13
Financial Abuse of the Elderly in Domestic Settings

Thomas L. Hafemeister*

In some ways financial abuse is very similar to other forms of elder abuse in that it can be devastating to the victim and is frequently traced to family members, trusted friends, and caregivers. But unlike physical abuse and neglect, financial abuse is more likely to occur with the tacit acknowledgment and consent of the elder person1 and can be more difficult to detect and establish. As a result, financial abuse requires a distinct analytical perspective and response. Unfortunately, these differences are often overlooked.

Little empirical research has been conducted that directly addresses financial abuse of the elderly, and in general it has received less attention than other forms of elder abuse (Nerenberg, 2000b). Although the amount of attention given to it has increased in recent years, most commentary rests

*  

Thomas L. Hafemeister, J.D., Ph.D., is Director of Legal Studies at the Institute of Law, Psychiatry, and Public Policy, University of Virginia. He is indebted to Lori Stiegel, Carla VandeWeerd, and Richard Bonnie, who read and provided valuable comments on an earlier draft of this report.

1  

There is some controversy over whether this population should be referred to as elder persons (the elderly) or as older persons (older people). This dispute tends to focus on conflicting views regarding which terminology is the most descriptive and the least likely to perpetuate inappropriate stereotypes. Resolving this dispute, however, is tangential to the focus of this report. “Elder persons” and “the elderly” are used throughout this report primarily because they are widely used terms and appear routinely in related legislation and legislative hearings (see U.S. Congress, 2000).



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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America 13 Financial Abuse of the Elderly in Domestic Settings Thomas L. Hafemeister* In some ways financial abuse is very similar to other forms of elder abuse in that it can be devastating to the victim and is frequently traced to family members, trusted friends, and caregivers. But unlike physical abuse and neglect, financial abuse is more likely to occur with the tacit acknowledgment and consent of the elder person1 and can be more difficult to detect and establish. As a result, financial abuse requires a distinct analytical perspective and response. Unfortunately, these differences are often overlooked. Little empirical research has been conducted that directly addresses financial abuse of the elderly, and in general it has received less attention than other forms of elder abuse (Nerenberg, 2000b). Although the amount of attention given to it has increased in recent years, most commentary rests *   Thomas L. Hafemeister, J.D., Ph.D., is Director of Legal Studies at the Institute of Law, Psychiatry, and Public Policy, University of Virginia. He is indebted to Lori Stiegel, Carla VandeWeerd, and Richard Bonnie, who read and provided valuable comments on an earlier draft of this report. 1   There is some controversy over whether this population should be referred to as elder persons (the elderly) or as older persons (older people). This dispute tends to focus on conflicting views regarding which terminology is the most descriptive and the least likely to perpetuate inappropriate stereotypes. Resolving this dispute, however, is tangential to the focus of this report. “Elder persons” and “the elderly” are used throughout this report primarily because they are widely used terms and appear routinely in related legislation and legislative hearings (see U.S. Congress, 2000).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America on a relatively thin empirical base and draws heavily on anecdotal observations and relies (perhaps inappropriately) on research and analysis addressing other forms of elder abuse, child abuse, and spouse/partner abuse. Because financial abuse is frequently addressed in conjunction with other forms of elder abuse, a brief overview of elder abuse in general is provided before turning specifically to financial abuse of the elderly. PREVALENCE OF ELDER ABUSE IN GENERAL Elder abuse, at least to some degree, has probably always existed. Only in the past few decades, however, has it been recognized as a major societal problem. Attention to elder abuse followed the “discovery” of child abuse in the 1960s and spouse abuse in the 1970s. Today, elder abuse is widely characterized as both a pervasive problem and a growing concern (Dessin, 2000; Heisler, 2000; Moskowitz, 1998b). The National Elder Abuse Incidence Study (NEAIS), which was described as the first national study of the incidence of elder abuse in the United States,2 estimated that nearly a half million persons aged 60 and over in domestic settings were abused or neglected during 1996 (National Center on Elder Abuse, 1998).3 Furthermore, this study determined that for every reported incident of elder abuse or neglect, approximately five incidents were unreported (National Center on Elder Abuse, 1998), supporting a wide consensus that elder abuse is greatly underreported (Choi and Mayer, 2000; Dessin, 2000; U.S. General Accounting Office, 1991; Kleinschmidt, 1997; Moskowitz, 1998b; National Center on Elder Abuse, 1996). The NEAIS confirmed a general view that state agencies established to receive such reports, such as Adult Protective Services (APS) agencies, receive reports of the most visible and obvious occurrences of elder abuse, but that there are many other incidents that are not reported. Nevertheless, 2   It should be noted that the methodology employed in the NEAIS study has been questioned (Comijs et al., 2000; Thomas, 2000). However, methodological limitations are associated with virtually all elder abuse research. The goal of this report is not to provide a methodological critique of elder abuse research in general or financial abuse in particular. In addition, regardless of any methodological limitations, the NEAIS study provides useful comparisons across categories of elder abuse. There is, however, a need for more rigorous research on both elder abuse in general and financial abuse of the elderly in particular. 3   An earlier and frequently cited report from the House Select Committee on Aging suggested that between 1 million and 2 million older Americans experience mistreatment each year (U.S. Congress, 1991). Recent review articles have estimated the number of elderly individuals victimized each year as 2 million (Moskowitz, 1998a), 1.5 million (Dessin, 2000), 1 million (Marshall et al., 2000), and 818,000 (Coker and Little, 1997). It has also been estimated that 5 percent of elder persons suffer some form of abuse each year and that one out of every four will experience abuse or neglect at some time (Dessin, 2000).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America the number of APS elder abuse reports substantially increased over the past 10 years, an increase that exceeded the growth in the elderly population during this period (National Center on Elder Abuse, 1998). FORMS OF ELDER ABUSE What constitutes elder abuse is defined by state law, and state definitions vary considerably (U.S. General Accounting Office, 1991; Kapp, 1995; National Center on Elder Abuse, 2001; Moskowitz, 1998b; Roby and Sullivan, 2000).4 Not surprisingly, researchers have also used many different definitions in studying the problem (Choi and Mayer, 2000; Kleinschmidt, 1997; Macolini, 1995; National Center on Elder Abuse, 2001; Pillemer and Finkelhor, 1988).5 The variation in definitions has been cited as a significant impediment to elder abuse recognition, management, research, and analysis (U.S. General Accounting Office, 1991; Kleinschmidt, 1997; Lachs and Pillemer, 1995; Moskowitz, 1998b; Nerenberg, 2000a; Roby and Sullivan, 2000; Rosenblatt et al., 1996). Elder abuse in domestic settings (i.e., within the older person’s own home or in the home of a caregiver) is often differentiated from elder abuse within institutional settings (i.e., within residential facilities for older persons such as nursing homes) (Brandl and Meuer, 2000; National Center on Elder Abuse, 1996, 2001). Domestic elder abuse has been asserted to be more prevalent than institutional elder abuse (Kosberg and Nahmiash, 1996; Marshall et al., 2000; Moskowitz, 1998b), in part because it has been estimated that 80 percent of the dependent elders in this country are cared for at home (National Center on Elder Abuse, 1996). However, research directly substantiating this assertion is lacking.6 Another dichotomy frequently used distinguishes between elder abuse by individuals who have a special relationship with the elder person (e.g., spouses, children, other relatives, friends, or caregivers providing services within the 4   These variations include whether elder abuse is addressed as a separate category or whether it is grouped with the abuse of adults with a disability of any age, the age cutoff used to define an elder person, the definitions of various types of abuse, and whether elder abuse encompasses self-neglect or sexual abuse (Dessin, 2000; Lachs and Pillemer, 1995; Mehta, 2000). 5   The little research that has been conducted has been criticized for conceptual and methodological weaknesses, including reliance on underinclusive or nonrepresentative samples of cases brought to the attention of social agencies or reporting authorities, unclear definitions of elder abuse, reliance on professional reports rather than victim interviews, and failure to use rigorous research designs, such as random-sample surveys and case-comparison studies (Pillemer and Finkelhor, 1988; Schiamberg and Gans, 2000). 6   Data on institutional elder abuse are so scarce that it is not possible to make any national estimates of its incidence or prevalence” (National Center on Elder Abuse, 1996:2).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America elder person’s home) and individuals with whom such a preexisting special relationship does not exist (Kosberg and Nahmiash, 1996; Marshall et al., 2000; National Center on Elder Abuse, 1996, 2001).7 Within domestic settings, it has been reported that the perpetrators of elder abuse are much more likely to be family members (National Center on Elder Abuse, 1996). Although conceptualizations of what elder abuse encompasses vary considerably, the National Center on Elder Abuse (2001) identifies six major categories of elder abuse. They include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial abuse. Among these categories, financial abuse has received limited attention and is often not assessed in studies of elder abuse (Choi et al., 1999; Kleinschmidt, 1997; Tueth, 2000). Nonetheless, financial abuse is increasingly viewed as both sufficiently important to necessitate its inclusion in studies of elder abuse in general and sufficiently distinct to justify addressing it separately (Choi and Mayer, 2000). PARAMETERS OF FINANCIAL ABUSE OF THE ELDERLY The remainder of this report focuses on financial abuse of the elderly within a domestic setting by individuals relatively well known to the elder person. This focus encompasses financial abuse by family members, friends, and caregivers of the elder person and excludes financial abuse within institutional settings or by strangers. Domestic settings are not only a frequent setting for this abuse,8 but their tendency to involve complex family dynamics and deep-seated conflicts tends to make them particularly challenging. Although financial abuse of the elderly within institutional settings (e.g., within nursing homes) and by strangers (e.g., in the course of consumer fraud) are serious concerns in their own right and in need of systematic study (of which little has been generated to date),9 they are not the foci of this report. To address financial abuse of the elderly, its parameters should first be defined. Variously referred to as financial mistreatment; exploitation; or fiduciary, economic, or material abuse, this type of abuse encompasses a 7   The latter would encompass most incidents of consumer fraud. 8   About 80 percent of the estimated 6 million dependent elders in this country are cared for at home” (National Center on Elder Abuse, 1996:11–12). Furthermore, although little research has been conducted on financial abuse within institutional settings, recent studies identifying the top 10 deficiencies in long-term care facilities identified physical abuse or neglect more frequently than financial abuse (Menio and Keller, 2000). 9   For a discussion of consumer fraud perpetrated on the elderly, see Deem (2000), McGhee (1983), Smith (1999), and U.S. Congress (2000).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America broad range of conduct (National Committee for the Prevention of Elder Abuse, 2001). There have been widespread complaints that financial abuse of the elderly is poorly defined, in part because it is hard to define, which makes it difficult to identify, investigate, and prosecute (Dessin, 2000; Langan and Means, 1996; Marshall et al., 2000; Roby and Sullivan, 2000; Sanchez, 1996; Wilber and Reynolds, 1996). The absence of a uniform definition perhaps explains why it is often not included or is poorly addressed in research on elder abuse in general (Langan and Means, 1996). Because elder abuse, like other domestic ills, has generally been considered a state concern rather than a federal concern, the absence of federal law pertaining to elder abuse has placed on the states the responsibility to define this activity. Forty-eight states and the District of Columbia are reported to specifically mention financial abuse in their elder abuse statutes (Roby and Sullivan, 2000; Wilber and Reynolds, 1996).10 States’ definitions, however, vary widely on what constitutes financial abuse and who can be held accountable for it (Roby and Sullivan, 2000; Sanchez, 1996). One complicating factor is variations in the class of individuals targeted for protection from financial abuse. Three general approaches are employed. In some states all individuals who have reached a given age are specifically protected, in other states protection is provided to all vulnerable or incapacitated adults regardless of age, and a third group of states uses a hybrid approach that protects vulnerable or incapacitated adults of any age and all adults over a certain age (Dessin, 2000; Roby and Sullivan, 2000). The last two approaches can make it difficult for researchers to distinguish reports of elder abuse from reports of adults in general (Coker and Little, 1997). The first approach, however, has been criticized for perpetuating the unfounded stereotype that all elderly persons are vulnerable and in need of protection (Roby and Sullivan, 2000). Also, some states require diminished decision-making capacity by the elder person before financial abuse is considered to occur, while other states do not impose such a requirement (Tueth, 2000). States even vary on the age when someone becomes “elderly” (Coker and Little, 1997; Paveza, 2001). Other variations in state definitions are associated with who can be held accountable for financial abuse. Some states require dishonest tactics by perpetrators, such as the use of force, duress, misrepresentation, undue influence, or other illegal means, to take advantage of the elder person. Other states do not require a showing of such tactics if the perpetrator knew or should have known that the elder person lacked the cognitive 10   As of 1995, New York and Oregon were purported to be silent on financial abuse (Wilber and Reynolds, 1996).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America capacity to make financial decisions (Tueth, 2000). Similarly, some states limit financial abuse to an intentional improper use of the elder’s resources, while other states encompass negligent, or at least reckless, advice or conduct, such as failing to use income effectively for the care of the older person (Dessin, 2000; Roby and Sullivan, 2000). Generally the victim must experience some disadvantage as a result of the transaction, but some states also require that the perpetrator gain some advantage from the transaction (Dessin, 2000). The latter would not penalize actions that merely wasted the elder person’s assets (Dessin, 2000). States also vary on whether abuse is limited to the abuse of the elder person’s money and real property or also encompasses other resources such as the elder person’s goods and services (Roby and Sullivan, 2000). Finally, some states limit financial abuse to those in a “position of trust” to an elder person (Roby and Sullivan, 2000). It is widely recognized that it is difficult, even for experienced professionals, to distinguish an unwise but legitimate financial transaction from an exploitative transaction resulting from undue influence, duress, fraud, or a lack of informed consent (Tom, 2001).11 The seasoned professional can also be tested by the complex and varied nature of these transactions (Dessin, 2000). It may also be difficult to distinguish abusive conduct from well-intentioned but poor, confused, or misinformed advice and direction (Dessin, 2000; Langan and Means, 1996). Evaluating whether financial abuse has occurred has been characterized as a complex and often subjective determination (Bernatz et al., 2001). Further complicating efforts to establish the parameters of financial abuse of the elderly are that both the elder person and the perpetrator may feel that the perpetrator has some entitlement to the elder person’s assets (Dessin, 2000). Elder persons may feel a desire to benefit their heirs or to compensate those who provide them with care, affection, or attention (Dessin, 2000; Langan and Means, 1996). It can be difficult to discern a transfer of assets made with consent from an abusive transfer (Dessin, 2000; Wilber and Reynolds, 1996). Also, conduct that began in the elder person’s best interests may become abusive over time, as when perpetrators initially provide helpful advice regarding financial investments but take on greater control and ulti- 11   Wilber and Reynolds (1996) provide a framework for distinguishing financial abuse of the elderly from acceptable exchanges, while Tueth (2000) identifies transactions needing careful scrutiny before concluding that financial exploitation has occurred. Roby and Sullivan (2000) argue that definitions of financial abuse should be broad enough to provide sufficient flexibility to address the range of financial abuse and offenders, yet specific enough to protect individuals acting in the best interests of the elder person.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America mately misappropriate funds for themselves as the elder person’s cognitive abilities decline (Dessin, 2000). Typically, financial abuse in a domestic setting reflects a pattern of behavior rather than a single event and occurs over a lengthy period of time (National Clearinghouse on Family Violence, 2001; Wilber and Reynolds, 1996). Determining when financial abuse began can be very difficult (Smith, 1999). Finally, a number of commentators have asserted that whether financial abuse is considered to have occurred should reflect the elder person’s perception of the purported abuse and the cultural context in which it takes place (Moon, 2000; Nerenberg, 2000a; Sanchez, 1996; Wolf, 2000; see generally Tatara, 1999). For example, attitudes about the legitimacy of a transfer may reflect expectations within a given culture that elderly persons will share their resources with family members in need, while other cultures reject this notion (Brown, 1999; Moon, 2000; Nerenberg, 2000a). Studies have shown considerable variation in what constitutes financial abuse across cultural, racial, and ethnic groups (Brown, 1999; Hudson and Carlson, 1999; Moon, 2000; Nerenberg, 2000a), and it has been argued that a failure to take into account these differences undercuts efforts to assess financial abuse of the elderly (Sanchez, 1996).12 TYPES OF FINANCIAL ABUSE OF THE ELDERLY In efforts to address financial abuse of the elderly, advocates for the elderly often delineate typical examples of this abuse.13 Examples specifically relevant to a domestic setting and financial abuse by individuals relatively well known to the elder person include: taking, misusing, or using without knowledge or permission money or property (Dessin, 2000; National Center on Elder Abuse, 2001; National Clearinghouse on Family Violence, 2001; National Committee for the Prevention of Elder Abuse, 2001); forging or forcing an elder person’s signature (National Center on Elder Abuse, 2001; National Clearinghouse on Family Violence, 2001; National Committee for the Prevention of Elder Abuse, 2001); abusing joint signature authority on a bank account (Rush and Lank, 2000); 12   At the same time, the law places considerable weight on the importance of establishing requisite standards of behavior that are uniform, consistent, and predictable across groups of individuals. 13   For a lengthy list of specific examples of financial exploitation, see U.S. Congress (1981).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America misusing ATMs or credit cards (New York State Department of Law, 2000); cashing an elder person’s checks without permission or authorization (National Center on Elder Abuse, 2001); misappropriating funds from a pension (New York State Department of Law, 2000; Langan and Means, 1996); getting an elder person to sign a deed, will, contract, or power of attorney through deception, coercion, or undue influence (National Center on Elder Abuse, 2001; National Clearinghouse on Family Violence, 2001; National Committee for the Prevention of Elder Abuse, 2001); providing true but misleading information that influences the elder person’s use or assignment of assets (Dessin, 2000); persuading an impaired elder person to change a will or insurance policy to alter who benefits from the will or policy (Central California Legal Services, 2001; Frolik, 2001; Smith, 1999); using a power of attorney, including a durable power of attorney, for purposes beyond those for which it was originally executed (Hwang, 1996; National Clearinghouse on Family Violence, 2001; Thilges, 2000); improperly using the authority provided by a conservatorship, trust, etc. (National Center on Elder Abuse, 2001); negligently mishandling assets, including misuse by a fiduciary or caregiver (Dessin, 2000); promising long-term or lifelong care in exchange for money or property and not following through on the promise (National Committee for the Prevention of Elder Abuse, 2001); overcharging for or not delivering caregiving services (Central California Legal Services, 2001); and denying elder persons access to their money or preventing them from controlling their assets (National Clearinghouse on Family Violence, 2001; Smith, 1999). PREVALENCE AND IMPACT OF FINANCIAL ABUSE Prevalence of Financial Abuse of the Elderly The prevalence of financial abuse of the elderly (like elder abuse in general) is difficult to estimate because there is no national reporting mechanism to record and analyze it, cases often are not reported, definitions vary, and it is difficult to detect (Coker and Little, 1997; Deem, 2000; National Clearinghouse on Family Violence, 2001). However, the consensus is that it is a significant problem (Dessin, 2000). The National Center for Elder Abuse found that financial abuse accounted nationally for about 12 percent of all substantiated elder abuse

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America reports in 1993 and 1994 (National Center on Elder Abuse, 2000; Zimka, 1997). A subsequent more comprehensive study conducted by the same entity found that 18.6 percent of the 115,110 substantiated elder abuse reports submitted to APS agencies nationwide in 1996—which included reports of self-neglect—and were reports of financial or material exploitation (National Center on Elder Abuse, 1998). Excluding reports of self-neglect, this exploitation appeared in 30.2 percent of the substantiated reports. This represented the third largest category of reports, less than neglect (48.7 percent) and emotional or psychological abuse (35.41 percent), but more than physical abuse (25.6 percent).14 A national survey in Canada found that financial abuse was the most common type of elder abuse in that country (Podnieks, 1992).15 Some parts of the country report an even greater prevalence of financial abuse.16 Financial exploitation has been reported to be the most frequent form of perpetrator-related elder abuse in Illinois (Neale et al., 1996) and Oregon (U.S. Congress, 2000). It has been asserted that half of all abuse cases in New York state include financial exploitation and that in New York City 63 percent of abuse cases involve finances (New York State Department of Law, 2000). A study of APS reports in upstate New York between 1992 and 1997 that led to state intervention found that financial exploitation was present in 38.4 percent of the cases (Choi and Mayer, 2000). A study in Massachusetts found that almost one-half of the cases of elder abuse serious enough to require reporting to a district attorney involved financial exploitation (Dessin, 2000). A review of California reports from 1987 found that fiduciary abuse was the most prevalent type of exploitation and appeared in 41.5 percent of the cases, with the next most prevalent type of exploitation being physical abuse, which appeared in 33.3 percent of the cases (County Welfare Directors Association, 1988). In their review of older studies, Wilber and Reynolds (1996) determined that between 33 percent and 53 percent of an estimated 1 million elder abuse victims experienced financial abuse. Financial abuse has also been reported to be greater among various minority populations. For example, exploitation was found to be the most commonly reported abuse in samples of Korean immigrant and black elders 14   More than one substantiated type of abuse could be reported for an incident. The study did not, however, provide specific information about this overlap (e.g., how often financial abuse occurred in conjunction with another form of elder abuse). 15   A British Columbia study is reported to have found that 8 percent of older adults had been financially abused, with an average loss of $20,000 each (National Clearinghouse on Family Violence, 2001). 16   The variation in rates among states may be attributed in part to differing definitions and assessments of financial abuse (Lavrisha, 1997).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (Hall, 1999; Moon, 1999). It has also been suggested that in general financial abuse is particularly likely to be underreported (Coker and Little, 1997; Hwang, 1996; Wilber and Reynolds, 1996). It has been asserted that financial abuse often occurs in conjunction with other forms of elder abuse (Choi et al., 1999; National Clearinghouse on Family Violence, 2001; Paris et al., 1995), although research generally does not establish how frequently this overlap occurs.17 In a study of one county’s investigated APS reports of financial exploitation Choi et al. (1999) found that caregiver neglect also occurred in 12.1 percent of the cases, self-neglect in 6.1 percent, physical abuse in 5.1 percent, and psychological abuse in 3.8 percent. In a later analysis, Choi and Mayer (2000) found that 33.7 percent of this county’s investigated reports involved financial exploitation plus either neglect or abuse, while 37.6 percent involved only financial exploitation. However, in a Canadian national survey, only 19 percent of victims were victims of more than one form of maltreatment, although it was not reported how often financial abuse occurred in conjunction with other forms of elder abuse (Podnieks, 1992). Financial exploitation has been described as the fastest growing form of elder abuse (New York State Department of Law, 2000), although empirical support for this assertion is scanty. Societal attention to elder abuse in general is a relatively recent phenomenon, and attention to financial abuse is even more nascent (Dessin, 2000). It has been suggested that an increase in reports reflects closer scrutiny by federal, state, and local officials rather than necessarily an increase in the prevalence of financial abuse (Lavrisha, 1997). Greater attention to this issue has been attributed to increases in the number of elderly people, an increased emphasis on care at home, and the substantial resources of the elderly (Langan and Means, 1996). The Impact of Financial Abuse on the Elderly One of the most frightening scenarios for an elder person is the possibility of financial ruin (Dessin, 2000). Although not systematically assessed, losing assets accumulated over a lifetime, often through hard work and deprivation, can be devastating, with significant practical and psychological consequences (Dessin, 2000; Nerenberg, 2000c; Smith, 1999). Financial abuse can have as significant an impact for an elder person as a violent crime (Deem, 2000) or physical abuse (Dessin, 2000). Replacing lost assets is generally not a viable option for retired indi- 17   Elder abuse examples provided in governmental reports often show a combination of financial abuse and physical or psychological abuse or neglect (County Welfare Directors Association, 1988; U.S. Congress, 1981).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America viduals or individuals with physical or mental disabilities (Coker and Little, 1997; Dessin, 2000; Moskowitz, 1998b; Nerenberg, 2000c). Also, because of their age, the elderly will have less time to recoup their losses and often are solely dependent on their savings to meet subsequent expenses and needs (Smith, 1999). A depletion of assets is likely to result in a loss of independence and security for the elder person (Choi et al., 1999; Nerenberg, 2000c), which can have significant symbolic and practical ramifications. Such abuse may necessitate that the elder person become dependent on family members, inducing or adding to their financial burden and stress (Coker and Little, 1997). Alternatively, financial abuse may result in elder persons becoming dependent on social welfare agencies, with a significant decline in their quality of life (Coker and Little, 1997). From a psychological perspective, a loss of trust in others has been identified as the most common consequence of financial abuse (Deem, 2000). In addition, victims may become very fearful, both of crime and of their vulnerability to crime, which in turn may lead to dramatic changes in lifestyle and emotional well-being (Fielo, 1987). Victims may also experience a loss of confidence in their own financial abilities, stress, and isolation from family or friends (Deem, 2000). Financial abuse may lead to depression, hopelessness, or even suicide (Nerenberg, 2000c; Podnieks, 1992). In addition, it has been noted that, unlike physical and psychological abuse, the effects of financial abuse may not end with the death of the victim. Family members whose inheritance was reduced or depleted as a result of the financial abuse will suffer loss and may themselves feel abused, particularly if they felt entitled to inherit the victim’s assets (Dessin, 2000). WHY ELDER PERSONS ARE TARGETS FOR FINANCIAL ABUSE Although empirical support is often not provided, many reasons have been identified for why the elderly are targeted for financial abuse. One set of reasons addresses the financial assets and acumen of the elderly. For example, one widely cited factor is that elder persons possess a large proportion of the nation’s wealth (Central California Legal Services, 2001; National Committee for the Prevention of Elder Abuse, 2001), with 70 percent of all funds deposited in financial institutions controlled by persons age 65 and older (Dessin, 2000). Other explanations have been that older people may be more trusting than their younger counterparts (Central California Legal Services, 2001) or may be relatively unsophisticated about financial matters, particularly when they are unfamiliar with advances in technology that have made managing finances more complicated (National Committee for the Prevention of Elder Abuse, 2001). Also, they may not realize the value of their assets—particularly homes that have appreciated greatly in value (Central California Legal Services, 2001; National Com-

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America that are more flexible, less costly, and avoid judicial scrutiny (Beauchamp, 2001; Weiler, 1989). At the same time, it has been recognized that these alternatives may also present problems, including a lack of oversight and means to ensure assets are devoted to the elder person’s needs (Beauchamp, 2001; Heisler and Quinn, 1995; Weiler, 1989). At least one commentator has concluded no alternative is foolproof and “society may just have to rely on the person who takes care of the vulnerable and hope that that person does not take advantage of her position” (Beauchamp, 2001). Health Care Providers Finally, it has been suggested that health care providers are in a unique position to prevent financial abuse of the elderly (Bernatz et al., 2001; Lavrisha, 1997). Health care providers who see their elderly patients regularly may be in the best position to know if an older person’s mental capabilities have declined to such an extent that the individual is subject to financial abuse (Smith, 1999).60 It has been suggested, for example, that nurses in the community and in clinics are likely to encounter elder persons at risk and can assess the level of social support available, provide education on how to avoid financial exploitation, and make appropriate referrals to volunteer companion programs and the like (Lavrisha, 1997). In addition, it has been argued that nurses have an ethical and often a legal responsibility to recognize and detect potential financial mistreatment and that gerontological nurses in particular can encourage the initiation of appropriate responses to financial abuse such as the establishment of a representative payee, a durable power of attorney, a trust, or a joint tenancy (Weiler, 1989). It has also been recommended that when a person is diagnosed with a disorder that diminishes mental capacity (e.g., Alzheimer’s disease), health care providers should warn the patient and family members about the potential for financial abuse and provide practical suggestions on how to avoid such abuse (e.g., by having a cosigner on bank accounts) (Bernatz et al., 2001). One physician has suggested that clinicians working with older people should consider including questions about financial affairs in their routine history and be particularly concerned when socially isolated and frail older people talk of unpaid bills, new friends who are visiting regularly and borrowing money, ongoing home renovations, or frequent large purchases (Cohen, 1998). 60   At the same time, an assessment of individuals 70 years of age or older who were presented for treatment at a hospital emergency room found that one of the three areas with which patients needed the most assistance was the management of finances (medications and ambulation were the other two areas) (Fulmer and Cahill, 1984).

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Education regarding financial abuse of the elderly, warning signs, and steps that can be taken to minimize or remedy such abuse could be targeted at health care providers who regularly provide services to the elderly. In addition, protocols for detecting elder abuse that include questions pertaining to financial abuse have been developed for physicians (Kleinschmidt, 1997; Tueth, 2000), nurses (Fulmer and Cahill, 1984), and emergency department professionals (Fulmer et al., 1992) and could be made more readily available to them. Social Services/Governmental Agencies Social services agencies may already be responsible for providing services to elder persons who are vulnerable to financial abuse and they could be assigned a specific or enhanced role in preventing such abuse. Alternatively, they could be given responsibility for providing financial assistance to the elderly. For example, as noted, some states have fiduciary abuse specialist teams (FASTs), which include expert financial and legal consultants, to help victims recover or prevent further loss of their assets (Bernatz et al., 2001). Such teams could be made available to elder persons seeking advice on or assistance with financial decisions as a means to prevent financial abuse of the elderly. Alternatively, assessment instruments for detecting elder abuse, which include signals of financial abuse, have been developed for caseworkers visiting elders in the community (Reis, 2000; Sengstock and Hwalek, 1986). However, one survey found little enthusiasm for involving social services agencies in these surveillance efforts, with caseworkers stressing that sorting out financial affairs was complex and time-consuming (Langan and Means, 1996). In addition, it has been noted that social service agencies have long recognized the need to provide financial assistance, including assistance with daily money management, but the scope and availability of such services vary greatly around the country and few free or low-cost programs provide a full range of such services (Bassuk, 2001). It is also likely that many elder persons would be reluctant to permit governmental agencies and personnel to become involved in their financial affairs. Moreover, it has been noted that elders and their relatives are often not aware of financial-management services offered by community-based agencies (Choi and Mayer, 2000). FUTURE RESEARCH NEEDED Two of the leading authorities on financial abuse of the elderly have identified what they consider to be the important research questions. Nerenberg writes:

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America [L]ittle is known about the extent or nature of financial crime. Apart from a few studies on telemarketing fraud, very little is known about other types of financial crime, including fraud by family members. Even less is known about the impact of financial crime on its victims, victims’ service needs, and promising approaches to meeting those needs. . . . Even less is known about victims’ mental health or social service needs and effective approaches to addressing them (2000c:70). In contrast, the NEAIS report (National Center on Elder Abuse, 1998) raised the following research questions: Are there characteristics of the caregiving relationships among younger family members who financially exploit their older relatives that could be affected by service interventions for the perpetrators? What are those interventions? Are there services or education for persons aged 60+ that would help them from becoming victims of financial abuse, particularly by younger family members? How can employees of banks be educated and encouraged to identify and report incidents of financial exploitation that may come to their attention while serving elderly customers? The analysis provided in the course of this report has also identified a number of research questions. Although greater attention has been given to financial abuse of the elderly in recent years, most of the accompanying commentary relies on anecdotal evidence, personal experience, or commonly shared beliefs. There is a great need for a research foundation to be generated to inform the debate over how best to respond to this abuse. In addition to the many issues that have not been subject to systematic research, there is a need for existing studies that rely on small samples to be replicated at a national or regional level and for this research to be conducted in a methodologically rigorous manner. Conducting research on elder abuse in general has proven to be difficult (see Comijs et al., 2000; Thomas, 2000), and these same difficulties generally apply to research on financial abuse of the elderly.61 In addition, there are special challenges associated with conducting research on financial abuse of the elderly. These challenges include the absence of a consistent, objective operational definition of what constitutes financial abuse; ascertaining what impact, if any, cultural differences and subjective perceptions (especially those of the elderly person) should play; whether a minimal financial amount should be involved before financial abuse is considered to have occurred; particular difficulties associated with 61   See Langan and Means (1996); Research on financial abuse is often quite limited, being based on very small samples or an investigation of case files of those elderly people defined by statutory agencies as victims of abuse.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America detecting and establishing the occurrence of financial abuse; what role the intent of the alleged perpetrator should play; discerning the existence, relevance, and impact of the tacit acknowledgment and consent of the elder person; and whether, particularly for smaller financial amounts, a pattern of abuse is required or a single incident will suffice to establish abuse. The following questions also need specific empirical examination. What is the prevalence of financial abuse of the elderly? Because it is under-reported and difficult to detect, it is difficult to mobilize public interest in this issue without this baseline information. What is the impact of financial abuse on the elderly? For example, does it typically result in financial devastation and a loss of independence? What impact does it have on the health of the elder victims? What is its psychological impact, both short-term and long-term? In a world of limited resources, does financial abuse justify the same level of scrutiny or intervention as do other forms of elder abuse? What other forms of elder abuse co-occur with financial abuse and to what extent? Are reports of other types of elder abuse likely to address most instances of financial abuse? If financial abuse is a distinct phenomenon, it may need separate and distinct responses. What types of financial abuse are most common? What are the characteristics of the victims? For example, are they socially isolated, where do they live, how old are they, what is their financial status, what is their cognitive state, what is their family history/status, and what is their ethnicity? Similarly, what are the characteristics of the perpetrators? For example, what are their motivations and how many are close family members, acquaintances, or caregivers of the elder person? What factors lead to financial abuse? For example, what is the nature of the interaction between victim and perpetrator and what risk factors associated with this interaction can be identified? What decreases the likelihood of abuse? For example, when do close family bonds buffer against financial abuse? What variations are associated with the cultural context in which the elderly person lives, and is it possible to develop objective standards that apply appropriately to all cultural groups? Such information is a prerequisite for developing and targeting interventions. What are the barriers to detecting financial abuse of the elderly? What are indicators that family and professionals can watch for that suggest financial abuse may be occurring? What are the best ways to identify financial abuse? What are elder persons’ perceptions of what constitutes financial abuse and how do they correspond with various professionals’ perceptions? How effective are reporting requirements? Does mandatory reporting result in different rates of identification than voluntary reporting? Do the various means of responding to financial abuse serve as deterrents for future financial abuse? Do these various means adequately meet the needs of elder victims? Which venue is most effective in responding to the

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America financial abuse of the elderly? Do adequate laws exist to address financial abuse, but the shortcoming lies with the enforcement of existing laws? What advantages would be associated with establishing a national standard/uniform law? Would such an approach fail to take into account local conditions and homogenize cultural variations? Perhaps the most critical and pressing problem is how to prevent financial abuse of the elderly in the first place. A number of options have been identified, but information is lacking on which are the most effective. For example, can financial advice and assistance be provided to the elderly in such a way that their vulnerability to this abuse is decreased? What impact do public education programs, particularly those aimed at the elderly, have on the prevalence of financial abuse of the elderly? Clearly, considerable information is needed regarding the occurrence of financial abuse of the elderly. In light of the nature of the problem and its impact, related research should be a high priority. REFERENCES AARP 1993 Abused Elders or Older Battered Women? Report on the AARP Forum. Washington, DC: AARP Women’s Initiative. 2001 AARP on the Issues: Elder Abuse. Available: http://www.aarp.org/ontheissues/issueelderab.html. Anetzberger, G.J. 2000 Caregiving: Primary cause of elder abuse? Generations 24(2): 46–51. Bassuk, K. 2001 Financial abuse. In The Encyclopedia of Elder Care, M.D. Mezey, ed. New York: Springer Publishing Co. Beauchamp, E.R. 2001 Chapter 565: One more law to reform conservatorships and guardianships; but is it needed? McGeorge Law Review (Winter):647–669. Beck, C.M., and L.R. Phillips 1984 The unseen abuse: Why financial maltreatment of the elderly goes unrecognized. Journal of Gerontological Nursing 10(12):26–30. Bernatz, S.I., S.J. Aziz, and L. Mosqueda 2001 Financial abuse. In The Encyclopedia of Elder Care, M.D. Mezey, ed. New York: Springer Publishing Co. Brandl, B. 2000 Power and control: Understanding domestic abuse in later life. Generations 24(2):39–45. Brandl, B., and T. Meuer 2000 Domestic abuse in later life. Elder Law Journal 8:297–335. Brown, A.S. 1999 Patterns of abuse among Native American elderly. In Understanding Elder Abuse in Minority Populations, T. Tatara, ed. Philadelphia, PA: Brunner/Mazel. Capezuti, E., B.L. Brush, and W.T. Lawson 1997 Reporting elder mistreatment. Journal of Gerontological Nursing 23:24–32.

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