Nursing

Debra Braun, RN, a visiting nurse in St. Tammany Parish, LA, knew something was wrong with the elderly couple she saw weekly when they were not home for a scheduled appointment. She learned why when she saw them the following week. The husband, who was diabetic, had been rushed to the emergency room due to a drop in his blood sugar. Braun questioned the wife to find out what had happened.

"I can remember her sitting on the sofa, looking concerned but being evasive," Braun recalled. "When I checked the refrigerator for insulin, there was beer, but no food. She told me they didn't have enough money for the co-pay on their medications." When Braun probed deeper, the woman revealed that her unemployed son had recently moved in with them, and that they were short of money because she was "helping" him financially. "At that point, it became clear to me the son was taking advantage of them, and I reported it to the local police department," she said. "They followed up on it, but only to the point where he realized someone was on to him, and he left the state."

Wendy Kramer, RN, a medical/social services investigator with the New Mexico Aging and Long-Term Services Department, experienced something similar a few years ago when an Albuquerque doctor reported his suspicions that an elderly patient was suffering either from self-neglect or abuse. "I performed a cognition test which made it pretty clear right off the bat that she shouldn't be living alone," Kramer said. "Then I found out that there was this new 'friend' who had begun visiting her weekly. She clammed up quickly when I tried to find more information about him, but I made a referral to adult protective services. When they investigated, they found he had taken more than $100,000 from her."

These stories are typical of a situation that nurses and other healthcare providers frequently encounter: elderly people who are financially exploited by relatives, neighbors, or hired caregivers. A 2003 survey of state adult protective services (APS) agencies around the country found approximately 38,000 cases of elderly financial abuse were investigated, but many experts believe the real number is far higher. "For every case reported to any type of authority, studies show that between 12 and 15 cases go unreported," said Bennett Blum, MD, a Los Angeles-based geriatric and forensic psychiatrist and consultant.

Sharon Merriman-Nai, co-manager of the National Center on Elder Abuse (NCEA), explained 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," she said. Common fears are that the perpetrator will retaliate by stealing even more, or will wind up being 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."

DEFINING FINANCIAL ABUSE A 2007 NCEA survey of adult protective service agencies 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 recognize and prevent financial abuse of the elderly. In his training sessions, he makes it clear that financial abuse takes place in the context of a trusting 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 whom the victim trusts," he said.

Merriman-Nai said abuse can be 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 he or she goes about gaining access to a person, weaning him or her away from other people, then manipulating the person into turning over assets. It is the definition of undue influence."

Sherry Ponce De Leon, a public health nurse with the Chicago Department of Senior Services, said financial exploitation is the most common abuse she sees among the elderly. "It comes in all forms. We see it in identity theft, home health agencies having seniors sign paperwork so they can bill Medicare but not providing services to the person, and relatives getting them to sign a power of attorney. When that happens, it's very difficult to prove that the senior was confused when signing it. It's a big dilemma for us."

RISK FACTORS FOR ABUSE Financial abuse victims may include men and women of any racial or ethnic group, and they can be rich, poor, or somewhere in between. However, some factors increase the risk of victimization, experts warn. "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," said Paul Greenwood, deputy district attorney and head of the elder abuse unit in the San Diego County District Attorney's Office.

Abusers can exploit their victims' confusion. Most people associate confusion with Alzheimer's disease or other dementia, but other conditions can be to blame. "Sometimes, something as simple as a urinary tract infection can make a normally functioning elderly person confused and susceptible to manipulation," noted Daniel Sheridan, RN, PhD, FAAN, associate professor at Johns Hopkins University School of Nursing, Baltimore.

SPOTTING FINANCIAL ABUSE Recognizing that a caregiver is financially exploiting a patient is more difficult than identifying physical abuse. Nevertheless, there are warning signs; for example, when a patient suddenly stops buying prescribed medications, said 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."

For visiting nurses, the signs often are easy to spot. "When you know they have an income, when they own their houses, as elderly people often do, but are sitting there with no food, no heat, no electricity, it means either they're too confused to handle things on their own, or someone is using their money for other things," said Ponce De Leon.

Nurses in clinical settings frequently cannot spend much time with individual patients, and don't have access to the patient's financial records, Sheridan noted. Consequently, nurses have to be alert to more subtle clues of exploitation. "What we can do is observe the interaction between the patient and support person," he said. "It's things such as, when you're trying to talk to the patient and the support person is trying to put words in the patient's mouth—not to correct them, but as a form of manipulation. I tell people, 'Trust your gut. If something doesn't feel right, it probably isn't.'"

Questioning the caregiver can reveal clues to financial abuse, but it has to be done carefully, Kahan said. "Sometimes I might ask the caregiver questions, such as, 'Are you working now? Do you have some means of support other than caregiving?' You have to couch it in a nonthreatening manner, because if the caregiver suspects you know something, they won't bring the patient back."

Talking to the patient is vital, but has to be done in private to be effective, said Sheridan. "The patient has to have privacy to tell us what's really going on. It's no different from a domestic violence situation. If you ask a woman if her husband or boyfriend is beating her, and he's standing right next to her, what do you expect her to say?"

While the need for privacy may appear obvious, Sheridan added, sometimes time-pressed nurses or doctors will rely on the caregiver for answers, particularly if the patient is slow in answering—as elderly, confused people frequently are.

WHAT NURSES SHOULD DO In all but a handful of states, nurses and other healthcare providers are mandated reporters; meaning, if they suspect an elderly person is being abused in any way, including financially, they are required to report it to law enforcement or APS. But that doesn't always happen. It's especially true in smaller communities, said Kramer, where the nurse may know the patient and the caregiver, and be reluctant to cause a stir.

Sometimes, said Sheridan, a clinical nurse will have a vague suspicion that something is amiss with a patient, but be unsure of what to do about it, or feel the evidence is not strong enough to report. In those cases, he advised, they should work with the doctor to get an order for a home assessment by a visiting nurse. "Nurses really are the best persons to go out and check on the well-being of a person," Sheridan added. "When the nurse shows up and says, 'The doctor wanted me to see how Mr. Smith is doing,' doors are likely to open. And if the nurse picks up on issues in the home, then he or she can get APS involved."

Sometimes care providers 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 has "good faith" reporting provisions in their APS laws, according to the American Bar Association's Commission on Law and Aging. Such provisions generally provide health-care providers with immunity from legal liability for reporting suspected elder abuse, as long as the reports were made in good faith.

"I've never heard of a successful litigation when someone has reported something like that," said Greenwood. "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.'"

Information about elder financial abuse is available through district attorneys, APS offices, and police departments. "I think every doctor's office should have a pack of these available to hand out," Blum said. Financial abuse of the elderly differs little from any other form of exploitation involving money, he stated. "The only difference here is that the elderly are being targeted due to their extra vulnerability."