 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Welcome back everybody. Today we're going to be talking about preventing elder abuse. And I know we talked about the indicators for child and elder abuse last week or the week before. This is going to go more in depth into elder abuse because it's a growing problem. And, you know, a lot of us specialize in adults, so to speak. But we will work with elders, whereas I very rarely work with children. So it's important to be aware of elder abuse and the issues that go along with that. So we're going to define elder abuse, examine the prevalence, identify the risk factors and explore prevention strategies. We're going to kind of go through the whole gamut. And please, if you have any questions, comments, want to add anything in here, feel free to put it in the chat window and I will answer those questions as quickly as possible. So physical abuse means the use of physical force which results or could result in physical injury to an incapacitated adult. Now, I don't like that term, but that was what was used in the Governor's Domestic Violence Task Force report that's in your class. So we're going to use it. So it is any adult, if you remember, that is 60 or older who for some reason does not have the capability to defend themselves or to make effective decisions. The same thing can be true for an incapacitated adult under the age of 60. But, you know, today we're going to focus on 60 plus. Sexual abuse means contact or interaction of a sexual nature involving an incapacitated adult who's being used without his or her informed consent. Now, one of the things that comes up with, especially with older adults who may have dementia, late stage dementia, they may not recognize the person that's in front of them as the person that's in front of them. They may see it as their husband who passed away 20 years ago or a former lover. And they may think that they are interacting with that person and that, you know, crosses that boundary into sexual abuse. If you know the person doesn't realize that they're interacting with you, then they're not making an informed decision. So we do need to pay special attention to sexual abuse issues with adults that have dementia. Emotional abuse means the misuse of power, authority or both, including verbal harassment, unreasonable confinement, which results or could result in the mental anguish or emotional distress of an adult. So we keep saying or could result. It doesn't necessarily have to produce harm. If it could produce harm, then it's considered abusive. For an example, for any kind of abuse, we'll take physical abuse because that's the most demonstrative, if you will. If a person is physically abused and, you know, gets hit with something really hard, but for some reason it doesn't leave a mark. It doesn't leave a bruise. Does that mean a physical abuse didn't happen? Well, no, we would never say that. So just because the being struck did not cause actual physical harm doesn't mean it wasn't abuse. Neglect means an active omission which results or could result in the deprivation of essential services necessary to maintain the minimum mental, emotional or physical health and safety of an adult. So again, when we look at neglect, we want to look at what could result. So if Aunt Sally is having difficulty taking care of herself and she needs somebody to bring her groceries, and, you know, the person who normally brings her groceries forgets to do it for a week. Could Aunt Sally probably survive on the remnants of what she's got in the house? Possibly, probably. You know, a lot of times they have crackers and stuff. Is it healthy now? But could it cause problems? Yes, if she went a week without food, it could cause a lot of problems. So we want to look at neglect and the possibility of neglect. And again, if you're reporting to an agency, then you can call and just tell them, you know, hypothetically or whatever, I've got this situation. You don't have to give names and addresses right away and ask them if it rises to a level that they are willing to take a report on it. If they say yes, make the report, get their operator number, badge number, whatever it's called, where you're at. If they say no, still get their operator number or badge number so you can document the time you called, the date you called, and the person you talked to who said that they were going to decline to take the report. That way you're covered. If you feel really strongly that something is wrong and they need to take a report, then you can always try to speak to a supervisor. Self-neglect is something that comes up with elders that's not going to come up with children for the most part. Most of the time we expect parents to care for children and we expect children to sometimes self-neglect. You know, when my children were little, if I did not stay on them about taking a bath every day and doing those sorts of things, they probably wouldn't. So, you know, as adults, we're responsible for doing that for children. Older adults typically are responsible for doing that for themselves. So are they sleeping? Are they eating? And eating changes are one that you see a lot in older people. In some situations, I've seen doctors prescribe certain medications like Remeron for older adults who have a little bit of depression but have no appetite. Because Remeron often increases appetite. Not that I'm recommending Remeron, I'm just giving you an example. So self-neglect are those things that we need to be aware of? Are they taking their medication? Are they willingly or willfully not taking their medication? Or can they not remember to take their medication? And if you've worked with elders, a lot of times as people get older, they get more and more pills that they've got to take, unfortunately. So sometimes it gets confusing about what to take when and to remember it and all that other stuff. Yes, they're not necessarily running six ways till Sunday, but their memory may not be that good. So there are things that you can do to prompt them in their environment to take their medications. One of the best ways if they have a mobile device is to get one of those medication reminder apps and have their medication separated out for them in those weekly divider thingies. So all they have to do is go take a handful of pills and they can get their medication in. So there are things that you can do to help them maintain their independence, but we need to make sure if they're not doing something. Number one, is it willful? If so, there's a whole different set of interventions. If it's not willful, if they're just forgetting or they have no appetite, then we want to look at what can we do to prompt them. When my grandmother was getting older, when she hit like 82, she just had no appetite. And I mean, when she was younger, she used to eat like a half a sandwich for lunch and not a whole big dinner. She was never a big eater, but she had no appetite and it wasn't that she was trying to starve herself. She would just plum forget to eat. She start looking at her stories as she put it and cleaning and doing those sorts of things and puttering around. And before she knew it, the day had gone by and it wasn't like she got hungry. She just forgot to eat. So we needed to remind her, you know, Grandma, you need to eat. And we put some prompts in her calendar that reminded her to eat. And my uncle calls her every night to make sure that she remembered to at least eat dinner if she ignored the other prompts. Exploitation means that the illegal use of an incapacitated adult person or property for another person's profit or advantage. And this can be done by caregivers, by family members, by friends, by businesses. So we're going to really look at that in a few more minutes. And domestic violence is a pattern of coercive control that one family member exercises over another. So elders can be in domestically violent relationships either, you know, with their partner or maybe they move back in with their kids and it becomes violent between them and their kids. Remembering that in some people, and unfortunately a lot of people in late stages of Alzheimer's, they can become somewhat aggressive. So we want to look at interventions for that aggressive behavior and not pathologize it and make the caregiver feel guilty like it's domestic violence. We want to make sure that we're addressing the violence, but we need to understand what's going on. Some people because of lack of understanding about how to handle progressive dementia may take steps that are abusive or neglectful. Trying to protect the person such as putting one of those storm doors. I just read a story about this the other day. An elder had a storm door attached to his bedroom. So one of those locked from the outside. So his grown child was locking him in his room at night so he wouldn't get out and wander. And that's a problem. We can't seclude and restrain people. So we want to look at any domestic violence that may be going on, any threats, you know, if grandma moves back in with the kids and the kids start saying, okay, we're not going to take care of you unless you do this and starts using power, threats, emotional abuse. That can all be considered domestic violence. So what's the prevalence? Unfortunately, it's about 10%. One in 10. Wow, just kind of let that sink in for a little while. Verbal mistreatment accounts for about 9% of the elder abuse. Financial mistreatment, about 3.5% of elders say they've been financially mistreated. And physical mistreatment, they often report is less than 1%, which is a lot lower than what I would have thought. Now again, you don't need to know these specific statistics for the test. I just kind of want to give you an overview. You realize that 9 plus 3.5 plus 1 is way more than 10. So you see that some elders are experiencing multiple types of abuse. 260,000 or approximately one in 13 older adults in the state of New York in one study had been victims of at least one form of elder abuse in the preceding year. That makes me sad. Adult protective service agencies show an increasing trend in the reporting of elder abuse. Now, I don't really think, and I'm just hypothesizing I don't have data, and obviously we wouldn't. But I'm thinking as we become more aware of elder abuse, it's becoming more reported. I don't know how much the incidence is actually increasing. I think our awareness is increasing, which is good. I mean, the incidence is bad, but the fact that we're becoming more aware is awesome. About one out of every 14 incidents of elder abuse are reported. So that's a really small number. That's like 8% or something. Only one out of every 25 cases of financial exploitation are reported. So these are the types of exploitations that we see in dramas on TV and you may see in your own family when people are trying to jockey for who's going to get what portion of the will and trying to get control of financial assets before the elder has even passed. According to the Nursing Home Abuse Center, and I put the link on there because these stats were kind of startling to me, about 3.2 million US citizens lived in nursing homes in 2009. Okay, that doesn't necessarily surprise me. 2000 nursing facility residents indicated an abuse rate of 44% and a neglect rate of 95%. So, I mean, let's think about that. Let's think about those numbers here. Those are huge stinking numbers. And I'm wondering why those numbers seem so much higher in the nursing homes where 95% of the patients, the 2000 patients surveyed, reported being neglected. So, we want to look at some of the methodology in that study before we draw conclusions that nursing homes are bad, but it's important to be aware. Complaints of abuse, exploitation or neglect accounted for 7% of complaints given to ombudsmen at long-term care facilities. So, even though 44% report being abused and 95% report being neglected, the ombudsmen only 7% of the complaints they get are for abuse and neglect. So, there's a disconnect here. There's a lot of patients who are experiencing what they perceive as unacceptable treatment and it's not going anywhere. They're just feeling trapped. Dementia is a risk factor. In a 2009 study, it revealed that close to 50% of people with dementia experienced some kind of abuse. So, why is this important? Well, if we've got a client that has early onset dementia, that has alcohol-related dementia, that has, you know, some cognitive deficits in any sort of way, but especially dementia, we want to be aware of that. But it also means that we need to start educating the caregivers about what dementia is, how it may progress, what resources are there, and, you know, what they can do when these behaviors come up. Oh, and what the difference is between dementia and normal behavior in an older person. As we get older, our system kind of slows down. Our cognitive processing slows down a little bit. It doesn't mean we lose intellect. We've actually shown that after retirement, a lot of people's intellect actually increases because they start engaging in recreational activities and learning new hobbies again. You know, they're taking on new things. I thought that was a neat little point. But it takes us a little bit longer sometimes to process stuff. So, what we want to look for in people that may have dementia is memory loss that disrupts daily life. You know, they get confused and forget how to brush their teeth or whatever. But there's also typical forgetfulness. You know, I'm not 60 plus yet and I forget where I left my keys. I'll forget where I left my shoes. Most of the time I put them away, but occasionally I forget. And that doesn't mean I've got early onset dementia. It's important that we help people not get freaked out if their parent or if an older adult starts forgetting some things. We really want to look at the extent, the degree of what they're forgetting and how important it is. If they're forgetting, for example, to take their pills, we can put reminders in. We can try putting interventions in to help them. If that doesn't work, then we may need to look for something else to assist them. They have challenges in planning or problem solving. You know, sometimes it's difficult to think things all the way through. And sometimes people, as they get older, get confused a little bit easier. That's not unnatural. And they may make occasional errors doing things like balancing their checkbook or paying bills or going from point A to point B. They may get lost in the way, but they can retrace their steps. They may have difficulty completing familiar tasks. This differs from normal aging and normal aging people occasionally need help with things. You know, think about, I think about myself and periodically I'm looking at the three remote controls that are sitting on the coffee table going, I just give them to my daughter. I'm like, Hey, Lee, turn something on TV. But, you know, occasionally as we age, things change, we may need help with things and that's okay. People with dementia have confusion with time or place and they can't seem to get re-grounded as opposed to temporary disorientation. As people get older, they will often wake up in the middle of the night and be disoriented for a moment. And for a moment is okay when they start forgetting people's names and not knowing where they are. That's a much bigger cue as to what's going on. Having difficulty reading or judging distance can interestingly be a sign of dementia, but it also can be a sign of cataracts. So again, we don't want to jump to conclusions. Problems with words in speaking or writing. Part of this again is because they may have slower processing. So if the older person takes a couple of minutes to get their thoughts together, doesn't necessarily mean there's a reason to freak out. Misplacing things with an inability to retrace their steps, especially if they indicate and start accusing people of stealing. Paranoia goes up, they can't figure out where it went. They can't think about, you know, okay, when I came home last night, what did I do? Where did I go? Where might I have left my keys? A lot of times, you know, people can retrace their steps even if it's sort of illogical. And I remember one time my grandfather had put his eyeglasses in the freezer. I don't know what he was doing, but, you know, he had come back from his run and he was making his aloe shake and doing other things and he went into the freezer. And I guess he must have had his glasses in one hand and he needed to get ice. So he said his glasses in the freezer to get ice. I don't know. But he was able to retrace his steps and figure out what he did. And that's how we found his glasses. Increases in poor judgment as opposed to occasional lapses in judgment. Withdrawal from social activities can be a sign of dementia because it's harder for people with dementia to understand what's going on. They don't feel understood. They get confused easy. And it starts to become a very scary place. Now, some people, as they get older, get tired and they're not going to want to do as much. If they were on the go all the time, as they get older, they may slow down a little. The woman that runs the rescue that I work with, she's 74 now and she still goes once a year on a trip somewhere and does a hundred mile bike ride. I'm like, you go, girl. That is awesome. I hope I have that much energy when I'm 60, let alone mid-70s. But not everybody has that level of energy that they can devote. And changes in mood or personality can, especially if they're rapid changes, can indicate that there might be some onset of dementia. Now, older people typically do develop rigid routines and may become a little cranky if their routines are interrupted in some way. So don't confuse having rigid routines and being a little bit cranky when that happens with people having rapid changes in their mood and personality. And Pat points out, and I hadn't thought of this, that hearing loss may also have some of the same signs. So again, always go from a biopsychosocial perspective. Get a physician to evaluate the person for cataracts, for hearing loss, for low blood pressure, anything that might contribute to some of these warning signs other than dementia. And we can start screening the person. It's always a good idea when you're working with clients that are over the age of 60 to start screening annually for dementia. It doesn't have to be a full assessment, just one of those quick validated screening instruments. Other risk factors for abuse and neglect include low social support and social isolation. If the person is, you know, homebound for some reason, then it's easier for people to take advantage of them because other people aren't going to find out. You know, grandma's at home, nobody's going to see the bruises. So it's important to try to get those people to come out or get visitors to go in. And depending on your community around here, we actually have a volunteer unit through the sheriff's office that will go drop in on homebound elders to make sure that they're doing okay. You know, it's not meals on wheels, that's a whole different program. But it's just sort of a preemptive well-being check, if you will. And it does a lot of good. If a person has experienced previous traumatic events, including domestic violence, it has been found to increase the risk for emotional, sexual and financial mistreatment. Previous traumas may make people feel disempowered, may make them feel afraid, may make them feel like they need to be passive. So it's easier for people to take advantage of them. They may also feel they deserve it. And so those are areas that we can address with elders to make sure that we're approaching treatment with them as well as with anybody else from a trauma-informed perspective. Functional impairment and poor health are also associated with a greater risk of abuse and reluctance to report. If grandma knows that she can't live on her own and she doesn't want to go live in a nursing home, even if she's living with her son or daughter or somebody who is abusing her, she may not say anything because she knows that if she turns them in, then she's going to an assisted living facility and she doesn't want to go there. So a lot of times older people will be more reluctant to report. Again, one of the things that we need to do is look at the quality of care in nursing homes and make sure that the places that they go actually are, you know, Jaco accredited and providing a high quality of care. If the person is living with a large number of household members other than a spouse, then they may have an increased risk of abuse, especially financial abuse. It's really easy for people to start hitting up the elder person for a little money here, a little money there, then a little more money and it can wear on the person. They may also be vulnerable due to grief from a recent loss. If they just lost their spouse, they may be willing to do anything in order to try to quell that grief. So by giving a lot of money to somebody, it may make them feel happy for the moment, but then they don't have any money to live on. So we want to make sure that people aren't taking advantage of their vulnerabilities. Lower income or poverty can contribute to increased physical or verbal abuse. Regular income or accumulated assets can increase verbal and or financial abuse. So if somebody has money, you know, we want to make sure that that person's money is protected. And I hate to keep talking about money, but it happens. And then you end up with elders who worked to their bone their entire lives and they're barely getting by in their later years because they've been exploited. If they're unfamiliar with financial matters, they can be exploited. My grandmother was a perfect example. Loved her to death, but my grandfather always handled the finances. And once he passed, when anything went wrong at the house, she would just her anxiety would literally go through the roof. She would pass out. She would get so stressed out. So my uncle would go over there and handle it because she wasn't familiar with working with contractors and paying bills and everything. That was just nothing, something that she had never had to do. She grew up during the depression. She grew up with a culture that the man of the house handled the money. Other factors have been found to be associated with financial exploitation, including the non use of social services. Again, the more isolated the person is, the easier it is for someone unscrupulous to come in and take advantage and nobody will notice. The need for activities of daily living assistance. So if they need a caregiver to come in and help them, that means there are more people coming in that could potentially take advantage of them. But it also means, if you remember from the last slide, that they may be less willing to report any abuse or exploitation because they want to stay in their house. They want to stay in their home. If they have poor self-rated health, then they may be more vulnerable to exploitation because they may feel grateful to anybody just coming in to take care of them. And they want to make sure those people stay around. If they don't have a spouse or partner, that loneliness may kick in, especially if they are homebound, but not necessarily. In South Florida, where I grew up, it was not uncommon, unfortunately, for young people to get in relationships with much older people and use them for their money. Now, not to say that there couldn't have been some true love there, but a lot of times, you know, the strippers from the clubs, strip clubs are really popular in South Florida would hook up with somebody who was a regular patron. So, you know, it was unpleasant. And African American race, interestingly, is another factor associated with financial exploitation. Sociocultural factors that may affect the risk. Depiction of older adults as frail, weak, and dependent. Some cultures see elders as very wise as the pinnacle of the family, as the one who's making a lot of the decisions. Other cultures see them as something to be discarded, unfortunately. So, we need to look at what do we see elders as, and make sure that the community values elders as important people. Yes, they may be frail and weak in some cases, but not all. So, we want to highlight some of these things in a culturally sensitive way, and that's, you know, you're going to have to walk sort of gingerly on a line there. There can be erosion of the bonds between generations of a family. So, if the kids have disowned mom, and as mom gets older, then she may not have anybody to lean on when she starts hitting her later years. Systems of inheritance and land rights affecting the distribution of power and material goods within families. If we're talking about people jockeying for space in a will, you know, you may see exploitation, you may see abuse, you may see somebody try to bully the elder into changing their will. Migration of young couples, leaving elderly parents alone in societies where older people were traditionally cared for by their offspring. Now, you think, well, that doesn't happen here. Yeah, it does. You know, culturally, people may migrate to the United States, but they may not become fully acculturated to American culture. They may still hold on to their cultural values. So, if that's true, and if in their culture they're supposed to take care of their parents, and then they decide to take a job across the country, then the parents may be left floundering a little bit, and lack of funds to pay for care. Within institutions, risk factors that we might want to look for are standards for healthcare, welfare services, and care facilities that are low. So, when you walk into the facility, if it smells like urine, if it looks dirty, if it gives you a bad feeling, you know, that's a warning sign. So, we want to make sure that, you know, all of these things are up to standards. If you walk into one of those facilities that's accredited by JCO or CARF, and you find it to be unacceptable, you can make reports to your local, to your State Department of Children and Families, to your Department of Elder Affairs, and to JCO or CARF, whatever their accrediting agency is, if you feel that something needs to be done, if the conditions are that bad. If the staff are poorly trained, poorly paid, and overworked, which is pretty much most of these facilities, you know, we can do things to increase education, so we increase training. If people are more educated, if they have more tools to effectively work with clients who may be experiencing dementia or grief or other things that are common in later life, then their workload will feel easier. They're not going to feel like they're walking against the wind. So, the low pay for it may not be as crucial, because if we can help them have the tools and feel empowered in their job, then they may like their job. And if you'll like your job, that goes a long way. If the physical environment is deficient, so ideally we want to look around for signs that there are not things there for stimulation, social stimulation, mental stimulation, the ability for people to get up and walk around. Or where policies operate in the interest of the institution rather than the residents. You're not going to see this in accredited facilities. You're really not. But in facilities that are not accredited, it can happen. So we want to make sure that all of the rules and regulations are really there to enhance the life of the resident. Perpetrators of financial exploitation. Family members, not surprising, are the most common perpetrators at about 58%. Followed by, interestingly enough, friends and neighbors at 17%. Then home care aides, 15%. The business sector, 12%. Physicians and nursing homes that bill Medicare and Medicaid are responsible for about 4% of the financial exploitation in terms of Medicare and Medicaid fraud. So they use the elder. You know, they may not be taking money from the elder, so to speak, but they are using the elder and misdiagnosing or kind of massaging the diagnose to get paid more than they should. Nearly 60% of perpetrators are men, most of financial exploitation, mostly between the ages of 30 and 59. The abuse of older residents by other residents in long-term care facilities is now recognized as a problem that is more common than physical abuse by staff. Now, remember that study with the 2000 residents where, you know, a preponderance of them said they'd been either neglected or abused. You know, that can fall into all levels of abuse, emotional abuse, physical abuse, sexual abuse and financial. So, you know, physical abuse by staff is, you know, not huge, but it's not small either, but we do want to recognize the risk for abuse between residents. Physical, mental, sexual and financial. So, paying attention to how residents are treating one another, making sure that residents without dementia are not taking advantage of residents with dementia, making sure they're not stealing each other's medications or, you know, trying to exploit them financially or taking advantage of the fact that the person with dementia is not oriented to person, place and time. The direct medical costs of injuries because of elder abuse and neglect cost more than $5.3 billion annually in the U.S. Most adverse events in nursing homes are due largely to inadequate treatment, inadequate care and understaffing, which leads to what they call preventable harm of $2.8 billion per year just in Medicare expenses each year. So, one of the things as clinicians we can do is try to connect with nursing homes and offer low-cost training, offer outreach services. Sometimes you can bill for that under certain parts of Medicaid or state funding. So, if you're at a publicly funded institution, you may be able to go do outreach in these sorts of facilities to help prevent this abuse. Other societal costs may include expenses associated with prosecution punishment and rehabilitation of elder abuse perpetrators. Elder abuse causes victims to be more dependent on caregivers. If you're injuring them, you're reducing their physical quality of life as well as their emotional quality of life, so they become more dependent. As a result of providing care, caregivers experience declines in their own physical, mental and financial health. So, it's a downward negative spiral here. We want to help build families up, not watch them wither away. It is so important that caregivers have access to information about, again, the signs and symptoms of dementia, but also other common issues with older adults when older adults move in with their adult children. Kind of like a blended family there. There are a whole lot of issues that can come up. And if we help people understand you're not alone and here are some tools and resources that you can access. Here are some support groups. Here are some respite care. We can reduce a lot of the problems and a lot of the abuse and neglect. So, signs. I'm going to go through these real quick because we went through them last week. Being malnourished, not directly due to an illness. If the elder has poor hygiene, untreated severe bed sores, an injury that hasn't been properly cared for. If they have sunken cheeks or eyes with evidence of poor circulation, that probably may give you an indication of dehydration. Being given the wrong type or wrong amount of medication. Maybe because the meds are being stolen or maybe because they want to dope up the elder so they don't have to deal with them. Frequently going to the emergency room or doctor, having a lack of basic necessities. STDs, bleeding, bruising on genitalia or inner thighs, heat or rope burns. You want to look for signs of restraint around the wrists and ankles. You want to look for those glove burns that we talked about where an elder may have had their entire hand put in scalding hot water or their entire foot put in scalding hot water or their entire bum. If medical doctors need to be aware of signs that the elder has been forced to sit in scalding hot water. Being ambivalent, resigned or responsive, making up implausible stories about how an injury occurred. Because their processing is a little bit slower, a lot of times adults have even more difficulty coming up with a plausible story. Being hesitant to talk freely, especially if they're caregivers in the room. Being disoriented and confused, having a fear of certain places. They don't want to go to the bathroom. They don't want to go to the bedroom. They don't want to go home with somebody or maybe they don't want to go to their daycare facility. Or if they have an overly protective caregiver. If they have a caregiver that's helicoptering, it may indicate that the caregiver is trying to make sure that the elder doesn't tell on them. If they have a lack of amenities that they can clearly afford, or the caregiver suddenly has a more affluent lifestyle. You know, driving around a beamer and used to have an old beater that she was driving around, then she may be exploiting. If things are disappearing from the elder's house, looking at, you know, wedding rings, jewelry, anything of value that might be able to be pawned. If the elderly person provides excessive gifts or monetary reimbursement in exchange for care or companionship. If especially elders who aren't familiar with financial matters may not be aware of, you know, what the going rate is. And they may be easily convinced that even if the person is getting paid the going rate, that it's not enough. And they may have a soft spot. And elders can easily be groomed to provide a lot of financial support to people. If the caregiver has control over the elderly person's finances, but is unwilling to provide for the needs of the elderly person. And this can be clothing, food, medical care, or even things like getting the air conditioner repaired. And inability on the part of the elderly person to understand what financial transactions mean. So if the elder person seems confused when you start asking about financial transactions, that could be a sign that they just never understood the financial matters. But also could be a sign that the person who's been taking care of the financial stuff has been feeding them a line of baloney. And so when you start presenting competing facts, they get confused. And if you see signatures on any contracts, especially powers of attorney, etc., that are not in the elders handwriting. And you have a good idea because they sign your documents, your intake documents and things. You have a good idea of what their handwriting looks like. And if the signatures on other stuff are dramatically different, you know, you want to bring that to somebody's attention. So interventions, we want to provide social support for the elders. And there are drop-in centers, elder daycare. I don't like using that word because that sounds like we're infantilizing them. But, you know, there are lots of different support places where people can go. For caregivers, we need to make sure they have social support. It's not just the elder person that needs companionship and support. Caregivers need to have a place they can go and vent. Sometimes churches have these. Sometimes your local United Way can help you connect with different support groups. Maybe you can start hosting one where people can come and just have a support group one night a week where they can kind of vent about things. Reach out to your local area agency on aging to find out where the support groups are in your area. We want to provide education, public and professional awareness campaigns. We want to let the caregivers know, but we also want to let other professionals that may come in contact with the caregivers or the elder know about things like what are reasonable expectations to have of someone who is aging, of someone who is aging and has dementia, of someone who is aging and has Alzheimer's. Parkinson's is another one because Parkinson's can have hallucinations and delusions that accompany it. So there are a lot of different diagnoses that may be unique to older people that caregivers need to be aware of, as well as professionals. We want to provide information about caregiving strategies because you don't take care of a 65-year-old person the same way you take care of a 5-year-old person. So it's important to help the caregiver understand that. There are a lot of emotional issues that also go along with caring for your parent because parents are becoming dependent on you, so roles are getting reversed. There's a grief process that some people go through. There's the recognition that your parent is going to die at some point. There's a lot of stuff that comes up when families get to this stage. So we want to make sure we have resources available for that. We want to have helplines to provide information and referrals regarding available resources. Again, Area Agency on Aging and United Way Information and Referral are going to be your two best places to start. We want people to know about abuse, the definitions, the signs, and the risks, so everybody is keeping an eye out from the pharmacist that fills the prescriptions to the doctors, to the clinicians, to the person that is serving lunch at the adult day drop-in facility. We want to make sure that everybody is providing routine screening for elder abuse, but also routine screening for any sort of problems that may need intervention. A lot of these issues that older people deal with, they've come up with new treatments that can prolong someone's cognitive and physical health. So for doing routine screenings for dementia and Alzheimer's and Parkinson's and heart disease and other things, we can help the elder maintain their highest quality of life, which will help them maintain independence for the longest amount of time. Try to find services for respite care, and this can be those drop-in centers. This can be volunteers that come in and will help out. In some university towns, they have mandatory volunteer hours, and college students are assigned to go in and visit people who are homebound. Sometimes churches will have a list of people who are willing to go in and visit someone. Again, you've got to make sure the background checks are done, and even with a background check, don't assume that that means the person is 100% safe. I'm sorry, I hate to be so negative, but that's the way it is. So you want to periodically check in on the elder, but try to make sure that there's not one person that is always responsible for that person's care. Everybody needs a break. Day treatment, as I've mentioned, counseling and stress management for the elder as well as the caregivers. Residential care policies to define and improve standards of care. We want to, again, go out and do outreach. Let nursing home administrators and clinical directors know about new treatments and new interventions and new findings for improving the quality of life for patients with X-issue. Tai Chi has been found to be an evidence-based practice for a lot of symptoms of normal aging. Safe houses and emergency shelters are also important, because sometimes you will have an elder that's in a dangerous situation or in a situation where they're being abused in some way, and we need to have a place that they can go right now, not when a space opens up or once we get approval from Medicare. They need to go there now. So what can loved ones do? Watch for warning signs that might indicate elder abuse, whether this is the elder living in your house and there are other people living there. Pay attention. Or if your elder loved one is in some sort of nursing home care, pay attention, even if they're still living independently. If you remember, some of the abuse, about 20% of it is done by friends and neighbors. So we want to check in and a portion of it by businesses. We want to check in with our elders and make sure everything's going okay and they're not getting exploited or abused. Periodically, take a look at the elder's medications. See when it was prescribed, how many pills are in there. Look at the pills. You can go to drugs.com and look at what that pill should look like. Or you can take a pill to the pharmacist and have the pharmacist verify that, yes, this is a Zoloft or whatever it is, to make sure that their medications aren't being switched out, to make sure that they're being given the right amount at the right time. Watch for possible financial abuse. You know, talk to your elder. You know, talk to the person about how much money they're spending, what they're spending it on. You may not have access to see their bank accounts. You know, and that's okay. Empower them to keep control of their finances. But also beware if you hear them talking about something that sounds like they're getting scammed. Call and visit as often as you can. And that doesn't mean you have to do it every day. But if you can call every day, then that's wonderful. So you can keep a tab on how things are going and you can hear the emotions in that person's voice. Ask them about their health, happiness, and safety. And offer to stay with them so the caregiver can have a break on a regular basis if possible. So, you know, if there are three kids, you know, don't let one person be the sole person responsible for the person, for the elder's care, 24-7, 365, henceforth and forevermore. You know, try to take turns. You know, try to take turns with who drops in and checks on them. That way it gets done. The person sees a variety of people which also reduces the chances of abuse or exploitation, makes the caregiver feel more involved and connected, and prevents abuse on a variety of levels. What elders can do, take care of their health, seek professional help for drug, alcohol, and depression concerns, and urge family members to get help for these problems. Because we know that people who commit acts of abuse often have some co-occurring stuff going on, whether it be substance use or depression or anxiety or something. So you want to make sure that your caregivers are healthy, but you also want to make sure that you, the elder, are healthy. That way you are empowered and able to stay as independent as possible for as long as possible. Have the elder plan for your own future. With a power of attorney or a living will, you can address healthcare decisions now in order to avoid confusion and family problems later. Seek independent advice from someone you trust before signing any documents. And, you know, it's important to have an attorney or somebody that can look over things before you sign anything. Powers of attorney, selling your house, anything that might negatively impact you. Send and open your own mail. It's important to be able to have your own privacy and communication, and keep your computer secure. If caregivers can log on to your computer, and I'm sorry, I hate this, it's so awful to have to say this, but if they can log on to your computer, they can install a keylogger so they can get your password, so they can log into your bank accounts and anything else. Keep your email private. Keep a password on your email. Have a password on your profile, on your computer. Do everything that you can to protect your security. And be aware, be very aware of companies that want to help you clean your computer or do remote support and they want to log in. Some companies are good, don't get me wrong, but there are a lot of unscrupulous companies out there who will install malware on elders' computers, which will lock it up, and then they will have to pay a king's ransom to, you know, get their data back. Keep all of your pin numbers secure for ATMs and things. Don't give out personal information over the phone. Just don't do it. There's generally no reason to do that. Encourage elders to use direct deposit for all checks so they don't have checks sitting around the house. Elders should have their own phone so they can call and they're not dependent on borrowing somebody's phone. And make sure that elders know their rights. If you engage the services of a paid or family caregiver, you have the right to voice your preferences and concerns. If you live in a nursing home, the ombudsman is your advocate and has the power to intervene, so seek out the ombudsman. So anyone who suspects that an older adult is being mistreated should contact a local adult protective service office, long-term care ombudsman if it's a nursing home, or the police. So we need to start reaching out and making these reports. Donna points out that getting families to pitch in is probably one of the most difficult things to fix. It often falls on the shoulders of the female offspring who is reluctant to ask for help, occasionally out of misguided feelings of guilt. And that's true. Sometimes kids are like, then why don't you just go to a nursing home? No way mom's moving in with me. And that can be because of family disharmony. That can be for a lot of reasons. But we need to help the elder figure out what a reasonable course of action is and what's the safest course of action. At a certain point they may have to go into long-term care because they're not safe staying on their own. So those are things that we need to do and we need to potentially get the family in for a family session and really talk about what's going on, what the resistance is to pitching in and helping out. And maybe they wouldn't haven't realized that there are small things they can do that can be a big help. Maybe they haven't realized that all about all the social services that are available that they can tap into. So it's not just going to be on them. So again, it's up to us to put that information out there and provide as much prevention as possible. And yes, I love LastPass. Passwords are often hard for elders to remember. So they'll use either the same password on everything or they'll use really insecure passwords. LastPass is something that you install in your browser and it remembers your passwords and it will autofill for you. And it's very, very nice because my husband won't let me use the same password on anything. And I can't remember all my passwords. So we have that. There's a free version that people can get or a paid version, which is really inexpensive, totally worth it. And Zachary points out that there are some people who will present themselves in the guise of being thankful and trying to be helpful to older people who are veterans. And by being so ingratiating, they can start grooming that elder and start exploiting that elder. So we do want to make sure that everybody is getting taken care of. Developing a close relationship with adult protective services if you work with adults is important. Whether you work exclusively with elders or you work with people, the spectrum ranges in their age, but the spectrum also may range in their cognitive abilities. So yes, it's really important to pay attention. And while I'm on that, if you do work a lot with elders, I can't strongly suggest enough. Educating yourself at least minimally on geriatric medication because elders' livers do not clear medication as quickly. Some things like Xanax and Valium can build up to toxic levels really quickly. And their opiates are cleared at a different rate. So medication prescribing for people over the age of 65 is different. And if they're not going to a specialized physician, they may experience negative side effects, including coma. So it's really important that if we see the elder starting to decompensate, that we look at any medications they're on and make sure that they're not on anything that could potentially be a problem. And if we think there is, then we need to refer them to a primary care and get some sort of input on that. Karen points out that unfortunately, police and adult protective services are not always effective where the elder lies or shades the truth out of fear and even with strong and repetitive evidence, they're left out on their own to deal with the situation. And unfortunately, this is true. If the elder is considered competent, the same thing we see happens in domestic violence incidents. If the adult person says, you know, there's really no problem, then adult protective services is often hamstrung with what they can do unless there's really glaring evidence and even then sometimes they won't take the case. But at least, like Carrie says, at least you're trying. You're putting in a report. You're starting a paper trail. And maybe after the third or fourth call, they'll get it through their heads. And work with your local state's attorney's office. If you're having trouble getting APS to take reports and do anything on things, consult with either the supervisors there or the state's attorney's office to find out what is it that you need. Because, you know, I can see that there's a big problem here. And I understand that if the person says that there's no problem, there's not much you can do. So how can we work together to advocate for this person and help them feel safe enough to make a report? Sometimes you're just going to be in a lose-lose situation. But if you get all of the minds together, APS, prosecutor's office and yourself all communicating, then you might be able to find out, okay, we need to know this, that and the other, or we need to have pictures or something else. And if we educate adult protective services and, you know, don't make the assumption that they don't have the same level of education that we do. And, you know, a lot of clinicians don't have specialized training in working with elders or elder abuse. So I don't want to knock them. They may not understand that building rapport with and engaging elders is different. Sometimes it does take multiple contacts in order for the elder to feel safe. Sometimes the elder is not going to talk to somebody who is the same age as their kid. You know, they're going to be more open and confiding in somebody who's closer to their own age. Not that that's always possible. But, you know, there are things that you can do that can help develop rapport and engagement. Another thing that can happen is to help elders not see APS necessarily as an adversarial agency. Maybe it's a place where they can get information and get assistance. So more resources. You can go to Kane from the University of Delaware. Awesome place to go if you're a statistics junkie like me. Clearinghouse on abuse and neglect of the elderly go there. You can find all kinds of papers specifically targeting elder abuse. Videos on elder abuse. Oh my gosh, these broke my heart. But they can help us educate the community about types of elder abuse and exploitations. So they're short little videos about elders who have been abused. And oh my gosh, Money Smart for Older Adults is an awesome course that can be put on by financial advisors to help older adults understand how to manage their finances. Participant resource guys. So it's 55 pages. It's not a short thing. But banks can put it on. Financial advisors can put it on. Clinicians can be trained to put it on. It's not something that gets super in depth. But it helps people learn how to recognize the risk of exploitation, guard against identity theft, plan for possible loss of the ability to manage finances. So if you have to have a power of attorney, what can you do? Prepare financially for disasters and find helpful resources for managing their money. So it really empowers older adults to take charge of their finances. So for every one case reported of elder abuse, it's estimated that 24 cases go unreported. Adult over the age of 60 who have cognitive or physical limitations are a greater risk of being abused or neglected. Abuse can be physical, emotional, sexual or financial. And it's important to be alert for signs of abuse in elders who are often reluctant to report. They're not going to come in and say, I've got to tell you this. They're going to hide it. They're going to blame themselves. They're going to say, I shouldn't have done this or whatever. A multidisciplinary approach to prevention and early intervention is most effective. And when we talk about multidisciplinary with elder abuse, we're talking about clinicians, physicians, social workers or care providers that may be in drop-in centers, the people that work in nursing homes, as well as APS and the state's attorney's office to make sure that we're covering all of our bases. Everybody's aware of what's involved. And we can start figuring out where the holes in the safety net that elders are falling through such that they're getting abused. Alrighty, I really enjoyed this conversation you guys had towards the end of class. And I appreciate all the input that you gave. Are there any other questions? Alrighty, next week we have one more domestic violence class coming up. And it talks about the impact of domestic violence on mental health. So it'll be a little bit more treatment applicable. We talk about interventions to use with batterers and interventions to use with survivors. So it'll give you more tools than just going over the random stuff and signs and symptoms that we've been talking about. Thank you, Pat, for bringing up the hearing loss thing as well as the last pass. Those were two really awesome points. Okay, everybody have a great weekend. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. 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