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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


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



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.


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



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


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



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


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



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


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



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.


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.



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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