FVS6

Diagnostic and Treatment Guidelines on Elder Abuse and Neglect

It is estimated that between 1.5 and 2 million older adults experience abuse or neglect each year in the United States. Elder mistreatment may be physical, psychological, or financial, and it may be perpetrated by family members or by other informal or formal caregivers. Physicians are encouraged to play an active role in assessment, intervention, and prevention.

(Arch Fam Med. 1993;2:371-388)

Although elder abuse and neglect has oc¬

curred for centuries, it is the most recent form of family violence to come to the at¬ tention ofmodern societies. Rigorous study of the problem only began in the last de¬ cade, and fewer empirical data are available on elder mistreatment than on other forms of family violence such as child abuse. The earliest modern reports of elder abuse and neglect came from the United Kingdom in the 1970s, when dramatic case reports of the phenomenon, called "Granny battering," shocked the medical community and pub¬ lic. By the end of the 1970s, small case-control studies in the United States confirmed that the problem was common in this country as well. In the mid-1970s, the US Senate Spe¬ cial Committee on Aging issued a series of reports on abuse and neglect occurring in nursing homes, and in 1981, the US House of Representatives Select Committee on Ag¬ ing conducted hearings in which victimized elders gave firsthand testimony oftheir plight.

Since 1981, congressional and federal agency inquiries have continued to target elder abuse and neglect, especially in insti¬ tutional care settings, and the media have continued to highlight the problem. In 1986,

the Institute of Medicine published recom¬

mendations for preventing elder mistreat¬ ment in institutions. In 1990, the Secretary of the US Department of Health and Hu¬ man Services created an Elder Abuse Task Force, which developed an action plan for the identification and prevention of elder mistreatment in homes, communities, and nursing facilities. The plan also proposes strat-

See also page 405

egies for national research and data collec¬ tion, technical assistance, training, and pub¬ lic education. In 1991, a National Institute on Elder Abuse was established as part of the Administration on Aging's Elder Care Campaign. Adult protective service organi¬ zations now exist in every state to serve vul¬ nerable adults, particularly the elderly in cases

involving abuse and neglect. Other actions have led to increased pub¬

lic and physician awareness of elder abuse and neglect. Since the 1980s, a small group of researchers has been conducting studies to assess the scope and causes of elder mis¬ treatment, and nearly every state has enacted mandatory reporting laws that require phy¬ sicians and others to report suspected cases.

The 1992 standards of the Joint Commis¬ sion on Accreditation of Healthcare Orga-

These guidelines were prepared by Sara C. Aravanis, Washington, DC; Ronald D. Adelman, MD, Mineola, NY; Risa Breckman, CSW, Brooklyn, NY; Terry T. Fulmer, PhD, RN, New York, NY; Elma Holder, MPH, Washington, DC; Mark Lachs, MD, New Haven, Conn; James G. O'Brien, MD, East Lansing, Mich; and Arthur B. Sanders, MD, Tucson, Ariz.

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nizations for emergency departments and ambulatory care centers call for improved identification and manage¬ ment ofelder abuse, as well as spouse or partner abuse and child abuse.

Physicians are ideally situated to

play a significant role in the detec¬ tion, management, and prevention of elder abuse and neglect. A physician may be the only person outside the family who sees the older adult on a

regular basis, and he or she is uniquely qualified to order confirmatory di¬ agnostic procedures such as blood tests or roentgenography, to recom¬

mend hospital admission, or to au¬

thorize services such as home health care. Opportunities for detection and intervention vary with the discipline and the site at which the abuse or

neglect is encountered. Family phy¬ sicians, general internists, and psy¬ chiatrists may have well-established relationships with older adults and their families that allow them to rec¬

ognize potential abuse or neglect and to intervene before a catastrophic event occurs. In contrast, emergency de¬ partment physicians routinely wit¬ ness the effects of elder mistreat¬ ment that require immediate action to ensure the patient's safety and pre¬ vent further harm. In institutional set¬

tings, physician monitoring of pa¬ tient health is crucial for preventing abuse and neglect and maintaining standards of care.

Since most instances of abuse and neglect are not reported, phy¬ sicians in all disciplines must be aware

of the potential for mistreatment, its signs and symptoms, and the appro¬ priate forms of intervention. When¬ ever possible, physicians should work with multidisciplinary teams to en¬

sure thorough assessment, interven¬ tion, and follow-up of elderly patients.

The purpose of these guide¬ lines is to: • sensitize clinicians to the fact that

elder abuse and neglect occur com¬

monly and that the problem is likely to be encountered in their medi¬ cal practices',

• present what is known about its

epidemiologie characteristics, clin¬ ical manifestations, and history;

• describe barriers to proper iden¬ tification and management of el¬ der mistreatment;

• outline an approach that physi¬ cians can use to facilitate recog¬ nition of elder abuse and neglect in a variety of clinical settings;

• identify strategies for manage¬ ment and prevention; and

• discuss relevant ethical and med- icolegal issues surrounding detec¬ tion and reporting of the abuse and neglect.

FACTS ABOUT ELDER MISTREATMENT

While the term elder abuse and ne¬

glect is commonly used to describe acts of commission or omission that result in harm or threatened harm to the health or welfare of an older adult, many authorities prefer to use

the term "elder mistreatment." Mis¬ treatment of the elderly person may include physical, psychological, or fi¬ nancial abuse or neglect, and it may be intentional or unintentional. In¬ tentional mistreatment involves a con¬

scious and deliberate attempt to in¬ flict harm or injury, such as verbal abuse or battering; unintentional mis¬ treatment occurs when an action in¬ advertently results in harm to the elderly person. Unintentional mis¬ treatment is usually due to igno¬ rance, inexperience, or a lack of abil¬ ity or desire of the caretaker to provide proper care. (Although this docu¬ ment deals with physicians' re¬

sponses to elder abuse and neglect perpetrated by others, self-neglect among the elderly is also a major con¬

cern for professionals caring for eld¬ erly patients. Many of the same agen¬ cies listed in this document also handle reports of self-neglect.)

It is difficult to obtain accurate information on the extent of elder abuse and neglect in the United States. Studies often focus on reports of se¬

lected populations and many cases

are unreported. Victims may be em¬

barrassed, intimidated, and over-

whelmed by the situation. They may be fearful of reprisals or unaware of the availability of help. In some cases, victims may be unable to report mis¬ treatment or do not realize that they are being mistreated. Finally, health professionals may ignore signs and symptoms of elder mistreatment be¬ cause they are unaware of the extent of the problem and uncomfortable with the responsibility of further as¬

sessment and action. A 1991 report from Congress

suggests that between 1.5 and 2 mil¬ lion older adults (persons older than 60 years) are abused annually in the United States. In one community- based cross-sectional survey, 32 of 1000 older adults reported that they had experienced some form of mis¬ treatment at least once since reach¬ ing age 65 years. This same popu¬ lation was asked whether they had been mistreated in the last year— yielding an estimated incidence rate of 26 new cases per 1000 persons aged 65 years or older. It is esti¬ mated that only one in 14 elder- mistreatment cases is reported to a

public agency. With the elderly seg¬ ment of the population rapidly in¬ creasing, clinicians can expect to see

a steady increase in the number of cases of elder mistreatment.

There have been attempts to elu¬ cidate risk factors for elder mistreat¬ ment both for older adults and their caretakers. These factors are based on

etiologic theories on the occurrence

of elder abuse and neglect. Unfortu¬ nately, none of these theories has been substantiated with good clinical data. However, awareness of such factors and the theories underlying them may help physicians understand, anticipate, and prevent situations in which elder mistreatment may occur.1

The transgenerational, or fam¬ ily violence, theory asserts that vio¬ lence is a learned behavior. Individ¬ uals who have witnessed or have been victims of family violence may deal with their problems in a like man¬

ner. A second theory implicates a psy- chopathologic problem of the care-

taker in some cases of elder

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mistreatment. Alcoholism, drug ad¬ diction, or severe emotional prob¬ lems on the part of the caretaker may predispose to abusive behavior. A third theory argues that medical, func¬ tional, or cognitive disability of eld¬ erly persons increases their depen¬ dency and vulnerability and, therefore, their risk for abuse or neglect. Other authorities point out that the care¬

taker may be dependent, especially economically, on the older patient. This dependency may lead to resent¬ ment and, when combined with other factors, may predispose to mistreat¬ ment.

Other theories emphasize stress as an important factor in elder mis¬ treatment. Although the caregiving role is inherently stressful, outside situa¬ tions such as economic pressures, lack of community support, or increasing care needs may heighten tensions and produce frustrations that lead to abu¬ sive behavior. While one theory will not explain all or even a majority of cases of elder mistreatment, it is use¬

ful for clinicians to view the interac¬ tion of these factors as contributing to the overall behavior pattern.

The following factors should be considered when evaluating a po¬ tential case of elder mistreatment: • Elder mistreatment occurs among

men and women of all racial, eth¬ nic, and socioeconomic groups.

• The perpetrator of abuse or ne¬

glect is often the spouse or an adult child of the older person, but paid or informal caregivers may also be involved.

• Physical, functional, or cognitive problems in caregivers may pre¬ vent them from providing proper care.

• Mental illness, alcoholism, or drug abuse in the older person or the caregiver may be associated with abuse and neglect.

• Social isolation and dependence of the elderly person may increase the risk for mistreatment.

• A past history of abusive relation¬ ships may predispose the victim to future mistreatment.

• Financial or other family prob-

lems may impair the ability to pro¬ vide adequate care.

• Inadequate housing or unsafe con¬

ditions in the home may increase the likelihood of elder mistreatment.

• Victims often have experienced sev¬

eral forms of elder mistreatment at the same time.

Cases of elder abuse and ne¬

glect can be identified by an alert cli¬ nician, and realistic interventions ex¬

ist for management and prevention. However, there are barriers to the identification of elder mistreatment. Some of these barriers stem from so¬

cietal attitudes about aging. Ageist views of society include a belief that functional decline and frailty are in¬ evitable results of aging. In fact, many of the typical problems encountered in old age are readily amenable to treatment. Problems such as incon¬ tinence, confusion, impaired mobil¬ ity, falling, and "failing to thrive" may be due to treatable underlying or¬

ganic causes.

Researchers also have noted a gen¬ eral reluctance among primary-care physicians to address family violence in all its forms, and elder mistreatment is no exception. Physicians cite the time- consuming nature of the evaluation, as well as their perceived inability to

successfully intervene. Proper evalu¬ ation of elder abuse and neglect re¬

quires a detailed history from the pa¬ tient, alleged abuser, and other fam¬ ily members, as well as a thorough physical examination. Unfortunately, current reimbursement policies do not favor such cognitively intensive tasks. Whenever possible, a multidisciplinary geriatric team should be used to con¬

duct the evaluation; the issues surround¬ ing elder mistreatment are complex, and the patient often needs more than one professional's knowledge and expertise.

INTERVIEWING

Physicians should incorporate rou¬

tine questions related to elder abuse and neglect into their daily practice. Even if the elderly person has a cog-

nitive impairment, it is reasonable to ask about abuse or neglect, since di¬ minished cognitive capacity does not

necessarily negate the elderly per¬ son's ability to describe mistreat¬ ment. The Mini-Mental Status Ex¬ amination can be helpful in evaluating the patient's cognitive status. If the patient has a significant degree of de¬ mentia and cannot answer ques¬ tions about abuse, the physician should seek out an appropriate re¬

spondent who is not likely to be a

perpetrator. The physician should consider how the interview can be conducted to afford the maximum of privacy, and how it can be struc¬ tured so that the patient and family members are interviewed sepa¬ rately. The interview and examination of an elderly patient should always be conducted first, away from the care-

giver or suspected abuser. Every clinical setting should have

a protocol for the detection and as¬

sessment of elder mistreatment. This may be a narrative, a checklist, or

some other type of standardized form that enables all providers in that prac¬ tice setting to rapidly assess for el¬ der mistreatment and document it in a way that allows physicians to look at patterns over time. (Several excel¬ lent protocols are available; physi¬ cians may wish to consult those pro¬ duced by Mount Sinai Medical Center and Victim Services Agency Elder Abuse Project in New York, NY, Beth Israel Hospital in Boston, Mass, or

the Harborview Medical Center in Se¬ attle, Wash.)

The protocol should include ba¬ sic demographic questions that en¬

able the physician to determine the patient's family composition and so¬

cioeconomic status. It should pro¬ ceed to general questions that give the physician a sense of the overall well-being of the older person and then screen for the various types of abuse or neglect (physical, psycho¬ logical, and financial). The protocol should target common indicators for each type of mistreatment and should include specific questions for the patient.

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Ask the patient direct ques¬ tions,2 such as: • Has anyone at home ever hurt you? • Has anyone ever touched you with¬

out your consent? • Has anyone ever made you do

things you didn't want to do? • Has anyone taken anything that was

yours without asking? • Has anyone ever scolded or threat¬

ened you? • Have you ever signed any docu¬

ments that you didn't under¬ stand?

• Are you afraid of anyone at home? • Are you alone a lot? • Has anyone ever failed to help you

take care of yourself when you needed help?

Any questions answered affir¬ matively should be followed up to determine how and when the mis¬ treatment occurs, who perpetrates it, and how the patient feels about it and copes with it. Efforts should be made to determine how serious the dan¬ ger is and what the older adult thinks can be done to prevent the mistreat¬ ment from recurring. Clinicians do not have to prove that elder mis¬ treatment has occurred; they need only document a reasonable cause to

suspect that it has. "Reasonable cause" reporting can be as simple as stating that the patient seems to have health or personal problems and needs as¬

sistance, especially if the clinician sus¬

pects forms of abuse or neglect that are difficult to quantify.

Effective diagnosis of elder mis¬ treatment depends on both profes¬ sional and patient education. All per¬ sonnel who come in contact with older patients, including nurses, nursing as¬

sistants, social workers, emergency health workers, and physical thera¬ pists should be familiar with the pro¬ tocol and should be alert to the var¬

ious types of mistreatment and possible risk factors. Physicians also should promote patient education on

elder mistreatment, including infor¬ mation about the forms of abuse and neglect, the older person's right to be free from mistreatment, and how to access local resources. Most state

departments on aging, adult protec¬ tive services, and area agencies on ag¬ ing have materials describing legal rights, prevention strategies, and sup¬ port services, which physicians can

provide to patients in their offices and waiting rooms.3·4

DIAGNOSIS AND CLINICAL FINDINGS

The physician should ensure that a com¬

prehensive medical examination is con¬

ducted and that the results of the ex¬

amination are documented, including the patient's statements, behavior, and ap¬ pearance. Symptoms of elder mis¬ treatment may result from physical abuse or neglect, psychological abuse or neglect, financial or material abuse or neglect, or any combination of these. In a broad sense, elder mis¬ treatment encompasses violation of any legal or human rights that are

accorded members of society. These rights promote concepts of self- respect and dignity and include the rights to liberty, property, privacy, and free speech.

Physical Mistreatment

Abuse. This involves acts of vio¬ lence that may result in pain, injury, impairment, or disease. Examples in¬ clude: • pushing, striking, slapping, or

pinching; • force-feeding; • incorrect positioning; • improper use of physical re¬

straints or medications; and • sexual coercion or assault (sexual

contact or exposure without the older person's consent or when the older person is incapable of giv¬ ing consent).

The physician has cause to sus¬

pect physical abuse when the eld¬ erly patient presents with unex¬

plained injuries, when the explanation is not consistent with the medical find¬ ings, or when contradictory expla¬ nations are given by the patient and the caregiver. Signs of physical abuse include bruises, welts, lacerations, frac-

tures, burns, rope marks (note bi¬ lateral injuries and injuries in vari¬ ous stages of healing); laboratory findings indicating medication over¬ dose or undermedication; and un¬

explained venereal disease or geni¬ tal infections.

Neglect. This is characterized by a

failure of the caregiver to provide the goods or services that are necessary for optimal functioning or to avoid harm. This may include: • withholding of health mainte¬

nance care, including adequate meals or hydration, physical ther¬ apy, or hygiene;

• failure to provide physical aids such as eyeglasses, hearing aids, or false teeth; and

• failure to provide safety precau¬ tions.

Physical neglect may be sus¬

pected in the presence of dehydra¬ tion, malnutrition, decubitus ulcers, poor personal hygiene, or lack of com¬

pliance with medical regimens.

Psychological Mistreatment

Abuse. This is conduct that causes

mental anguish in an older person. This includes: • verbal berating, harassment, or in¬

timidation; • threats of punishment or depriva¬

tion; • treating the older person like an

infant; and • isolating the older person from fam¬

ily, friends, or activities.

Neglect. This is the failure to pro¬ vide a dependent elderly individual with social stimulation. This may in¬ volve: • leaving the older person alone for

long periods of time; • ignoring the older person or giv¬

ing him or her the "silent treat¬

ment"; and • failing to provide companion¬

ship, changes in routine, news, or

information. The possibility of psychological

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if the older person seems extremely withdrawn, depressed, or agitated; shows signs of infantile behavior; or

expresses ambivalent feelings toward caregivers or family members.

Financial or Material Mistreatment

Abuse. This involves misuse of the elderly person's income or re¬

sources for the financial or personal gain of a caretaker or advisor, such as: • denying the older person a home; • stealing money or possessions; and • coercing the older person into sign¬

ing contracts or assigning durable power of attorney to someone, pur¬ chasing goods, or making changes in a will.

Neglect. This is failure to use avail¬ able funds and resources necessary to sustain or restore the health and well-being of the older adult.

Financial abuse or neglect should be considered if the patient is suffer¬ ing from substandard care in the home despite adequate financial resources, if the patient seems confused about or unaware of his or her financial sit¬ uation, or has suddenly transferred as¬

sets to a family member. Older adults are particularly vulnerable to this type ofmistreatment, yet it may be the most difficult to identify.

Violation of Personal Rights This occurs when caretakers or pro¬ viders ignore the older person's rights and capability to make decisions for

Figure 1. Intervention and case management, part 1. Screening and assessment for elder mistreatment should follow a routine pattern. Assessment of each case should include the illustrated pattern.

himself or herself. This failure to re¬

spect the older person's dignity and autonomy may include: • denying the older person his or her

rights to privacy; • denying the older person the right

to make decisions regarding health care or other personal issues, such as marriage or divorce; and

• forcible eviction and/or place¬ ment in a nursing home.

This type of abuse may be rec¬

ognized through reports by the pa¬ tient or through observation of fam¬ ily or patient-caregiver interactions.

ASSESSMENT

The physician should consider the following in assessing for elder mis¬ treatment (Figures 1 and 2).

Safety • Is the patient in immediate dan¬

ger? If so, consider hospital ad¬ mission and/or a court protective order.

• Does the patient understand risks and consequences of the decision concerning safety? What steps can

be taken to increase safety in non-

emergency situations?

Access

• Are there barriers limiting or pre¬ venting further assessment? If so, the physician may improve access

by engaging a trusted family mem¬

ber or friend of the patient, by con¬

sulting state adult protective ser¬

vices, and by building a cooperative relationship with local legal advo¬ cacy programs.

Cognitive Status

• Does the patient have cognitive im¬ pairment on the basis of demen¬ tia and/or delirium? Formal, brief instruments such as the Mini- Mental Status Examination can pro¬ vide an objective, reliable assess¬

ment of this. • If cognitive impairment is present,

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Figure 2. Intervention and case management, part 2. Case management should be guided by choosing the alternatives that least restrict the patient's independence and decision-making responsibilities and fulfill state-mandated reporting requirements. Intervention will depend on the patient's cognitive status and decision-making capability and on whether the mistreatment is intentional or unintentional. Elder mistreatment occurs among men and women of all racial, ethnic, and socioeconomic groups. Ask the patient direct questions. Residents also have the right to be free from physical restraints or

psychoactive drugs administered for purposes of discipline or convenience. Nearly all states have mandatory reporting laws.

is it potentially reversible or re¬

mediable (is it due to medica¬ tions, thyroid disease, depres¬ sion, or other organic causes)? If irreversible cognitive impair¬ ment is present, is it severe

enough to preclude an accurate

history from the older person? Is it severe enough to impair decision-making capacity?

Emotional Status

Does the patient manifest depres¬ sion, shame, guilt, anxiety, fear, and/or anger? If yes, explore beliefs associated with these emotions. Is the patient reluctant to discuss the possibility of abuse or ne-

gleet? If so, attempt to determine the reason.

Does evidence suggest patient de¬ nial? (Does the patient minimize or rationalize family tension or con¬

flict?) If yes, does this denial in¬ terfere with patient's recognition or admission of mistreatment?

Health and Functional Status

What medical problems exist? Could mistreatment have caused or exacerbated them? If the patient requires assistance with activities of daily living, who provides it? Does the person have the emotional, financial, and in¬ tellectual ability to provide the care?

Does the patient have physical lim¬ itations that impair his or her abil¬ ity to protect himself or herself?

Social and Financial Resources

• Does the patient have family or

friends able and willing to nur¬

ture, listen, and assist with care, if needed? If not, why not?

• Does the patient have adequate fi¬ nancial resources for basic sub¬ stantive needs? If yes, but these needs are not being met, why is this?

Frequency, Severity, and Intent

• Has mistreatment increased in fre¬ quency or severity over time?

• Are there motives or remediable causes for the mistreatment? If so, incorporate appropriate services into intervention/treatment plan. ABUSE AND NEGLECT IN

INSTITUTIONS

Institutional elder abuse and ne¬

glect refers to mistreatment that occurs in nursing homes, board and care homes, and other assisted living facilities. Nursing home medical directors, as well as pri¬ vate practitioners who see individ¬ ual residents, play a critical role in identifying, treating, and prevent¬ ing abuse and neglect in these settings.

In institutions, elder abuse may be perpetrated by a staff member, an¬

other patient, an intruder, or a vis¬ itor. The forms of abuse and neglect that occur in institutions are virtu¬ ally the same as those that occur in domestic settings. One form of mis¬ treatment that is of special concern

in institutions is the failure to carry out a plan of treatment or care. This may involve unauthorized use of phys¬ ical or chemical restraints or the use

of medication or isolation as pun¬ ishment, for staff convenience or as

a substitute for treatment and in con¬

flict with a physician's order. Physi¬ cians must be aware that substan-

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dard care or routine neglect can result in declining health, serious deterio¬ ration, pain, and emotional trauma. The plan of care is a critical docu¬ ment used to determine whether ac¬

tion or inaction by facility staff is abu¬ sive or neglectful.

Older persons in institutional care are at risk for mistreatment both because of their extreme vul¬ nerability and because of inade¬ quate training and experience among caregivers. Residents of nursing facilities are typically de¬ pendent, extremely frail, and/or chronically ill, and many do not have regular visitors who can

monitor their care. Cognitive, vi¬ sion, and hearing impairments are

common; a recent government re¬

port states that at least one half of all nursing home residents—about 600 000 individuals—suffer from dementia. Patients with cognitive impairment may be resistant to

care, and difficult to help. In addi¬ tion, problems such as insufficient resources, staff shortages, high turnover, and inadequate supervi¬ sion and training increase the risk of mistreatment. Finally, abuse and neglect may be exacerbated by societal ignorance about quality care and by the acceptance of abu¬ sive or neglectful behavior as inev¬ itable in institutional life.

Although institutional abuse and neglect has been recognized for more

than 40 years, there are no uniform national prevalence data. Sources of information include state licen- sure and certification agencies, state Medicaid and Medicare fraud and abuse agencies, long-term- care ombudsman programs estab¬ lished under the Older Americans Act, and most state adult protec¬ tive services programs. Data collec¬ tion should be improved through planned improvements in the fed¬ eral Medicare and Medicaid facility survey system, new reporting re¬

quirements to state nurse aide reg¬ istries, and revised ombudsman and adult protective service pro¬ gram reporting requirements.

Regulations and Legal Protection

All but a small number of private nurs¬

ing facilities are monitored by state and federal regulatory agencies, and other specialized programs, with ex¬

pectations that public standards of care will be provided. Even so, there is continual concern and increasing information about serious mistreat¬ ment in government-licensed and cer¬

tified facilities. Nonmedicai residen¬ tial facilities or board and care homes usually do not employ health and medical staff. Although most states license such facilities, they do not pro¬ vide active regulation of the stan¬ dards of care. Information about abuse and neglect in board and care homes is often obtained by physicians (par¬ ticularly emergency department staff), family members, investigators, and, increasingly, by the state long-term- care ombudsman program.

Most states have legislation that addresses elder mistreatment; such statutes are usually contained in adult protective service or domestic vio¬ lence legislation. Several states (in¬ cluding Delaware, Georgia, Mary¬ land, Massachusetts, Missouri, and Oregon) have laws specific to the in¬ stitutional setting. Many state laws identify physicians and other health¬ care providers as key professionals who must report suspected abuse and neglect to state officials.

National standards for care in nursing homes are based on public policy set forth in the Nursing Home Reform Act of 1987 (Public Law 100- 203; Social Security Act, Title C). This law, as part of the Omnibus Budget Reconciliation Act, is often referred to as "OBRA '87." (It became effec¬ tive October 1990.) The intent of the law and its regulations is to promote high-quality care and to prevent sub¬ standard care, abuse, and neglect.

The law provides that a set of residents' rights are ensured for each person. These include protection against Medicaid discrimination; the right to participate in health-care de¬ cisions and to give or withhold in¬ formed consent for particular inter-

ventions; safeguards to reduce inappropriate use of physical and chemical restraints; provisions to en¬

sure proper transfers or discharges; and full access to a personal physi¬ cian, the long-term-care ombuds¬ man, and other advocates. Each res¬

ident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and in¬ voluntary seclusion. According to the federal guidelines for implementa¬ tion of the law, "abuse means the will¬ ful infliction of injury, unreasonable confinement, intimidation, or pun¬ ishment with resulting physical harm or pain or mental anguish, or dep¬ rivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being."3

Residents also have the right to be free from physical restraints or psy- choactive drugs administered for pur¬ poses of discipline or convenience. The inappropriate use of physical or

chemical restraints is of special con¬

cern. Federal guidelines specify that "the decision to apply physical re¬

straints should be based on the as¬

sessment of each resident's capabil¬ ities, an evaluation of less restrictive alternatives, and the ruling out of their use. The plan of care should also con¬

tain a schedule or plan of rehabili¬ tative training to enable the progres¬ sive removal of restraints or the progressive use of less restrictive means, as appropriate."5

Despite federal and state laws to protect residents, abuse and ne¬

glect continue to occur for a variety of reasons. Some states have lax en¬

forcement of standards. Many resi¬ dents do not have regular visits from family and friends who can monitor their care; and not all communities have local long-term-care ombuds¬ man programs to help residents re¬

solve problems and complaints. The Role of the Physician

Both because of their prescribed roles and because they may be among the

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few persons from outside the facility to see the resident on a regular ba¬ sis, physicians can play a critical role in identifying, treating, and prevent¬ ing abuse and neglect in institu¬ tional settings. State laws require that patients be admitted by physicians to nursing homes (and, in some cases, to other types of residential facili¬ ties). After admission, each resi¬ dent's care must be under the su¬

pervision of an attending physician (or a physician assistant, nurse prac¬ titioner, or clinical nurse specialist su¬

pervised by a physician), and facil¬ ities are mandated to provide them immediate access to their patients. Several of the prescribed roles for per¬ sonal physicians are likely to permit recognition and prevention of insti¬ tutional abuse and neglect. These in¬ clude: • participating in the development

and monitoring of the resident's plan of care;

• assessing the need for and pre¬ scribing physical restraints and an-

tipsychotic drugs only when ap¬ propriate for treatment of a

resident's particular condition and not for behavioral modification or

control; and • monitoring reports that by law must

go to the physician, including any irregularities in drug regimen as

found by the pharmacist who con¬

ducts a monthly drug regimen re¬

view of all residents, and findings of substandard care by the state's inspection agency.

New legal requirements under the Omnibus Budget Reconciliation Act should help to reduce the inap¬ propriate use of physical and chem¬ ical restraints. Physicians should be aware that these regulations will cause

their medical prescriptive decisions to be more closely reviewed to en¬

sure that psychotropic drugs are pre¬ scribed appropriately, ie, for diag¬ noses of dementia. Personal physicians can play a crucial role in the iden¬ tification and prevention of mistreat¬ ment by ongoing monitoring of the resident's health through regular phys¬ ical examinations, review of the pa-

tient's record, and review of resi¬ dent assessments. These assessments must be completed annually, with up¬ dates every quarter and whenever there is a significant change in the patient's condition. Other physi¬ cians may identify and prevent in¬ stitutional elder mistreatment while serving as medical directors or as phy¬ sician members of the facility's qual¬ ity assessment and assurance com¬

mittee. A physician may serve in all three of these capacities at the same

time.

DOCUMENTATION

Thorough, well-documented medi¬ cal records are essential. They pro¬ vide concrete evidence and may prove to be crucial to the outcome of any legal case. If the medical record and testimony at trial are in conflict, the medical record may be considered more credible. Records should be kept in a precise, professional manner and should include the following: • chief complaint and description of

the abusive event or neglectful sit¬ uation, using the patient's own

words whenever possible rather than the physician's assessment;

• complete medical history; • relevant social history; • a detailed description of injuries,

including type, number, size, lo¬ cation, stages of healing, color, res¬

olution, possible causes, and ex¬

planations given (where applicable, the location and nature of the in¬ juries should be recorded on a body chart or drawing);

• an opinion on whether the inju¬ ries were adequately explained;

• results ofall pertinent laboratory and other diagnostic procedures;

• color photographs and imaging stud¬ ies, if applicable; and

• if the police are called, the name of the investigating officer and any ac¬

tions taken. In addition to complete writ¬

ten records, photographs are partic¬ ularly valuable as evidence. The phy¬ sician should ask the patient for permission to take photographs.

When the patient is unable to give consent, photographs may be taken and a surrogate decision-maker may need to be consulted after the fact. Imaging studies also may be useful. State laws that apply to the taking of photographs usually apply to roent-

genograms as well. • When possible, take photographs

before medical treatment is given. • Use color film, along with a color

standard. • Photograph from different angles—

full body and close-up. • Hold up a coin, ruler, or other ob¬

ject to illustrate the size of an in¬ jury.

• Include the patient's face in at least one picture.

• Take at least two pictures of every major trauma area.

• Mark photographs precisely and promptly with the patient's name, location of injury, date, time ofday, and names of the photographer and others present.

For medical records to be ad¬ missible in court, the physician should be prepared to testify: • that the records were made dur¬

ing the "regular course of busi¬ ness" at the time of the examina¬ tion or interview;

• that the records were made in ac¬

cordance with routinely followed procedures; and

• that the records have been prop¬ erly stored and their access lim¬ ited to professional staff.

LEGAL CONSIDERATIONS

The first priority of the physician when mistreatment is detected or suspected is to ensure the safety of the victim. The second is to report the case to the ap¬ propriate state agency, such as adult protective services, in accordance with state laws that govern elder abuse and neglect. The physician's legal obliga¬ tions may vary depending on whether the patient resides at home or in an

institution. In cases of abuse or ne¬

glect in the home, the physician si¬ multaneously may request a variety of other services, including respite

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care, a visiting nurse service, and a

social work evaluation. Awareness of some general principles in the initial stages, such as not confronting the perpetrator and not blaming the vic¬ tim, is likely to result in a better out¬ come. The patient's safety and well- being is the goal of any intervention, and must be the physician's primary concern.

A competent older adult who is not being coerced may choose to stay in an abusive situation. In such cases, the physician's role in assessment and referral may be more complicated than it would be in the case of an incom¬ petent patient. On the other hand, most patients and their families wel¬ come physician support and refer¬ rals for home services and respite care.

This is particularly true when mis¬ treatment results from the caregiver being overburdened and there is no

malicious intent. It is usually less in¬ trusive and threatening to the family to have these interventions sug¬ gested by a physician or other pro¬ fessional who is known to them than by an unfamiliar physician or case¬

worker. The primary-care physician can

participate in ongoing treatment or

at least serve as a monitor who can

reactivate assistance if the situation is deteriorating and provide fol¬ low-up after a referral has been made. If an abused elderly person is treated by a physician who does not inquire about or make an assessment for el¬ der mistreatment, that physician may be held liable for any subsequent in¬ juries. In some states, failure to re¬

port is a misdemeanor, the penalty for which may be a fine or even im¬ prisonment.

Elder mistreatment is a com¬

plex problem that requires the as¬

sistance of a variety of individuals in¬ cluding social workers, visiting nurses, in-home health aides, and, occasion¬ ally, legal and financial experts. Ge¬ riatric assessment programs at large hospitals are ideally equipped to re¬

spond in these situations. The alter¬ native is for informal community- based teams to respond on an ad hoc

basis. A multidisciplinary approach benefits the victim of mistreatment and also lessens the burden of re¬

sponsibility shared by the profes¬ sionals involved in the case.

Reporting Requirements and Ethical Dilemmas

Nearly all states have mandatory reporting laws that require a vari¬ ety of designated health-care pro¬ fessionals and paraprofessionals to

report suspected elder abuse and neglect to a designated state au¬

thority, usually the adult protec¬ tive service agency, department of aging, or ombudsman. Some state laws specify that once authorities have been alerted to even the sus¬

picion of elder abuse or neglect, an agent of the state will make an

on-site investigation in an attempt to corroborate the report.

There is considerable debate as

to whether mandatory reporting laws aid in the identification of elder abuse and neglect. A recent study by the US General Accounting Office con¬

cluded that states with mandatory and nonmandatory reporting laws could not be meaningfully compared be¬ cause of differences among the states in investigative mechanisms, defini¬ tions of abuse and neglect, and who is defined as a mandatory reporter. There also is no consensus among states on the definition of the eld¬ erly population by age. An accom¬

panying survey of protective service officials concludes that raising pub¬ lic and professional awareness of the problem of elder abuse and neglect is much more important in uncov¬

ering cases than any legislative edict. While at first glance manda¬

tory reporting laws seem to be an ad¬ mirable attempt at identifying more

cases of elder abuse and neglect, some

observers have criticized their ad¬ vent as an ageist response to the prob¬ lem. They argue that older adults who are victims of family violence should have the same opportunity as younger adults to endorse or refuse referral to an investigating agency. Manda-

tory reporting laws for elder abuse and neglect, like child abuse stat¬ utes, are based on the state's parens patriae power to protect persons who cannot or will not protect them¬ selves.

Thus, mandatory reporting laws can engender difficult ethical dilem¬ mas for the physician. He or she has taken an oath to maintain the con¬

fidentiality of the physician-patient relationship, but may have to vio¬ late that trust to comply with cer¬

tain state laws. How then should the physician proceed in cases in which clear historical or physical evidence of abuse or neglect is present but a

competent patient requests that no

report be made? The physician should explain to the patient that he or she is obligated to report suspected mis¬ treatment and should strive to main¬ tain a positive physician-patient re¬

lationship, keeping in mind the medical need for intervention. The goal is not to punish the individual or family, but to stop the abuse or

neglect and to access help in the form of outside resources. While there is little case law on this subject, most

experts would agree that a physi¬ cian's legal duty to report cases of suspected abuse would supersede the issue of physician-patient confiden¬ tiality.

Another useful strategy is to maintain a good working relation¬ ship with local adult protective ser¬

vice personnel. In addition to inves¬ tigating abuse, these professionals are

typically charged with serving as ad¬ vocates for frail elderly in the com¬

munity. They often procure a vari¬ ety of services to which the older person is entitled that may not be re¬

lated to elder abuse or neglect. Ac¬ cordingly, a home visit by one of these professionals can be used to gain in¬ formation about the health and safety of the patient.

Most adults in need of help al¬ low adult protective services to work with them. However, capable adults have the legal right to refuse the pro¬ vision of ongoing protective ser¬

vices. For the incapacitated older per-

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son who insists on remaining in an

abusive environment, the court may need to appoint an impartial con¬

servator who can manage his or her finances and affairs, and/or a guard¬ ian who is responsible for health care

and other decisions. In such cases, the physician's role includes the doc¬ umentation of cognitive and other findings to determine a patient's ca¬

pacity, which may aid the court in a

competency hearing.

Testimony Some physicians are concerned about the time and inconvenience in¬ volved with a court appearance. In some cases, medical records can be admitted without requiring the phy¬ sician's in-court testimony. How¬ ever, if testimony is required, it may be possible to place the physician "on call" so that she or he need appear only when it is time to testify.

The physician may testify about general observations of behavior or

statements made, a function that is distinct from the use of the physi¬ cian as an expert. A physician should never feel insulted if called to give only this type of "layperson" testi¬ mony or to testify about a nonmed- ical issue, because this may be the only way to get such information be¬ fore the court. When called as an ex¬

pert witness, the physician may be requested to give an opinion on

whether the explanation given is con¬ sistent with the injury.

For any testimony, the follow¬ ing guidelines should be followed: • Insist on pretrial preparation by the

attorney presenting you as a wit¬ ness.

• Determine the legal and factual is¬ sues and how your testimony re¬ lates to these issues.

• Determine what demonstrative ev¬ idence (ie, photographs) should be part of your testimony.

• If testifying as an expert witness, propose questions for the attor¬

ney to ask. • Brief the attorney on questions to

ask the opposing expert.

• Answer only the questions asked. • If a question is not understood, ask

that it be repeated; explain when a one-word answer is not enough.

• Do not volunteer information. • Calmly correct an attorney who

misstates prior testimony.

RISK MANAGEMENT

Duty to the Victim

Most physicians will encounter cases

of elder abuse and neglect in their practices. Physicians must be aware

of their obligations in these cases, as

well as their potential liability for fail¬ ing to diagnose and/or report cases

of suspected mistreatment. In gen¬ eral, doing what is medically best or

most appropriate is good risk man¬

agement. The duty to the victim may arise from the special relationship be¬ tween physician and patient or from the courts' interpretations of report¬ ing laws. The argument would be that other physicians, under the same cir¬ cumstances, would have diagnosed inflicted trauma and taken appro¬ priate management steps that would have prevented subsequent harm.

Thus, physicians must be will¬ ing to ask all elderly patients about mistreatment and should know how to diagnose it. Failure to conduct the interview and examination apart from the suspected perpetrator may inter¬ fere with an accurate diagnosis. Phy¬ sicians must be prepared to inter¬ vene in situations that are particularly dangerous for the elderly person such as repeated, similar injuries; malnu¬ trition or dehydration; undermedi- cation or overmedication; mental ill¬ ness in the patient or caregiver; substance abuse by the patient or car¬

egiver; and threatened suicide by the caregiver (there may be increased risk for a murder/suicide).

In states that have enacted man¬

datory reporting statutes, a physi¬ cian's failure to report could give rise to liability, but since reporting laws rarely explicitly give victims such a

right to sue, courts must determine whether their state's statutes implic-

itly contain that right. Physicians could be liable, however, under various common law tort actions, including negligence or wrongful death.

Most states provide that re¬

ports of suspected mistreatment are

kept strictly confidential. Reporters' names may not be released without written consent. In addition, the phy¬ sician is immune from any civil or

criminal liability for making a good- faith report of suspected abuse or ne¬

glect. To be held liable for report¬ ing, the physician would have to be shown to be acting in a knowingly and intentionally false and mali¬ cious manner. Reports made in the context of employment are also gen¬ erally protected against employer re¬

taliation by "whistleblower" and other public welfare statutes.

Reporters should not be reluc¬ tant to report incidents or concerns

because they seem "minor" or "not threatening"; physicians should re¬

port any reasonable suspicion of abuse or neglect. State reporting agencies will prioritize cases and can provide needed interventions such as emer¬

gency food and care, transportation, medical evaluation, relocation, legal assistance, and other community- based services.

Duty to Warn

Many states recognize a legal duty that physicians have toward third par¬ ties who might be harmed by their patients. In those states, if a physi¬ cian is aware of a patient's intent to harm a third party, such as the pa¬ tient's spouse or parent, he or she may have a legal duty to breach the patient's confidence and to warn the third party of the impending dan¬ ger. Physicians, and especially ther¬ apists, should know the law of the area in which they practice.

Despite taking all possible mea¬

sures to handle cases correctly, phy¬ sicians may still become defendants in medical malpractice suits. These physicians should: • not panic; • not discuss the case with any-

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one until they have spoken with their attorney; • contact their malpractice insur¬

ance carriers; • record the circumstances in¬

volved in the serving of a sum¬

mons; and • have thorough documentation.

TRENDS IN TREATMENT AND PREVENTION

State programs such as adult pro¬ tective services and long-term-care ombudsman programs have made it easier for physicians to intervene on

behalf of patients who have been vic¬ tims of elder mistreatment. Depend¬ ing on the state, adult protective stat¬ utes may include a statewide system with the capability of immediate in¬ vestigation and emergency services, including evaluation, counseling, and, if needed, relocation. Physicians may contribute to the success of state ser¬

vices by serving as trainers for adult protective services, explaining how mistreatment is diagnosed, and of¬ fering suggestions for improving the effectiveness of interventions. They may also wish to serve on advisory committees in their state or county medical societies. As more research is conducted on elder abuse and ne¬

glect, more information will be avail¬ able to assess protocols and medical and legal interventions.

One of the most important developments in addressing elder mistreatment in recent years has been the use of multidisciplinary teams in hospitals and communi¬ ties. Specialists in geriatrics, social work, nursing, psychiatry, and other fields offer insight that can

help the primary-care physician to

develop an appropriate interven¬ tion plan. These specialists may have important referral informa¬ tion for patients or family members—support groups and other services in the community that focus on aging parents, home care, substance abuse, family vio¬ lence, and financial and legal plan¬ ning. Perhaps most important,

physicians need to become familiar with long-term care and in-home health-service options in their communities. Caring for an elderly parent at home is inherently stress¬

ful, and abusive situations can be pre¬ vented by providing support to over¬

burdened caregivers.

RESOURCES FOR PHYSICIANS

The following resources are avail¬ able to assist physicians in their eval¬ uation and interventions on behalf of elderly patients. Physicians should become familiar with their own state resources and state laws that deal with elder abuse and neglect.

State Elder Abuse Hot Line

Most states have instituted a 24- hour toll-free number for receiving reports of abuse and neglect. Calls are confidential.

Adult Protective Services

This is the primary service agency with legal responsibility and authority to

investigate reports of abuse and ne¬

glect in the home and community and in institutions (in a majority of states) and to provide services to elderly vic¬ tims. Adult protective services works closely with the medical community to obtain services that will increase the older person's safety and well- being.

Law Enforcement

Local police and sheriffs are being given more power to intervene in cases of family violence, and they may have already been notified of the abuse or neglect by the elderly person or by a friend or advocate. Where state statutes define elder mistreatment as a crime, physi¬ cians may be required to report suspected abuse to a law enforce¬ ment agency. Some forms of abuse are crimes that must be prose¬ cuted; these may include cases in¬ volving sexual abuse or assault.

Long-term-Care Ombudsman Program

Every state has a long-term-care ombudsman program, as estab¬ lished by the Older Americans Act in 1978. Each program provides regular visitation of nursing facili¬ ties by an ombudsman and trained volunteers; these services may be extended to board and care facili¬ ties. Information about the om¬

budsman program is provided through local area agencies on ag¬ ing, and such information is re¬

quired to be posted in nursing facilities.

Facility Abuse Investigations

Every nursing-care facility must have a process for investigating reports of abuse, neglect, and misappropria¬ tion of resident property.

State Licensure and Survey Agency

The state agency responsible for sur¬

vey and certification of nursing fa¬ cilities has developed a process for the receipt, timely review, and in¬ vestigation of allegations of abuse and neglect and misappropriation of res¬

ident property by staff or other pro¬ viders of services to patients at the facility.

Medicaid Fraud Control Units

Each unit, located in the state at¬

torney general's office, is required by federal law to investigate and prosecute Medicaid provider fraud and patient abuse or neglect in health-care facilities that partici¬ pate in Medicaid.

Nurse Aide Registry A registry maintained by the state lists the names of nurse aides who have been found guilty of mis¬ treatment. Nursing facilities are re¬

quired to check with the registry before hiring staff.

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State Boards for Nursing and Medicine

The state must also notify the ap¬ propriate licensure authority about abuse and neglect by other health¬ care professionals.

Accepted for publication January 21, 1993.

These guidelines are not intended to be construed or to serve as a stan¬ dard of medical care. Standards of med¬ ical care are determined on the basis of all the facts and circumstances in¬ volved in an individual case and are

subject to change as scientific knowl¬ edge and technology advance and pat¬ terns of practice evolve. These guide¬ lines reflect the views ofscientific experts and reports in the scientific literature as of October 1992.

These guidelines were also re¬

viewed by experts in law and geriatric health whose assistance is greatly ap¬ preciated. American Medical Associa¬ tion staff assistance was provided by Roger L. Brown, PhD; Sona Kalous- dian, MD, MPH; Carol O'Brien, JD; Marshall D. Rosman, PhD; Elaine Tej- cek; and Martha Witwer, MPH.

Reprint requests to Department of Mental Health, American Medical As¬ sociation, 515 State St, Chicago, IL 60610 (Roger L Brown, PhD).

STATE UNITS ON AGING AND ADULT PROTECTIVE

SERVICE AGENCIES

The organization and structure of adult protective service programs vary among the states. Use the numbers in bold to report suspected cases of abuse or neglect.

Alabama

Elder Abuse Hot Line: In state: (800) 458-7214; Oscar D. Tucker, Direc¬ tor, Commission on Aging, Suite 470, 770 Washington Ave, Montgomery, AL 36130; (205) 242-5743.

Gethryn Giles, Director, Adult Services Division, Department of Hu¬ man Resources, S. Gordon Persons

Bldg, 50 Ripley St, Montgomery, AL 36130; (205) 242-1350.

Alaska

Connie Sipe, Director, Older Alaskans Commission, Department ofAdmin¬ istration, Pouch C-Mail Station 0209, Juneau, AK 99811-0209; (907) 465- 3250.

Patricia O'Brien, Coordinator, Adult Protective Services, Division of Family and Youth Services, Depart¬ ment of Health and Social Services, Pouch H-05, Juneau, AK 99811- 0630; (907) 465-2145.

Arizona

Richard Littler, Director, Aging and Adult Administration, Department of Economic Security, 1400 W Wash¬ ington St, Phoenix, AZ 85007; (602) 542-4446.

Joseph Zink, Operations Man¬ ager, Adult Protective Services, Ag¬ ing and Adult Administration, De¬ partment of Economic Security, 1400 W Washington St, Phoenix, AZ 85007; (602) 542-4446.

Arkansas

Elder Abuse Hot Line: In state: (800) 482-8049 or (800) 922-5330; Herb Sanderson, Director, Division of Ag¬ ing and Adult Services, Department of Human Services, PO Box 1437, Slot 1412, Seventh and Main streets, Lit¬ tle Rock, AR 72201 ; (501) 682-2441.

California

Robert Martinez, Director, Depart¬ ment of Aging, 1600 St, Sacra¬ mento, CA 95814; (916) 322-5290.

Bob Barton, Chief, Adult Ser¬ vices Bureau, Department of Social Services, Adult and Family Services, 744 St, M 59-536, Sacramento, CA 95813; (916) 657-2186.

Colorado

Rita Barreras, Manager, Aging and Adult Services, Department of So-

cial Services, 1575 Sherman St, 4th Floor, Denver, CO 80203-1714; (303) 866-3851.

Joanne Marlatt, Program Ad¬ ministrator for Adult Protection/ Assisted Living, Aging and Adult Ser¬ vices, Department of Social Services, 1575 Sherman St, 4th Floor, Den¬ ver, CO 80203-1714; (303) 866- 5910.

Connecticut

Edith Prague, Commissioner, De¬ partment on Aging, 175 Main St, Hart¬ ford, CT 06106; (203) 566-3238.

Leslie Burkhart, Program Super¬ visor, Department ofHuman Resources, 1049 Asylum Ave, Hartford, CT 06106- 2431; (203) 566-3117.

Delaware

Eleanor Cain, Director, Division on

Aging, Department of Health and So¬ cial Services, 1901 DuPont Hwy, New Castle, DE 19720; (302) 577- 4791.

Barbara Webb, Administrator, Division on Aging, Adult Protective Services, Department of Health and Social Services, CT Bldg, 1901 Du¬ Pont Hwy, New Castle, DE 19720; (302) 421-6791.

District of Columbia

Jearline Williams, Director, Office on

Aging, 1424 St NW, 2nd Floor, Washington, DC 20005; (202) 724- 5626.

Donald Butler, Acting Chief of Social Service, Family Services Ad¬ ministration, Department of Human Services, Randall Bldg, First and I streets SW, Washington, DC 20024; (202) 727-0113.

Florida

Elder Abuse Hot Line: In state: (800) 96-ABUSE; Bentley Lipscomb, Sec¬ retary, Department of Elder Affairs, Bldg 1, Room 317, 1317 Winewood Blvd, Tallahassee, FL 32301; (904) 922-5297.

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Christopher C. Shoemaker, Pro¬ gram Administrator, Aging and Adult Services, Department of Health and Rehabilitative Services, Bldg 2, Room 328,1317WinewoodBlvd,Tallahas- see, FL 32399-0700; (904) 488-2650.

Georgia

Judy Hagenbak, Director, Office of Aging, 878 Peachtree St, No. 632, At¬ lanta, GA 30309; (404) 894-5333.

Sara Brownlee, Unit Chief for Adult Services, Division ofFamily and Children Services, Social Services Sec¬ tion, Department ofHuman Resources, 878 Peachtree St NE, Suite 503, At¬ lanta, GA 30309; (404) 894-4440.

Hawaii

Jeanette Takamura, Director, Execu¬ tive Office on Aging, Office of the Gov¬ ernor, 335 Merchant St, No. 241, Ho¬ nolulu, HI 96813; (808) 586-0100.

Patricia Snyder, Program Ad¬ ministrator; Adult Services, Depart¬ ment of Human Services, PO Box 339, Honolulu, HI 96809; (808) 548- 5902.

Idaho

Ken Wilkes, Director, Office on Ag¬ ing, Statehouse, Room 108, Boise, ID 83720; (208) 334-3833.

David DeAngelis, Chief, Bu¬ reau of Adult Services, Department of Health and Welfare, 450 W State St, 10th Floor, Boise, ID 83720; (208) 334-5531.

Illinois

Elder Abuse Hot Line: In state: (800) 252-8966; Maralee Lindley, Direc¬ tor, Department on Aging, 421 E Cap¬ itol Ave, Springfield, IL 62701; (217) 785-2870.

Indiana

Adult Abuse Hot Line: In state: (800) 992-6978; Geneva Shedd, Director, Bureau of Aging/In-Home Services, 402 W Washington St, Room E-431,

Indianapolis, IN 46207-7083; (317) 232-7020.

Arlene Franklin, Director; Ad¬ vocacy Services, Department of Hu¬ man Services, PO Box 7083, India¬ napolis, IN 46207-7083; (317) 232- 1750.

Iowa

Elder Abuse Hot Line: In state: (800) 362-2178; Betty Grandquist, Direc¬ tor, Department of Elder Affairs, Jew- ett Bldg, Suite 236, 914 Grand Ave, Des Moines, IA50319; (515) 281-5187.

Sandy Koll, Program Manager, Adult Services, Bureau of Adult, Chil¬ dren, and Family Services, Depart¬ ment of Human Services, Hoover Building, 5th Floor, Des Moines, 50319; (515) 281-6219.

Kansas

Elder Abuse Hot Line: In state: (800) 432-3535; Joanne Hurst, Secretary, Department on Aging, Docking State Office Bldg, 122-S, 915 SW Harri¬ son, Topeka, KS 66612-1500; (913) 296-4986.

Rosilyn James-Martin, Adult Abuse Program, Commission on Adult Services, Department of Social and Rehabilitative Services, Smith- Wilson Bldg, 300 SW Oakley, To¬ peka, KS 66606; (913) 296-2575.

Kentucky

Sue Tuttle, Director, Division of Ag¬ ing Services, Cabinet for Human Re¬ sources, CHR Bldg, 6th Floor W, 275 E Main St, Frankfort, KY 40621 ; (502) 564-6930.

Richard Newman, Branch Man¬ ager, Adult Services, Division of Fam¬ ily Services, Department of Social Ser¬ vices, Cabinet for Human Resources, 275 E Main St, Frankfort, KY 40621; (502) 564-7043.

Louisiana

Robert Fontenot, Director, Office of Elderly Affairs, 4550 North Blvd, 2nd

Floor, PO Box 80374, Baton Rouge, LA 70806; (504) 925-1700.

Terry Gibson, Administrator, Program Operations Services, Divi¬ sion of Children, Youth, and Family Services, Department of Social Ser¬ vices, 1967 North St, PO Box 3318, Baton Rouge, LA 70820; (504) 342- 9931.

Maine

Elder Abuse Hot Line: In state: (800) 452-1999; Christine Gianopoulos, Di¬ rector, Bureau of Elder and Adult Ser¬ vices, Department ofHuman Services, State House Station, No. 11, Augusta, ME 04333; (207) 624-5335.

Maryland Rosalie Abrams, Director, Office on

Aging, State Office Bldg, 301 W Pre¬ ston St, Room 1004, Baltimore, MD 21201; (410) 225-1100.

Handy Brandenburg, Program Manager, Adult Protective Services, Department of Human Resources, 311 W Saratoga St, 5th Floor, Baltimore, MD 21201; (410) 333-0161.

Massachusetts

Elder Abuse Hot Line: In state: (800) 922-2275; Franklin Ollivierre, Sec¬ retary, Executive Office of Elder Af¬ fairs, 1 Ashburton PI, 5th Floor, Bos¬ ton, MA 02108; (617) 727-7750.

Donna Reulbach, Director, Pro¬ tective Services, Executive Office of Elder Affairs, 1 Ashburton PI, 5th Floor, Boston, MA 02108; (617) 727- 7750 Ext 302.

Michigan

Nancy Crandall, Director, Office of Services to the Aging, PO Box 30026, Lansing, MI 48909; (517) 373- 8230.

Ralph Young, Director, Office of Adult and Employment Services, De¬ partment of Social Services, 235 S Grand Ave, No. 504, PO Box 30037, Lansing, MI 48909; (517) 373- 2869.

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Minnesota

Elder Abuse Hot Line: In state: (800) 652-9747; Gerald Bloedow, Direc¬ tor, Board on Aging, 444 Lafayette Rd, St Paul, MN 55155-3843; (612) 296-2770.

Jim Varpness, Adult Protection Consultant, Aging and Adult Ser¬ vices, 444 Lafayette Rd, St Paul, MN 55155-3843; (612) 296-4019.

Mississippi Elder Abuse Hot Line: In state: (800) 354-6347; James Johnson, Direc¬ tor, Council on Aging, Division of Ag¬ ing and Adult Services, 421 W Pas- cagoula St, Jackson, MS 39203- 3524; (601) 949-2070.

Marva Hayes, Manager, Adult Protection Services, Department of Human Services, PO Box 352, Jack¬ son, MS 39205; (601) 354-6631.

Missouri

Elder Abuse Hot Line: In state: (800) 392-0210; Bryan Forbis, Director, Di¬ vision on Aging, Department of So¬ cial Services, 615 Howerton Ct, PO Box 1337, Jefferson City, MO 65102- 1337; (314) 751-3082.

Montana

Charles Rehbein, Acting Aging Co¬ ordinator, Governor's Office on Ag¬ ing, State Capitol Bldg, Capitol Sta¬ tion, Room 219, Helena, MT 59620; (406) 444-3111.

Donald Sekora, Program Of¬ ficer, Adult Protective Services, Pro¬ gram Bureau, Program and Plan¬ ning Division, Department of Family Services, PO Box 8005, Helena, MT 59604; (406) 444-5900.

Nebraska

Elder Abuse Hot Line: In state: (800) 652-1999; Jacklyn Smith, Director, Department on Aging, PO Box 95044, 301 Centennial Mall S, Lincoln, NE 68509; (402) 471-2306.

MaryJ. Iwan,Administrator, Spe-

cial Services for Children and Adults, Medical Services Division, Department ofSocial Services, PO Box 95026,301 Centennial Mall S, 5th Floor, Lincoln, NE 68509-5026; (402) 471-9345.

Nevada

Suzanne Ernst, Administrator, Divi¬ sion for Aging Services, Department of Human Resources, 340 11th St, Suite 114, Las Vegas, NV 89101; (702) 486-3545.

Dale Capurro, Director, Adult Protective Services, Department of Hu¬ man Resources, Welfare Division— Medicaid, Capitol Complex, 2527 Carson St, Carson City, NV 89710; (702) 687-4588.

New Hampshire Elder Abuse Hot Line: In state: (800) 852-3345; Richard Chevrefils, Di¬ rector, Division of Elderly Adult Ser¬ vices, 6 Hazen Dr, Concord, NH 03301-6501; (603) 271-4680.

New Jersey

Elder Abuse Hot Line: In state: (800) 792-8820; Lois Hull, Director, Di¬ vision on Aging, Department of Com¬ munity Affairs, South Broad and Front streets, CN807, Trenton, NJ 08625- 0807; (609) 292-4833.

Elga Lee, Supervisor, Adult Pro¬ tective Services, Division ofYouth and Family Services, Department ofHuman Services, 1 S Montgomery St, CN717, Trenton, NJ 08625; 609 292-6726.

New Mexico

Elder Abuse Hot Line: In state: (800) 432-6217; Michelle Lujan Grishan, Director, State Agency on Aging, LaVilla Rivera Bldg, 4th Floor, 224 E Palace Ave, Santa Fe, NM 87501, (505) 827-7640.

Shelley Gallegos, Bureau Chief, Adult Services Bureau, Social Ser¬ vices Division, Human Services De¬ partment, PO Box 2348, Pollón Bldg, Santa Fe, NM 87504-2348; (505) 827-8402.

New York

Jane Gould, Director, Office for the Aging, Agency Bldg 2, NewYork State Plaza, Albany, NY 12223; (518) 474- 4425.

Greg Guiliano, Director, Bu¬ reau of Community Services, State De¬ partment of Social Services, 40 Pearl St, Albany, NY 12243; (518) 432- 2980.

North Carolina

Elder Abuse Hot Line: In state: (800) 662-7030; Alfred B. Boyles, Assis¬ tant Secretary, Division of Aging, CB 29531, 693 Palmer Dr, Raleigh, NC 27626-0531; (919) 733-3983.

Vicki Kryk, Program Consult¬ ant for APS, Adult and Family Ser¬ vices, Division of Social Services, De¬ partment of Human Resources, 325 Salisbury St, Raleigh, NC 27611; (919) 733-3818.

North Dakota

Linda Wright, Director, Aging Ser¬ vices Division, Department of Hu-

,

man Services, PO Box 7070, North- brook Shopping Center, North Washington Street, Bismarck, ND 58507-7070; (701) 224-2577.

Ohio

Elder Abuse Hot Line: In state: (800) 686-1581; Judith Brachman, Direc¬ tor, Department ofAging, 50 W Broad St, 9th Floor, Columbus, OH 43266- 0501; (614) 466-5500.

Erika Taylor, Chief, Bureau of Adult Services, Division of Adult and Child Care Services, Family, Chil¬ dren, and Adult Services, Depart¬ ment of Human Services, 30 E Broad St, Columbus, OH 43266-0423; (614) 466-0995.

Oklahoma

Elder Abuse Hot Line: In state: (800) 522-3511; Roy Keen, Division Ad¬ ministrator, Aging Services Divi¬ sion, Department of Human Ser-

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vices, PO Box 25352, Oklahoma City, OK 73125; (405) 521-2327.

Barbara Kidder, Program Su¬ pervisor, Adult Protective Services, Aging Services Division, Depart¬ ment of Human Services, 312 NE 28th St, Oklahoma City, OK 73105; (405) 521-3660.

Oregon Elder Abuse Hot Line: In state: (800) 232-3020; Jim Wilson, Acting Ad¬ ministrator, Senior and Disabled Ser¬ vices Division, 313 Public Service Bldg, Salem, OR 97310; (503) 378- 4728.

Aileen Kaye, Program Man¬ ager, Abuse and Protective Services, Senior Services Division, Depart¬ ment of Human Resources, 313 Pub¬ lic Service Bldg, Salem, OR 97310; (503) 378-3751.

Pennsylvania Fraud and Abuse Hot Line: In state: (800) 992-2433; Linda Rhodes, Sec¬ retary, Department ofAging, 231 State St, Harrisburg, PA 17101-1195; (717) 783-1550.

James L. Bubb, Jr, Aging Ser¬ vices Specialist, Department of Ag¬ ing, 231 State St, Harrisburg, PA 17101-1195; (717) 783-6007.

Puerto Rico

Celia E. Cintron, Executive Direc¬ tor, Governor's Office for Elderly Af¬ fairs, Corbian Plaza, Stop 23, 1063 Ponce De Leon Ave, UM Office C, San Ture, PR 00908; (809) 721- 5710.

Maria I. Soldevila, Program Di¬ rector, Services to Adults, Depart¬ ment of Social Services, PO Box 11398, FernandezJuncos Station, San- turce, PR 00910; (809) 723-2127.

Rhode Island

Elder Abuse Hot Line: In state: (800) 322-2880; Robert F. McCaffrey, Ad¬ ministrator, Adult Services, Depart¬ ment of Human Services, 600 New

London Ave, Cranston, RI 02920; (401) 464-2651.

Maureen Maigret, Director, De¬ partment of Elderly Affairs, 160 Pine St, Providence, RI 02903-3708; (401) 277-2858; (401) 277-2880.

South Carolina

Ruth Seigler, Director, Commission on Aging, 400 Arbor Lake Dr, Suite B-500, Columbia, SC 29223; (803) 735-0210.

Tim Cash, Director, Division of Adult Services, Office of Children, Family, and Adult Services, Depart¬ ment of Social Services, PO Box 1520, Columbia, SC 29202-1520; (803) 734-5670.

South Dakota

Gail Ferris, Director, Office of Adult Services and Aging, Kneip Bldg, 700 Illinois St, Pierre, SD 57501; (605) 773-3656.

Tennessee

Emily Wiseman, Director, Commis¬ sion on Aging, 706 Church St, Suite 201, Nashville, TN 37243-0860; (615) 741-2056.

Marilyn Whalen, Program Man¬ ager, Adult Protective Services, So¬ cial Services Programs, Department of Human Services, Citizens Plaza, 400 Deaderick St, Nashville, TN 37219; (615) 741-5926.

Texas

Elder Abuse Hot Line: In state: (800) 252-5400; Mary Sapp, Executive Di¬ rector, Department on Aging, PO Box 12786, Capitol Station, 1949 IH 35 S, Austin, TX78741-3702; (512)444- 2727.

Judith Rouse, Director, Adult Protective Services, Department of Hu¬ man Services, PO Box 149030, Aus¬ tin, TX 78714-9030; (512) 450- 3211.

Utah

Robin Arnold-Williams, Director, Di¬ vision ofAgingandAdult Services, De¬ partment of Social Services, 120 N, 200 W, PO Box 45500, Salt Lake City, UT 84145-0500; (801) 538-3910.

Vermont

Elder Abuse Hot Line: In state: (800) 564-1612; Lawrence Crist, Commis¬ sioner, Aging and Disabilities, Ladd Hall, 103 S Main St, Waterbury, VT 05676, (802) 241-2400.

Mark Schroeter, Chief, Adult Protective Services, Aging and Dis¬ abilities, Ladd Hall, 103 S Main St, Waterbury, VT 05676; (802) 241- 2345.

Virginia

Thelma Bland, Commissioner, De¬ partment for the Aging, 700 Centre, 10th Floor, 700 E Franklin St, Rich¬ mond, VA 23219-2327; (804) 225- 2271.

Joy Duke, Program Supervisor, Adult Protective Services, Bureau of Adult and Family Services, Division of Service Programs, Department of Social Services, 8007 Discovery Dr, Richmond, VA 23229-8699; (804) 662-9241.

Washington

Charles Reed, Assistant Secretary, Ag¬ ing and Adult Services Administra¬ tion, Department of Social and Health Services, PO Box 45050, Olympia, WA 98504-5050; (206) 586-3768.

Vicki Loyer, APS Program Man¬ ager, Adult Protective Services Pro¬ gram, Department of Social and Health Services, 623 Eighth SE, Olympia, WA 98504-0095; (206) 753-5227.

West Virginia

Elder Abuse Hot Line: In state: (800) 352-6513; David K. Brown, Execu¬ tive Director, Commission on Ag¬ ing, Holly Grove-State Capitol,

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Charleston, WV 25305; (304) 558- 3317.

Ronald Nestor, Director, Ser¬ vices to the Aged, Blind, and Dis¬ abled, Social Services Bureau, De¬ partment of Human Services, State Capitol Complex, Bldg 6, Room B850, Charleston, WV 25305; (304) 558- 7980.

Wisconsin

Donna McDowell, Director, Bureau ofAging, Division of Community Ser¬ vices, 217 S Hamilton St, Suite 300, Madison, WI 53707; (608) 266- 2536).

Wyoming Elder Abuse Hot Line: In state: (800) 528-3396; Morris Gardner, Admin¬ istrator, Commission on Aging, 139 Hathaway Bldg, Cheyenne, WY 82002- 0710; (307) 777-7986.

Joe Nies, Program Manager, Fam¬ ily Services, Division of Public Assis¬ tance and Social Services, Department ofHealth and Social Services, 139 Hath¬ away Bldg, Cheyenne, WY82002-0710; (307) 777-6082.

STATE LONG-TERM-CARE OMBUDSMAN PROGRAM

DIRECTORS

The following numbers should be used for assistance in evaluating po¬ tential abuse and neglect in institu¬ tions.

Alabama

Marie Tomlin, Commission on Ag¬ ing, RSA Plaza, Suite 470, 770 Wash¬ ington Ave, Montgomery, AL 36130; (205) 242-5743.

Alaska

William O'Connor, Office of the Long- term-Care Ombudsman, Older Alas¬ kans Commission, 3601 C St, Suite 260, Anchorage, AK 99503-5209; (907) 563-6993 (accepts collect calls from older persons).

Arizona

Rosalind Webster, Aging and Adult Administration, PO Box 6123- 950A, 1789 WJefferson 950A, Phoe¬ nix, AZ 85007; (602) 542-4446.

Arkansas

Raymond Harvey, Division of Aging and Adult Services, 1417 Donaghey Plaza S, PO Box 1437, Seventh and Main streets, Little Rock, AR 72203- 1437; (501) 682-2441.

California

Sterling Boyer, Department on Ag¬ ing, 1600 St, Sacramento, CA 95814; (916) 323-6681; (800) 231- 4024.

Colorado

Virginia Fraser, The Legal Center, 455 Sherman St, Suite 130, Denver, CO 80203; (303) 722-0300; (800) 332- 6356.

Connecticut

Ida Arbitman, Department on Ag¬ ing, 175 Main St, Hartford, CT 06106; (203) 566-7770.

Delaware

Marietta Z. Wooleyhan, Division on

Aging, 1113 Church Ave, Milford, DE 19963; (302) 422-1386; (800) 223- 9074.

District of Columbia

Ann Hart, Legal Counsel for the Eld¬ erly, 601 E St NW, Washington, DC 20049; (202) 662-4933.

Florida

Barbara Hengstebeck, Executive Di¬ rector, State LTC Ombudsman Coun¬ cil, Office of the Governor, 154 Hol¬ land Bldg, Tallahassee, FL 32399- 0001; (904) 488-6190.

Georgia

Joanne Mathis, Office of Aging, De¬ partment of Human Resources, 878 Peachtree St NE, Room 632, At¬ lanta, GA 30389; (404) 894-5336.

Hawaii

Sandy Rongitsch, Executive Office on

Aging, 335 Merchant St, Room 241, Honolulu, HI 96813; (808) 548-2593.

Idaho

Arlene Davidson, Office on Aging, State House, Room 108, Boise, ID 83720; (208) 334-3833; (208) 334-2220.

Illinois

Neyna Johnson, Department on Ag¬ ing, 421 E Capitol Ave, Springfield, IL 62701; (217) 785-3140.

Indiana

Robyn Grant, Division of Aging and Rehabilitative Services, Department of Family Social Services Adminis¬ tration, 402 W Washington St, No. 454, PO Box 7083, RE-431, India¬ napolis, IN 46207-7083; (317) 232- 7134; (800) 622-4484.

Iowa

Carl McPherson, Department of El¬ der Affairs, Jewett Bldg, Suite 236, 914 Grand Ave, Des Moines, 50319;(515) 281-5187.

Kansas

Myron Dunavan, Department on Ag¬ ing, Docking State Office Bldg, 122 S, 915 SW Harrison, Topeka, KS 66612-1500; (913) 296-4986; (800) 432-3535.

Kentucky

Gary Hammonds, Division for Ag¬ ing Services, Cabinet for Human Re¬ sources, CHR Bldg, 6th Floor W, 275

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E Main St, Frankfort, KY 40621 ; (502) 564-6930; (800) 372-2291.

Louisiana

Hugh Eley, Linda Sadden, Gover¬ nor's Office of Elderly Affairs, 4550 North Blvd, PO Box 80374, Baton Rouge, LA 70898-3074; (504) 925- 1700.

Maine

Brenda Gallant, Legal Service for the Elderly, PO Box 2723, 113 Bangor St, Augusta, ME 04333; (207) 289- 4056.

Maryland Condict Stevenson, Office on Ag¬ ing, 301 W Preston St, Room 1004, Baltimore, MD 21201; (410) 225- 1083.

Massachusetts

Mary McKenna, Executive Office of Elderly Affairs, 38 Chauncy St, Bos¬ ton, MA 02111; (617) 727-7750.

Michigan Hollis Turnham, Citizens for Better Care, 416 Homer St, Suite 101, Alpha Bldg, Lansing, MI 48912; (517) 336-6753; (800) 292-7852.

Minnesota

Jim Varpness, Board on Aging, Of¬ fice of Ombudsman for Older Min- nesotans, 444 Lafayette Rd, St Paul, MN 55155-3843; (612) 296-0382; (800) 652-9747.

Mississippi Cinda Martin, Council on Aging, 421 W Pascagoula St, Jackson, MS 39203; (601) 949-2070.

Missouri

Carol Scott, Division of Aging, De¬ partment of Social Services, PO Box

1337, 615 Howerton Ct, Jefferson City, MO 65102; (314) 751-3082.

Montana

Doug Blakley, Governor's Office on

Aging, State Capitol Bldg, Capitol Sta¬ tion, Room 219, Helena, MT 59620; (406) 444-4676; (800) 332-2272.

Nebraska

Geri Tucker, Department on Aging, PO Box 95044, 301 Centennial Mall S, Lincoln, NE 68509-5044; (402) 471-2306; (402) 471-2307.

Nevada

Steve Empey, Division for Aging Ser¬ vices, Department of Human Re¬ sources, 340 11th St, Suite 114, Las Vegas, NV 89101; (702) 486- 3545.

New Hampshire

Doris Beck, Division of Elderly and Adult Services, 6 Hazen Dr, Con¬ cord, NH 03301-6508; (603) 271- 4375; (800) 442-5640.

New Jersey

Thomas Brown, Acting State Om¬ budsman, Office of the Ombuds¬ man for the Institutionalized Eld¬ erly, 28 W State St, Room 305, CN808, Trenton, NJ 08625-0807; (609) 292-8016; (800) 624-4262.

New Mexico

Tim Covell, State Agency on Aging, LaVilla Rivera Bldg, 4th Floor, 224 E Palace Ave, Santa Fe, NM 87501; (505) 827-7640.

New York

David Murray, Office for the Aging, Agency Bldg, No. 2, Empire State Plaza, Albany, NY 12223; (518) 474- 7329.

North Carolina

Debbie Brantley, Department of Hu¬ man Resources, Division ofAging, 693 Palmer Dr, CB-29531, Raleigh, NC 27603;(919) 733-8400.

North Dakota

Jo Hildebrant, Aging Services Divi¬ sion, Department of Human Ser¬ vices, Northbrook Shopping Cen¬ ter, North Washington Street, PO Box 7070, Bismarck, ND 58507; (701) 224-2577; (800) 472-2622.

Ohio

Roland Hombostel, Department of Ag¬ ing, 50 W Broad St, 9th Floor, Co¬ lumbus, OH 43266-0501; (614) 466- 1221; (800) 282-1206.

Oklahoma

Esther Allgood, Division ofAging Ser¬ vices, Department of Human Ser¬ vices, PO Box 25352, Oklahoma City, OK 73105; (405) 521-6734.

Oregon Meredith Cote, Office of Long-term- Care Ombudsman, 2475 Lancaster Dr NE, Bldg , No. 9, Salem, OR 97310; (503) 378-6533; (800) 522-2602.

Pennsylvania LindaJackman, Department ofAging, Barto Bldg, 231 State St, Harrisburg, PA 17101; (717) 783-7247.

Puerto Rico

Norma Venegas, Governor's Office for Elderly Affairs, Corbian Plaza, Stop 23, 1603 Ponce De Leon Ave, UM Office C, San Ture, PR 00908; (809) 722-2429.

Rhode Island

Cathy McKeon, Department of Eld¬ erly Affairs, 160 Pine St, Provi¬ dence, RI 02903;(401) 277-6883.

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South Carolina

Mary B. Fagan, Office of the Gover¬ nor, Division of Ombudsman and Cit¬ izens' Service, 1205 Pendleton St, Co¬ lumbia, SC 29201; (803) 734- 0457.

South Dakota

Rolland Hostler, Office of Adult Ser¬ vices and Aging, Department of So¬ cial Services, Richard F. Kneip Bldg, 700 Illinois St, Pierre, SD 57501- 2291; (605) 773-3656.

Tennessee

Jane Bridgman, Commission on Ag¬ ing, 706 Church St, Suite 201, Nash¬ ville, TN 37219-5573; (615) 741- 2056.

Texas

John Willis, Department on Aging, PO Box 12786, Capitol Station, 1949 IH 35 S, Austin, TX 78741-3702; (512) 444-2727; (800) 252-9240.

Utah

Sally Brown, Division of Aging and Adult Services, Department of Hu-

man Services, 120 , 200 W, Room 401, PO Box 45500, Salt Lake City, UT 84145-0500; (801) 538-3920 (Attn: Michelle Wisner).

Vermont

Camille George, Department of Ag¬ ing and Disabilities, 103 S Main St, Waterbury, VT 05676; (802) 241- 2400; (800) 642-5119.

Virginia

Mark Miller, Department for the Ag¬ ing, 700 E Franklin St, 10th Floor, Richmond, VA 23219-2327; (804) 225-2271; (800) 552-3402.

Washington

Kary Hyre, State Ombudsman Pro¬ gram, Multi-Service Center, 1200 S 336th St, Federal Way, WA 98504- 5600; (206) 838-6810; (800) 422- 1384.

West Virginia

Carolyn Riffle, Commission on Ag¬ ing, State Capitol Complex, 1900 Kanawha Blvd E, Charleston, WV 25305-0160; (304) 558-3317.

Wisconsin

George Potaracke, Board on Aging and LTC, 214 Hamilton St, Madison, WI 53703;(608) 266-8944.

Wyoming

Debra Alden, State Ombudsman Pro¬ gram, 953 Water St, PO Box 94, Wheatland, WY 82201; (307) 322- 5553.

REFERENCES

1. Pillemer K, Finkelhor D. The prevalence of elder abuse: a random sample survey. Gerontologist. 1988;28:51-57.

2. The Mount Sinai/Victim Services Agency Elder Abuse Project. Elder Mistreatment Guidelines for Health Care Professionals: Detection, Assess- ment and Intervention. New York, NY: Mount Sinai/ Victim Services Agency Elder Abuse Project; 1988.

3. Douglas RL. Domestic Mistreatment of the Eld- erly: Towards Prevention. Washington, DC: Crim- inal Justice Services, American Association of Retired Persons; 1987.

4. American Association of Retired Persons. Do- mestic Mistreatment of the Elderly: Towards Pre- vention\p=m-\Some Dos and Don'ts. Washington, DC: Criminal Justice Services, American Association of Retired Persons; 1987.

5. Health Care Financing Administration. Survey Pro- cedures, Forms and Interpretive Guidelines for the Long Term Care Survey Process. Spring- field, Va: National Technical Information Ser- vice, US Dept of Commerce; 1992. Publication No. PB-92-95003.

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