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OLDER PEOPLE AT RISK

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CHAPTER

243

Elders at Risk: Older Women and Older Minority Group Members

The learning objectives of this chapter include understanding

The demographics and life expectancy of older women, older minority group members, ■ and lesbians, gays, bisexual, and transgender (LGBT) elders in America. The economic challenges of older women, racial/ethnic minorities, and sexual ■ minorities. The role of caregiving responsibilities, partner status, and living arrangements on eco- ■ nomic security among elders at risk. The self-assessed health and chronic health conditions of elders at risk. ■ The use of preventive health services among elders at risk. ■

WHO IS AT RISK?

This chapter focuses on Americans at risk for poor economic and health outcomes as they age—women, racial/ethnic minorities, and LGBT individuals. At various points in the history of gerontology, intersections of age, gender, and race/ethnicity have been perceived as producing double or triple jeopardy for the well-being of older Americans. Now well into the second millennium, nondominant sexual orientation should be added to these identities, which leads to the possibility of quadruple jeopardy—old, female, racial/ethnic minority, and sexual minority.

Demographics: Women, Racial/Ethnic Minorities, LGBT

What are the demographics of American elders at risk? Women outnumber men at every age, but the difference increases with age. Thus, an aging society is an increasingly female society. Figure 16.1 displays U.S. Census Bureau (2012) data on the number of older women and men in 2011.

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244 V. OLDER PEOPLE AT RISK

Between ages 65 and 74, American women outnumber men by 15% (1.7 million); beginning at age 75, the difference increases to 24%. At age 85 and older, it is 46%, a ratio of just under two women for every man alive in that age bracket. In 2011, there were more than 22 million American women age 65 or older; 3.3 million of them were age 85 or older. It is projected that by 2060, there will be almost 50 million American women age 65 or older, and more than half a million of them (523,000) will be 100 years of age or older.

Figure 16.2 shows the proportion of our older population in each racial/ethnic group—White Americans, Black Americans, Hispanics, Asian Americans, and other races (the latter, alone or in combination) in 2010, and also the projected proportions in 2050 (U.S. Census Bureau, 2011). At 80%, White Americans are currently a large majority of the older population, with more than 32 million elders. Racial and ethnic minority elders rep- resent just 20% of older Americans, with 3.4 million Black Americans, 2.8 million Hispanic Americans, 1.4 million Asian Americans, and 640,000 older Americans of other races.

The diversity of older Americans, however, will increase signifi cantly over the next several decades. By 2050, racial and ethnic minority group members will grow to become 42% of older Americans. Though their numbers will grow (to 52 million), older White Americans will be a much smaller majority of the 65 and older population in the future. The number of Black Americans will increase twofold to 10.5 million. The largest increases will be in the number of Hispanic elders, who will increase more than fi vefold to 17.5 million, and in the number of Asian American elders, who will increase more than fourfold to 7.5 million. This increase in minority elders is a consequence of two factors. One factor is improvements in the health of minority group members over their lifetime, leading to an increase in their longevity. A second factor is increases in immigration, espe- cially among Asian and Hispanic people.

Data on the demographics of the LGBT population are scarce. Government agen- cies, such as the U.S. Census Bureau, have only just begun to include questions about sexual orientation and gender identity on their surveys, and it is uncommon to collect such data on older people. Of the fi ve surveys described in the Institute of Medicine’s (IOM) report on LGBT health, none included people over age 59 in their samples (IOM, 2011). One estimate is that there are 2 million people age 50 and older who self-identify as

1,000

2,000

3,000

4,000 N

u m

b e r

(i n t h o u sa

n d s) 5,000

6,000

7,000

65–69 70–74 75–79

Age

80–84 85+

Women

Men

FIGURE 16.1 Number (in thousands) of Older Men and Women in the United States by Selected Age Groups: 2011.

Source: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2011, Table 1.

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16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 245

lesbian, gay, or bisexual (LGB; Fredriksen-Goldsen, 2011). The National Gay and Lesbian Task Force estimates that there are 1.5 million LGBT people age 65 or older, which is expected to double to 3 million by 2030.

RISKS TO ECONOMIC SECURITY

Risks to the economic security of older women and minorities abound, and poverty is an all-too-common outcome. Among all older Americans, women and minority group mem- bers are the most likely to live at or near poverty levels. In 2010, the poverty threshold for a single American age 65 years or older was an annual income of $10,458, and for two people with a householder 65 years or older, it was $13,194. The “near poor” threshold is defi ned by an annual income between the poverty threshold and 125% of that thresh- old—$13,073 and $16,493 for one and two persons, respectively. People who are identi- fi ed as living in poverty or near poverty are very likely to have inadequate resources for food, housing, health care, and other needs.

Based on the federal government’s defi nitions of poverty, in 2010, over 17% of all older women were considered poor or near poor (U.S. Social Security Administration, 2011). For older men that proportion was 11.6%. Rates of poverty and near poverty for Black, Hispanic, and Asian Americans were 28.5%, 27.8%, and 20.6%, respectively, com- pared to 13% for White Americans.

A popular stereotype about LGBT people is that they are wealthy. Evidence to the contrary comes from a report by the fi rst researchers to analyze data on poverty rates in this population. Albelda, Badgett, Schneebaum, and Gates (2009) found “clear evidence that poverty is at least as common in the LGB population as among heterosexual people and their families” (p. i). In fact, they said, “Gay and lesbian couple families are signifi - cantly more likely to be poor than are heterosexual married families” (p. i) and, as is the case for heterosexuals, women have much higher rates of poverty than do men. Older lesbians are twice as likely to be poor as different-sex married couples.

Asian 8.5%

Black 8.5%

Black 11.9%

2010 2050

White 80%

Hispanic 6.9%

Hispanic 19.8%

Asian 3.4%

Other races 1.6%

Other races 2.7%

White 58.5%

FIGURE 16.2 Percentage of Older Americans (65+) by Race and Ethnic Group: 2010 and 2050 (Projected).

Note: Other races includes all other races alone or in combination. Percentages do not add to 100% due to rounding.

Source: U.S. Census Bureau (2011). Projections of the population by sex, race, and Hispanic origin for the United States: 2010–2050. 2010 Census Summary File 1, Table 4.

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246 V. OLDER PEOPLE AT RISK

Income Inequities

One important reason for women and minorities’ greater probability of being impover- ished in old age is that their earnings throughout their years in the labor force are rela- tively low. Ultimately, the lower a person’s wages, the less likely it is that they will be able to accumulate assets and savings for retirement.

Women face cumulative discrimination in the workplace that begins when they fi rst enter the labor force, continues in their wages and promotions throughout their employ- ment, and then affects their fi nancial resources and benefi ts in retirement (Sugar, 2007). Black and Hispanic Americans also experience discrimination in the workplace that affects their lifetime earnings and retirement benefi ts. Figure 16.3 shows median weekly earnings in 2010 for full-time workers, by sex and race/ethnicity.

Several patterns are apparent in Figure 16.3:

Women’s earnings are lower than are men’s for every racial and ethnic group. ■ On average, Asian Americans earn the most, followed by White Americans (11% ■ less), Black Americans (an additional 18% less), and then Hispanic Americans (yet another 9% less). The difference between the highest and lowest earning racial/ethnic groups is 37%—an average of $320 per week in 2010. There is an interaction between gender and race, a reminder that characteristics ■ that contribute to elders being at risk are not simply additive. Even though Asian and White American women earn more than their Black and Hispanic sisters, the differences between their earnings and their male counterparts are 20% and 17%, respectively. Black and Hispanic Americans meanwhile earn just 7% and 9% less, respectively, than do their male counterparts. The smaller differences between female and male Black and Hispanic workers are likely attributable to the fact that these male workers’ wages are low enough that the wages of their female peers cannot be that much lower.

$200

$400

$600

$800

$1,000

White Black Hispanic Asian

Men

Women

FIGURE 16.3 Median Weekly Earnings for Full Time Workers, by Sex and Race/Ethnicity: 2010.

Source: U.S. Bureau of Labor Statistics (2011).

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16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 247

One of the saddest commentaries on our society is that so many women live in poverty during their elder years. One “explanation” for this is that because women live to older ages than do men, women are more likely to outlive their fi nancial resources. Although it is certainly true that, on average, women live longer than do men, it seems more than disingenuous to blame older women’s poverty on their longevity. In fact, dis- criminatory policies and practices in the United States result in a substantial proportion of American women beginning their golden years with few, if any, accumulated fi nancial resources.

To get a sense of just how much lower a woman’s earnings could be over a life- time of work, Sugar (2007) constructed a hypothetical case of a woman (call her Sonia) who begins full-time employment in 1975 and plans to retire in 2015. Using data from the U.S. Bureau of Labor Statistics on average sex differences in salary, Sonia’s annual salary shortfalls were calculated for each of her hypothesized 40 years of full-time paid work between 1975 and 2015. The resulting total is a whopping $480,000 less in earn- ings than a male employee would receive over the same time period! This amount does not include the interest and potential other income that Sonia could accrue through investing the “extra” $480,000 she would have earned if she was a male employee. That amount for every older woman would go a long way toward ending poverty among older women.

Some good news about women’s employment-related income is that the longstand- ing wage gap between women and men has been gradually closing. Both the women’s movement in the 1970s, and its concomitant effects on the increased participation of women in the paid workforce, has helped to decrease sex differences in wages and sala- ries. In 1970, women on average earned 40% less than did men. By 2010, that gap had been reduced to 19%. The bad news is that women’s wages are still signifi cantly lower than men’s. This is because, although women’s wages have increased, men’s wages have stagnated over that time period.

Although differences in salaries within occupational types do exist, what is clear is that female workers earn less than do male workers in all occupational categories (Sugar, 2007). So, occupational choices alone do not protect women from lower wages. Nor does a college education. In a study of male and female college graduates’ pay, Judy Dey and Catherine Hill, researchers with the Educational Foundation of the American Association of University Women (AAUW), found:

Controlling for hours, occupation, parenthood, and other factors [experience, train- ing, etc.] normally associated with pay, college-educated women still earn less than their male peers earn . . . . As early as one year after graduation, a pay gap is found between women and men who had the same college major. . . . In biological sciences, a mixed-gender major, women earn only 75 percent as much as men earn. Female students cannot simply choose a major that will allow them to avoid the pay gap. (Dey & Hill, 2007, p. 9)

Thus, while some progress has been made in improving women’s salaries relative to men’s, women are still at a signifi cant disadvantage in their paychecks. This disadvan- tage results in lower wages throughout their employment years, and a substantial risk of economic insecurity or poverty after they are no longer in the labor force.

And, if women stay in the labor force, or reenter it, after age 65, they can continue to expect lower wages than men receive. In 2010, the median earnings of full-time year- round female workers 65 years or over were $38,946, compared to $50,454 for their male counterparts (DeNavas-Walt, Proctor, & Smith, 2011), a gap which is larger than the over- all average difference between women and men, regardless of age.Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

248 V. OLDER PEOPLE AT RISK

Caregiving

Taking on the role of a caregiver presents another notable reason for being at risk for economic insecurity and poverty in late life. As was pointed out in Chapter 12, the major- ity of caregivers in America are women. Caregiving responsibilities of any kind often lead women to cut back on their work hours, go from full- to part-time work, pass up promotions, change jobs for greater fl exibility in their work schedules, take leaves of absence, quit their jobs, and take early retirement. Caring for a child usually brings about these interruptions in work history when women are younger, and caring for a parent, parent-in-law, or other relative has a similar impact on middle-aged and older women. Ultimately, these gaps in women’s employment negatively affect not only their wages but also their retirement benefi ts, leading to long-term consequences for their economic security. The MetLife Study of Caregiving Costs to Working Caregivers (2011) estimated that the fi nancial costs to female caregivers of exiting the labor force early totaled $324,000 in 2008—$143,000 from lost wages, $131,351 from lost Social Security benefi ts, and $50,000 from lost private pension benefi ts.

Work History

The role of work history in economic insecurity is also especially pertinent for women. It is impossible to understand the vulnerability of older women in American society with- out acknowledging the social roles that women have conventionally held. Traditionally, women’s roles have focused on being wives, homemakers, mothers, community vol- unteers, and caregivers of ill and frail family members. For these roles, so important to any society, women have received no pay and no credits toward any retirement system. Their familial roles and less-than-full-time and intermittent participation in the labor force interact, frequently leading to economic and social dependency, costly for both them and society.

One of the main reasons women work part-time rather than full-time is to enable them to fulfi ll caregiving responsibilities for family members. Although more American women age 16 years and over are employed full-time than part-time (48 vs. 18 million), they are twice as likely to be part-time workers as are men (27%, and 13%, respectively, U.S. Bureau of Labor Statistics, 2011). In fact, during the critical years between 25 and 54 years of age, when employees are in the growth years of their careers for earnings, pro- motions, and accumulating retirement savings, only 75% of employed women are work- ing full time compared to 89% of men.

Working part-time, as opposed to full-time, leads to several problems for women as they age:

Their income will typically be too low to allow them to set aside savings for ■ retirement. They are less apt to be offered promotions that would increase their incomes. ■ Their contributions toward Social Security and other retirement vehicles, if any, ■ will be lower. They are less likely to receive benefi ts, especially health care and employers’ con- ■ tributions to a pension fund.

Working part-time is one strategy women use to manage caregiving and other familial responsibilities. Another is taking leaves of absence. Due to concerns about young women taking leaves of absence and then potentially not returning to work, Sylvia Hewlett and Carolyn Luce (2005) conducted a survey to learn about ways C

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16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 249

to keep talented women on the road to career success. Among other questions, the nationally representative group of more than 2,400 college-educated women were asked about their experiences on returning to their jobs after taking leaves for various periods of time. The effect on their salaries was striking: compared to women who had not taken time out, those who took 1 year or less lost an average of 11% in their salaries, and those who took 3 years or more lost an average of 37% in their salaries. They were also signifi cantly less likely to receive promotions after their return to work. The negative effect of the women’s leaves, both in the short-term and the long- term, are examples of the costs women bear when they have an intermittent work history.

Partner Status

The likelihood of being impoverished is infl uenced by a person’s partner status, including whether they are legally married. Compared to being single, having a part- ner, and thus two potential earners in a household as well as shared living arrange- ments, signifi cantly reduces the chances of living in poverty. Unmarried folks (single, divorced, or widowed) who live alone have poverty rates between 2.5 and 5 times higher than their married counterparts. The rates of poverty for older men and older women who are married are very similar, ranging from 3.1 to 11.5%. Rates of poverty for older women who live alone range from 14.2 for White women to a shocking 41.5% for Hispanic women (U.S. Census Bureau, 2012).

In addition to adverse economic consequences, living alone means that as people continue to grow older and are more apt to need assistance at various times, if not on a long-term basis, help will not be readily available. Furthermore, being legally married bestows advantages on partners when it comes to health care and retirement benefi ts. Most employers do not provide benefi ts for an employee’s partner unless the employee is legally married, and unmarried people cannot collect survivor benefi ts from Social Security. Couples in the LGBT community are at a distinct disadvantage in this regard because the federal government, and most states, have not legalized same-sex marriage, or civil unions that would grant same-sex couples the same rights as opposite-sex couples (read more on the status of legalized same-sex marriage in Chapter 6).

The modal partner status for older heterosexual men is married, whereas the modal status for heterosexual older women is widowed. In 2010, over three quarters (78%) of men age 65 to 74 were married, compared to a little over half (56%) of women in the same age group (Older Americans 2012). The proportion who are married is lower at older ages: 38% of women age 75 to 84, and 18% of women age 85 and over. For men, the proportion who are married is also lower at older ages, but not as low as for older women. Even among the oldest-old in 2010, the majority (58%) of men were married.

As they age, women of every racial/ethnic group are much more apt to live alone than are men, mostly due to their longer lives and the tendency for women to marry men some years older, which together bring about the greater prevalence of widowhood among women. In fact, older women are twice as likely as older men to live alone (37% and 19%, respectively). Figure 16.4 shows the living arrangements of older Americans in 2010 by sex and race/ethnicity.

Older White women and Black women have the highest rate of living alone, at 39% each, compared with 23% for older Hispanic women and 21% for older Asian women. Older Black men have a much higher rate of living alone—28%—than do other men.

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250 V. OLDER PEOPLE AT RISK

Widowhood

Many older women live alone because, compared to older men, they are much more likely to be widowed, and the prospect of widowhood rises with age. Women age 65 and over are 3 times as likely as men of the same age to be widowed, 40% compared to 13% (Older Americans 2012). Nearly three quarters (73%) of women age 85 and over are wid- owed, compared to only 35% of men of the same age.

Widowhood presents especially serious economic problems for older women for several reasons. First, many older women rely on their husbands’ retirement benefi ts. When their husband dies, Social Security benefi ts are reduced to the level of a single person. Private pension benefi ts are similarly reduced, and sometimes provide nothing for the surviving spouse. Women’s accumulated savings throughout their lifetime are frequently inadequate to meet expenses without funds from their husband’s retirement benefi ts. Secondly, a considerable portion of any savings may have been spent on medi- cal bills prior to the husband’s death. Thirdly, they lose the benefi t of reduced costs from economies of scale for basic needs such as housing.

Retirement Pensions and Policies

Retirement benefi ts adequate to support older women and minorities in old age are rare. This is an especially challenging issue for women of all races and sexual orientation because their greater longevity means they need more fi nancial resources in old age than do men.

The lifetime pattern of work that is often used as a standard or norm is a linear one in which a period of education is followed by a period of work, and then by a period of

P e

rc e

n t

Alone

Women Men

With Spouse

Women Men

White

Black

Hispanic

Asian

FIGURE 16.4 Living Arrangements of Older Americans (65+), by Sex and Race/Ethnicity, 2010.

Note: Numbers are percentages. (They do not total 100% because two additional categories for living arrangements [with other relatives, with nonrelatives] were excluded from this fi gure.) These data refer to the civilian noninstitutionalized population.

Source: Older Americans 2012, Table 5a.

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16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 251

retirement. This has been the predominant pattern for American men, especially White men. Consistent with this lifetime pattern, all plans for pension income, including Social Security, are based on a model of full-time, and long-term, employment in the labor force, which is also the most common scenario for White American men.

Pension plans are based on earnings, and, as has been noted, on average, the earn- ings of women and minority group members are comparatively low. Remember the hypo- thetical case of Sonia presented a little earlier in this chapter? Both her Social Security benefi ts and private pension would be adversely affected by her lower income because both are based on employment earnings. And, because employers must match employ- ees’ Social Security contributions, and often match contributions to private pension plans too, Sonia’s employer would also contribute considerably fewer dollars to her pension savings than would be the case if her paychecks were larger.

Policies regarding vesting periods for pensions also work against women’s tendency to be in and out of the labor force. Vesting means that the employee has earned the right to keep pension contributions an employer makes on the employee’s behalf. Regulations regarding vesting periods used to be highly advantageous to employers. For example, workers who left a company prior to an established 20-year vesting period would relin- quish all contributions their employers had made to their pensions. (No matter how long a person works for a company, when they leave they always have the right to keep their own contributions.) Continuous employment for 20 years with a single company is not the norm for young women who may want to temporarily leave the labor force to bear and raise children, for example. Thus, long vesting periods discriminate against women, and, in so doing, contribute to the likelihood that they will be impoverished in their later years. This situation has improved as vesting periods have been reduced, and now the federal government requires employers to choose from two options, though employers can also provide more generous plans (e.g., shorter vesting periods). One option is for workers to be 100% vested after 3 years with the company. The other option is a 6-year graduated schedule through which workers become 20% vested after 2 years and 20% for each year until they reach 100% after 6 years with the company.

With the uptick in employers’ use of 401(k) plans for pensions, married women face the possibility of new inequities. One example comes from the Pension Rights Center (n.d.):

A wife will lose her right to a share of the money in her husband’s 401(k) plan if her husband leaves the job that sponsors the plan and cashes out the account or rolls it over into an IRA. The wife’s consent is not required. With 401(k) money increas- ingly becoming the largest asset of many marriages, this can result in a signifi cant reduction of retirement income for women who work inside the home. . . . Spousal consent is required to cash out benefi ts from defi ned benefi t plans as well as defi ned contribution . . . plans.

RISKS TO HEALTH

Life expectancy is a basic measure of the overall health of a population. In Chapter 1, the average life expectancy of Americans was presented. How do elders at risk fare on this measure of health? Table 16.1 presents data on life expectancy at birth and also at age 65 by sex, race, and Hispanic origin.

It is a well-known fact of biology that the females of every species outlive the males, and humans are no exception. The differences between men and women at birth, which range from 4.7 to 6.3 years, narrow for all racial and ethnic groups to about 3 years by age 65. Thus, a signifi cant proportion of the sex differences in life expectancy is a result C op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

252 V. OLDER PEOPLE AT RISK

of conditions and events that lead to earlier deaths for men, for example, risky behav- iors of young men that lead to deaths from traffi c accidents. Reaching age 65 depends upon a person surviving all those health conditions and events that are more prevalent at younger ages. Of course, other health conditions, for example, heart disease, start to become more prevalent as a person ages.

As Table 16.1 shows, Hispanics have a greater life expectancy than White or Black Americans at birth, and at age 65. The better health outcomes of Hispanics compared to Whites has been deemed the Hispanic paradox, because the relatively low socioeconomic circumstances of many Hispanics should predispose them to poorer health outcomes (Markides & Eschbach, 2005). This paradox, and the greater life expectancy of female Asian/Pacifi c Islanders, suggest that there is much to be learned from studying life expectancy, health status, and the infl uences on them, in our increasingly diverse older population.

What do older people think about their own health? Chapter 4 included data show- ing that a majority of older people, including those over age 85, report good to excellent health. But what of the self-ratings of health among elders at risk? Table 16.2 presents the percentage of older Americans who rate their own health as good or excellent, by sex and race-ethnicity. Older White women and men self-ratings are equally likely to be high. However, Black and Hispanic women are less likely than their male counterparts to rate their health as good or excellent. A study by the IOM (2011) on the health of LGBT individuals found that cohabitors of the same-sex rate their health as poorer than married people of different sex.

Health Disparities and Health Inequities

The terms health disparities and health inequities are frequently used interchangeably, though they focus on different aspects of the fact that there are large gaps between population groups in the United States in access to health care, and the diagnosis, treatment, and

TABLE 16.1 Life Expectancy at Birth and at Age 65, by Sex and Race/Ethnicity

AT BIRTH AT 65 YEARS

Men Women Men Women

Whites 76.4 81.1 17.7 20.3

Blacks 71.4 77.7 15.8 19.1

Hispanics 78.5 83.8 18.8 22.0

Note: Data for “At 65 Years” refer to years of life remaining for people who reach age 65.

Source: Older Americans 2010: Key Indicators of Well-Being, Table 14b.

TABLE 16.2 Percentage of Older Americans Rating Their Health as Good or Excellent, by Sex and Race/Ethnicity

MEN WOMEN

All 74.8 74.4

Whites 76.4 76.9

Blacks 65.2 60.7

Hispanics 64.8 62.5

Source: Older Americans 2010: Key Indicators of Well-Being, Table 18.

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16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 253

outcomes of health conditions. The term health disparities focus on differences between groups, and especially on groups with the poorest health. On the other hand, the term health inequities focus on the causes of such differences, especially the unfair distribution of health resources among population groups.

Health disparities and inequities among older Americans are a growing problem. The rapidly increasing population of older adults and the increasing diversity of that population are two reasons for concern, and escalating costs of health care are another. LaViest, Gaskin, and Richard (2009) at the Joint Center for Political and Economic Studies have determined that the costs of medical care and lost productivity as a result of racial and ethnic health disparities amounts to an alarming $309 billion per year. Considerable evidence exists that eliminating those health disparities will require improvements in “broader social, economic, and political inequalities alongside more downstream proxi- mate factors that give rise to health inequalities” (Warren & Hernandez, 2007, p. 349). Furthermore, achieving a healthy nation is impossible unless all population groups are healthy and unless health inequities among these population groups are eliminated.

There are differences across the life span between the most prevalent health condi- tions in men and women, some of which, of course, are due to anatomical differences—for example, the prevalence of some types of cancers, such as uterine, cervical, and prostate. In addition, although breast cancer and osteoporosis occur in both men and women, they are much more prevalent in women. But other differences exist between older men and women, too. As age increases, so does the likelihood of developing a chronic condition, so it is not necessarily surprising that because women live longer than men do, they are also more likely to be affected by a chronic condition. Arthritis is almost twice as prevalent in women (35%) as in men (22%), and high blood pressure, the most common chronic condi- tion in older adults, is also more prevalent in women (61%) than in men (54%). However, more men (36%) than women (27%) have heart disease. In general, older women (72%) are more likely to have two or more chronic health conditions than are older men (65%; Centers for Medicare and Medicaid Services, 2012).

Table 16.3 gives the percentage of older Americans with the top fi ve chronic condi- tions by race/ethnicity. The differences among the groups are striking. Black Americans are more likely to have hypertension and diabetes; White Americans are more likely to have heart disease, and they are much more likely than Black Americans and Hispanics to have cancer; and Hispanics, like Black Americans, are more at risk for diabetes than White Americans. Consistent with the Hispanic paradox, the percentage of Hispanics with arthritis or heart disease is lower than other racial/ethnic groups.

It is one thing to be diagnosed with a chronic disease and another to die prematurely from one. A fi ne-grained analysis of data on coronary heart disease (CHD) reveals that Black women and men aged 45 to 74 years had much higher rates of death due to CHD than do White, Asian/Pacifi c Islander, or American Indian/Alaskan Native women and men. Premature death rates for Black women are higher (37.9%) than for White women

TABLE 16.3 Percentage of Older Americans With Selected Chronic Conditions By Race/Ethnicity

WHITES BLACKS HISPANICS

Hypertension 54.3 71.1 53.1

Arthritis 50.6 52.2 42.1

Heart Disease 33.7 27.2 23.8

Cancer (any) 24.8 13.3 12.4

Diabetes 16.4 29.7 27.3

Source: Older Americans 2010: Key Indicators of Well-Being, Table 16a.

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254 V. OLDER PEOPLE AT RISK

(19.4%), and higher for Black men (61.5%) than for White men (41.5%; Truman et al., 2011).

Although data on the health of American Indians, Native Alaskans, Native Hawaiians, and other Pacifi c Islanders are gradually becoming more readily available, these data seldom include information on older adults. Thus, there is limited knowledge about the health status and health disparities in these populations. The same is true for the LGBT community.

For American Indian and Alaska Native (AI/AN) elders, chronic diseases with high prevalence rates are arthritis, diabetes, and heart disease. The prevalence of arthri- tis among AI/AN elders is 43.5%, and, consistent with other groups, is more prevalent in women (50.2%) than men (35.4%; Center for Rural Health, 2006a). Among AI/AN elders with arthritis, 87% also have other chronic diseases, the most common of which are hypertension (59.2%) and diabetes (43.6%). Diabetes is more prevalent among AI/AN elders than among elders of any other racial/ethnic groups, with a rate of 31.3% (Kim, Bryant, Goins, Worley, & Chiriboga, 2012). Cancer rates in AI/AN elders are the lowest of all racial/ethnic groups in the United States, and one reason may be that the survival rate for in these elders is lower than it is for other groups (Center for Rural Health, 2006b). Poor survival rates are usually associated with late diagnosis and treatment.

A study of heart disease and its risk factors among Asians, Pacifi c Islanders, and Whites in Hawaii found that rates of heart disease, diabetes, and hypertension for Native Hawaiians were elevated relative to Whites (Juarez, Davis, Brady, & Chung, 2012). The researchers concluded that

Our study highlights the importance of examining prevalence rates of disease and risk factors separately for API [Asians and Pacifi c Islanders] sub-groups and reveals the extent to which health disparities emerge at an early age. . . . By age 40, Native Hawaiians were at higher risk for diabetes and by age 50, they were at higher risk for heart disease than other groups. (p. 1008)

Little is known about the health of older LGBT individuals. The LGBT literature seldom includes information on older people, and the gerontology literature seldom includes information on the LGBT population. Due to experiences of stigmatization and their historically marginalized status in society, LGBT people often avoid or delay seeking health care, and even when they do they may not divulge their sexual orientation or gender identity to health care providers, all of which can jeopardize their health (IOM, 2011). Data from the Women’s Health Initiative (Valanis et al., 2000) include informa- tion on lesbians and bisexual women. Compared to heterosexual women, breast cancer was found to be more common in lesbians and bisexual women, and the latter were less apt to have had a mammogram. Hypertension was found to be more common in heterosexual and bisexual women than it was in lesbians. In another study, the rate of hypertension in LGBT elders was reported to be 45%, which is lower than the rate for heterosexuals (IOM, 2011). The health effects of transgender individuals’ long-term use of hormone therapy have not been studied, although it is thought that risks of cancers and cardiovascular disease may be elevated (IOM, 2011). HIV/AIDS is a concern in the LGBT community, especially for men who have sex with men and transgender women. Data on HIV/AIDS in older sexual minorities, however, are lacking. Although older adults, regardless of their sexual orientation, are largely ignored when HIV/AIDS is discussed, Chapter 6 presents information about the rates of HIV/AIDS among older adults and why they may be at a higher risk for HIV transmission than most people recognize, including older adults themselves. It is noted that HIV prevention programs rarely address older adults.Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 255

Preventive Services: Vaccinations and Screening Tests

Preventive services are one of the keys to preserving and extending the health of older Americans. With appropriate follow-up when necessary, services such as immunizations and screening tests are effective in preventing many health conditions and diseases, or detecting them in their early stages when treatment is more effective. Older adults’ use of preventive services depends on a wide variety of factors including their access to health care professionals and preventive services, what they know about the services, as well as the actual costs of the services. Barriers for elders at risk, including poverty, discrimina- tion, and health literacy, affect the use of preventive services. Racial and ethnic discrimi- nation within health care settings have also been shown to affect whether, or how late, preventive services, such as cancer screenings, are provided (Crawley, Ahn, & Winkleby, 2008).

Vaccinations

Chapter 4 includes a discussion of the vaccinations that are most benefi cial for older adults, which include infl uenza (fl u), pneumococcal (pneumonia), and herpes zoster (shingles). Nevertheless, many seniors do not get vaccinated, including a disproportion- ately larger proportion of older minority group members. Of all vaccinations, the high- est vaccination rates are for infl uenza—67.7% for White Americans, 66.8% for Hispanics, 67.9% for Asian Americans, and 68.7% for American Indians and Alaskan Natives, with a lower rate of 56.1% for Black Americans (Centers for Disease Control and Prevention [CDC], 2011). These numbers have substantially increased from very low rates prior to 1993, when Medicare Part B began covering the cost of annual fl u vaccinations.

Pneumonia is one of the leading reasons that seniors go to hospital emergency rooms. It is also all too frequently a cause of death for them. Even though Medicare Part B has covered the cost of pneumonia vaccinations since 1981, a large proportion of older adults are not vaccinated for the disease, and there are health inequities between racial and eth- nic groups here, too. White Americans have higher rates (63.5%), and Black Americans, Hispanics, and Asian Americans have lower rates of vaccination (46.2%, 39.0%, and 48.2%, respectively). A vaccine for shingles was fi rst approved by the U.S. Food and Drug Administration in 2006, and subsequently all Medicare Part D plans started covering it. Unlike fl u and pneumonia vaccinations, for which Medicare Part B covers all the costs, Part D plans may require cost-sharing, with the patient partially paying through their deductible or a copay. The newness of the vaccine and the potential cost undoubtedly contribute to the very low vaccination rates for shingles: 16.6% for White Americans, 4.5% for Black Americans, 4.4% for Hispanics, and 13.7% for Asian Americans (Greby, Lu, Euler, Williams, & Singleton, 2011).

Screenings

Lower rates are also found among women and racial/ethnic minorities in screening for preventable conditions and conditions that benefi t from early detection. For example, for women between the ages of 50 and 74, White and Black Americans have the high- est percentages of mammogram screenings (72.8% and 73.2%, respectively), and Asian Americans have the lowest percentage (64.1%; CDC, 2012).

A lot of attention has been focused on screening for colorectal cancer because, of those cancers that affect both men and women, it is the second leading cause of cancer- related deaths in the United States. Furthermore, when screening is done early enough the prognosis is very good. The CDC (2009) estimates that if everyone aged 50 years C op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

256 V. OLDER PEOPLE AT RISK

or older was regularly screened for colorectal cancer, at least 60% of deaths from this cancer could be avoided. Medicare Part B provides coverage for screening for many can- cers, including colorectal cancer. Nevertheless, there are still signifi cantly lower rates of screening for women and for racial and ethnic group members. Differences in screening rates suggest the need for further research to determine the reasons for these differences and then to fi nd ways to address them, keeping in mind that reasons are likely to vary by gender and race/ethnicity (Jerant, Fenton, & Franks, 2008).

Research on health disparities is still in its infancy. Basic data collection on popula- tions and subpopulations of elders at risk is critical for identifying and prioritizing the issues, for designing ways to ameliorate the disparities, and for evaluating the effective- ness of proposed solutions. There is also a

need for community-based approaches that include policy, systems, environmental, and individual-level changes . . . and [a] need to tailor prevention strategies to the needs of specifi c communities to eliminate health disparities” (Liao et al., 2011, pp. 16–17)

Heterogeneity of Racial/Ethnic and LGBT Groups

Racial/ethnic and LGBT groups have been presented in this chapter as if they were homo- geneous. Of course, within these groups there is much diversity. In the case of racial/ ethnic groups, for example, Cuban Americans, Mexican Americans, and Puerto Ricans are all grouped with the ethnic label of Hispanic despite vast differences in their economic and sociopolitical backgrounds, which, in turn, can impact how much at risk they may be for different health conditions. The LGBT community is similarly diverse with respect to gender, sexual orientation, and race/ethnicity. Although some of the issues facing older adults in these groups have much in common, such as their historically marginalized social status, it is important to note that there are signifi cant differences among subgroups within these populations. Such differences signal a need for more refi ned strategies and policies, including data collection, to improve the overall health of all older adults.

SUGGESTED RESOURCES

National Asian Pacifi c Center on Aging: http://www.napca.org Dedicated to ensuring resources and support for Asian American and Pacifi c Islanders as

they age, the Center’s website provides information on valuable resources, which include direct services, outreach, research, and advocacy.

National Caucus and Center on the Black Aged: http://www.ncba-aged.org The Caucus serves low-income elderly Black Americans. It works with policy makers, legis-

lators, and the government to ensure that Black elderly communities are represented fairly. Information is available via the website for aging Black Americans on access to employment, health and wellness programs, and housing.

National Hispanic Council on Aging: http://www.nhcoa.org The Council works to educate, empower, and support aging Hispanic communities, through

research, education, referrals to health care, and fi nancial resources. They have information on a variety of health programs that they operate, such as an HIV/AIDS initiative, wellness programs, and immunizations for the aging Hispanic population.

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http://www.napca.org

http://www.ncba-aged.org

http://www.nhcoa.org

16. ELDERS AT RISK: OLDER WOMEN AND OLDER MINORITY GROUP MEMBERS 257

National Indian Council on Aging: www.nicoa.org The Council’s website provides resources on health care, conferences, advocacy, and employ-

ment for Native Americans and Alaskan Natives. Information is available on diabetes, long- term care, and elder abuse, among other topics.

National Resource Center on Lesbian, Gay, Bisexual and Transgender (LGBT) Aging: http://www. lgbtagingcenter.org

The Center offers technical, educational, and training assistance to LGBT organizations, aging providers, and LGBT older adults. On the website are links to articles, publications, videos, webinars, slideshows, and audio programs, which can be searched by topic (more than 25, ranging from fi nancial security to transgender issues). Website visitors can also search for resources in their communities.

Older Women’s League (OWL): http://www.owl-national.org OWL is a nonprofi t organization that serves to bridge the gap between women who are aging

and groups that support aging communities. It focuses on research and advocacy.

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http://www.nicoa.org

http://www.lgbtagingcenter.org

http://www.owl-national.org

http://www.lgbtagingcenter.org

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CHAPTER

259

Elder Abuse: Crimes/Scams/Cons

The learning objectives of this chapter include understanding

The defi nition and types of elder abuse. ■ Characteristics of victims and perpetrators. ■ Why older persons are vulnerable to abuse and/or neglect. ■ Indications of physical abuse and/or neglect. ■ The various types of scams perpetuated on older persons, and ways to prevent them. ■

OLDER VICTIMS OF ABUSE OR FRAUD

Mr. W had promised his wife that he would never put her into a nursing home. Even though she has severe Alzheimer’s disease, he still tries to take care of her at home. He is 82 and she is 81. He has arthritis and has diffi culty bending. He frequently shouts at his wife. Over and over he says, “Rose, don’t do that. Rose, don’t do that.” He also slaps her hands. He told a visitor that he stopped trying to prevent her from eating the dog’s food.

Mr. P is 62 years old, unemployed, an alcoholic, and lives with his 82-year-old mother. She is mentally alert but not able to get around without a walker. She depends totally on her son for groceries and for any transportation. Her son charges her $20 to take her anywhere. In addition, he demands that she give him “loans” of several hundred dollars. If she refuses, he becomes verbally and physically abusive. She usually gives him money, knowing he will use it for alcohol. She feels there is no alternative because she has no other children and is isolated from other people.

Ms. R is 72. Her mother is 92. Ms. R is suffering from congestive heart failure and is trying to take care of her aged mother. She is also suffering from depression, and over the last 4 months she has really neglected her mother’s basic needs. On top of this, Ms. R is suffering from guilt feelings, because she has screamed at her mother, calling her a whiner. In the last week, she slapped her mother several times for her incontinence. She is thinking about suicide.

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260 V. OLDER PEOPLE AT RISK

Ms. S has an income of over $300,000 a year by being involved in telemarketing scams. For years, she has been calling older people and is good at winning their confi dence. She tells them she is interested in their fi nancial future. She tells them about high-paying securities that she is selling, warns them that they will be sold out within the next 24 hours, and hopes that they will not lose an opportunity to buy these “gold-plated” fi nancial instruments. Ms. S then asks for their savings account number and recommends that they not purchase anything less than $5,000 worth of these securities. Her voice sounds caring, soothing, confi dent, and trustworthy. Her fi nancial instruments are virtually worthless and most of her clients lose most of their money.

Mrs. B received a call from a person offering a comprehensive physical exam, including state-of-the-art diagnostic testing, at “very little cost.” The caller on the phone was so friendly and sounded so knowledgeable; it was a pleasure to talk to him. Mrs. B was not feeling ill at all, but after the friendly person called a number of times, she fi gured, given her age, why not give it a try. The 2-hour exam ended up costing Mrs. B $7,500.

ELDER ABUSE: A NATIONAL ISSUE

In the United States, elder abuse as a national issue fi rst surfaced in 1978 when Congressman Claude Pepper, a tireless advocate for the needs and rights of the elderly, held hearings in the House of Representatives to expose the “hidden problem.”

Around the same time, an episode of Quincy, a late-1970s TV drama series, depicted a case of elder abuse, [which, it has been argued] . . . built support for the elder abuse agenda and contributed to public demands for changes in state and federal statutes. Also, The Battered Elder Syndrome was published by Block and Sinnott (1979) around this time. (Payne, 2009, p. 581)

A joint hearing by the U.S. Senate and U.S. House of Representatives in 1980 led to a report recommending that the federal government help the states deal with elder abuse by establishing a Prevention, Identifi cation, and Treatment of Elder Abuse Act (Wolf, 1988). There was essentially no federal action until Congressman Pepper tried a new strategy, adding amendments to the 1987 reauthorization of the Older Americans Act (OAA) that defi ned elder abuse and authorized $5 million for program grants for elder abuse services and education. Nevertheless, Congress waited until 1990 to appro- priate $3 million for fi scal year 1991 for these services. In the 1992 amendments to the OAA, $15 million was authorized to fund elder abuse programs, however, only $4.4 million was actually appropriated for fi scal year 1993 (Tatara, 1994). OAA appropria- tions for elder abuse prevention in fi scal year 2011 were $5 million, which is a reduction in funding of approximately $1.85 million relative to the value of the dollar in 1993.

Defi ning Elder Abuse

The World Health Organization defi nes elder mistreatment as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (WHO, 2011). The OAA defi nes specifi c types of elder mistreatment, including elder abuse, neglect, and exploitation (learn more about the OAA in Chapter 13). Protection against these misdeeds is listed as part of the overall goals of the Declaration of Objectives for Older Americans of the OAA as amended back in 1972. State laws defi ne elder abuse, but the defi nitions vary from one state to another. The National Center on Elder Abuse (NCEA) is one of the important gatherers of national data on elderly abuse and can be easily accessed via the Internet (see additional C

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17. ELDER ABUSE: CRIMES/SCAMS/CONS 261

information on the NCEA in Suggested Resources at the end of this chapter). The NCEA has organized the defi nition of elder abuse into the following three basic categories:

Domestic elder abuse ■ Institutional elder abuse ■ Self-neglect or self-abuse ■

Domestic Elder Abuse

Domestic elder abuse generally refers to forms of mistreatment of an older person by someone who has a special relationship (a spouse, a child, a sibling, a friend, a caregiver) in the older person’s home or in the home of the person caring for the elder including:

Physical abuse: Deliberate use of physical force that results in bodily injury, pain, ■ or impairment. Sexual abuse: Nonconsensual sexual contact of any kind. ■ Emotional or psychological abuse: Willful infl iction of mental or emotional ■ anguish by threat, humiliation, intimidation, or other verbal or nonverbal abu- sive conduct. Neglect: Willful or nonwillful failure by the caregiver to fulfi ll his or her caretak- ■ ing obligation or duty. Financial or material exploitation: Unauthorized use of funds, property, or any ■ resources of an older person. According to research conducted by Karen Roberto, director of the Center for Gerontology at Virginia Tech University, of the 1,128 news articles on elder abuse published from November 2010 through January 2011, 31% dealt with abuse of a fi nancial nature, and older Americans are los- ing $2.9 billion annually to elder fi nancial abuse (“The MetLife Study of Elder Financial Abuse,” 2011). All other types: All other categories of elder maltreatment that do not belong to ■ the above-mentioned fi ve categories.

Institutional Abuse

Institutional abuse generally refers to the abuse that occurs in facilities designated for older people, such as foster homes, group homes, nursing homes, and board-and-care facilities. Persons infl icting institutional elder abuse usually are those who have a legal or contractual obligation to provide care and protection to the victims. They may include paid caregivers, staff, and professionals.

Self-Neglect or Self-Abuse

Self-neglect or self-abuse refers to neglectful or abusive behavior by an older person that is threatening to his or her own safety or health (Kelly, Dyer, Pavlik, Doody, & Jogerst, 2009). This type of activity generally results from the physical or mental impairment of the older person (Mosqueda et al., 2008). Most instances of physical, sexual, and fi nan- cial/material abuses are classifi ed as crimes in all states. Certain emotional abuse and neglect cases are considered criminal offenses depending on the perpetrator’s conduct and the consequences for the victims (Connolly, 2008). On the other hand, self-neglect is not considered a crime in all states. Elder abuse laws in some states do not even address self-neglect (Naik, Teal, Pavlik, Cyer, & McCullough, 2008).

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262 V. OLDER PEOPLE AT RISK

How Widespread Is Elder Abuse?

For the National Elder Mistreatment Study, Ron Acierno and his colleagues at the Medical University of South Carolina interviewed 5,627 community-residing people aged 60 and over who were cognitively intact (Acierno et al., 2010). They found that 11.4% of their interviewees reported that they had experienced at least one type of elder abuse in the past year—emotional, physical, sexual, or neglect. In addition, 5.2% reported fi nancial abuse by family members. Note that the survey did not include cases of self-neglect or fi nancial abuse by people other than family members. Furthermore, residents of nursing homes and other facilities were not interviewed, so the prevalence rates found in this research do not refl ect the full extent of the problem of elder abuse.

Estimates put the number of elders who have been injured, exploited, or otherwise mistreated as high as 5 million. That may only be the “tip of the iceberg.” Consistent with previous studies, the interviewees for the National Elder Mistreatment Study said that they seldom reported their experiences of abuse to police. The NCEA (2012) states that only 1 in 14 elder abuse incidents come to the attention of authorities.

Who Are the Victims?

Research has found that among confi rmed cases of elder abuse, one third to one half are instances of self-neglect or self-abuse (Gray-Vickrey, 2004). It should be noted that while most states offer some protective services for elderly persons who neglect themselves, they are careful to consider a person’s right to refuse these services (Connolly, 2008). This may result in a guardianship being established through court action, where a person appointed by the court can act on the behalf of the self-abused/neglected. Sometimes self-neglect results in placing the person in an institution, again through court action. These procedures usually are used only as last resorts for people in situations that are threatening to their health and safety.

Overall, low social support and isolation signifi cantly increase the likelihood for elder abuse, as does having dementia (Bonnie & Wallace, 2003). Risk factors can also depend on the type of abuse. For example, for emotional, physical, and sexual abuse, as well as neglect, living with someone is a risk factor, while for fi nancial abuse, living alone is a risk factor.

Who Are the Abusers?

Who is responsible for elder abuse? The NCEA reports that 90% of abuse is perpetrated by family members, most commonly spouses and adult children. Abusers often have mental illness or alcohol problems, and being fi nancially dependent on an elderly relative is also a signifi cant risk factor (Bonnie & Wallace, 2003). Data from state adult protective service units consistently fi nd that women are more likely to be abused than are men, although these results may be skewed by the fact that there are more elderly women than men. According to the American Psychological Association (2012), “Elder abuse affects older men and women across all socioeconomic groups, cultures, races, and ethnicities” (p. 3).

CAUSES OF DOMESTIC ELDER ABUSE

A number of theories have been developed as to why elder abuse occurs. Why does a person become an abuser of an elderly individual? What are the circumstances that tend to lead to the abuse of an elder? The NCEA points out that elder abuse, similar to any type of domestic violence, is very complex and many factors are involved in its cause. Psychological, social, and economic factors that affect interpersonal and family relation- ships often combine with the physical and mental conditions of older persons and their

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17. ELDER ABUSE: CRIMES/SCAMS/CONS 263

potential abusers to result in domestic elder abuse according to this approach to analyz- ing the problem. When new stresses are added to already stressful situations that exist between elderly persons and the people around them, elder abuse may result. There is a mix of the existing situations between elderly persons and the people around them, their physical and mental conditions, and added stresses that enter their lives. The added stresses may be psychological, social, or economic, or a combination of these.

Theories to explain the causes of elder abuse include a situational model, which focuses on the affects of stress of the caregivers; an exchange theory, which focuses on dependency of elders on their caregivers; a social learning theory, which focuses on a repeated cycle of violence; and psychopathology, which focuses on mental or emotional problems of the abuser. In looking at these theories, it is important to note that they often combine to produce instances of abuse.

Stress of the Caregivers

As has been pointed out previously, caregiving for older people is a stressful role. This role is made more diffi cult when the older person being cared for is mentally or physically impaired, the caregiver has severe limitations because of his or her own problems or lack of knowledge of how to be a caregiver, and support from other family members is lacking. This theory stresses that a combination of internal factors in the caregiver—lack of coping skills, emotional problems—combined with external factors—mental or physical impair- ment of the older person being cared for, the fi nancial burden of caregiving, lack of family or community supports—can result in elder abuse. This theory has wide support in the professional community.

Increased Dependency of Older Persons

This social exchange theory of elder abuse holds that abuse can occur when one person is contributing signifi cantly more to a relationship than is the other person. The more pow- erful person in the relationship can manipulate the more dependent person, and being abusive may be an extension of that manipulation.

Cycle of Violence

Some families seem to be more prone to violence than others. Reacting to given situations in a violent way is a learned behavior that is passed from one generation to another. For these families, violence remains a normal behavior pattern throughout their lives—from child abuse through elder abuse. Clinical workers who have worked in both child abuse and elder abuse have observed these ongoing patterns of violence (Tatara, 1994).

Personal Problems of the Abusers

It has been found that persons who abuse older people usually have more personal prob- lems than nonabusers. Adult children who abuse their parents often have mental and emotional problems, fi nancial problems, or substance-abuse problems. As a result of these problems, these adult children are often dependent on their parents for support—the par- ents they end up abusing. This theory contends that the abuse of these parents by these dependent adult children is a response to their feelings of inadequacy (Tatara, 1994).

In looking at these and other possible theories to explain the causes of elder abuse, it is important to consider that no single theory can give a complete explanation. More research is needed to explore the causes of elder abuse as the aging revolution continues during the 21st century.

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264 V. OLDER PEOPLE AT RISK

INSTITUTIONAL ABUSE AND NEGLECT

Up to this point, this chapter has focused on domestic elder abuse. It is important to describe briefl y another setting in which elder abuse occurs—institutional settings, such as nursing facilities/homes or mental hospitals.

The rate of elder abuse is unclear for many institutional settings except community- based nursing facilities. In one study, 44% of nursing home residents reported that they had been abused (National Center on Elder Abuse, 2012). Psychological abuse, such as yelling at patients, has been observed by 81% of nursing home staff (Hudson, 2008). At least half of all nursing facility residents suffer from some form of dementia, mental ill- ness, or impairment. These types of patients are particularly vulnerable to elder abuse and are unlikely to report instances of it.

Causes of Elder Abuse in Nursing Facilities

The reason for elder abuse in nursing facilities has been traced to four major underlying problems: (a) the lack of understanding of the cause of patient behavior, (b) dissatisfaction among the staff, (c) staff/patient confl ict, and (d) burn-out among the staff. What these conditions result in is clear: a population of elder patients that is at high risk for abuse, as predicted by their multiple psychiatric and medical problems, cared for predominantly by young people who are poorly trained to work with the elderly population. They, in turn, are supervised by professional staff with limited experience in psychiatric diseases (Buzgová & Ivanová, 2009; Phelan, 2008).

POSSIBLE SIGNS OF PHYSICAL ABUSE AND NEGLECT

There are a variety of indicators that may point to elder abuse. For each category of elder abuse, these indicators include the following:

Physical Abuse

Unexplained bruises and welts; ■ Unexplained burns; ■ Unexplained fractures, lacerations, or abrasions; ■ Unexplained hair loss; and ■ Evidence of past injuries. ■

Physical Neglect

Consistent hunger, poor hygiene, inappropriate dress including soiled clothing, ■ unexplained weight loss, dehydration; Consistent lack of supervision, especially in dangerous activities or for long ■ periods; Constant unexplained fatigue or listlessness, or increased confusion; ■ Unattended physical problems or medical needs, including urine burns or pres- ■ sure sores; Lost or nonfunctioning aids, for example, glasses, dentures, hearing aids, walk- ■ ing aids, and wheelchairs; Over/under-medication; and ■ Abandonment, immobility, hypothermia indicating possible isolation. ■

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17. ELDER ABUSE: CRIMES/SCAMS/CONS 265

Sexual Abuse

Diffi culty in walking or sitting; ■ Torn, stained, or bloody underclothing; ■ Pain or itching in genital area; ■ Bruises or bleeding in external genitalia, vaginal, or anal areas; and ■ Unexpected and unreported reluctance to cooperate with toileting and physical ■ examination of genitalia.

Emotional Mistreatment

Habit disorder (e.g., sucking, biting, rocking); ■ Conduct disorder (antisocial or destructive behaviors toward self or others); ■ Neurotic trait (e.g., sleep disorders, speech disorders, inhibition of play); and ■ Psychoneurotic reaction (e.g., hysteria, obsession, compulsion, phobias, hypo- ■ chondria).

Note: It is necessary to assess whether symptoms and signs disappear in hospital or resi- dential care over a period of time (Decalmer, 1993).

OTHER CRIMES AGAINST OLDER PEOPLE

In addition to elder abuse, older people are victimized by other forms of crime—the types that have become a focus of national attention in recent years. These include strong-arm robbery, murder, rape, aggravated assault, burglary, vandalism, purse snatching, theft of checks, and fraud.

Fear of Crime

It is important to note that older people tend to be more fearful of crime than are younger persons, and yet they are far less likely to be victims of violent crime—rape or sexual assault, robbery, aggravated assault, and simple assault. According to the 2011 annual report of the Bureau of Justice Statistics, rates for violent crime (which do not include homicide) were 4.4 per thousand for those 65 and older, and 49.0 for 18- to 24-year-olds (Truman & Planty, 2012). Data on homicides, which are collected by the Federal Bureau of Investigation (FBI), showed 607 homicides committed against those 65 and older, and more than 5 times that number—3,157—against 18- to 24-year-olds in 2011 (FBI, 2012). This does not mean that there are not many older people living in high-crime areas where it is dangerous for them to leave their homes. The fear and reality of crimes have resulted in many older people, particularly those who live in urban settings, becoming virtual prisoners in their own homes.

FRAUDS, SCAMS, AND CONS—RIPOFFS OF OLDER PEOPLE

A series of crimes that older people are not immune from, and indeed are often the prime targets for, are frauds, scams, and confi dence schemes—all classifi ed as consumer fraud. There are so many types of consumer fraud—the Federal Trade Commission tracks 30 types, and different ways that these types of fraud are committed, that it is diffi cult to

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266 V. OLDER PEOPLE AT RISK

calculate their full scope and impact. Fraud committed via the Internet has become such a problem, that in 2000 the FBI and the National White Collar Crime Center established the Internet Crime Complaint Center (IC3). According to the IC3’s 2011 annual report, “Internet fraud has become one of the fastest-growing crime concerns facing the pub- lic. Nearly all crime that once was committed in person, by mail, or over the telephone can now be committed through the Internet” (Internet Crime Complaint Center, 2012, p. 19). The IC3 website lists and describes current and ongoing types of Internet crimes, provides prevention tips, and includes instructions for reporting such crimes (www.ic3.gov/default.aspx). Seniors are using the Internet more and more, so they, and future generations of seniors who have more lifetime experience with the Internet, will increasingly become targets for fraud committed through this medium. A discussion on how to avoid frauds, scams, and cons can be found in video 9.

Older People and Consumer Fraud

While people age 60 and over make up about 18.5% of the U.S. population, over 22% of consumer fraud was directed at them in 2011 (Federal Trade Commission, 2012). Research focusing on fi nancial abuse has found that older people’s annual losses amount to at least $2.9 billion (“The MetLife Study of Elder Financial Abuse,” 2011).

There are a variety of reasons why older people are so often the victims of consumer fraud (Sharpe, 2004) including the following reasons:

Older consumers are more easily contacted by telephone. ■ Retired people and those who suffer from health problems or who have restricted ■ mobility tend to spend much of their time at home, making them available to the swindler. Older people tend to be more trusting of salespeople. ■ Older consumers tend to be less informed of their consumer rights. ■ Many older persons welcome someone to talk with and are likely to let the con ■ artists into their homes.

These factors do not mean older people are less intelligent. Older people experi- enced earlier times when trust was based on knowing the seller. In addition, older con- sumers often are inclined to rely on the expertise of salespeople who seem trustworthy and knowledgeable. This is particularly true for complex products about which an older person has little or no knowledge. Some are pressured by high-handed tactics of sales- people who get into their homes and will not leave until the older person agrees to sign on the dotted line. They literally become hostages in their own home. These predators of the elderly look for the most vulnerable older persons and then try to wear them down, play on their fears and needs, and increase their sense of helplessness. They end up rob- bing them of their money, dignity, and self-confi dence (U.S. Senate Special Committee on Aging, 2005).

Episode 9: Avoiding Cons, Scams, and Rip Offs

High Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_9_large/grcc_player.html

Low Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_9_small/grcc_player.html

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http://www.ic3.gov/default.aspx

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_9_large/grcc_player.html

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17. ELDER ABUSE: CRIMES/SCAMS/CONS 267

Telemarketing Scams

Telemarketing scams involve using the telephone to contact people in their homes with intent to defraud them. Older people are more likely to be targeted because the callers assume they may live alone, have a nest egg, and will be more polite toward strangers (Federal Trade Commission, 2012). In one version of these scams, older persons are asked to call an “800” or “900” number. They will then be offered prizes or low-priced trips, or an easily obtained loan. The “guaranteed” prize is one of numerous telephone-marketing scams. Often the caller will request a credit card number, and use that credit card infor- mation to make purchases, which are then charged to the older person. These callers often work from “boiler rooms,” in which groups of persons will be calling constantly, trying to make “connections” with older people. They usually tell the person that the offer must be accepted immediately because it is only good for very short period of time (e.g., 24 hours or less). Some fraudulent telemarketing outfi ts contract with legitimate nonprofi t organizations to raise funds but keep most of the funds for themselves to cover the “expenses” of calling. One version of this type of scam is to offer needed items such as trash bags, light bulbs, or birthday/holiday cards. These items usually are quite inferior and are priced very high. The telemarketing schemers then keep most of the profi ts.

Other telephone scams involve “cheap” trips, or “free” trips, or vacation housing at reduced prices, if the person acts immediately, which usually includes providing a credit card number. The swindlers will usually be willing to settle for a checking account num- ber. Once the telemarketers have checking account numbers, they put them on “demand drafts,” which function much like checks but do not require signatures. Often the victims are unaware that the bank has paid the drafts until they receive their monthly statements. As one older victim said,

They called and told me I’d won an all-expense paid trip to Hawaii. All I had to do was purchase a round-trip ticket to Los Angeles. I gave them my checking account number and they took out $800 the next day. Two weeks passed and I hadn’t heard from them. Turns out the company didn’t exist. (Reyes, 1992, p. 72)

Con artists have found that it takes no more time to swindle $100,000 out of an older person than it does to swindle a younger person out of $3,000. Although persons 65 and over comprise about 12% of the population, they control over 30% of the wealth.

Mail Fraud

The mail service is frequently used to defraud older persons as well as persons of any age who are able to respond to mail-order advertisements. Some real-life examples of mail- order offers include:

A “universal coat hanger” advertised for $3.99. What did consumers get stuck ■ with? A sturdy 10-cent nail. A “solar clothes dryer” for only $39.99. Trouble is, it looked just like the clothes- ■ line and clothespin that were used years ago, and that was what it was. An ad for a 15-piece wicker set including a table, settee, two chairs, and a rocker ■ guaranteed that the set would be exactly like the picture; that is just what the consumer got—a copy of the picture. An ad showing an actual photo of the product (a complete tool set and box for $40), ■ so one couldn’t be fooled, right? The ad was carefully worded to mention only the box—which was all the consumer got (Bekey, 1991; Morse, 2010; Steiner, 1989).

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268 V. OLDER PEOPLE AT RISK

Medical Quacks/Frauds

Medical quackery is mostly targeted at older people. There is almost no limit to the fraud- ulent products and procedures offered to older people to reverse the aging process and treat or cure almost anything from athlete’s foot to cancer. To pitch their quack remedies, the con artists use modern-day marketing techniques including ads in national maga- zines, supermarket tabloids, direct-mail fl yers, television promotions that look like talk shows (“infomercials”), door-to-door salespeople, telemarketing, and the Internet. It is no surprise that anti-aging products fl ood the market promising new vitality and enhanced sexual vigor.

People with arthritis are especially vulnerable to medical quackery because most forms of arthritis go through periods in which the disease fl ares up, and then tempo- rarily subsides. Knowing that, it is easy to claim that virtually any treatment will be effective because sooner or later the person will go into a natural remission, at which time the claim can be made that the treatment works. When the symptoms come back, as they are likely to do, it can be claimed that the person should either increase the treat- ment or just wait and the treatment will become effective. That is why many people who wear cooper bracelets for arthritis will claim that doing so is effective. In fact, scammers make these claims, because sooner or later anything will seem like it is effec- tive. Not only are medical scams costly to the victims in terms of lost money and poten- tial harm to the body, but relying on fraudulent products and treatments delays seeking diagnosis and treatment from reputable medical providers; and delays can be deadly in many instances.

Investment Fraud

With many older people trying to live on savings that they accumulated over years of work, they are natural targets for fraudulent investment schemes. Bank certifi cates of deposit are no longer paying the kinds of interest rates that made them attractive in the past, so older people across the nation have looked for higher returns from their invest- ments so they could have a higher level of income. Fraudulent investment schemes may include phony artworks, gold, wines, gemstones, leveraged precious metals, rare coins, oil and gas leases, cellular telephone licenses, wireless cable and Internet licenses, and many more. They may include investments that are legal but simply not appropriate for older people because the risks associated with these investments are so high. In 2010, a survey conducted for the Investor Protection Trust found that “20 percent of Americans aged 65 or older—more than 7.3 million senior citizens—already have been taken advan- tage of fi nancially in terms of an inappropriate investment, unreasonably high fees for fi nancial services, or outright fraud” (Investor Protection Trust, 2010, p. 3).

One approach to getting seniors to invest their money is to offer “free lunch” semi- nars, often presented as opportunities to become more educated about investing choices. Concerned about escalating numbers of reports of fi nancial scams being committed against seniors, federal and state regulators have been attending “free lunch” seminars to learn more about them. “In Arkansas, state agents . . . found that the dozens of seminars they attended all featured hard-sell pitches for fi nancial products, many of which weren’t appropriate for elderly investors” (Levitz, 2009). Of course, fi nancial advisors are in the business of selling investments, but there are standards and rules set by the Financial Industry Regulatory Authority (FINRA), a private self-regulating organization. FINRA can and does adjudicate cases brought by investors. In addition to collecting $68 mil- lion in fi nes, in 2012, the FINRA recovered $34 million in funds wrongfully taken from investors.Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

17. ELDER ABUSE: CRIMES/SCAMS/CONS 269

Older people are especially vulnerable to investment fraud because they generally have more assets than younger people, live on fi xed income, and may suffer from loneli- ness. Older widows can be more vulnerable because many have had limited experience in managing fi nancial assets. Sophisticated, computer-generated lists provide the con art- ists with ways to identify newly retired employees, those receiving lump-sum pension payments, newly widowed older women, or older persons who sell their homes (Alt & Wells, 2004).

Living Trust Scams

Another scam largely targeted at older people is the high-pressure sale of living trusts. A living trust is a legal device to transfer real or personal property into something called a trust. The trust is managed by a trustee who may be the same person who set up the trust. It is an estate planning device that avoids probate. With this device, a person’s property does not have to be processed through a Probate Court, which takes time and money.

This scheme takes advantage of the fact that between 30% and 50% of all the adults in the United States at any given time have not made adequate fi nancial arrangements relating to their death (U.S. Senate Special Committee on Aging, 1993). As a result, slick- talking salespersons approach older Americans telling them how they can save purchas- ers of living trusts thousands of dollars in taxes and probate costs by “signing on the dotted line” and giving them what amounts to enormously infl ated prices for what is often a very inferior service. They generally charge for something that may be inappro- priate for an older individual’s circumstances.

Phony Prizes

Either by telephone or by mail, these fraudulent schemes are used to notify potential victims that they have won a valuable prize such as a vacation, car, cash, or jewelry. Using various misrepresentations, these con artists lead the victim into buying items at prices that far exceed the value of the prizes. Through these schemes, it is easy for people to spend hundreds and even thousands of dollars on nearly worthless items. In many instances, the consumers never get the prizes that were promised.

Misuse of Guardianships

Another major area of fraud against the elderly is the misuse of guardianships. Guardianships are granted by court orders to manage the affairs of individuals who are judged incompetent to manage their own fi nancial and personal affairs, including mat- ters related to their health. A guardian can be a family member, a nonprofi t social service agency, a public guardian, or a professional guardian. State or county offi ces may appoint a public guardian, and these offi ces also determine the conditions under which someone can be designated as a professional guardian. The appointment of a guardian typically means that the incapacitated person loses basic rights, such as the ability to sign contracts, vote, marry or divorce, buy or sell real estate, or make decisions about medical procedures (U.S. Government Accountability Offi ce [GAO], 2010). Once a guardianship is granted by the court, it is not easy to reverse. Many people seek guardianship status to serve the best interests of their older clients. Unfortunately, many others take advantage of their author- ity, usually for fi nancial gain, which can be accompanied by physical and psychological abuse.C op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

270 V. OLDER PEOPLE AT RISK

In response to a request from the U.S. Senate’s Special Committee on Aging, in 2010 the U.S. Government Accountability Offi ce (GAO) was tasked with investigating the scope of allegations of abuse by guardians, looking into examples of abuse cases, and testing the processes by which states certify guardians. The federal government itself does not regulate or directly support guardians. The GAO’s research could not draw conclusions about the extent of abuses by guardians because there is no entity— federal, state, or local government agency, or any other organization—that compiles data on allegations of such abuse. As a consequence, the number of abuses perpe- trated by guardians is unknown. Examples of cases the GAO (2010, p. 7) did encounter include:

In Arizona, court-appointed guardians allegedly siphoned off millions of dollars ■ from their wards, including $1 million from a 77-year-old woman whose proper- ties and personal belongings, such as her wedding album, were auctioned at a fraction of their cost. A Texas couple, ages 67 and 70, were declared mentally incompetent and placed ■ in a nursing home after the husband broke his hip. Under the care of court- appointed guardians, their house went into foreclosure, their car was repos- sessed, their electricity was shut off, and their credit was allowed to deteriorate. The couple was allegedly given a $60 monthly allowance and permitted no per- sonal belongings except a television. A 93-year-old Florida woman died after her grandson became her temporary ■ guardian by claiming she had terminal colon cancer. He then moved her to hos- pice care, where she died 12 days later from the effects of morphine. The woman’s condition was later determined to be ulcerative colitis, and the guardian’s claims that she had 6 months to live were false. In addition, the guardian is accused of stealing $250,000 from the woman’s estate.

In testing the guardianship approval process, representatives for the GAO applied to four states for guardianship certifi cation using fake identities of someone with bad credit or the Social Security number of a deceased person. Guardianship certifi cation was granted in all of these states—Illinois, Nevada, New York, and North Carolina (GAO, 2010). Even after appointing a guardian, most states do not demand much accountability from them. Most state courts are too busy to become very involved in examining in any great detail the activities of the guardians. The GAO found three consistent problems:

State courts failed to adequately screen potential guardians, appointing 1. individuals with criminal convictions and/or signifi cant fi nancial problems to manage estates worth hundreds of thousands or millions of dollars. State courts failed to adequately oversee guardians after their appointment, 2. allowing the abuse of vulnerable seniors and their assets to continue. State courts failed to communicate with federal agencies about abusive 3. guardians once the court became aware of the abuse, which in some cases enabled the guardians to continue to receive and manage federal benefi ts. (GAO, 2010, pp. 7–8)

Proving fi nancial exploitation is diffi cult because it usually requires the examination of fi nancial records and following the fl ow of the victim’s and the victimizer’s funds. Added to these diffi culties is the probability that if a guardianship has been granted, the victim is not able to provide testimony because of physical or psychological conditions. In other Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

17. ELDER ABUSE: CRIMES/SCAMS/CONS 271

situations, the victimized person may die, and the guardian’s exploitation of his or her estate may never become known.

These are some of the old as well as the newer frauds that are targeted at older people. The types and variations of scams and cons committed against older persons are endless. They continue to evolve, and marketing techniques continue to develop based on new technologies and strategies. What does not change is the fact that older people are exploited by greedy, ruthless con artists—exploitation that can result in fi nancial ruin, loss of health, and even death.

PREVENTING CRIMES AGAINST THE ELDERLY

The con artist is often seen by the victim as a pleasant and caring person. They practice being friendly and try to project a kindly image. Not infrequently, the victim will state that they seemed to be such a nice person. Persons must always, unfortunately, be wary. They should never hurry in making a decision and should consult with family members and/or neighbors or others that they trust.

Many organizations and programs have been developed to educate older adults and their loved ones about warning signs and best practices for avoiding scams and other such crimes. For example, the National Council on Aging (n.d.) has created a list of “Top 8 Ways to Protect Yourself from Scams”:

Be aware that you are at risk from strangers—and from those closest to you.1. Don’t isolate yourself—stay involved!2. Always tell solicitors: “I never buy from (or give to) anyone who calls or visits 3. me unannounced. Send me something in writing.” Shred all receipts with your credit card number.4. Sign up for the “Do Not Call” list and take yourself off multiple mailing lists.5. Use direct deposit for benefi t checks to prevent checks from being stolen from 6. your mailbox. Never give your credit card, banking, Social Security, Medicare, or other 7. personal information over the phone unless you initiated the call. Be skeptical of all unsolicited offers and thoroughly do your research.8.

Some communities have formed something called Triad/SALT organizations in order to combat crimes against the elderly. Triads are organized when the local police and sher- iff’s departments agree to work cooperatively with senior citizens to prevent victimiza- tion of the elderly (Cantrell, 1994). The Triad concept began in 1987, when members of the AARP, the International Association of Chiefs of Police (IACP), and the National Sheriffs’ Association (NSA) met to consider methods of reducing crime against the elderly.

SALT (Seniors and Lawmen Together) is the organization that the Triad usually creates when law enforcement personnel ask older persons, as well as people who work with them, to serve on an advisory council. The SALT organization typically conducts a survey to determine the needs and concerns of older people in their region regarding criminal activity. In describing the operation of the program, Cantrell (1994) wrote,

Volunteers may staff reception desks in law enforcement agencies, present programs to senior organizations, conduct informal house security surveys, and become lead- ers in new or rejuvenated neighborhood watch groups. They may also provide information and support to crime victims, call citizens concerning civil warrants, or

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272 V. OLDER PEOPLE AT RISK

assist law enforcement agencies in maintaining or property rooms of substations or in other areas. (p. 21)

In some areas, a Triad will create telephone programs in which older persons are called daily. In other areas, they have created shopping programs where grocery stores provide vans to transport older persons in regularly scheduled shopping trips. Triads also teach older per- sons safe ways to carry money and other valuables, as well as carjacking prevention.

Additional information on elder abuse, neglect, and exploitation as well as the ethi- cal responsibilities of professionals working with older persons in reporting these forms of abuse can be found in the Practical Application at the end of Part V.

SUGGESTED RESOURCES

Center of Excellence on Elder Abuse and Neglect: http://www.centeronelderabuse.org/index.asp This Center, located at the University of California, Irvine’s School of Medicine, supports and

disseminates research on innovative approaches to preventing elder abuse. It also conducts training activities and provides training materials via their website for home health aides and certifi ed nursing assistants, nursing students, pharmacists, and pharmacy students, among others.

Elder Investment Fraud and Financial Exploitation (EIFFE) Prevention Program: http://www. nasaa.org/1733/eiffe

A variety of organizations have joined forces to create the EIFFE program to educate caregiv- ers, including medical professionals, about fi nancial abuse of elders. The website includes links to resources for seniors, service providers, and educators.

International Network for the Prevention of Elder Abuse (INPEA): http://www.inpea.net Established in 1997, the INPEA’s mission is to eliminate mistreatment of older adults glob-

ally. Members include individuals and organizations. Reports and resources from around the world are available via this website.

National Adult Protective Services Association (NAPSA): http://www.napsa-now.org A national nonprofi t organization, this association aims to improve the quality of services

for older and vulnerable adults who have been mistreated, as well as to prevent mistreat- ment whenever possible. Among other resources, the site provides links to Adult Protective Services offi ces in all 50 states, Puerto Rico, and Guam.

National Center on Elder Abuse: http://www.ncea.aoa.gov The Center’s website provides descriptions and defi nitions of elder abuse, and laws concern-

ing elder abuse. Resources, for families, caregivers, and individuals, include who to notify about elder abuse, how to contact authorities, and how to fi nd state resources.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.centeronelderabuse.org/index.asp

http://www.nasaa.org/1733/eiffe

http://www.inpea.net

http://www.napsa-now.org

http://www.ncea.aoa.gov

http://www.nasaa.org/1733/eiffe

1Practical Application

273

Older People at Risk

Michael A. Faber

INTRODUCTION

The two chapters in this section focus on the issues of older women and minorities, as well as elder abuse, neglect, and exploitation. This practical application will take a closer look at each of these issues, as well as examine the ethical responsibilities of the profes- sional working with older persons.

Older Women and Minorities

As outlined in Chapter 16, older women and minority elders are economically and socially disadvantaged in many ways in American society. As a result, they are two of the highest need populations. Those who choose gerontology as a profession need to understand the needs and issues of older women and minorities in order to work effectively with these populations. This requires an open mind and a willingness to learn about different cul- tures, belief systems, and lifestyles.

For those considering a career in gerontology, this author recommends that they push themselves outside of their comfort zone through volunteerism. One can utilize volunteer activities to meet new people, experience different cultures and belief systems, and try new things to discover their potential niche within the fi eld of gerontology.

Be Inspired . . . Be Inspiring

There is much one can learn from the wisdom of elders. This is one of the fortunate aspects of a career in gerontology; the fact that one has the opportunity to learn many important life lessons from the wit, wisdom, and life experiences of older persons. Those who choose to work with older persons should be open to the inspiration around them, and, in turn, use the knowledge and insight gained to inspire and teach others.

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274 V. OLDER PEOPLE AT RISK

Elder Abuse, Neglect, and Exploitation

Families often get a bum rap with the common stereotype that they abandon their older loved ones. As noted throughout this text, families actually provide the majority of care for their elderly loved ones. American families often provide heroic levels of loving care including physical, fi nancial, emotional, social, and spiritual support for their older loved ones. The sad reality, however, is that not all families provide such loving care, and, although not commonplace, elder abuse and fi nancial exploitation do exist in America.

Another sad reality is the fact that elder abuse, neglect, and exploitation often go unreported. It is important to note that professionals working with older persons are required to report any suspicion of elder abuse, neglect, and exploitation. Many profes- sions are legally required to report such abuse, including anyone licensed, registered, or certifi ed to provide health care, education, social welfare, mental health services, and law enforcement. The role of the professional in helping to prevent elder abuse, neglect, and exploitation should not be underestimated. Through education, close observation, dili- gence, and when necessary, early reporting, the gerontology professional can help save the lives and well being of those older adults at risk.

The Ethical Responsibilities of the Professional

Financial exploitation of the elderly may be perpetrated by strangers such as con artists, but more often older adults are victimized by family, or other persons known to them including professional caregivers. Therefore, professionals working with older persons need to be ever vigilant, always know and practice ethical behavior, and remain above reproach doing everything they can to protect those who are vulnerable.

Gift giving is one area that professionals working with older persons may deal with in this regard. Older persons will on occasion offer personal gifts to those who pro- vide them care and support. This can be a very delicate issue to deal with, because the last thing that anyone wants to do is to offend the giver and deprive him or her of the opportunity to express his or her gratitude. But it can also be a very tricky issue for the professional calling into question their honesty, integrity, and motivation. Was the older adult vulnerable due to lacking the mental capacity to make an informed and appropri- ate decision regarding the item that they gifted? Were they vulnerable due to physical or emotional intimidation or their reliance on the professional providing care? Let me pro- vide an illustration. You are a professional providing regular in-home care to an elderly individual with whom you have developed a close relationship. On your last visit to their home, you mentioned how much you admired the painting hanging over their fi replace and jokingly hinted that your birthday was next week. Then on your visit to their home the following week, you were presented with this painting as a birthday present. If you accepted this gift, you might later fi nd that it was worth thousands of dollars or a price- less family heirloom. The family, on discovering what happened, might even accuse you of theft. The good news is that most organizations/agencies that serve older adults have detailed policies on how to deal with this issue. It is this author’s opinion that it is best to politely decline any such gift and to refrain from any comments that could be misinter- preted as a personal request for anything in their possession.

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