Older Adults and Self-Neglect: the Need for New Strategies to Preserve Housing

Preserving safe housing for elders who experience mental illness or cognitive decline can require collaboration among many parties. If the tenant is motivated, landlord is accommodating, and intervention occurs in time, the tenancy typically can be successfully preserved. During my first year of representing older adults with mental illness and cognitive decline in eviction cases, many of my clients have remained in their apartments with proper supports and/or treatment in place. As described in a previous post, this ideal outcome leads to improved health, decreased frustration on both sides, and lower costs for the state.

In some cases, however, a successful resolution is more difficult to identify. How can a well-meaning team best support an older adult whose condition not only puts his housing at risk, but also prevents him from actively participating in treatment or even recognizing his landlord’s concern? Despite attempted intervention by numerous providers, family members, and friends – and often despite their own strongly expressed desire to do whatever necessary to remain in their current apartment – some individuals continue to engage in behavior that puts themselves or other tenants at risk or in fear. In these cases, landlords feel an understandable need to proceed with the eviction for the protection of their other tenants, especially when other alternatives been unsuccessful. Other providers may cease services, if frequent refusals or behavior challenges make their limited resources better spent on other consumers. The most challenging cases leave concerned family and would-be helpers with few options – while these cases fall under the elder abuse category of self-neglect, if the person is deemed to have capacity to make decisions, the reality may be homelessness. Even if they obtain new housing, if a mental health condition remains unrecognized, the challenges are likely to reoccur.

The difficulties of accessing mental health care, and the need for increased training for many professions who respond to people with mental disabilities, have been addressed recently in the Boston Globe. When it comes to elders with mental health conditions, even systems and centers that are designed for people with mental illnesses, and whose staff are prepared to encounter a variety of conditions, cannot always accommodate their needs. Group homes, homeless shelters, therapy delivery systems, and mental health emergency response teams often are designed and funded for younger, able-bodied populations, rather than older adults who often present with longer histories of trauma, compounded loss, and increased physical needs. Differing manifestations of illnesses in older adults can lead to misdiagnoses of dementia. Just as for younger populations, a lack of culturally competent training for staff and providers can be a barrier to accessing assistance or even exacerbate the issue.

Working with members of this population over the past year, I have gained familiarity with the real-life consequences of barriers to effective assistance for elders with mental health conditions. When a tenant and landlord do not perceive a situation through the same lens, making a feasible agreement impossible to create and/or uphold, there are no simple resolutions and often seem to be more questions than answers. How should capacity be assessed, when the consequence is homelessness? Within our quest to maximize autonomy and avoid overprotectiveness, how can we assess whether a client is making an informed decision? If it becomes clear that a person does not have capacity, how does this change his or her options going forward? For a person whose current housing is in fact inappropriate, what type of housing supports should be sought? Are they currently available, or could they be created, and at what cost?

As our population ages and expands over the next several years and decades, our society must confront these issues. Through blog posts over the next several months, I will attempt to shed light on some of these questions, along with highlighting programs, agencies, and individuals across Massachusetts and elsewhere who are making strides toward closing the gap in services for this population. With the preservation of housing as a focal point, I will aim to show the prevalence and reality of undiagnosed and untreated mental illness in older adults, explore new and innovative approaches to reaching and working with this population, and ultimately advocate for the funding and expansion of successful models.

Loneliness and Elder Abuse

In trying to prevent elder abuse of all types, including financial exploitation, it is crucial to understand why older adults are targeted and what risk factors increase the chance of an elder being abused or exploited.  Multiple studies have found that loneliness and isolation can significantly raise the risk of elder abuse. Elders may be isolated due to health related issues; the death of family and friends; mobility difficulties; lack of transportation; living alone; or the deliberate acts of an abuser.  In 2014, according to the U.S. Census Bureau, 46 percent of women 75 and older and 23 percent of men that age lived alone. As our longevity boom continues and older adults in this country continue to live longer, we will have an ever growing percentage of our population who live alone and are isolated.

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How does loneliness play a role in elder abuse?

Loneliness and isolation tend to make elders more vulnerable to being taken advantage of.  This can happen when a “new best friend” comes on the scene and takes advantage of a lonely elder’s desire for companionship. The new friend may exert significant influence over the elder which can create easy access to financial and other important decision making.  Loneliness may also make an elder vulnerable to a scammer on the phone who targets older people just craving someone to talk to.  Phone scams, including romantic or “sweetheart scams,” are rampant and can result in financial devastation for older victims.  Isolation can also occur when a perpetrator known to the elder – a family member or friend – deliberately isolates the elder to better exploit them. In order to keep the abuse hidden from others, perpetrators may monitor the elder’s communications, block family and friends from access with the elder, attend medical appointments or meetings with financial institutions with the elder, and create obstacles for the elder to socialize outside the home.

All elder abuse prevention efforts must include a plan to address the social isolation that many older adults in a community experience.  How can we increase the possibility for social connections in our communities – even to the most socially isolated elders?  Here is a link to a recent story on the “Epidemic of Loneliness” and an innovative program in Great Britian that attempts to address this critical issue.

Elder Abuse: The Untold Cost of the Opiate Crisis

This Sunday’s Boston Globe ran a wonderful article about the toll that the opiate crisis has taken on older adults across the Commonwealth.  The statistics in the article are quite sobering, “since 2011 elder abuse reports have climbed 37 percent, with more than 1,000 additional cases reported each of the past five years to protective services offices. The Executive Office of Elder Affairs, the agency that tracks and investigates abuse, recorded nearly 25,000 cases last year.”    Unfortunately, the statistics just confirm what many of us who work with older adults see every day – the untold illness, injury, and suffering of victims of abuse which often leads to the loss of housing, depletion of scare economic resources, exacerbation of medical problems, and a host of other issues. Articles like this help with prevention efforts – they raise the profile of the issue and turn a bright light on a problem that most people do not know about.  Kudos to Kay Lazar of the Boston Globe for pulling this issue out of the shadows and putting it on the front page of the Globe.

http://www.bostonglobe.com/metro/2016/05/14/reports-elder-abuse-surge-massachusetts/FcrmDP2wMiZ0FK0amZ179L/story.html?s_campaign=8315

The Heart and Soul of Elder Abuse Prevention

Our community elder abuse prevention coalitions are comprised of members who work with and care about older adults in their community.  As a regular feature of this blog, we plan to highlight members who have committed their knowledge, passion, skills, and time to protect older adults in their community.

 

 

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L to R: Lillyana Hebbert (FriendshipWorks), Margaret Noce (Tree of Life), Cynthia Wilkerson (Little Brothers-Friends of the Elderly)

 

Lillyana Hebbert:  I’m the Program Director for FriendshipWorks neighborhood office in Jamaica Plain. We provide free services in Spanish and English to elders age 60 and over to help eliminate elder isolation.  FriendshipWorks is one of the founding members and also co-chairs the JP/Egleston Square Elder Care Network.

Margaret Noce:  I’m the coordinator of the Jamaica Plain Coalition: Tree of Life/Arbol De Vida we work on issues involving Family Support, Public Health and service to seniors. The JPC:  Tree of Life is a founding member and a co-chair of the JP/Egleston Elder Care Network.

Cynthia Wilkerson: I’m the Program Manager at Little Brothers – Friends of the Elderly. We work with Boston residents who are 70+. Our office is in Jamaica Plain and we’re members of the Jamaica Plain/Egleston Square Elder Care Network.

Question – As aging network professionals, what drew you to focus on elder abuse prevention?

Many of us provide direct service or work with staff who provide direct service to elders. We hear their stories and know that elder abuse is very real–but sometimes difficult to identify or talk about. We wanted to better understand the issue so we can better serve our community–and we want to help educate community members so we can tackle this complicated challenge together.  Every year the JP Elder Care Network addresses topics that are important to service providers and elders.  Last year the group agreed that the topic of financial abuse was a growing concern and chose to address this through a number of workshops to educate providers who will in turn educate the community.

Question – Can you talk about your Jamaica Plain providers group and why the group decided to focus on elder abuse issues?

The Jamaica Plain/Egleston Square Elder Network has been in existence for 12 years. We are a group of elder service providers serving Jamaica Plain residents and we gather to share resources and support each other’s work. In 2010, we hosted a community meeting, attended by more than 60 older adults from Jamaica Plain and Egleston Sq to provide information, raise awareness, identify health concerns and develop possible solutions.  The top concern was transportation access.  In 2016 the topic is elder abuse prevention.

Question – what do you think the best methods are to prevent elder abuse?

We are beginning with the premise that education and community involvement will help spread the word that elder abuse exists in many forms throughout our neighborhood. Sometimes elders are embarrassed or ashamed to talk about abuse or exploitation and sometimes those working with elders miss signs of abuse because of a lack of education. We want to raise awareness as we did with the transportation project that helped bring our network and our communities together and we wanted to find a new area to help focus our efforts and discussion. When we learned about the elder abuse prevention coalitions that several communities near Boston have formed, we decided to explore how we as providers and community members could educate and organize around elder abuse and remind everyone that abuse–whether physical, emotional, sexual, or financial–is not the fault of the victim and not something that has to be hidden.  We want to help people bring it out into the light of day so we can address it and, ultimately, help prevent it.

Question:  What are your next steps?

After a series of a half dozen workshops on various elder abuse topics, the group will work with the community to bring the information to elders.  In the Fall, we will commence a series of community meetings to inform elders and caretakers of the many facets of abuse.  This work will be done with Congregations and other community organizations.

 

 

The Heart and Soul of Elder Abuse Prevention

Our community elder abuse prevention coalitions are comprised of members who work with and care about older adults in their community. As a regular feature of this blog, we plan to highlight members who have committed their knowledge, passion, skills, and time to protect older adults in their community.

RickF- RRick Fentin is a Financial Adviser and a founding member of the Arlington Elder Abuse Prevention Task Force

What drew you to the Arlington Elder Abuse Prevention Task Force?

About twelve years ago, I started volunteering at the Arlington COA. I meet with individuals a couple of times each month to answer financial planning questions. I have loved the opportunity to meet so many nice people, answer questions and be of service. Plus, I continue to learn a lot about the basic financial issues that people are trying to understand. So, when Susan Carp, the terrific director of the Arlington COA on Aging mentioned that they were trying to organize a committee to prevent elder financial abuse, it was of immediate interest to me.

I should mention that I came to my work as a financial planner after working in human services for fifteen years. I was always oriented in the direction of wanting to help people. And I would like to give credit to my mother who passed away recently for giving me and all my family members an example to follow and a desire to help others.

What do you do professionally and do you ever encounter elder abuse issues in your work?

I have worked as a financial adviser for over twenty-five years. I also teach courses on Social Security and retirement planning. In my practice, I have seen a lot of very difficult and sad financial situations involving seniors.

When I have encountered elder financial abuse, it has not been through scams but even more troubling by family members not doing the right thing. Early on in my career, I was working with a client whose husband had passed away and then discovered that the life insurance policy they had paid premiums into for many years had another woman as the beneficiary. I encounter many situations where ignorance of personal financial and estate planning practices creates very upsetting situations for families. Inheritances go to unintended beneficiaries, clients are not aware of the level of risk in their portfolios, assets are depleted by nursing home expenses, pension and Social Security claiming mistakes are made and people over estimate how long their assets will last.

Anything else you would like to add about yourself, your time on the task force, etc.

I have tremendously enjoyed my time on the task force. It gives me a rare opportunity to meet dedicated and concerned people in other fields of work who want to come together to help seniors. There is a very lively exchange as we attempt to find the best ways to help prevent elder financial elder abuse in Arlington. It is a huge local and nationwide problem. There are many different and innovative scams targeting seniors as well as many challenging family situations that can lead to abuse. As our leader, Betsey Crimmins brings a tremendous amount of energy and resources to the group. She always keeps it interesting. Additionally, it is very helpful to hear from the Arlington Police about current situations being investigated.

Elder Abuse Prevention to End Elder Homelessness

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Elder homelessness is a pervasive problem in Massachusetts. Many elders become homeless as a result of being evicted from their apartments. Too often, elders face eviction from public housing as the result of an issue that could have been addressed or prevented with appropriate services. This is especially true for older adults who have mental illness or who suffer from cognitive decline. In these cases, the reason for the eviction frequently is related to the elder’s underlying mental health issue. The elder frequently might have been unable to recognize the need for or unaware of available services.

The problems that put elders at risk for eviction often result from elder abuse. When an elder’s mental health or memory is compromised, self-neglect can cause him to forget to pay rent, complete paperwork, or attend scheduled appointments. Some elders become unable to remember to take medication or create hazardous living environments, due to undiagnosed or untreated conditions. Others experience behavioral changes that are alarming to other tenants or landlords. In some cases, elders are targeted by others due to their vulnerability and become victims of abuse, neglect, or financial exploitation. Any of these situations puts elders at risk for loss of housing, as bills go unpaid or the elder is seen as a risk to himself and others. Often, an eviction notice is the first and only step taken by a landlord or housing authority to resolve the issue. Elders with compromised mental health are rarely in positions to properly defend themselves in eviction cases. Unfortunately, when elders are evicted from public housing, it is likely that they will spend the rest of their lives in shelters or institutionalized in a nursing home. In many cases, institutionalization is premature, costly, and unnecessary.

My Equal Justice Works Fellowship project, sponsored by Biogen and Foley Hoag, advocates for more holistic responses to situations that put elders at risk for eviction. One client faced eviction due to the conditions of his apartment, which had deteriorated due to his hoarding disorder. With a reasonable accommodation that took his disability into account, and required communication between his landlord and social worker, he was able to maintain his housing. Another client was evicted as a result of behavioral changes, stemming from an undiagnosed mental condition. After legal advocacy and social work intervention, the eviction was postponed. The client now has benefited from proper mental health treatment and continues to live safely in her apartment.

Rather than immediately resorting to eviction, which frequently exacerbates mental health issues and increases the likelihood of homelessness, landlords who recognize that a tenant’s issue has roots in a mental health condition can seek or suggest appropriate assistance for that tenant. Some individuals may benefit from mental health counseling or day programs. In other situations, money management, home care assistance, or visiting nurse services can be put in place to enable a person to remain in his or her apartment. Proper supports can alleviate the stress on an elder, minimize tension between the elder and other tenants and landlord, and ultimately prevent the types of elder abuse that contribute to elder homelessness.

The Heart and Soul of Elder Abuse Prevention

Our community elder abuse prevention coalitions are comprised of members who work with and care about older adults in their community.  As a regular feature of this blog, we plan to highlight members who have committed their knowledge, passion, skills, and time to protect older adults in their community.

 

Picture of Norah 2Norah Al-Wetaid is a Protective Services Worker at Somerville-Cambridge Elder Services and a member of the Cambridge Elder Abuse Prevention Coalition

Question:  Could you let us know what you do as a Protective Services Worker at SCES?

The life of a Protective Service Worker is very dynamic and no two days are ever the same. At the most basic level, the role of a Protective Service Worker is to respond to and investigate elder abuse allegations and then work with the elder to develop a plan to reduce risk. Our cases range from self-neglect such as evictions or hoarding to more extreme cases such as physical abuse. Most of my job is largely about harm reduction and is the product of a collaborative effort with the elder and other individuals involved in their life. The plans developed can include any number of interventions including connecting someone with in-home services, installing lifeline or a medication dispenser, providing advocacy, safety planning, obtaining restraining orders, eviction prevention, money management assistance, referring to other community providers and in some rare cases pursuing guardianship or conservatorship. Protective Services is short-term, so we try and connect people with more long-term assistance whenever possible.  I love my job and the ability to help people remain safe in the community. All of us in Protective Services strive to increase understanding of Elder Protective Services, and we hope to remove some of the stigma or fears associated with our name. We also strive to ensure that people understand that we are not the elderly equivalent to Child Protective Services. Unlike with children, elders with decision-making capacity have the right to self-determination and the right to make decisions regarding their life, regardless of whether or not they are decisions that you or I might make.

Question:  What drew you to the Cambridge Elder Abuse Prevention Coalition?

I was drawn to the Cambridge Elder Abuse Prevention Coalition for a number of reasons, but one of the main reasons was because it offered an opportunity to be involved in efforts to prevent elder abuse, rather than purely responding after the incident has occurred. Protective Services is frequently crisis oriented and generally responsive as opposed to being preventative, so we often don’t have a chance to participate in explicitly preventative work. The Coalition is also an amazing opportunity to directly participate in prevention work and efforts. It has also offered the chance to engage with a wide array of service providers and community members that I may not normally be able to work with. It has been incredibly helpful to hear about other people’s perspectives on elder abuse, issues that they see and to find out about their experiences with Protective Services. The Coalition also allows me an opportunity to talk directly with community members and providers about Protective Services and what we do.

Question:  What do you think is the best way to prevent elder abuse?

This is such a hard question. I think that one of the best ways to prevent elder abuse is outreach, education and awareness. Outreach efforts should include an emphasis on both elders and community members who encounter elders (banks, medical providers, building managers, neighbors, family, friends, etc). An important step in raising awareness is to ensure that people are aware of elder abuse in its many forms, knowledgeable about the resources, and ensuring that everyone understands that elder service providers place a high emphasis on respecting elder’s autonomy and right to self-determination. I strongly believe that if elders know about resources, ways to access help and also know that we will respect their autonomy, that they will be more inclined to reach out for help. Asking for help is often incredibly difficult and can be a source of shame, so anything we can do to make asking for help easier should be a priority.  At Coalition meetings, we often talk about the idea that there is no wrong door when it comes to accessing help. This is a wonderful approach and fits in perfectly with outreach efforts. The more people who know about elder abuse and how to get help, the more likely we are to reach more elders, even those who are isolated.

Question:  Is there anything else you would like to add about yourself or your work?

The name Protective Services often brings up feelings of fear which can result in people feeling reluctant to engage with us. I would love to take this opportunity to hopefully alleviate some of the fear. First, as an agency, Somerville-Cambridge Elder Services is very committed to keeping people safely in their homes and we will do just about anything we can to help make that happen. Our approach in Protective Services is very much in alignment with the agency’s mission and a lot of work is around increasing safety and harm reduction. When we meet with an elder about suspected abuse, self-neglect, exploitation, or neglect we try to ensure that they understand we are not there to make accusations, but rather our goal is to get a picture of what’s going on and then we will work collaboratively to increase safety. Protective Services does NOT come in and remove people from their homes and we highly value self-determination and an elder’s right to make their own decisions regarding their life. We are here to work with the elder to do our best to reduce risk and help them retain their independence. It can also be important for providers to understand this. Filing a Protective Service report can sometimes cause people to worry about making things worse or harming their relationship with an elder or the family. I hope that if people understand that we never reveal who reported to Protective Services and can better understand our approach to address suspected elder abuse, that they will feel more comfortable and inclined to reach out for help. If you are concerned about an elder (someone aged 60 and over), please don’t hesitate to call us.

One last thing, if you are reading this and want to find out more about Protective Services, we are happy to come and talk with you, answer any questions you may have or come out and do a presentation. Please contact Somerville-Cambridge Elder Services’ Protective Services Department at 617-628-2601.