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.