Response to Elder Abuse Varies Widely Across the U.S.

16 Dec 2007

By Tracy Breton

Diane Lewis was asleep in her Portsmouth home on May 14 when she was awakened by her beeper about 5:30 a.m. It was the first night for Rhode Island's new elder-abuse hot line service. Someone needed her help.

It was a police officer at T.F. Green Airport. He told her he was concerned about an 80-year-old woman who'd been sitting for hours in the airport terminal. The woman was disoriented and didn't seem to know anyone in the state to call to pick her up.

Lewis, a social worker with a master's degree who's worked with vulnerable elderly clients for more than a decade, determined immediately that she needed to go to the airport and meet with the woman.

When she got to Green, she found the elderly woman sitting in a wheelchair wearing a polyester dress, sturdy shoes and thick white stockings. She told Lewis she was from Los Angeles and that she'd come to Rhode Island because she'd "discovered" that the Roman Catholic Diocese of Providence needed her help.

Lewis learned that the woman had spent the prior few weeks flying from city to city, toting a purse with a maxed-out credit card. She didn't have any suitcase, just a plastic bag crammed with receipts from hotels and restaurants. The woman's husband and only child were dead. It was unclear how she'd gotten the money for her airline tickets or whether she'd had money and credit cards stolen from her as she'd made her way from coast to coast. She was so trusting, says Lewis, that "she was fortunate to have made it to Rhode Island unharmed."

Lewis arranged for the woman to be admitted to Kent Hospital, in Warwick, for a psychiatric evaluation. She now lives in a long-term-care facility here.

The woman may not have been abused, but her safety was clearly at risk. In fact, Corinne Calise Russo, director of Rhode Island's Department of Elderly Affairs, says 50 percent of the nearly 300 calls that have come in to the state's new after-hours hot line since May have been to report issues of self neglect or concerns about the welfare of an elderly person. The other half have been reports of actual abuse or financial exploitation.

Every year, an estimated 2.1 million older Americans are victims of physical, psychological or other forms of abuse, according to the American Psychological Association. Congress says the number could be closer to 5 million.

But the nation's safety net for seniors is not nearly as good as it is for children.

A survey of all 50 states conducted by The Providence Journal over the past several months shows that even though most states have mandatory reporting laws for elder abuse, fewer than half of them have statewide, 24-hour-a-day hot lines to record complaints and offer immediate response.

By contrast, all but five states have social workers on duty 24 hours a day responding to complaints of child abuse - even though the elderly population is booming.

Up until six months ago, Rhode Island was one of those states that had a substandard after-hours hot line for its elderly. But since May, the state has offered round-the-clock hot line services, and, according to Russo, the number of calls coming in after business hours has increased each month. Although the mechanisms for response are different, Massachusetts and Connecticut also have emergency response systems that offer 24/7 assistance to the elderly from a cadre of caseworkers.

But there are seven states that don't have any after-hours hot line services for the elderly to report abuse, and most states that do take calls on nights and weekends don't provide immediate response from a social worker. That leaves victims with no one to turn to after state government closes down for the day - unless the victims want to call in the police or the local sheriff. And that doesn't often happen.

That's because most elder abuse and neglect occurs in domestic settings. Ninety percent of the time, the perpetrator is a family member, most often an adult child or spouse, according to the National Center on Elder Abuse. And most elderly people don't want a loved one sent to prison, even if the abuse is recurrent. Many depend on the perpetrator to perform essential tasks for them such as cooking, driving and cleaning. If their abuser is incarcerated, many of them would have to move into a nursing home.

Consequently, just 1 in 14 incidents of elder abuse is ever reported to the police. And the figure is even less for financial exploitation: Current estimates put the overall reporting of elder financial exploitation at only 1 in 25 cases.

The elderly, which the federal government classifies as anyone over 62, are the fastest-growing segment of the nation's population. In 2005, almost 17 percent of Rhode Islanders were 62 or older, according to the U.S. Census Bureau. By 2030, almost 25 percent of the state will be populated by people 62 or older; just 5 percent of the state will be younger than 5. From 1990 to 2000, Rhode Island experienced a 30.5-percent increase in the number of residents aged 85 or older.

Over the next 30 years, the proportion of the entire U.S. population over 60 will drastically increase as more than 76 million baby boomers age.

But historically, experts say, state and national financing to combat elder abuse and neglect has lagged far behind that for protective services for children and for other forms of domestic violence. If the Elder Justice Act - introduced in the U.S. Senate nearly six years ago - ever passes, it would provide hundreds of millions more in federal financing for adult protective services to the states - money to detect, investigate, prevent, prosecute and study elder abuse and to train more people who interact with victims.

The act would also provide money for research and data collection to track elder abuse and determine the effectiveness of various forms of intervention to make elders safer. But there is no line item in the bill that would compel the states to create statewide hot line services to respond to after-hours complaints. So unless the legislation is amended, experts say, there will be continuing disparity in how the states respond to this problem.

Rhode Island Congressman Patrick J. Kennedy, who has made mental health issues a priority of his political agenda, says he fears that unless more money is spent on round-the-clock protective services for the vulnerable elderly - especially those who live at home and suffer from Alzheimer's disease and other cognitive impairment - "there will be a tsunami coming."

A national study conducted in 1996 found that 60 percent of victims of elder abuse had some degree of mental impairment. But as Kennedy pointed out in a recent interview, "There's a terrible sense of stigma against elders. Many seniors feel like it's their fault if they are being abused, that they are bringing it upon themselves by their own behaviors. And many people in society think the same way. The stigma means that the elderly are less likely to seek mental health treatment - only 3 percent of the elderly do. But the highest rates of depression and suicide are amongst the elderly, people 65 and older."

"We have good hot lines in place for child abuse and domestic violence," said Kennedy, but there is a real need for round-the-clock hot lines for the nation's seniors, too. "Oftentimes seniors are intimidated to report abuse to the police. There needs to be an impartial process to help family members through these kinds of situations," so the abuse doesn't get repetitive and spiral out of control, said Kennedy.

But whether corrective action will be taken is another story. According to dozens of interviews conducted with those who provide services to vulnerable and abused elderly across the nation, the major roadblocks to providing better hot line services are lack of financing and how state officials prioritize expenditures.

Elder abuse "is the least funded of the abuses and gets the least priority when it comes to funding. Politicians don't like thinking about it," says Pamela B. Teaster, a professor at the Graduate Center for Gerontology at the University of Kentucky and an expert in the delivery of elder protective services. But "this kind of abuse is real. The 2004 Survey of Adult Protective Services shows a 19.7-percent increase in the combined reports of elder and vulnerable adult abuse and neglect and a 15.6-percent increase in substantiated cases in the four years since the last survey was conducted."

The Elder Justice Act, which has been stalled in Congress for years, recognizes that "differences in state laws and practices in the areas of elder abuse, neglect and exploitation lead to significant disparities in prevention, protective and social services, treatment systems and law enforcement, and lead to other inequities."

The Journal found that while some states have made the protection of the elderly a priority, others seem to barely acknowledge their senior populations.

Florida, which has the largest percentage of elderly in the country, trumps most states in terms of dollars spent and number of employees paid to watch out for its most vulnerable residents. Its round-the-clock hot line, which takes in reports of child and elder abuse, has been in existence since 1988. It is staffed by 140 counselors (up to 58 who work after 5 p.m.), 17 supervisors and 3 managers. The Florida legislature allocated $15,535,121 for the hot line for this fiscal year alone, according to Al Zimmerman, spokesman for the Florida Department of Children and Families. "We average about 6,000 calls per month related to adult abuse," he says.

In Florida, all counselors who work the hot line have at least eight weeks of training to help them identify signs of abuse and neglect in the elderly and children. Many have degrees in social work; others are former schoolteachers. The state has 110 regular adult protective services (APS) investigators - who all have extensive training in geriatrics issues. They rotate on-call duties nights and weekends, and if a counselor for the hot line determines there is an emergency that requires immediate response from one of the state caseworkers, the on-call APS worker is woken up "even if it's 2 in the morning" and is required to make in-person contact with the elder within two hours, according to Elizabeth Schlein, director of the Florida Abuse Hotline.

During the fiscal year that ended in June, the Florida abuse hot line received 75,068 elder abuse, exploitation or neglect calls - 51,860 of which became full-fledged reports that were investigated. Schlein says she is proud that Florida also has a computerized statewide adult-abuse tracking system to enable its protective services investigators to better respond to complaints and that "we are the only state that does the criminal checks for adult abuse prior to the investigator going out." She says the background checks enable the investigator to know, "prior to going into the home at 3 a.m., that this is the third time that the son has beaten the victim up and she hasn't wanted to press charges before. It gives the APIs a good global view of what's going on within the family."

Schlein says interviews with elderly victims show that "a lot of people call us instead of contacting law enforcement."

Massachusetts is another state that has historically spent big bucks to protect its elderly. Since 1983, it has operated an after-hours abuse hot line - which it contracts out to a Massachusetts hospital. This year, $425,996 in state money is being spent to operate it. The hot line picks up elder abuse and neglect calls from 5 p.m. to 9 a.m. on weekdays and on weekends and holidays. The hot line has a 16-person staff. Many are licensed social workers. Of the 14,197 elder-abuse complaints received in Massachusetts in the last fiscal year, almost 23 percent came in to the after-hours hot line. About 41 percent of the elder-abuse reports accepted for investigation last year demanded an immediate response.
Connecticut has found a different way to respond after-hours to elder-abuse complaints. If a call comes into its hot line after-hours, it is automatically routed to the state's 211 InfoLine, which is financed partially by the United Way.

But these states are exceptions to the norm.

In 1990, a congressional committee studying elder abuse found that the State of Louisiana had virtually no operational program to protect the elderly from abuse because the legislature wouldn't provide any money for it - even though the federal government had earmarked $700,000 to provide these services to the state. (It still has no elder protective services workers on call after-hours, even after Katrina.)

The House Select Committee on Health and Long-Term Care found that in 1989, nearly one-fourth of the states reported spending less than a dollar per elderly person for protective services.

And things haven't gotten a whole lot better since then.

In many rural areas, social workers are still assigned to investigate both child- and elder-abuse complaints, along with complaints from those with disabilities. Some counties have no one investigating elder abuse at all.

Up until this July, Wyoming had just one elder-abuse investigator on its entire state payroll, but that worker also was given child-abuse cases and could cover only one county, according to Dorothy Thomas, Wyoming's adult protective services coordinator. The Wyoming legislature has just allocated money to provide training for four more people to investigate elder-abuse complaints, but they, too, are still required to investigate child-abuse complaints as well as cases involving adults with disabilities.

In a recent interview, Thomas bemoaned the lack of resources given by her state to combat elder abuse. "We have the second-fastest aging population in the country and are very rural and so many people keep firearms in their homes. … We have some rural communities where the nearest doctor is 40 miles away."

"Prior to these four positions being funded in July, my budget for APS for the entire state was $270,000 per year," she said.

But state financing is just one impediment. "We have a huge work-force shortage here in Wyoming. We don't have people with college degrees staying in the state. We have senior center directors that make $8 per hour," she said.

In its survey, The Providence Journal found that even in states that advertise hot line numbers, some of them don't work. Even during normal business hours, callers can get tape recordings instead of a live person answering the phone. Sometimes, they are put on hold indefinitely.

When the newspaper called Georgia's Division of Aging Services this summer during business hours, the reporter was left on hold for 15 minutes before being asked to leave a message. Calls made to North Carolina's Careline repeatedly got a busy signal four days in a row. When a receptionist finally answered, she offered another number to try that she said would also receive complaints. But a call to that number led to 20 minutes on hold before the reporter hung up. The recording said nothing about elder abuse but talked instead about Medicaid issues and other social services. The newspaper also found that several states that claim to have an elder-abuse hot line merely greet callers with a recorded message - directing them to hang up and call 911 or the local sheriff.

Some states, such as Delaware, have after-hours hot lines that are contracted out to answering services. But they are available only to health-care professionals and members of law enforcement - not the general public.

The Journal also found a huge disparity in the amount of time it takes an abuse investigator to respond to an elder-abuse complaint. Some states give social workers up to 10 days to investigate; others just two hours to make face-to-face contact with a victim. The best response time was in states with after-hours hot lines that had paging systems where social workers could be summoned immediately.

The newspaper also found that whenever a state created an after-hours hot line, there was more reporting of elder abuse. It also discovered that some of the poorest states had some of the best elder-abuse hot lines - even if they had to find innovative ways of making them work.

Prior to February of this year, New Mexico had a system - like many states - in which elder-abuse and neglect cases were phoned into the same hot line that picked up calls for child abuse. But now there's a toll-free number just for elders that operates round-the-clock. After regular business hours, calls are transferred to a cell phone carried by a state adult protective services investigator who assesses the situation to determine whether immediate response is required. If necessary, the on-call worker can route a call to a fellow worker in another county. Victims in need can get help in less than three hours anywhere in the state.

The on-call workers - who make $16 to $25 per hour - are paid one-twelfth of their hourly salary to be on-call (and their regular pay if they have to take action). That can amount to less than $2 per hour for some who are assigned to pick up calls in the middle of the night. But Tony Louderbough, deputy chief of adult protective services for New Mexico, says, "We don't have too much hard feelings about it." His workers know they are providing a valuable service and usually agree to take comp time instead of overtime pay. "We get 10,000 to 11,000 calls a year on the elder hot line and maybe 60 percent are investigated. Probably a bit more than half of those are substantiated. Most of the time it's self-neglect that is being reported, but 20 percent of the time, it is elder abuse by others or caregiver abuse or exploitation."

West Virginia pays $250,000 a year to a nonprofit agency to run its elder- and child-abuse hot line. The hot line operators - most of whom get paid $7.50 per hour - contact state social workers who can respond right away to emergencies at any hour of the day or night. "The majority of the calls come in at night and on weekends and holidays when we are bombarded with calls," says Sandra Miller, the executive director of the nonprofit that operates the hot line.

Wendy Stout, who has worked the West Virginia hot line for nine years, says that most elder-abuse victims "either have no telephones or no cars or are too physically or mentally handicapped to be able to call in" and that most of the calls that she takes are from the police, caregivers, neighbors, clergy, doctors and hospitals or long-term-care facilities. On the day she was interviewed for this story, she had picked up 21 calls between 8 a.m. and 3 p.m., while state APS workers were taking in additional abuse reports.

Kathleen Quinn, director of the National Adult Protective Services Association - who formerly worked as the director for elder protective services for the State of Illinois - says that those who work in her field have struggled for years to draw attention to the plight of abused elderly.

"It is extremely frustrating to me that we have people who are being preyed upon who do not have intervention services that they need and don't know where to go for help. These are the people who fought in WWII, who built the prosperity we all enjoy. These are the people we are leaving to lie in their own waste, to be preyed upon sometimes for years."

Says Quinn: "There's so much of this going on and nobody knows about it. The District of Columbia's budget is $129 million a year. And that's what we are trying to get from the feds to fund all adult protective services in the country through the Elder Justice Act. … There's not one single federal employee whose job is solely to think about elder abuse, yet the fastest growing population is 85 and over and they are the most vulnerable people in our society."

Quinn says the U.S. Justice Department is providing money so that police around the country can learn how to better respond to elder-abuse calls. That will be followed by similar training for prosecutors and judges. But better police training does not substitute for sufficient financing for social workers who work with abused elders.

"Not all elder abuse justifies crime reporting or should be investigated or prosecuted as crimes. We have complementary roles. The more we can promote multidisciplinary teams, the better services we will get," she says.

Teaster, the gerontology expert, says the creation of 24/7 hot lines for the elderly should be a priority for the states. "The issues of elders should be dealt with in a timely and quick fashion by an informed responder." Sometimes, she says, the police can exacerbate a situation.

"Cops are not necessarily the people who understand old or vulnerable people. It's highly important to give the right help because if you give the wrong kind of help, it can make things worse."

"Quick-fix" solutions won't work, Teaster says. It's not appropriate to have child-abuse investigators responding to elder-abuse complaints. "The vast majority of elder-abuse cases are not similar to child-abuse cases. These are complex, intricate adults and the solutions to their problems are more nuanced because they are adults who have more intricate, complex lives and some legal rights that children don't have - like the right, if they are competent, not to accept services."

Teaster is under no illusion that every case of elder abuse would get reported if every state had a better hot line. Even in states with hot lines, "you only have 1 in 5 or as few as 1 in 14 people who are abused calling in or someone calling in for them. But if you lag in response, the abuser can come to know that the elder has made a public statement about the abuse and that abuse could ratchet up and get worse," she said. "If no one picks up the phone when they call, they're going to decide to bear the abuse and not call in again."

Editor's Note: She was assisted in reporting for this story by Michael Gonda, one of her Brown University journalism students, who received an Undergraduate Teaching and Research Award from the university to assist Breton with her research.

Copyright 2007. Used with permission from The Providence Journal.