatives (9.7%) • (Metlife, 2009)

• Caregiving roles – Places elder parent/grandparent in a dependent

position (e.g., mobility, social connection, manage ADLs)

– Places adult child/grandchild in a dependent position (e.g., food and shelter)

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Who Intervenes?

• The Participant - by accidentally uncovering misuse of finances

• Adult children/siblings or other family members

• Outside observer (neighbor; community members)

• PACE IDT members

• Law Enforcement and Adult Protective Services

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Community Collaboration is Vital

• Despite increased awareness at the local, state, and national levels, the professional response remains inadequate.

• Services are scarce, fragmented, of varying quality, and poorly understood by the public.

• In many communities, coordination among law enforcement, social service agencies, courts, health care providers, and others is poor.

• Few perpetrators are brought to justice, and many victims do not receive needed compensation, services, or treatment.

• The time is ripe to bring together a diverse group of committed partners to raise awareness, educate, and better respond to cases of abuse, neglect and exploitation.

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The Benefits of the PACE IDT

• Provides a venue for:

– Identifying abuse cases.

– Gaining multiple discipline’s perspectives.

– Updating IDT members about new services,

resources, and legislation.

– Revealing systemic problems to identify opportunities

for internal training and policy development.

– Partnering with Adult Protective Services and law

enforcement.

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Typical Community Response

Client

LE APS Service Agency

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PACE Participant-Centered Approach

APS

PARTICIPANT

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Rocky Mountain PACE Financial Safety Education and Survey

• Project Goal: To inform participants of potential financial abuse from solicitors.

– IDT discussion to determine need.

– PowerPoint developed for day center screening and handouts provided to ppts.

– Didactic component provided by BH during lunch.

• Training was well-received by ppt’s which prompted increased discussions about scams.

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Follow-up Survey

• 2 months after training – Needs assessment conducted using survey methodology.

• Purpose: To understand the experiences of PACE ppts as it relates to the growing problem of financial exploitation.

• Ppts were advised of the purpose of the survey and assured that their identify would be anonymous unless they indicated wanting to talk with a PACE staff member.

• Ppts consented to their participation by completion of the questionnaire.

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The purpose of this questionnaire is to understand the experiences of our PACE participants as it relates to the growing problem of financial exploitation. This survey is optional and voluntary. By answering the questions below, you are consenting to participate. Your name and identifying information will not be used unless indicated below that you wish to talk with PACE staff regarding your personal experiences related to the content matter. Your answers on the survey will help our staff develop training programs to educate all PACE participants about the warning signs and prevention strategies related to financial fraud and exploitation. We thank you for your participation! Please indicate your answer by circling the appropriate choices below: Have you ever been contacted by telephone or mail claiming that you owe money, have won a lottery or sweepstakes, and/or requesting your personal identifying information be disclosed to a third party (such as your social security number, date of birth, or bank account information)? YES or NO Have you or do you suspect that you have been a victim of financial fraud or a financial scam? YES or NO If you answered “YES”, approximately how much money did you lose in the transaction? (please circle the answer that best fits your situation)

Under $500 Between $500-$1000 Between $1000-$5000 Over $5000

Did you tell anyone about the situation or seek advice from a trusted person? YES or NO Please use the back of this page to add any comments regarding your experience or concerns about this issue: If you would like to talk to a PACE staff member about your experience or concerns, please write your name in the space below and a PACE staff member will follow-up with you privately: ________________________________________________________

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Methods

• Surveys distributed during lunch service at 4 time points.

• Total of 20 surveys were returned and analyzed by BH.

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Findings

• 90% (n = 19) of ppts reported they had been contacted by either telephone or mail claiming they owed money, had won a lottery or sweepstakes, and/or had been solicited to provide identifying information to a third party.

• One-fourth (n = 5) believed they had been a victim of financial fraud or financial crime.

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Monetary Loss

• Of the five ppts who reported victimization: – 1 ppt reported losing under $500

– 2 ppts reported a loss totaling $500-$1000

– 1 ppt reported $1000-$5000

– 1 ppt reported losses over $5000

• Of the victims, 63% stated they did not tell anyone about the situation or seek advice from a trusted person.

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Qualitative Data

• “I dropped my gas credit card. They moved to Texas, filled up their cars, bought cigarettes, etc.”

• “They are still calling.”

• “Years ago, I got a call from a hospital I never heard of. First, I asked the name of the doctor who I didn’t know – a date I didn’t know – the name of the procedure. They hounded me and hounded me. Finally said they were turning it over to a credit bureau.”

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Discussion

• Findings support previous research suggesting that older victims are less likely to report victimization for multiple reasons.

• Although specific monetary losses were not obtained by the present assessment, ppt’s answers indicated a total loss upwards of $12,500.

• PACE ppts represent a more fragile subset of the older adult population and are at higher risk for financial mistreatment and exploitation.

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Strategies for Intervening

• Empowering the elder – Identifying ambivalence – Commitment to unhook from victim behavior – Safety net strategies

• Family mediation

– Education – Role re-structuring (therapy) – Negotiation (formal mediation)

• Reporting to Local police and Adult Protective Services

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Barriers to Criminal Remedies

• Can be hard to convince prosecutors to pursue

• Victims may not be viable witnesses

• Document intensive cases – can be hard to prove

• Historical and ongoing belief that misappropriation by family members is a civil matter

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PACE Prevention Strategies

• Staff training – Mandatory reporting procedures

– Internal reporting and documentation P & P

– Multicultural training

• Supervisory support to staff – Ethical principles of autonomy, non-maleficence,

beneficence.

– Understanding our own beliefs about autonomy and protection that are shaped by society and personal experience

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National Resources

• National Committee to Prevent Elder Abuse (NCPEA): www.preventelderabuse.org

• National Center on Elder Abuse: www.ncea.aoa.gov

• Elder Justice Coalition: www.elderjusticecoalition.com