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DOI: 10.1177/1534650113496143 2013 12: 373 originally published
online 19 July 2013Clinical Case Studies
Sheena M. Horning, Stacy S. Wilkins, Shawkat Dhanani and Donna
HenriquesGeriatric Interdisciplinary Team
A Case of Elder Abuse and Undue Influence: Assessment and
Treatment From a
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Article
A Case of Elder Abuse and Undue Influence: Assessment and
Treatment From a Geriatric Interdisciplinary Team
Sheena M. Horning1, Stacy S. Wilkins1,2, Shawkat Dhanani1,2, and
Donna Henriques1
AbstractElder abuse is a pervasive problem that can have lasting
emotional and physical consequences, increasing its victims risk of
mortality. Healthcare providers are frequently involved in the
detection and intervention of elder abuse. Because of the
complexity of these cases, applying treatment interventions within
an interdisciplinary care team has been recommended to ensure older
adults safety and welfare. Psychologists in particular are
frequently relied upon in these situations because of their
expertise in cognitive, psychiatric, and capacity assessment, as
well as their ability to intervene in a variety of difficult
situations. The following is a report examining the case of Mr. B,
who was a victim of elder abuse involving financial exploitation
and undue influence. Assessment and treatment interventions were
used within the context of an interdisciplinary care team, using a
bio-psychosocial approach. A decision-tree model describing the
steps to take in assessing and treating financial elder abuse is
proposed.
Keywordselder abuse, undue influence, dementia, decision-making
capacity
1 Theoretical and Research Basis for Treatment
Abuse, neglect, and exploitation of older adults are significant
and pervasive problems in the United States (Fulmer, Guadagno,
Dyer, & Connolly, 2004; Lachs & Pillemer, 2004) and have
been associated with an increased mortality among victims (Lachs,
Williams, OBrien, Pillemer, & Charlson, 1998). The estimates of
abuse and mistreatment range from 3% to 25% of the older adult
population depending on the type of abuse (Laumann, Leitsch, &
Waite, 2008), with finan-cial abuse and exploitation identified as
the most common types of abuse (Acierno et al., 2010). Although the
exact legal definition of elder financial abuse and exploitation
varies by state, it has been broadly defined as the misuse or
mishandling of an older adults finances, assets, or income by
another individual (Setturlund, Tilse, Wilson, McCawley, &
Rosenman, 2007).
1VA Greater Los Angeles Healthcare System, CA, USA2University of
California, Los Angeles, USA
Corresponding Author:Sheena M. Horning, Department of
Psychology, VA Greater Los Angeles Healthcare System, 11301
Wilshire Blvd, Los Angeles, CA 90025, USA. Email:
[email protected]
496143 CCS12510.1177/1534650113496143Clinical Case
StudiesHorning et al.research-article2013
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374 Clinical Case Studies 12(5)
Clinicians and healthcare professionals are likely to be the
first to recognize the mistreatment of older adults (Quinn, 2002)
with psychologists in interdisciplinary care teams being identified
as especially important in the assessment and treatment of elder
abuse (Wiglesworth, Kemp, & Mosqueda, 2008). Psychologists are
frequently consulted by geriatric care teams because of their
expertise in assessment and management of elder abuse, making them
important in the clinical care of these patients (Wiglesworth et
al., 2008). Although several research and case studies have
highlighted and addressed the need for proper assessment and keys
to the recognition of abuse, less is known about interventions,
treatment, and outcomes in situations involving this type of
patient care (Lachs & Pillemer, 2004). Because of the
interdisciplinary nature of this type of work, the recognition,
assessment, and treatment of older adult patients at risk for abuse
neces-sitate a team approach, (Jayawardena & Liao, 2006) with
the psychologist on the team playing an instrumental role
(Wiglesworth et al., 2008).
Although physical signs of abuse and neglect may be easily
recognized by a skilled physician or healthcare worker, such as
malnutrition or evidence of bruising, emotional and financial abuse
tend to be less transparent. A patients self-report of these types
of abuse also tends to be unreli-able, as patients may be unable to
accurately report abuse because of dementia or may be unwill-ing to
report because of a sense of guilt, shame, or even dependency on
their perpetrator for caregiving (Fulmer et al., 2004). Uncovering
financial exploitation involves a thorough assess-ment,
particularly among patients judged to be at greater risk, such as
those with cognitive impairment, the medically compromised, or
those who are socially isolated (Fulmer et al., 2004; Laumann et
al., 2008). Determination of financial abuse is difficult as a
person is free to make his or her own financial decisions, such as
giving financial gifts or monies away to charities or even
individuals as they so please. However, the person must act freely
without duress and also have the decision-making capacity to make
these choices (Quinn, 2002). Therefore, if financial abuse is
suspected, assessment of the patients financial decision-making
capacity should follow, as well as an investigation of the patients
susceptibility to undue influence.
Decision-making capacity may be diminished in older adults,
usually because of a neurode-generative disease and/or medical
problems that interfere with ones cognitive functioning, such as
dementia or delirium. Decision-making capacity, therefore, must
carefully be judged by a clinician through the use of a thorough
clinical interview, as well as through the use of neurocog-nitive
tests (Moye & Marson, 2007). Generally speaking, judgment of
capacity involves evaluat-ing whether the patients physical and
mental abilities meet the demands of a given situation and whether
the patient is able to appreciate the risks and benefits of the
choices and outcomes involved and express a choice (Guzman-Clark,
Reinhardt, & Wilkins, 2012; Moye & Marson, 2007). Several
standardized capacity interviews, as well as cognitive assessment
tools, can be used to aid in this process, such as the Financial
Capacity Instrument (Marson et al., 2000), the Montreal Cognitive
Assessment (MOCA; Nasreddine et al., 2005), and the Independent
Living Scales (ILS; Loeb, 1996). Assessment of capacity is usually
the first step in the determination of financial elder abuse, as
many state laws require a person to have diminished capacity to
deter-mine whether the abuse has been perpetrated (Hall, Hall,
& Chapman, 2005).
In addition to questions of capacity, older adults may remain at
risk for financial exploitation if they are under undue influence.
Although a legal construct, the concept of undue influence and its
involvement in elder abuse and exploitation is clinically well
understood (Peisah et al., 2009). Undue influence is a form of
psychological or emotional abuse and manipulation perpetrated for
financial gain (Quinn, 2002), usually involving a significant power
differential between the per-petrator and the victim (Kurst-Swanger
& Petcosky, 2003). Hall et al. (2005) provide a compre-hensive
list of characteristics that predispose a victim to undue
influence, including being of advanced age, frailty, financial
autonomy, medical or physical limitations, depression, and some
degree of cognitive impairment or dementia. Older women also tend
to be disproportionately affected by mistreatment and exploitation
(Kurst-Swanger & Petcosky, 2003). Unfortunately, the
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Horning et al. 375
perpetrators of this type of abuse are commonly family members,
close friends, or acquaintances and may even reside with the victim
(Moon, Lawson, Carpiac, & Spaziano, 2006; Quinn, 2002).
However, regardless of the relationship, the perpetrator often
engages in a distinct set of behav-iors to isolate and manipulate
the victim to gain control over them and their finances. For
exam-ple, they may socially isolate the victim, particularly from
family members, thereby making the older adult reliant on the
perpetrator for social or even instrumental support. They may do
this by engendering suspicion in the victim, causing them to
question the intentions or even concern of other friends or family,
which again furthers their reliance on the perpetrator (Hall et
al., 2005; Quinn, 2002). By offering some degree of caregiving to
the victim, the perpetrators subtle manipulations may be difficult
for the victim to discern, especially if the older adult has any
degree of cognitive impairment and/or functional limitations. Even
among psychologists, medi-cal providers, and skilled clinicians,
the perpetrator may appear to have the patients best interest in
mind. In reality, however, they are opportunistic, predatory, and
are likely to cause psychologi-cal and even physical distress to
the patient for the purpose of their own personal financial gain.
Therefore, careful observations of changes in the patients
behavioral patterns is suggested, par-ticularly noting older adult
patients who make sudden or abrupt changes in their finances or
financial management, as well as those involved in a
caretaker/care-recipient relationship with an obvious power
differential (Hall et al., 2005; Quinn, 2002). Because of the fact
that victims are often socially isolated, clinical providers with
whom they have an ongoing and trusting relation-ship may be most
likely to become suspicious of, and recognize, the wrongdoing
(Quinn, 2002).
After an older adult patient has been assessed and mistreatment
has been identified, the treat-ment interventions are recommended
to be handled within an interdisciplinary care team (Jayawardena
& Liao, 2006; Lachs & Pillemer, 2004; Wiglesworth et al.,
2008). Through an interdisciplinary team approach, the expertise of
each member (e.g., psychologist, physician, social worker, case
manager, nurse, etc.) can be used to efficiently and effectively
intervene. Team members should work together to form a treatment
plan to assess the individualized needs of the patient.
Community-based organizations (e.g., adult protective services
[APS]), law enforcement, and long-term care ombudsmen are also
typically contacted at the onset, if war-ranted (Kurst-Swanger,
& Petcosky, 2003; Moon et al., 2006; Wiglesworth et al., 2008).
As mandatory reporters of abuse, clinicians should contact APS as
soon as abuse is suspected (Luu & Liang, 2005). In addition,
team interventions may include the following, based on the specific
nature of the situation: setting up family meetings with the
patients loved ones, even perhaps with the perpetrator; assisting
in the conservatorship process; contacting home healthcare
ser-vices to provide increased assistance in the patients home;
placement of the patient from unsafe living environment to an
assisted living facility (ALF) or more appropriate level of care;
and referring the patient for psychotherapy services to address any
associated depression or adjust-ment-related concerns. According to
Moon et al. (2006), the most common geriatric team inter-ventions
to ensure patients safety after elder abuse had been established
were placement from unsafe living environments to a live-in care
setting (e.g., nursing home; ALF), followed by arrangement of a
conservator. In addition, caregiver interventions and education may
also be appropriate to assist the families in their care of the
at-risk seniors (Schulz, Martire, & Klinger, 2005).
Clearly, the tasks of detecting, assessing, and intervening in
situations of elder abuse require the consultation and
collaboration of many disciplines. However, as Wiglesworth et al.
(2008) suggest, the psychologist tends to play an instrumental role
in this process because of their exper-tise in cognitive,
psychiatric, and capacity assessment, and are frequently consulted
by team members in some stage of this process because of their
specialized skills. Therefore, knowing how to approach this
daunting task and the common missteps that may occur is crucial for
suc-cessful treatment and intervention. The following case example
of the patient, Mr. B, who was a victim of elder abuse and undue
influence will be discussed. From the perspective of
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376 Clinical Case Studies 12(5)
psychologists on a specialized geriatric interdisciplinary
primary care team (Geriatric Research, Education, and Clinical
Center, GRECC), our approach to the identification and assessment
of elder abuse, undue influence, and decision-making capacity will
be addressed, as well as how we approached and conceptualized his
care through a bio-psychosocial framework and interdisci-plinary
treatment approach.
2 Case Introduction
Mr. B is an 89-year-old, divorced, Caucasian male veteran with
16 years of education. He is a retired businessman. He has two
adult children with whom he remains in contact. Mr. B resides in a
townhome in the Los Angeles area with his girlfriend. He is a
long-term patient of the GRECC outpatient primary care clinic of
the VA Greater Los Angeles Healthcare System. Mr. B was referred to
the GRECC psychologist in 2012 by his primary care physician
because of the concerns about his cognitive functioning, anxiety,
recent escalation of his depressive symptoms, and conflict within
his relationship with his girlfriend, who will be referred to using
the pseudonym Diana.
3 Presenting Complaints
Mr. B was brought to the initial meeting with the GRECC
psychologist by his daughter, Judy. During the clinical interview,
he endorsed several concerns over his cognitive functioning,
spe-cifically related to his memory, as well as periods of
depression and anxiety. He stated that his mind feels cloudy, and
believed that he had dementia. He also repeatedly stated that he
had never felt so strange. For example, he explained that he often
cannot recognize his daughters face. As a result, he endorsed
feeling scared and uncomfortable and was quite distressed over his
belief that his memory and health had been declining. In addition,
Mr. B mentioned several times that he could not recall who had
brought him to the present appointment (his daughter), and was
unable to recall his daughters name. Mr. B reported that these
problems began only over the past 3 months, although his medical
record documented deficits in his memory beginning over the past
few years. In addition, Mr. B reported having frequent, severe
headaches, which fluctuate throughout the day. He also reported
some difficulties with his balance, frequent falls, and peri-odic
dizziness.
Mr. B explained that he resided in a home with his long-term
girlfriend, Diana. He reported that he and Diana had been together
for many years, although their relationship was tumultuous because
of frequent arguments and Dianas fluctuating mood. While at home,
Mr. B endorsed requiring assistance with many of his instrumental
activities of daily living (IADLs). He indi-cated that he received
meals-on-wheels for his lunch and dinner and, at times, received
some meals prepared by Diana. Mr. B stated that he receives
assistance with his financial management from Diana as well (he
stated that she pays all the bills), as he added her name to his
savings account and trust. Mr. B reported that he continues to
shop, do laundry, manage his medications, and engage in housework
independently. In addition, Mr. B indicated that he continues to
hold a valid drivers license and endorsed driving short distances
around his neighborhood.
Mr. Bs daughter, Judy, also reported that her father was having
difficulties with his memory and easily became confused. However,
she stated that his difficulties fluctuated from day to day and
appeared to worsen if he had a headache. She also indicated that he
appears anxious and believed her father was stressed as a result of
his living situation and relationship with his girl-friend. She
also believed that her father had been noncompliant with his
medications, specifically hypertension medication, as a result of
Dianas influence. She explained that her father was not receiving
the type of caregiving and support that he required and reported
her concerns about possible financial exploitation as well,
perpetrated by Diana.
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Horning et al. 377
4 History
Mr. B was born in Ohio and moved to California during his
adolescence. He was the second child in a sibship of five and has
three brothers and one sister. He was raised by his biological
parents, both of whom died at an early age. He graduated from high
school and attended college at a prestigious university, earning a
bachelors degree in business management. Mr. B served in the U.S.
military from 1943 to 1948, where he worked in the intelligence
department. After his mili-tary service, he worked as a
businessman, participating in multiple business ventures, including
holding real-estate investments.
Mr. B was married twice and is currently divorced. His first
marriage lasted 14 years, until his divorce in the late 1960s. He
remarried, but later divorced after 5 years of marriage. He has two
children, one son, Johnny, and one daughter, Judy. Mr. B resided in
California in a townhouse with his long-time girlfriend, Diana. He
recently moved in with her within the last year after liv-ing in
his own apartment nearby. He reported having a good relationship
with his daughter and son; however, his two adult children resided
just outside the greater Los Angeles area (approxi-mately 90 miles
away).
Mr. Bs relationship with Diana was tumultuous, once described by
him as a lovehate rela-tionship. In 2002, Mr. B sought
psychotherapy treatment through the Mental Health Clinic at the VA,
specifically requesting couples therapy to help resolve the
conflict between himself and Diana. At that time, he endorsed
escalation of conflict, frequent arguments, and deterioration of
their relationship over the past several years. He also reported
experiencing a depressed mood and anxiety, with the onset of his
mood symptoms appearing to temporally coincide with the stress
associated within his relationship. Mr. B did not continue with
psychotherapy or couples therapy at that time, which appeared to be
due to Dianas lack of engagement in the process. However, several
years later in 2007, he again sought treatment through psychiatry
at the VA. He endorsed experiencing heightened anxiety, panic
attacks, and depression, which were exacerbated by con-tinued
difficulties within his relationship. He explained that Diana was
irrational, had mood swings with bouts of anger, and they engaged
in daily arguments and conflict. He also complained of severe
headaches, which were diagnosed as vascular or tension headaches,
stress-induced, and which occurred during arguments with his
girlfriend. They also were judged to be related to his uncontrolled
hypertension given his refusal to take his hypertensive medication.
His psychiatrist began him on psychotropic medication and he was
again referred to psychotherapy.
Mr. B began individual psychotherapy with a VA psychologist to
help him cope with his anxi-ety and relationship difficulties. He
reported that he felt he could not leave his relationship or
separate from Diana, as a result of feeling as if he had no one
else to turn to for support. During his treatment, he also had
reported a physical altercation that involved Diana grabbing him in
a violent manner. As a result of this revelation, the psychologist
at that time had again reviewed the limits of confidentiality, and
his requirement to report any suspected elder abuse. However, Mr. B
then acknowledged that he had been aggressively touched in the past
by Diana but denied that this had occurred within the past 5 years.
Therefore, based on the psychologists judgment, an APS report
regarding elder abuse was not deemed appropriate. Mr. B continued
in psychotherapy for a period of 6 months.
In 2009, Mr. Bs care was transferred to the GRECC primary care
outpatient clinic. At that time, he continued to complain of
anxiety and depression secondary to ongoing relationship
dif-ficulties with Diana. He complained of her verbal abuse,
frequent arguments, lack of physical intimacy, and her negative
impact on his overall mood. He explained that his mood was happy
when he was not around her, as she constantly criticized him and
would not allow him to talk about anything. He also stated that he
only remained with Diana because of his fear of being alone. He
also endorsed multiple somatic complaints, particularly tension
headaches, dizziness, and insomnia, which appeared to be
exacerbated by stress. Mr. B had demonstrated a long history
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378 Clinical Case Studies 12(5)
of noncompliance with his hypertensive medication, as well as
other prescribed medications, as a result of his belief that
medications would be detrimental to his health based on the advice
of Diana. Mr. B was referred to the GRECC geriatric psychiatrist
and for a neuropsychological assessment as a result of his ongoing
mood disturbances, relationship difficulties, and his physi-cians
concern over possible cognitive decline after he performed poorly
on a cognitive screen. He obtained a neuropsychological evaluation
and was diagnosed with Cognitive Disorder not otherwise specified
(NOS) and Depression NOS, with significant impairments in nonverbal
learning and memory observed. At that time, Diana began taking over
his financial management. However, several months later in 2010,
Mr. B separated from Diana by moving into his own condo within the
same complex to reduce conflicts between them and avoid her
frequent verbal rages. Diana remained financially supported by Mr.
B. Although his mood had improved because of living away from
Diana, he moved back in with her shortly thereafter out of a fear
of being alone.
In 2012, after several years of being followed as a patient in
the GRECC clinic for his primary care, concerns regarding Mr. Bs
emotional functioning, cognitive functioning, safety, and ability
to live independently were again reevaluated based on the expressed
concerns of his children. These concerns were brought to the
attention of the GRECC psychologist who was consulted by Mr. Bs
primary care physician and his case manager. Mr. Bs daughter, Judy,
had contacted the GRECC team case manager based on her concern over
her fathers well-being and his risk for financial exploitation. She
explained that she believed her fathers cognitive functioning had
deteriorated and, therefore, he was no longer making good
decisions. She also expressed a belief that Diana had prevented her
father from taking his medications and, as a result, his medical
problems had worsened. Judy also reported her belief that her
father was being financially exploited. Judy had received a call
from her fathers bank stating that Mr. B had attempted to transfer
over a quarter of a million dollars to Diana earlier in the year;
however, because of the banks concerns over this transfer, the
transaction was held, which resulted in Mr. B writing a check for
approximately US$20,000 to Diana instead. Upon becoming aware of
this information, Judy began filing for conservatorship over her
father to avoid financial abuse. Therefore, an appointment with the
GRECC psychologist was made to evaluate Mr. Bs cognitive abilities,
emotional functioning, and financial decision-making capacity, as
well as to assist in individual and family interventions to ensure
Mr. Bs emotional well-being and safety.
5 Assessment
Mr. B arrived to his appointment accompanied by Judy. He
presented as an older male, casu-ally dressed and well groomed. He
ambulated independently with a cane, but gait was observed to be
slowed and slightly shuffled. He reported his mood as depressed and
anxious and his affect was congruent. Speech was normal with regard
to volume, rate, and prosody, although he had word-finding
difficulties. His thought processes were logical and goal-directed
and no inappropriate or unusual thought content was observed. Mr.
Bs overall insight and judgment appeared to be impaired. He denied
any suicidal or homicidal ideation, hallucinations, and delusions.
In addition, as part of his clinic visit, Mr. Bs blood pressure was
checked by the GRECC nurse and found to be significantly elevated
(163/82); therefore, he was seen by his GRECC primary care
physician immediately following his appointment and again started
on hypertensive medication.
Mr. B and his daughter underwent a clinical interview with the
GRECC psychologist and psychology intern. He endorsed multiple
cognitive complaints, particularly memory impair-ments, as well as
periods of anxiety and depressed mood. He also reported somatic
complaints, including severe headaches, frequent falls, and balance
problems. Mr. B was also interviewed regarding his psychiatric
history, substance use history, medical history,
occupational/education
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Horning et al. 379
history, and psychosocial history. In addition to the clinical
interview, Mr. B was administered a MOCA (Nasreddine et al., 2005),
the Health and Safety and Financial Management Subscales of the ILS
(Loeb, 1996), and asked structured questions as part of an
evaluation of his decision-making capacity for financial and
healthcare management.
Cognitive Functioning
The MOCA (Nasreddine et al., 2005) is a brief assessment of
cognitive functioning, assessing visuospatial/executive
functioning, attention, language, abstraction, memory recall, and
orienta-tion. Mr. Bs performance on the MOCA was compromised
(13/30), performing significantly below the threshold suggestive of
cognitive impairment (26 points is within normal limits; Nasreddine
et al., 2005), especially given his high pre-morbid level of
functioning based on his occupational history and educational
attainment. He missed points for visuospatial/executive
functioning, naming, attention, language, abstraction, delayed
recall, and memory.
ILS
On a measure of his understanding of basic health and safety
domains related to independent liv-ing (ILS; Loeb, 1996), Mr. B
performed in the moderate range (ILS Health and Safety Subtest =
34/40; 38th percentile). He showed awareness of basic health and
safety concepts, such as being able to recall the emergency number
911, understanding reasons why taking care of ones body is
important, and acknowledging that one should seek medical
assistance in a medical emer-gency. However, some of Mr. Bs
responses to health and safety scenarios were vague, concrete, and
lacking in the necessary complexity required to fully address the
situation. For example, when asked what he would do if he
unintentionally lost 10 pounds in 4 weeks, he was only able to
respond that he would eat more food. When asked what two
precautions he could take to protect himself when going out at
night, he stated, be careful and watch what you are doing. He was
unable to identify any further specific strategies.
On a measure of the knowledge necessary for financial management
(ILS; Loeb, 1996), he performed in the moderate range (ILS,
Financial Management Subtest = 27/34; 31st percentile). Mr. B
demonstrated basic knowledge of the information required for
financial management. For example, he was able to accurately fill
out a fake check for a hypothetical telephone and gas company bill
and also complete a simple arithmetic problem. However, he was
unable to com-plete more complicated arithmetic problems; for
example, he was unable to set up or complete a subtraction problem
involving three amounts. In addition, his answers to more
complicated financial questions lacked in sophistication. For
example, he was only able to provide one reason for why it is
important to pay bills (e.g., they will turn off your service), or
why it is important to understand and read documents carefully
before signing them (e.g., you have to make sure the amount is
correct).
Decision-Making Capacity
Mr. B was asked a series of questions regarding his decisional
capacity for healthcare and finan-cial management. No barriers to
his ability to communicate were noted at the start of the
inter-view. Although he did exhibit some word-finding difficulties,
his comprehension and expression of spoken language was grossly
intact.
Regarding his decisional capacity for healthcare, Mr. B was
unable to provide an accurate assessment of his current health
problems or diagnoses, only stating that his health was
deterio-rating, he has an increase in headaches, and that his sleep
isnt easy. Mr. B also indicated that he manages his own
medications, explaining that pills do more harm than good.
Despite
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380 Clinical Case Studies 12(5)
having hypertension, he had been noncompliant with multiple
hypertensive medications; he failed to appreciate the risks
involved in not taking his medications, or the connection between
his current physical symptoms (i.e., headaches) and the underlying
condition (i.e., vascular). Regarding his decisional capacity for
financial management, Mr. B stated that his current source of
income was his savings account and social security. He was unable
to provide complete details of his assets and had to be reminded by
his daughter, Judy. He also acknowledged that he no longer managed
his finances and that Diana, his girlfriend, controls them. Based
on his responses, Mr. B was found to lack decisional capacity for
healthcare decisions and financial management.
6 Case Conceptualization
Mr. Bs symptoms and clinical presentation were conceptualized
using a bio-psychosocial frame-work. Specifically, the focus was on
how his physical, cognitive, and emotional symptoms devel-oped from
psychological, biological, and socio-relational factors, and how
these factors made him susceptible to undue influence and elder
abuse. With regard to his biological and physical functioning, Mr.
B was frail, experienced balance problems with gait disturbance,
frequent falls, had uncontrolled hypertension, and experienced
severe headaches and cognitive impairment. The degree of cognitive
impairment exhibited in his 2012 evaluation demonstrated
significant decline from his previous cognitive testing (2010),
particularly in learning and memory, as well as executive
functioning, and suggested evidence of dementia. He was diagnosed
with Dementia NOS. Neuroimaging evidence revealed that he had
experienced a thalamic stroke and also gen-eralized cerebral
atrophy. Therefore, although his cognitive deficits were most
probably associ-ated with cerebrovascular disease due to
uncontrolled hypertension, Alzheimers disease was also a strong
possibility and was unable to be ruled out at the time. In addition
to his uncontrolled hypertension causing cognitive impairment, his
headaches had been diagnosed as vascular or tension headaches,
which were likely exacerbated by stress. However, Mr. B was under
the assumption that his medication would do more harm than good and
thus he did not take his medi-cations. Although he may have
experienced relief from his headaches by taking his medications,
the daily influence of Diana that he should not be taking his
medications, including his poor executive functioning and memory,
reduced his ability to make a good decision regarding his own
healthcare and comply with his physicians recommendations.
In addition to his cognitive decline and overall frailty, the
interplay between the socio-relational and psychological factors
was considered. Mr. B had been in a long-term relationship with
Diana. He did not live in close geographic proximity to either of
his two children and there-fore was relatively isolated from his
family. Although he had expressed ongoing and chronic difficulties
within their relationship, which he frequently expressed resulted
in depression, anxi-ety, and significant distress, he felt
dependent on her. His dependency appeared to grow as his age
advanced, cognitive functioning declined, and his physical health
worsened. He remained some-what aware that he required assistance
with his daily functioning and feared that he would not be able to
obtain that caregiving without her. He also became scared of being
alone because of his caregiving needs and lack of social
relationships and companionship. Therefore, Mr. B continued to live
with her out of his dependency and fear of being alone, subjecting
himself to constant conflicts, arguments, and verbal abuse. He was
able to recognize how damaging this relationship was on his overall
mood, particularly as he was aware that he felt happier during
their moments of separation. However, his overall dependency and
cognitive decline reduced his ability to free himself from the
toxic relationship.
In terms of uncovering the financial exploitation and
classification of undue influence, several factors had to be
evaluated. First, Mr. B was deemed to be at a high risk for
financial exploitation and had many of the risk factors that
predisposed older adults to abuse. Based on the risk factors
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Horning et al. 381
for financial abuse outlined by Hall et al. (2005), Mr. B met
the following: advanced age (89); divorced; cognitive impairment;
experienced depression/anxiety; was socially isolated from his
children; dependent on the abuser; lived with the abuser; and was
financially independent. The extent of Mr. Bs vulnerability,
however, was not clear until he was assessed by the GRECC
psychologist and found to have dementia and lack decision-making
capacity for financial management.
Dianas behaviors and personality were judged to be quite
characteristic of female perpetra-tors, as outlined by Hall et al.
(2005). She had a caregiving relationship with Mr. B., isolated him
from others, and instilled a sense of dependency within him on her.
For example, it was revealed that she had suggested, on numerous
occasions, to Mr. B that his children (Judy and Johnny) did not
love him or care for him. Judy had reported that she received phone
calls from her father crying, expressing this belief based on what
he had been told. Although Diana pre-sented herself as a support
and partial caregiver for Mr. B, she likely did harm to his mental
and physical health by convincing him not to take his medications
(i.e., antihypertensive), thereby exacerbating his cognitive
impairment and severe headaches. She was also noted as being
rela-tively uninvolved in his medical care, as she did not attend
any of his medical appointments over a 10-year span. It was not
until Judy had begun seeking conservatorship over her father that
Diana had finally accompanied him to a medical appointment. In
addition, Diana was judged to be emotionally unstable, frequently
demonstrated emotional liability, and was verbally and, possibly,
physically abusive toward Mr. B. She also had a history of multiple
unstable relation-ships, with reports that she had been married and
widowed three times in the past. Financially, she was reliant on
Mr. B for support, as he paid her rent even when they lived apart.
She eventu-ally took over his financial management. However, it was
not until Mr. Bs bank became suspi-cious of the attempted transfer
of US$250,000 to Diana that the financial exploitation became
obvious.
7 Course of Treatment and Assessment of Progress
The course of treatment involved three stages: assessment,
intervention, and follow-up care. Because of the complexity of Mr.
Bs case, multiple providers working as a team were involved in his
treatment to ensure his physical and mental well-being and safety.
Treatment interventions were aimed at first ensuring his safety and
welfare and next improving his cognitive, physical, and emotional
complaints, such as through behavioral activation strategies
(Kanter et al., 2010; Logsdon, McCurry, & Terri, 2007).
Caregiver education and family interventions were also used to
assist the patient and his children through this process.
The initial assessment involved not only the clinical interview
and cognitive assessment but also a thorough medical record review
to establish Mr. Bs medical and psychiatric history, as well as
prior consultation with GRECC team members who had a long-standing
relationship with the patient. The GRECC interdisciplinary care
team highlighted their concerns for the patient, as well as their
observations of the patients present difficulties. The integration
of this information was necessary to help facilitate the initial
meeting with the GRECC psychologist and assisted in the
identification of Mr. Bs current problems, as described above under
the section Assessment. Through the initial clinical interview and
cognitive assessment with the patient and his daughter, elder abuse
was discovered and the extent of Mr. Bs cognitive deficits and
diminished decision-making capacity were brought to light.
After the assessment in which elder abuse and undue influence
were indentified, the psycholo-gist consulted with the
interdisciplinary care team and the following treatment
interventions were used. The primary target of intervention became
ensuring Mr. Bs safety and welfare. First, Mr. Bs children were
encouraged to intervene as communicated by the GRECC psychologist
by moving the patient to a safer living environment, as he was
judged to no longer be able to live
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382 Clinical Case Studies 12(5)
independently. Mr. B did not return to his place of residence
shared with Diana but was moved by his family into an ALF that he
had previously considered. Judy had already begun the process of
filing for conservatorship, which was further facilitated by the
psychologist. In addition, the GRECC team was on the cusp of filing
an APS report of elder abuse; however, the family had removed Mr. B
from his home shared by Diana and took over his financial
management. Therefore, although filing an APS could have been
completed, Mr. Bs safety was no longer thought to be in danger at
the time he was evaluated by the psychologist, as he was in the
process of being conserved and now in the care of his daughter.
Next, Mr. B held a valid drivers license. However, he was not
judged to be safe to continue to drive and therefore he and his
family were advised to refrain him from driving. In addition,
because of Mr. Bs diagnosis of dementia, California state law
required that his diagnosis be reported to the Department of Public
Health. Therefore, a confidential morbidity report was filed by the
GRECC psychologist and primary care physician to initiate a
suspension of Mr. Bs drivers license unless tested by the
Department of Motor Vehicles and determined safe. Third, Mr. Bs
children were supported in their desire to file for conservatorship
over their father. To facilitate this process, the psychologist
worked together with Mr. Bs clinical case manager and completed
capacity assessment paperwork that documented Mr. Bs cognitive
impairments and his diminished capacity for medical, healthcare,
and placement-related decisions.
Two weeks after Mr. Bs initial intake and assessment, Mr. B and
his family returned to meet with the GRECC psychologist with
treatment interventions focusing on psychoeducation regard-ing Mr.
Bs cognitive abilities and behavioral strategies for improving
cognitive and emotional functioning. During this family meeting,
Mr. Bs mood, current functioning, and adjustment to living at the
ALF were discussed. The family had reported that Mr. Bs ALF had
been offering him assistance with most of his IADLs. His
medications were now being appropriately managed, particularly his
antihypertensive medications, and his headaches appeared to have
remitted to some degree. Mr. B also reported feeling comfortable
and satisfied with his current living envi-ronment. He explained
that he enjoyed his meals, was engaging in social activities with
other residents, and reported improvements in his mood. Mr. Bs
affective state was observed to be much improved compared with his
previous presentation, which was reflected to him in the meeting.
Behavioral activation strategies for the treatment of depressive
symptoms (Kanter et al., 2010; Logsdon et al., 2007) were also
explained to the patient and his family. In particular, the
importance of engaging in pleasant events, such as socialization,
playing games, reading, and so on, on ones mood was discussed and
encouraged.
Feedback regarding the results of his cognitive assessment was
also given to Mr. B and his children, with his cognitive strengths
and weaknesses being highlighted. Psychoeducation was provided
detailing the likely impact of Mr. Bs cognitive impairments on his
daily functioning. Several recommendations were also made to the
patient and his family, including providing him with strategies to
help improve his recall. For example, Mr. B and his family were
encouraged to use organizational aids, such as daily calendars and
notebooks, as well as to use verbal and visual reminders, such as
lists and alarms, to assist his memory. They were also recommended
to create a routine for his daily activities and to maintain a
structured, consistent living environment to help minimize memory
and problem-solving demands. In addition, Mr. B and his family were
reminded of the importance of taking his antihypertensive
medications and managing his vascular risk fac-tors, such as
through nutrition and exercise, to potentially prevent further
cognitive decline.
Over the weeks thereafter, Mr. Bs daughter, Judy remained in
telephone contact with the GRECC psychologist for caregiver
support. Judy was beginning to struggle with the burden of her
newfound role as the primary caregiver for her father and the
continuing conflict that existed between herself and her fathers
girlfriend, Diana. The sadness and sense of loss regarding
accepting her fathers cognitive decline and personality changes
were also acknowledged and normalized. Judy also continued to have
many questions regarding communication with her
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Horning et al. 383
father given his memory deficits and was provided with
recommendations to facilitate their inter-actions. For example, she
was recommended to communicate using simple, straightforward
statements. She was also encouraged to ask about her fathers past
or remote memories, which were likely to have remained more intact
than his recent ones. In addition, Judy was encouraged to engage in
self-care related activities to reduce her overall level of stress
to prevent caregiver burnout. After several telephone calls for
supportive caregiver therapy, Judy appeared to have adjusted to her
role and felt more equipped to continue to provide care for her
father. At this point, Mr. B and his family continued to be
followed by the GRECC interdisciplinary care team but were no
longer receiving direct services from the psychologist. Mr. B was
judged to be in a safe and stable living environment, apart from
his girlfriend, and was no longer at risk for finan-cial
exploitation as he was conserved by his son and daughter.
8 Complicating Factors
At the time elder abuse and undue influence were determined,
interventions were done swiftly because of the coordination of the
members of Mr. Bs interdisciplinary care team and his fam-ily
members. However, in the course of his treatment and the weeks that
followed, several complicating factors arose, specifically
regarding the continued relationship between Diana and Mr. B.
Although Mr. B remained rather content with the transition from his
home to an ALF, Diana did not cease her relationship with him.
Although his daughter immediately began the process of filing for
conservatorship over him, an unanticipated clerical error was made
by the courts and therefore his conservatorship paperwork was on
hold. This allowed Diana a chance to continue to exert her
influence in an attempt to financially exploit the patient. By
report of the ALF, she had stopped by on several occasions to
continue to coerce Mr. B into offering financial assistance. On one
occasion, she took Mr. B to his bank to withdraw money; however,
the bank had been put on alert and refused to make any transaction.
Diana also had made plans to marry Mr. B during this small window
of time that his conservatorship paper-work was on hold. When this
announcement was made, the staff at the ALF was asked to ban Diana
from visiting the patient.
In addition, Diana continued to use coercive methods to sway Mr.
B. For example, she fre-quently called Mr. B, leaving him highly
agitated and upset after these conversations. She con-tinued to
report false statements about his children, making him believe that
his children were against him. She also wanted Mr. B to move back
in with her; however, he refused, as he reported being satisfied
with his current living situation, particularly that he was
provided daily meals. Because of this constant upset, Mr. Bs
depression temporarily worsened and he began experi-encing suicidal
ideation. His suicidal ideation was evaluated by his primary care
physician, and he was judged to be at a low risk as he denied any
plans or intention. His depressed mood, anxi-ety, and thoughts of
suicide coincided with interactions with Diana. Therefore, Mr. Bs
family decided to take further legal action and involved a family
attorney to take legal action against Diana if she did not stop her
harassment, such as through a restraining order. Judy again
con-tacted the GRECC psychologist for a letter of support. A letter
documenting Mr. Bs diminished decision-making capacity, cognitive
impairment, and clinical opinion regarding the risk of harm that
Diana posed to the patient were outlined and faxed to the attorney.
Diana eventually moved out of town. Mr. Bs mood was reported as
improved and his suicidal ideation had resolved. He continued to
engage in social activities at the ALF and his hypertension began
to stabilize.
9 Access and Barriers to Care
Because of the severity of Mr. Bs cognitive impairment, he was
not judged to significantly benefit from traditional
psychotherapies. Therefore, treatment interventions for his
mood
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384 Clinical Case Studies 12(5)
involved pharmacotherapy and behavioral activation strategies,
including involvement in pleasant events and social activities
(Logsdon et al., 2007). Caregiver support interventions were used
to help improve Mr. Bs mood, such as by providing education
regarding how to communicate and interact with Mr. B to avoid
unnecessary agitation or exacerbation of his affective complaints,
as well as helping the children process their own emotions of
anxiety and sadness in adjusting to the caregiver demands and the
changes taking place in their fathers abilities.
10 Follow-Up
Mr. B continued to be followed by the GRECC outpatient program
for his primary care. Shortly after his move, Mr. Bs primary care
physician made an at-home visit to his ALF to monitor his medical
problems and to determine his adjustment to his new residence.
Several safety recommendations were made to reduce his risk for
falls. He continued to be seen at the GRECC clinic for monthly
medical checkups, as well as by the GRECC psychiatrist to moni-tor
his mood and cognitive functioning. Although his mood appeared to
fluctuate, his overall mood had generally improved and his
depression remitted to some degree. Pharmacotherapy was also
initiated, including antidepressants for his affective symptoms and
memantine for his cognition. In addition, his clinical case manager
remained in contact with the patient, his family, and his ALF to
ensure that he remained safe and was receiving adequate care while
at the facility.
11 Treatment Implications of the Case
Mr. B demonstrates the interplay between psychological, social,
and medical factors that made him highly susceptible to financial
exploitation and undue influence, further emphasizing the necessity
of the bio-psychosocial model in treatment approaches. As a result
of his emotional vulnerability, cognitive impairment, and the
relational dynamics between him and his perpetra-tor, the
psychologist played an instrumental role in the assessment of his
current problems and the facilitation of his treatment.
Interventions aimed at his safety and overall well-being required
an interdisciplinary care team, as the literature on elder abuse
suggests (Jayawardena & Liao, 2006; Lachs & Pillemer, 2004;
Wiglesworth et al., 2008). Like others in Mr. Bs situation, older
adults who experience significant cognitive impairment and
demonstrate diminished decision-making capacity are frequently
unable to care for themselves independently and thus require
placement in a structured living environment or care facility, as
well as an arrangement of a conservator. Both of these are the most
common interventions to suspend and further prevent financial
exploitation of older adults (Moon et al., 2006).
Elder financial abuse and undue influence can go on for many
years undetected, as it likely did in the case of Mr. B. In
addition to being difficult to detect and discern, many clinicians
fail to broach the topic of finances or financial management with
patients, likely because of a lack of awareness regarding how to
broach the topic, particularly if the patients themselves lack
aware-ness of any wrongdoing. In addition, clinicians working with
older adults may experience coun-tertransference in working with
their older adult patients (Genevay & Katz, 1990). For example,
clinicians tend to minimize the older adults limitations in
handling their daily affairs because of their own belief in
personal independence and autonomy, particularly through older age.
Clinicians may also harbor negative biases and stereotypes toward
assisted living or nursing home placement because of their own
beliefs that this is an undesirable outcome of aging (Genevay &
Katz, 1990). If clinicians are unaware of their own personal biases
and countertrans-ference toward working with older adults, they may
be less likely to inquire about a patients ability to live
independently and may fail to intervene in a timely manner.
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Horning et al. 385
12 Recommendations to Clinicians and Students
The detection, assessment, and treatment of financial elder
abuse and undue influence are com-plex and multifaceted processes.
Figure 1 displays a decision tree to use as a framework to help
guide psychologists and other clinicians through the process from
detection to intervention in cases of elder financial abuse. In
addition, the following are recommendations based on
Elder Abuse and Undue Influence
Is the older adult at-risk for financial exploitation as
indicated by the following risk factors?
Advanced Age (80+) Female Frailty or Physical Limitations Social
Isolation Financial Independence DepressionCognition Impairment
(see Hall et al. (2005) for complete list).
Unless suspected, do not evaluate for elder abuse.
Assess the elders financial situation / management for signs of
abuse / or poor decision-making.
Have they been giving away large sums of money to another person
or a charity?
Or Have they made significant or recent changes to their
finances / assets? (i.e., changing will; trust; adding names to
bank accounts or property, etc.).
Assess for undue influence by a third-party.
Does the older adult rely on another person to manage finances?
If so, is this person using the seniors finances for their own
personal gain?
Or Are they financially supporting another individual, such as a
caregiver or relative? If so, are there signs of undue influence or
a significant power imbalance?
(see Quinn (2002) for more details regarding the signs of undue
influence).
If both are No,then financial exploitation is unlikely.
Assess for cognitive impairment. Assess for financial
capacity.
Is there evidence of cognitive impairment? Below threshold score
on measure of global cognitive functioning (e.g., MOCA <
25;Nasreddine et al., 2005). Evidence of cognitive decline or
impairment on neuropsychological evaluation.
Or Does the patient lack decision-making capacity for financial
management?
Impaired score on objective measure of financial management
(e.g., ILS Managing Money Subtest; Loeb, 1996); Lacks the basic
skills for financial management (e.g., unable to write a check,
count change, complete simple calculations, etc.). Demonstrates a
lack of knowledge of information regarding their finances,
financial concepts, or their total income / assets; Demonstrates a
lack of judgment to make financial decisions (Moye & Marson,
2007).
Or Has the older adult self-reported being a victim of financial
exploitation or a scam with financial losses?
If the older adult has capacity and is cognitively intact, then
financial abuse is unlikely, unless they self-report.
Contact Adult Protective Services (APS) to report suspicion of
elder financial abuse. * *Laws regarding the reporting of elder
abuse varies state by state. Refer to your local APS for
details.
Other possible immediate interventions: If the patient is
considered at imminent risk, call 911 or the police and request a
Health & Welfare check, and report the abuse. If the patient
resides in a residential care facility (e.g., nursing home), notify
the ombudsmen and necessary care staff.
No
No
Yes
No
No
Yes
Yes Yes
Figure 1. Decision tree for the detection and treatment of
financial exploitation of older adults.Note. Clinical judgment
should always take precedence in the reporting of suspicion of
elder abuse.
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386 Clinical Case Studies 12(5)
the literature, as well as from lessons learned from the case of
Mr. B. First, be aware of the risk factors and signs of elder
financial abuse and undue influence (Hall et al., 2005; Quinn,
2002). For those who are at a high risk for abuse, clinicians may
want to briefly evaluate their patients ability to complete their
IADLs, particularly financial management. Using an elder abuse
screen-ing measure may be useful to help structure the evaluation
of abuse (Fulmer et al., 2004). Although these tools may be
helpful, clinicians should keep in mind that the self-reporting of
abuse tends to be unreliable, because of some older adults
inability to accurately report abuse because of dementia or
dependency on their perpetrator for caregiving (Fulmer et al.,
2004). Therefore, clinical judgment should always be prioritized.
Second, when possible, work within an interdisciplinary care team
to assist in immediate case management and treatment interven-tions
(Jayawardena & Liao, 2006; Lachs & Pillemer, 2004;
Wiglesworth et al., 2008). When working as a sole practitioner,
consult a colleague for additional support, or the older adults
primary care physician. Third, if elder abuse of any kind is
suspected, call APS to report and to ask for assistance. Finally,
with consent from the older adult, contact family members or a
close friend to inform them of the situation. Consider holding a
family meeting to discuss the need for the following treatment
interventions: placement options or in-home caregiving;
conservator-ship/power of attorney; caregiver support;
psychoeducation about cognitive impairment; and any other safety
concerns. Dealing with elder abuse can be an overwhelming and
frightening experi-ence for the patient and the clinician.
Therefore, having awareness of the steps necessary when faced with
these situations can assist clinicians in effectively and
efficiently intervening to ensure their patients safety and
well-being.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Sheena M. Horning is a postdoctoral fellow at the West Los
Angeles VA Healthcare Center with emphasis in
Geropsychology/Neuropsychology where she also completed her
clinical internship. She attended the University of Colorado at
Colorado Springs earning her PhD in Clinical Psychology with
emphasis in Geropsychology in 2012.
Stacy S. Wilkins is a geriatric neuropsychologist at the Greater
Los Angeles VA Healthcare Center with the GRECC and GEM geriatric
medical inpatient and outpatient programs. Dr Wilkins is also a
Clinical Professor at the David Geffen School of Medicine at UCLA
in the Department of Medicine.
Shawkat Dhanani is a physician who is board certified in
Internal Medicine and Geriatric Medicine. He is the director of
Geriatric Evaluation and Management Unit and the Associate Chief of
Staff for Geriatrics and Extended Care. His research interests are
health promotion and improved functional status through
exercise.
Donna Henriques, RN, PhD, is currently the GRECC clinic
associate/manager at the West Los Angeles VA Healthcare Center. She
is also involved in research exploring the improvement of focus and
concentra-tion in patients with Alzheimers Disease through response
to continual stimuli.
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