Invisible Scars

Charles Mouton, MD, MS, knew something was amiss with his 88-year-old patient when he examined her. The woman had suffered a stroke a few years earlier, and her blood pressure, which previously had been in an acceptable range, now was out of control.

 “I asked her some questions, and pretty soon it came out she wasn’t taking her blood pressure medication,” recalls Mouton, who now chairs the family and community medicine department at Howard University College of Medicine. “She also had mild dementia, and the son tried to imply that she wasn’t agreeing to take it. They got into a bit of an argument, so I asked to talk to her alone.”

 Upon further questioning, Mouton discovered that the son was taking half the woman’s monthly social security check as “payment” for the care he was providing. That didn’t leave enough to cover her medication. But when Mouton tried to report the case to the state’s adult protective services, his patient protested. “It turned out the son had been arrested twice before for drug possession, and she was afraid if he was convicted a third time he’d be sent away for life and she would be put into a nursing home,” he says.

 Jeffrey Kagan, MD, an internal medicine specialist practicing in Newington, Connecticut, recalls a similar case involving an elderly patient for whom a conservator had been appointed because he was not taking medications and was neglecting his personal care. “Two women, a home aide, and another who said she was a neighbor were with him, and they wanted me to write a letter to the probate court saying he no longer needed a conservator to pay his bills because he wasn’t demented.”

 The patient seemed confused about why he had been brought to see Kagan, so Kagan administered several brief cognition tests, on which the patient performed poorly. “At that point, the women said they would get another opinion and stomped out of the room,” he recalls. “I really got the feeling that these two women were planning on taking his finances.”

 In many ways, Mouton’s and Kagan’s patients were fortunate. The two doctors recognized signs of financial abuse, took the time to probe more deeply, and followed up on their suspicions. Too often, experts say, primary care doctors don’t know when their elderly patients are being taken advantage of financially or are reluctant to take action when they suspect it may be occurring.

 “In my 12 years of prosecuting crimes against the elderly, it has not been my experience that a physician is the one reporting the crime,” says Paul Greenwood, deputy district attorney and head of the elder abuse unit in the San Diego County District Attorney’s Office. “They may be trained to spot signs of physical abuse, but it’s rare for them to be called on or even think to report suspicious financial transactions.”

What Constitutes Financial Abuse?
A 2007 survey of state adult protective services from the National Center on Elder Abuse (NCEA) defines financial abuse as “the illegal or improper use of an older person’s or vulnerable adult’s funds, property, or assets.” Examples cited in the survey include cashing checks without authorization or permission, forging a signature, misusing or stealing money or possessions, coercing or deceiving someone into signing a document, and the improper use of conservatorship, guardianship, or power of attorney.

Randolph Thomas, MA, past president of the NCEA and a former law enforcement officer, trains police and social workers around the country to help recognize and prevent financial abuse of the elderly. In his training sessions, he makes clear that financial abuse is defined as taking place in the context of a trusted relationship between the victim and the perpetrator. “The public seems to be more aware of things like telemarketing and crimes perpetrated by strangers. We look for a family member or someone else who the victim trusts,” he says.

Sharon Merriman-Nai, NCEA co-manager, says abuse sometimes is as blatant as the outright theft of cash, jewelry, or credit cards. But often it is more subtle. “Frequently the perpetrator is very strategic in the way they go about gaining access to a person, weaning them away from other people, then manipulating the person into turning over their assets. It is the definition of undue influence.”

An Underreported Problem?
Pinning down the frequency of elderly abuse is difficult. Adult Protective Services around the country investigated about 38,000 cases in 2003. But many experts believe the true number is much higher. “For every case reported to any type of authority, studies show that between 12 and 15 cases go unreported,” says Bennett Blum, MD, a geriatric psychiatrist and consultant.

Merriman-Nai explains that underreporting occurs for a number of reasons. “Often the victim is embarrassed and doesn’t want to talk about it, or they may be in denial or afraid of the consequences of what might follow such a disclosure.” Common fears are that the perpetrator will retaliate by stealing even more or that the perpetrator will be jailed, leaving the victim without a caregiver and forced into a nursing facility. “Even if the person is aware they are being abused, if the perpetrator is a family member or loved one, the feelings of love can override everything else,” she says.

Risk Factors for Abuse
Financial abuse victims may include men and women of virtually any racial or ethnic group and can be rich, poor, or somewhere in between. Some life events, however, are likely to increase the risk of victimization. “We often see it in a person who has just lost a spouse, is living alone, doesn’t have much family support, and has recently hired a caregiver,” says Greenwood.

Financial dependency is another factor. “If my son is taking care of me, and he is dependent on me for his livelihood, I am much more likely to be a victim of financial abuse,” notes Mouton.

Recognizing Financial Abuse
Recognizing when a patient is being financially exploited by a caregiver is obviously more difficult than identifying physical abuse. Nevertheless, there are warning signs that physicians can look for when examining their elderly patients.  A major one is if a patient suddenly stops buying prescribed medications, says Fay Kahan, LCSW, elder abuse coordinator at Mt. Sinai Hospital in New York. “If they say they can’t afford them and they always had been affording them, I would be suspicious that someone is using their money inappropriately.”

Therese Zink, MD, MPH, assistant professor in the department of family and community health at the University of Minnesota Medical School with a private practice in rural southeastern Minnesota, advises primary care doctors to be on the lookout for weight loss not connected to known medical conditions and a general unkempt appearance-both possible indicators that a patient is not getting access to her money.

Regardless of the patient’s physical condition, experts advise, sometimes just asking patients about what’s going on in their lives can reveal signs of financial exploitation. However, it must be done in a way that does not anger or alienate the patient, notes Mouton. “The way I try to couch it is to ask if the person feels what’s going on is appropriate. Is this what you want to have happening, and why?’ If I get a rational response, I don’t report it. But if they say no, I don’t want this to happen, or they can’t give me a rational answer to the question, then I lean towards reporting.

“It’s definitely a judgment call, but in general I lean more toward reporting than not,” he adds. “I tell the family the law requires me to do it, and it could result in more resources being made available to help the person you’re caring for.”

It is also vital for doctors to question patients alone, away from their caregivers. “People who know they are being taken advantage of are not going to be forthcoming in the presence of their victimizer,” notes Frick.

“I think doctors should always try to speak to patients away from the caregiver,” adds Blum. “The caregiver typically will say something like, ‘Oh, Miss Jones is just getting confused.’ Sometimes they are telling the truth, but you have to allow for the possibility they are lying. The smartest perpetrators always come across being loving and supportive when they’re around other people, so you have to get the victim alone if you want the truth.”

Kagan says questioning the caregiver can reveal clues to financial abuse, but it must be done carefully. “Sometimes I might ask the caregiver questions like ‘Are you working now?’ ‘Do you have some means of support other than caregiving?’ You have to couch it in a non-threatening manner because if the caregiver suspects you know something, they won’t bring the patient back.”

Blum and others recommend administering cognitive tests, such as the Folstein exam, to elderly patients He cautions, however, that the Folstein does not assess the part of the brain that evaluates the consequences of actions. “That part of the brain can be fine when other areas are impaired, and vice versa. If a doctor suspects a patient is not capable of making financial decisions, he should refer them to a neuropsychologist for more in-depth evaluation.”

Frederick Sherman, MD, MSc, professor of geriatrics and medicine at the Mount Sinai School of Medicine, medical director at Senior Health Partners in New York, and medical editor of Geriatrics, asks his patients to simulate paying a utility bill and observes them as they go through the steps of looking over the bill, writing a check for the correct amount, and addressing the envelope. While the test was designed to assess a patient’s financial capability, failure to “pass” it also indicates vulnerability to financial abuse, he says.

What Doctors Should Do
Physicians who suspect a patient is being victimized financially are required, in most states, to report it to law enforcement or their local Adult Protective Services (APS). But even in states where reporting is mandatory, doctors frequently don’t do so, says Blum. “Most physicians don’t want to get involved. Partly it’s financial. The process of reporting and what follows can be time-consuming, and doctors aren’t reimbursed for the time it takes. Lots of doctors try to assuage their concerns by telling themselves they’re not really experts or what they’re seeing is really something else.”

Sometimes doctors are reluctant to report suspicions of abuse because they fear being sued if their allegations prove to be unfounded. However, every state except South Dakota and Puerto Rico has “good faith” reporting provisions in their APS laws, according to the American Bar Association’s Commission on Law & Aging. Such provisions generally provide physicians with immunity from legal liability for reporting suspected elder abuse, as long as the reports were made in good faith.

Deputy District Attorney Greenwood advises doctors to act on “gut feelings” if they suspect financial abuse, but good corroborating evidence might include signs of patient neglect, a patient expressing anxiety about their financial situation, or sudden inability to pay medical charges. In any case, he adds, “I’ve never heard of a successful litigation when someone has reported something like that. I would be the first to come to anyone’s defense who said, ‘I thought this person was being abused, reported it, and now I’m being sued.’”

Blum notes that information about elder financial abuse is available through district attorneys’ and APS offices and police departments. “I think every doctor’s office should have a pack of these available to hand out,” he says.

Patients’ reluctance to admit they are being financially exploited should not stop doctors from reporting it if they have reason to believe it is occurring, says Greenwood. “Don’t try to second-guess a victim. Let me be the one to figure out how to prosecute a case, with or without the victim’s cooperation.”

As for Mouton’s and Kagan’s patients, their stories had happy endings. Mouton reported his suspicions to APS, which responded by appointing a guardian to oversee the patient’s finances. Rather than reporting her son to the police, they found him a job so he no longer had to depend on her for income. Kagan complied with a request from his patient’s conservator to file a report with probate court on his patient’s visit.

According to Blum, financial abuse of the elderly differs little from any other form of exploitation involving money. “The only difference here is that the elderly are being targeted due to their extra vulnerability.”

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TEN TIPS TO HELP YOU REDUCE THE RISK OF BECOMING A VICTIM OF FINANCIAL ELDER ABUSE

1) CHOOSE A CAREGIVER WITH CAUTION
Do not assume that by hiring a caregiver through a bonded agency you are guaranteed to get someone who has been checked.  There is no current law requiring mandatory background checks for in-home caregivers in California.

2) KEEP AN INVENTORY OF ALL JEWELRY
Jewelry is the number-one item stolen from homes occupied by elders. Not only should your jewelry be kept in a locked drawer; keep photographs of rare, valuable, or sentimental items in a separate location.  In the event of theft, such photographic evidence will be useful in tracking down the missing jewelry at a pawn shop.

3) EVERY HOME SHOULD HAVE A SHREDDER
Every piece of mail containing your name, address, and any other identifying information should be shredded before being discarded. The most effective type of shredder is the criss-cross cut shredder.  Even envelopes with your name and address should be shredded.  Never throw away old checkbooks from closed accounts or bank credit card application forms.  There is no danger in over shredding!

4) PROTECT YOUR INCOMING AND OUTGOING MAIL
Never allow incoming mail to sit in an unsecured mailbox with public access. Mailbox theft is rampant. Similarly, never leave outgoing mail in an unsecured mailbox with the red flag raised, as this simply provides an easy alert to the thief who is cruising the streets. Consider purchasing a locked mailbox or renting a post office box from your local post office.

5) OBTAIN A CREDIT SEARCH ON YOURSELF AT LEAST TWO OR THREE TIMES A YEAR
Identity theft is on the rise. The only way to have peace of mind is to obtain a credit search on yourself periodically from one of the three major credit bureaus–Experian, Equifax, or Trans Union. This will enable you to discover whether someone has applied for or obtained a credit card in your name.

6) EVERY TELEPHONE SHOULD HAVE CALLER ID
All modern telephones are equipped with Caller ID capability, and the additional cost for the service is minimal. By seeing if the incoming call is classified as “private” or “unknown,” you can be immediately on your guard.  Crooks love the telephone. It is now their weapon of choice.

7) YOU WILL NEVER WIN THE CANADIAN LOTTERY
If a smooth-talking 25-year-old male tells you on the telephone that you are the proud winner of the Canadian lottery, he is a liar.  Similarly, if you get an e-mail from Nigeria or letter from Madrid indicating that you could receive a substantial amount of money, such communications are always fraudulent.

8) CONSIDER ALLOWING YOUR BANK TO SEND A DUPLICATE COPY OF YOUR MONTHLY STATEMENT TO A TRUSTED FAMILY MEMBER OR PROFESSIONAL ADVISER
Sadly, most financial elder abuse cases are discovered six to nine months after the initial losses have occurred.  Elders whose sight is failing are at greater risk because they may rely on the very person who is stealing from them to ensure that the financial transactions are in order. An independent pair of eyes that is able to look over bank statements every 30 days will be able to catch suspicious activities in the early stages.

9) DON’T ASSUME THAT THE FRIENDLY HANDYMAN IS IN FACT LICENSED
Before committing to any work on your home, always obtain at least three estimates in writing and check on the name of the contractor with both the Better Business Bureau and with the State License Contractor’s Board.  Just because someone gives you an impressive business card with a contractor’s license number on it does not mean that the person is qualified.  The license number may have been stolen.  Additionally, never pay more than 10 percent of the contract price up front.

10) ALWAYS HAVE A SECOND LINE OF DEFENSE AT YOUR FRONT DOOR
Have a locked screen door or a security chain guard at your front door.  Criminals will attempt to gain entry to your home by using excuses such as a fake emergency or false uniforms and badges.  By having a second line of defense, you will be able to communicate with the stranger on the doorstep without exposing yourself to the possibility of a forced entry.  Never allow any stranger into your home, even if the emergency seems real.  Instead, tell the stranger that you will call 911.

Compiled by Paul Greenwood, Deputy District Attorney, San Diego District Attorney’s Office, Head of Elder Abuse Prosecution