The ever-present threat of elder abuse and neglect is always a concern for professionals who work with older adults. Elder abuse can be physical, psychological, and financial. Like many other healthcare professionals, as a psychologist I am a mandated reporter: if I suspect an adult over the age of 65 is being physically abused or denied food, hygiene, or medicine, I must report my suspicions in a timely manner to my local county Department of Health (via Adult Protective Services or APS). Failure to do so could subject me to civil or criminal penalties. Conversely, the law protects providers who make reports in good faith from lawsuits.
In California, the primary law that protects older adults from abuse is the Elder Abuse and Dependent Adult Civil Protection Act (EDACPA), codified at Welfare & Institutions Code §§15600 et seq. There are many reasons to be particularly concerned about financial abuse when one is working with this population. Older adults simply by virtue of their age are at higher risk of dementia compared to the general population. Additionally, contemporary research has suggested one of the early warning signs of dementia is increasing episodes of poor financial decision making. Older adults tend to also have higher incidences of physical frailty, and therefore often depend on others for physical care. Combine all of these factors, and you have a recipe for financial disaster.
Often older persons or their families will see the need to hire a home health aide. Unfortunately, these services are particularly expensive if the home health aides are well-trained, licensed, and bonded. Costs can be reduced by hiring home health aides from less reputable sources; however, cost-cutting in such a manner can impart some significant risk.
In my career working with outpatient, homebound older adults, I’ve at times seen geriatric clientele paired with young family members, often a young grandniece, nephew, or grandchild. On the surface this may seem like a good idea, particularly when the younger family member is unemployed or out of school. Unfortunately, the same factors that make this younger family member ideal to “keep an eye” on grandpa or grandma (for example, the younger family member has lots of free time) may be the same ones that make them a risk: older adults, even close family members, may be an irresistible source of income to fund a younger family member’s drug or gambling addiction.
After a report has been made to adult protective services (APS), it’s sometimes found that the best plan for the older adult is to be admitted to long term care, such as an assisted living or a community nursing home. Typically, at this point, APS considers its work over. This doesn’t seem an unreasonable position to take; after all, once the older adult is under the care of a licensed facility that provides 24/7 care and supervision, the responsibility for safeguarding the welfare of the older person has shifted to the facility.
Of course, we all know that residing in long term care facility doesn’t automatically provide an older adult with iron-clad protection against abuse. I’m sure we’ve all seen the occasional lurid news story documenting the rare instances where nursing staff engage in overtly abusive acts, ranging from out-and-out violence to criminal neglect. However, this is in my experience an exceedingly rare event. Not only does the training and hiring process for nursing home providers tend to weed out abusers, it’s also not a particularly convenient environment for an abuser to commit their acts undetected by their fellow employees. Also, nursing homes are, without a doubt in my mind, some of the most highly regulated category of healthcare facilities in the country. Consequently, there is an enormous amount of oversight and considerable incentives for nursing homes to prevent and, if necessary, detect and respond to abuse by staff when it happens.
But what happens when a fellow resident victimizes a vulnerable older adult? This is a particularly sticky problem for a number of reasons. First, patient privacy is at issue here – how do you document that resident X seems to be targeting resident Y in their chart? Given the laws governing patient privacy (for example, HIPAA), this is impossible. Second, although nursing staff are technically responsible for the welfare of their residents, it’s impossible for nurses at a sweeping majority of facilities to be able to keep tabs on their residents all of the time. In the evening hours (what nurses call the “off shifts”) the number of nurses on the floor typically shrinks even further.
I’ll cover this particular issue in more detail in my next post. Suffice it to say, at many nursing homes an underground economy operates: even the most watchful nursing staff do not always detect residents covertly trading contraband and desirable items like cigarettes, food, candy (possibly even drugs and alcohol). What does it mean when one-half to three-quarters of the potential participants in this trade are demented or otherwise have diminished capacity? A number of extremely thorny liability and management issues are potentially in play here.