and Clinical Assistant Professor of Psychiatry at University of Vermont, and I'm also a psychiatrist at White River Junction VA and the Burlington Lakeside Community-Based Outpatient Clinic. So representing many areas of Northern New England. And we have here Dr. Vineeth Jhan, Professor of Psychiatry and Vice Chair of Education, Director of Geriatric Psychiatry Section, and Program Director of Adult Psychiatry Residency Program at the Luis Fales MD Department of Psychiatry and Behavioral Sciences McGovern Medical School in Houston. And we also have Dr. Ryan Pate, and he's a Clinical Assistant Professor of Psychiatry at Stanford. We have no conflicts of interest to report, and I am employed by the VA, but the views expressed in this presentation do not reflect those of the VA or the U.S. government. So if you're more interested in this topic, I recently published an article in the Primary Care Companion of CNS Disorders called Financial Abuse of the Older Adults, and it's readily available on PubMed and Google, and you'll be able to get yourself a copy of that. And it has really helpful tips for primary care providers, but which also apply to mental health providers as well. So I wanted to start with our Bloom's Taxonomy here of learning objectives. So we'll be reviewing some examples of financial abuse and talking about cases that we've actually seen in our own real-world experience. We'll work on establishing best practices for effectively detecting financial abuse. We'll discuss pragmatic and formal safeguards against financial abuse, and also define potential interventions which may support vulnerable victims. So we'll lead off to a case and hopefully hook you in with this story. A patient I saw at the VA clinic in his late 60s, he had a major TBI about 50 years prior. He was heavily intoxicated and ended up having a motor vehicle collision and was in a coma for weeks and eventually recovered but still had some severe cognitive deficits. And he initially presented to myself as a consult for primary care up at the VA clinic. And his sister had some very big concerns about his financial decision-making. He had erratic behaviors which included rummaging in dumpsters around his apartment and also just kind of scavenging in people's lawns. And what he was looking for was, as you see in the picture here, aluminum cans to redeem. And so upon further questioning, when trying to figure out why he was doing this, he was trying to procure funds for financial scammers. So he was searching through the dumpsters, scavenging on private property, and the neighbors ended up calling the police because he was so loud and doing this. And it was actually a lease violation. So he was putting his very livelihood and housing in jeopardy. And when we asked him the approximate amount of money that he spent on this endeavor with scammers, it was approximately 30,000 over 10 years. That's a lot of cans, folks. So here are some of the different schemes that we learned about through a careful review of his records and other reports, including some paperwork that his sister put together. And we'll talk about the outcome for this case and what we ended up doing to try to support and help the patient. One was a fraudster claimed to be a victim of a robbery and needed emergent financial assistance. One was someone who said they needed an urgent medical procedure and needed them to send money right away. There was another fraudster who needed money to travel to another country to escape danger. Another time, they asked the victim to reship items for a charitable cause. And just so you can get a visual, I'm sitting in the office with the patient and his sister and talking to both of them, engaging in the interview, and he was quite dismissive of any concerns that the sister or I had about where his money was going. And in addition, he was actually on his smartphone and he was communicating with scammers in the middle of the appointment. So he was emailing back and forth with people. And I started to look at him as somebody who lacked what I'd call anomaly detection. He really couldn't tell the difference between a genuine interaction and something that was more nefarious, so to speak. And there was another one where people were online psychics looking to bait him into their services, foreign attorneys and website operators, people asking for upfront payment for travel so they could come and visit the victim, and then also asking him for his bank account. So there are quite a lot of red flags in this overall. And the common themes are urgency, rescue from danger, and emotional appeal. So it was really these high-pressure sales tactics. I need the money right now, I'm in danger, it's extremely upsetting situation, and I really need your help. So it's appealing to his wanting to help other people. And also, you know, he was lonely. He didn't have that rich of a life, I'd say. Quite isolated sister was really his only social contact. So it kind of gave him human interaction that he'd be missing otherwise. So now we're gonna review, just as a broad overview, the types of elder abuse. So we know about physical and sexual, emotional, psychological, financial, and neglect. And we're gonna hone in from this big picture of the different types of abuse that can occur on the financial, as that's the topic of our talk today. So here's the definition for the National Center for Elder Abuse. The illegal or improper use of an elder's funds, property, or assets, including, but not limited to, misusing or stealing an older person's money or possessions, coercing or deceiving an older person into signing any document, like a contract or a will, and the improper use of conservatorship, I can't say that word without thinking about Britney Spears, and guardianship and power of attorney. So there are these major mechanisms, which Dr. John will be talking with us later on in the talk about, but these major mechanisms, of course, can have misuse as well. And this definition incorporates both fraud, so intent to deceive and carry out a predatory act by a stranger, and exploitation, so those would be acts committed by someone who's already in a position of trust. So here are the types of elder financial abuse. There's crimes of occasion or opportunity, crimes of desperation, and this generally occurs with someone who's already in a position of trust, like a friend or a family member, and they could be desperate for money. This could be related to substance misuse with a relative, and they could have developed an addiction and be trying to steal money from the older adult just because they're desperate. So they wouldn't necessarily do that if it weren't for that particular situation. And Dr. Pate will be talking with you just in a few about the attributes of both those who are exploited and those who exploit. And then another type of crime would be a crime of predation. So that would be when the trust is gained with the intention of exploiting the older adult later. And actually, just this past week in the clinic, I essentially am in an embedded clinic with primary care, we're right down the hall from them, and I ended up evaluating a patient via video from a rehab center where he was rehabilitating a back injury, and initially, when people were asking him about what's going on with his money, because he was getting, this is an older gentleman, almost 80, and he was getting social security disability, VA disability, and also pension from being in the National Guard for about 30 years. So quite a lot of money was going towards him, and then there was this question of where's all the money going? And he was initially quite defensive when he spoke with one of our social workers about the possibility of making changes and how his money is managed. So as it turns out, he had these family friends, well, they were his friends, and it was a couple, and later on, in his public service career, this woman befriended him when he was about to retire, and the reason he was so defensive about having us intervene in any way is because he valued their friendship, he valued their support, his wife died over 20 years ago, and he really didn't have anybody else. And so this couple, they would visit him when he was hospitalized and talk to him on the phone, but there was also kind of a nefarious side of things as well, where he mentioned that the husband in the couple was quite, he called it sticky-fingered in terms of taking his stuff, and another example is he ended up selling his house in Vermont, and he was thinking that there was gonna be a $50,000 profit because the real estate market has exploded there, and it ended up being only a $15,000 profit, and what the couple had told him was that they had used that money on refurbishing the property in order to resell it, and there really wasn't any good evidence of that, and like he said, this person was a handyman, but again, there might be some type of contractor fraud going on there as well, so all kinds of red flags coming up for me, and because I was able to establish a good rapport with the patient and talking about things that had been going on in his life and his experience and his distinguished career of public service, we had a good alliance, and this changed from a capacity evaluation, because in talking to him, I realized he wasn't overtly cognitively impaired. He was able to name three out of three objects and pass his mini-cog, and he was oriented and seemed quite sharp in his short and long-term memory and quite able to describe the exploitation that had been occurring, so it turned from a capacity exam to more of a advocation session where I'm saying, well, wouldn't it be good to have some more oversight for what's going on with your money, since we're really not sure what happened to this $30,000, and he was agreeable to actually getting a VA fiduciary, so that ended up really well, so the point of that is getting a good history, getting to know the patients can be really important in teasing out what type of crime this is, and so I'd characterize those events as a crime of predation, because it seems like this family saw him as being somewhat vulnerable and lonely and widowed, and he didn't have any children, so it seems like they were looking to try to exploit him. So what is the scope of the problem? Just going into the epidemiology, one out of every 18 community-dwelling, cognitively intact older adults face scams annually, and the number of victims is actually substantially higher in those who are cognitively impaired. And then also, when you look at the community-dwelling, cognitively intact folks, over half of them are exploited by family members, which is quite sad, most often adult children, and also 17% by friends and neighbors, and 15% by home carriers, so what do all those people have in common? They have trusted roles, and so the guards are gonna be up less when it comes to the patient, and also to the providers, so just be aware of that, someone might have a very valuable role in someone's life, but still be doing crimes of exploitation. And then also, people that don't engage with social services and need more functional help with their daily activities are uniquely associated with increased likelihood of financial mistreatment. So what are the costs of this plague? It's linked to financial abuse, it's linked to loss of $3 billion annually, and some sources think that it might be much higher than that, it's devastating in its impact, and there are complex reactions to being taken advantage of. There's shame, guilt, grief, and it can even go into suicidal ideation, because you just feel that you've been taken advantage of, and you're not the same as you used to be, and it also can be lethal, because there's mortality rates that occur for people that are financially abused, or similar to those who are neglected. So really, a very big issue, it's important to note that older people are more targeted, there's an assumption that they're lonely, and they're trusting, and they also have big savings, so that's why there are usually target schemes aimed at them. It doesn't mean that older people in general are less capable, and oftentimes, people that are in their 60s, 70s, 80s, 90s, can be cognitively sharp. One thing that they do as a generation, compared to younger generations, is that they answer the phone more often. So my cell phone is attacked with scammers, or spam calls constantly, and I almost never answer my phone, because I generally, I talk to people all day for my job, so I really don't wanna know what's going on, or answer the phone, so that's one thing, but then also, generationally, we tend to answer the phone less. The older folks are coming from a generation where they had a landline, and they would answer it, and they would usually be somebody that they knew, or something important, and so there's that cultural divide. Wanted to mention a famous case, there was Jen Shah, I don't know if we have any Real Housewives fans here? Okay, outstanding. Thank you very much. I feel dignified now. And she was on Real Housewives of Salt Lake City, quite an entertaining and dramatic character, and certainly her drama helped the ratings of the show, but she's currently doing 6.5 years in prison, and had to pay 6.6 million in restitution, and also had a bunch of her items, millions and millions of dollars of her items were confiscated, because she was running for years and years telemarketing schemes, which were calling potential victims, claiming to offer website enhancement, or business coaching, and as it turns out, after the investigation, the services that she was offering were really not all that valuable to the customer, not valuable at all, and furthermore, she would help collect lists of vulnerable adults, so people that had been exploited before, she was collecting lists of those folks, because if you've been exploited before, you're at risk for being exploited again. So that's just the lay of the land, this is a really big thing out there, and when you do talk to your older adult patients, ask, hey, has someone tried to run one of these type of scams on you? And providing some psychoeducation about it is really valuable. So what are the barriers to reporting financial abuse? So there's fear of consequences of reporting, my patient that I discussed earlier in the nursing home, he had mentioned he was worried that the male friend of his was six foot six, and was kind of physically intimidated, so there were concerns about that. We're doing an APS report, and also getting a fiduciary for that particular patient, and we'll talk about recommendations later, but report, unless proven otherwise, I mean, the default is report, because even if you don't have concrete evidence, it's good to report, and the patient was also worried about the loss of the friendship, and I leveled with the patient, and I said, well, if these folks are going to be upset with you because you didn't let them control all of your money, are they really your friends anyway? And he was able to understand, probably not, right? So if he got a fiduciary, and they disappeared, they weren't good friends anyway. So just leveling with someone like that can be helpful. There's cultural differences, or religious beliefs, there's psychological barriers, there could be embarrassment about what happened, there's also dependency issues, so victims of financial abuse may be dependent on their abuser for access to basic needs and functional assistance, and there could be synergistic dependency, which means both of the abuser and the victim have dependency upon one another, and that makes it tougher to tease out, and so there's gonna be some pushback from the victim about untethering with the relationship with the other, because they're both dependent on each other. And there's also, the exploiter could be dependent on the victim as well. And then there's a lack of awareness about programs, and that's something that we're gonna try to address here today. So I did upload the slides on the website and the app, and then also in the slides is the reference to the article. So honestly, spending a little bit of time with that, like on the plane back to wherever you come from, is not a bad thing if you're really interested in learning more about this topic. Okay, so what are our types of scams? So we have the sweetheart or caretaker scam. The exploiter will befriend an elderly person and offer friendship, romance, sex, or assistance with activities in the household. And then after the courting period, they steal cash or property. There's also home repair contractor frauds. We had a little variant of that where my patient's friends told him that the reason there was basically $30,000 missing from his bank account is because they had to invest in the property to boost the sale price. And that's what ended up happening, and so they were actually calling themselves like contractors when there was really no evidence of that. And utility company impersonators, that one's pretty obvious. You can figure out someone knocks on the door, says, hey, I gotta come in and fix your lights. They'll give an estimate, they'll do the work, which is often shoddy or haphazard, and then say, actually, as it turns out, the price is higher than the estimate. So we all know, in general, the price is always higher than the estimate, but it ends up being really a lot higher for these utility company impersonators. And then there's the pigeon drop scam. So I know, Vineeth, there was a movie that might have used this scam you were telling me about. The Sting? Okay, good, I'll have to catch that one. But anyway, the older adult victim is approached by the exploiter, who claims they just found a bag full of large sums of cash. The exploiter may suggest that for the victim to keep the found cash, they must withdraw funds for their own accounts as collateral. So, hey, I just found this bag of money. In order for me to give it to you, you have to give me money. For us, it sounds ludicrous, but when you don't have that anomaly detection, when you don't realize whether it's because of dementia or TBI or some other type of mental health condition, when you don't realize the person's trying to take advantage of you, it might make sense. There's the handkerchief switch, kind of a variant on a theme. The stranger approaches the victim and asks for assistance in sending a large amount of cash to a charity or another country. They appear to put cash into a bag and tell the victim to do the same. Then they take off with one bag, and then they leave the victim with the other bag, which, as it turns out, doesn't have cash. It's probably just blank pieces of paper. And then there's bank scams and other types of scams. We talked about telemarketing and mail fraud. And when the three of us were chatting about this presentation earlier, now there's artificial intelligence scams. So there's like robocalls, where the AI can modulate what their message is depending on who they're talking to and depending on the information they're getting from the person they're calling. And for some of us, it might be obvious, hey, this is not a real person on the other line, but for someone that has that difficulty with detecting fraud, that can be a real big problem. And then because of MTV, we know about catfishing, right? Manipulating virtual relationships and there's been a lot of famous cases about that in the news, Manti Teo, the Notre Dame football star, they had a documentary, I think it was on Netflix about him being catfished. And this happens, of course, with older adults as well who might have lost their significant other and not have family, and so they're gonna be more vulnerable to being catfished. And then there's reverse mortgage scams. So reverse mortgages sound pretty good. And overall, they're something where you can take money out of your house and be able to spend it on going to visit some warm weather climate or something like that, or do other things you wanted to do that are on your bucket list. But there's also reverse mortgage scams. So whenever one of your older patients, especially those with cognitive impairment, whenever they're doing types of business arrangements, you wanna make sure that they talk to a social worker or legal representation and not just get into these agreements without full knowing about what's going on. And then we have the modern scams. There's the grandparent scam, and oh, is this one sad. And I've actually had some patients who have had people attempt to do this. Someone will call, say, hey, this is so-and-so, your 15-year-old daughter or granddaughter. I've just been in a car accident. I'm getting charged. I need you to send me $3,000 via Western Union to bail me out. And they're able, it might be a grandkid that the person hadn't heard from in years. They might not recognize the voice. They might believe that it's actually that person, and they're gonna be eager to build that relationship with the grandchild. And so basically, if you're a caring person, you're more likely to be taken advantage of in one of these scams. And like the fraudsters say, once you get them emotionally involved, they will do anything for you, basically. And they have actually, there was a special on CBS, I think it was 60 Minutes, where they were interviewing someone who was in prison for running these scams. And they have literally these warehouses where people are, it almost looks like cubicles, where there's like 100 people doing these calls all at the same time. So it's kind of like a troll farm, basically, but for the grandparent scam. So with that, I'm going to turn over the microphone to my friend, Dr. Pate, who will be talking about vulnerability to elder abuse. And thank you, everybody. And we'll be here for questions after, too. Hi, good afternoon. I'm Ryan Pate. I'm a geriatric psychiatrist. I spend most of my time in outpatient, doing medication management and therapy. Can you hear better now? Ah, good, I'll get closer. There's some echo back here. Yeah, so what I'm going to talk about is, I'm going to talk a little bit about some of the things that increase vulnerability for people. Some of the red flags to look out for, both with exploiters and for victims. And also thinking about why this may occur for both exploiters and victims. And then we'll look at some things you can do in a time-limited course with working with patients. Maybe some skills to use in a questionnaire. So some things that increase vulnerability with older adults and to elder abuse, including financial abuse, is living in shared living situations, being part of the queer community, history of interpersonal trauma, mental health or neuropsychiatric disorders or challenges. And it's also important to remember that any person can be victimized. That's something I'll talk about with my case. So what are some red flags of vulnerability or victimization? Some things to look for from the victim or patient's perspective are things like indecisiveness, confusion, deference to the new companion. There can be cognitive or physical impairments of the older adult, particularly if recent or sudden onset. Recent changes in demeanor, clothing or physical appearance. That's where our mental status exam becomes really important. New acquaintances, particularly if they seem vested in finances or have a financial interest. Change in legal paperwork like power of attorney or wills. Sudden increase or change on debts or inability to meet financial obligations. Big sums of money going missing. And any new suspicious signatures on things like checks, documents or legal paperwork. So now we'll shift gears a little bit and we'll talk more about a case and maybe why this happens for people. Before we talk about that, some interesting facts that I found is that adults check their phone every six and a half minutes. So really connected to the internet, especially now. And during the coronavirus pandemic, and to this point, financial fraud, especially online has increased, especially through dating apps and dating app usage itself has increased by 18.4% since the pandemic. And with this internet, it creates this virtual world with the use of the internet, a virtual world where meetings can take place, secrets can be exchanged, and there's not this intervening presence of two bodies sharing one space, which we'll talk about in a little bit why that's important. It also gives a place for our conscious and unconscious desires to find new expression in the form of the internet. There's that ability to be anonymous, increased accessibility, and a play for fantasy leading to enactment of these fantasies and desires. And also people's identities aren't limited like they are in real life. And the only limit can be their imagination. So let's think about my case. So there's a man I'm working with, we'll call him Rob. He's in his early 80s. And he came to me after his wife had recently passed. Some important things to note, he doesn't have any neurocognitive disorder. He's been very successful throughout his life. As a PhD, he's been a CEO, and he continues to be a C-level executive in a pharmaceutical company. After his wife passed away, he started using an online dating app where he met a younger woman in her 30s, or so he presumed. It started out by they were talking, chatting, they got to know each other, talking infrequently, maybe a couple times a week. And it increased to him talking to her every day, moving from using the dating app to personal email and phone number. Over the course of about three or four months, he ended up spending or sending $200,000 to this person. He would send $25,000 to $50,000 at a time to them. Of course, at this time, they were promising to come meet him, to visit with him, to potentially live with him, to care for him. And when that time comes, something would always come up, whether it was illness or difficulty with transportation or a flight being delayed. This continued to go on until one of his children found out about it and confronted him about it. And then at that time, the sending of money stopped. In the backdrop, he described feeling like he had a poor relationship with his children, being unhappy with his life, lonely, isolating at home, not really getting out and doing much. The only thing he was spending his time doing was sleeping and reading. And he stated while he was in this exchange and sending this money, he felt cared for, he felt loved, he felt a sense of intimacy. And that's what we see a lot when we start to try to understand why this can happen to people, especially people that don't seem to have a cognitive disorder or maybe like a clinical psychiatric diagnosis like major depression, is that with the interaction, it conceals these feelings of loneliness and neediness and fills it with this feeling of intimacy. And it also lends itself where there's this time where we can always connect with somebody, always have that social interaction, always have that feeling filled. And it really denies us to allow ourselves to reflect and experience those wounds, that pain that come along with the real world, those times of introspection and reflection. And really separates us from that mourning by using the internet and can release a person, or momentarily from that burden of being themselves. So let's talk a little bit about exploiters. So they may have legitimate roles in victims' lives. They can be care helpers or social supports. And they may not appear to be that personification of evil that we may expect or the fantasy we may have in our minds. There can be some attributes, though, that exploiters have in common. They can have their own physical and mental health challenges. There may be substance use that's driving the experience. Dependency upon the victims, whether it's financially or emotionally. They themselves could have limited coping skills, negative attitudes about caregiving, relationship problems, isolation, having been involved in trauma or a victim themselves, or low social support. So what are some of the red flags to look for within the interaction? So the patient, the victim, can be hostile or nervous towards the helper. The older person can appear uncomfortable or fearful. They can isolate from family or friends, which is something that happened with my patient. The exploiter can be controlling or overbearing, reluctant to leave the room or give privacy, which is why it's always important, especially with seeing older adults, to interview them separately and make space for that. There can be inconsistent explanations regarding the relationship. And two, even times they could have previously been employed by agency but left to directly work with the person to make things easier. So what might be driving the exploiter? What things might be going on? So there can be many reasons why people exploit others. And maybe, especially when it comes to catfishing or online, they may find that the online version of themselves better matches that inner self that they're not able to express outwardly. They may wanna enact revenge on someone. They may want to humiliate or control others. They may wanna swindle money. Or they may just wanna escape their own limitations of their body and self, where there's no things like odors, fluids, stains, or shames that go along with it. Something that occurs too is that there's this change in the relational frame. It's altered. And that relational frame is how we react or interact with one another in a physical setting. And a big part of it is linguistics and body language. So with that online presence, that online interaction, there can be lack of intonation, gestures, facial expressions, all things that send unconscious messages to us about motives, longing, hopes, and fears. And typically how it will happen too, like with my case is, you'll have an exploiter who will go on a dating app or an online site, and they'll find a profile, they'll find a victim, and they'll tailor a profile to the victim based on what they think the desires and hopes of the victim are, maybe what some of their wishes or some of the things that are noted in their profile that they're looking for. And like I was talking about with my case, they'll start, maybe infrequently talking, and then move it to daily interactions, and then even more personal forms of communication like email or telephone. And then they start connecting pretty frequently, exchange of money occurs, a meetup is arranged, and then when that time comes, of course something happens, some crisis occurs where they're not able to meet. And this further engenders and fosters sympathy and longing that wish for intimacy from the victim. And then typically what can happen is also there's larger sums of money sent, and that relationship intensifies. So we talked a little bit about what can happen from the victim's standpoint and also the exploiter's standpoint. But why does this relationship occur? There's benefit for both parties. And these two people are effectively colluding to become co-created characters in their own romance. So right, this collusion to create an illusion where they come up with these subjective identities that may be more intriguing. And a lot of times that can happen where our characters are more intriguing than the authors themselves. And these love stories that are more idyllic than the real thing. And there's self-deception on both parts of the parties in different ways, but it occurs. I think similarly they're both trying to hide, to avoid, or even deny parts of themselves. The exploiter's denying their role as an imposter while the victim avoids asking questions that might expose the ruse. The exploiter conceals themselves, maybe feelings of inadequacy or malice, while the victim conceals feelings of loneliness and neediness, and potentially even denies any suspicion or any evidence of being victimized. They both are hiding the feelings of lack in themselves and in their lives. And then the exploiter rationalizes acts of duplicitous sedation or seduction while the victim rationalizes and justifies acts of gullibility, creating this online world where they're both deeply ingrained within one another and felt in this fictional intimacy. So let's talk two more, maybe, about some practical things you can do in the first couple meetings and some tips to help a starting place. So we wanna think about screening and prevention of financial abuse. So what's our role as clinicians? Of course, psychoeducation. When we hear something like this going on, understanding why it's occurring, help discussing with the patient, noticing some of these things and pointing them out, addressing some of the fallacies. And we can direct them towards resources. There are things like the Consumer Financial Protection Bureau. And we can do screening. And there are some specific screening tools that we can use and we'll look at. And then Dr. John will talk to us more about the management of this situation. So there's no perfect screening tool, like most things. And there's not one for elder abuse. And it can really be based on the setting, how we wanna practice, if we wanna do self-administered or direct questioning. So let's look at one of the screening tools. So this is the Financial Decision Tracker. And when I think of it, it kind of reminds me of capacity. There's understanding, reasoning, rationale. So some of the, it's 10 questions. So the questions are, what's the financial decision you're making? Was this your idea or did someone suggest it? What is the purpose of your decision? What is the primary financial goal? How will this decision impact you now and over time? How much risk is involved? How may someone else be negatively affected? Who benefits the most from this financial decision? Does this decision change previously planned gifts? To what extent did you talk with anyone regarding this decision? And of course, too, we can always use supportive interview techniques, showing validation, empathy, understanding, using open-ended questioning. We can also think about developing trust, enhancing the therapeutic alignment. A lot of these things can bring a lot of shame, a lot of guilt to tell other people about. We can set up this holding environment. That's that understanding, that compassion for others. And then even set up this containment, which takes that holding a step further and helps people understand and work through these things. And one of the goals is to help recreate what in those corrective emotional experiences, allowing people to work through their trauma and their suffering in a new, helpful, transformative way. And then some questions we can ask is like, does your care helper depend on you? Has money been stolen from you? Just some openers. I hope today is to provide you with a framework for this complex issue. There should be thoughtful balance of patient autonomy, patient safety. And as Dr. Parrish said, this underlying need for us to truly appreciate what's going on in the patient's life and to understand this psychological mechanism at play. In my clinical experience, I came across a similar situation described by both Dr. Rostad and Dr. Parrish. And it was an elderly lady, financially well off, but living a very lonely existence. At some point, made contact, maybe answering one of those calls. And developed, in her opinion, a real relationship with somebody who was sort of encouraging her to send money because she's won this amazing cash prize. But to be eligible, a certain kind of nominal fee needs to be given to her. Her daughter was a psychiatrist, and they all met me, and the patient felt that this particular person who calls her and tries to make her send, you know, this incremental amount was the only one who understood her. She would look forward to these phone calls. And eventually, she was lost to follow up. I still don't know what really happened, but it sort of talks about, it told me about how complex the situation is. Even with what both Dr. Rostad and Dr. Parrish was talking to us about, even if we indulge in thoughtful summary of what has been happening and gone through all the questionnaires and sat and discussed the psychological mechanism at play, I can assure you that most of our patients will reject this whole well-constructed hypothesis straightaway. And the other theme in dealing with financial abuse of elderly patients is that our patients will need time to process the information and also to be aware of the true state of the financial, of their financial status. So when we try to sort of put it all together and craft this framework of how to manage, it won't be the task of just one person. Sitting as a psychiatrist, even as a therapist, in these one-to-one dealings with our patients, I don't think we could even fathom how complex this would be, and I will try to sort of take you through at least some of the steps we could think about. One key theme is to still think about our diagnostic process, what could be behind this particular situation, either medical or neuropsychiatric or behavioral syndromes. When Dr. Rostad talked about his patient collecting cans and causing disturbance, there was some allusion to the Diogenes syndrome of living in squalor, but clearly his patient does not meet that. Neurocognitive disorders, people could have significant cognitive problems, mood disorders, psychotic disorders. I really felt my patient actually was in love with this particular exploiter, so was that a dilution of romance? So this group of patients represent physical frailty and mental vulnerability to think critically and make appropriate decisions. Sometimes it's that physical frailty which invites quite a lot of people into their homes, which they probably wouldn't have invited the first time. So when we look at how to manage these patients, I would like us to think about, at least from a psychiatric standpoint, any intervention which could enhance their thought process, improve their mood, decrease any kind of psychotic thinking, improve their insight and judgment, and then, in some level, improve their coping skills when entwined in these abusive situations. I don't have to go through the workup part, which we all do when we see somebody who may be going through some of the symptoms, but it could include ruling out substance use, blood alcohol level, urine drug screen, vitamin B12 thyroid level, metabolic screen, and also paying attention to the nutritional functional status. But again, as I said, we are not alone. We are part of multidisciplinary efforts, and quite a lot of time it is our social work colleagues who could take a very central role in trying to do a psychosocial assessment. And then, together, you may have to think about a safety plan, and the safety plan could include pragmatic safety safeguards, and we'll get to it in a second, or very formal safeguards, which also we'll talk to you about. Then of course facilitating access to various services and resources, which could include even financial assistance, food services, transportation, and then paying close attention to the healthcare preference and advanced directives, and continue to think for continuing to do the cognitive screening, and then using some of the scales to evaluate for financial decision-making capacity, as Dr. Perry talked to us about. So I'm just going to focus on two things which are sort of helpful to us as we try to have the conversation with the patients. One of them would be what we call pragmatic safeguards. We should be prepared to discuss arrangements with trusted people well before the patient might be at risk for dementia, so encouraging the patient to talk about creating people who they trust, and then able to outline one's financial arrangements in detail with helpers, and creating, I would say, a system in the family so that the older person never signs a blind check, and not to give out constant repetition and reminders not to give out bank cards or card information, and to also have some kind of a mechanism in place to consult an attorney before becoming a party to any type of legal agreement. And in your sessions with them, even if at that point they look financially sound and not a victim of any kind of financial abuse, please see them as a potential victim, so providing psychoeducation, as Dr. Perry talked about, avoiding telemarketing and mail scams, and even those wonderful examples of what the pigeon drop and hidden handkerchief and all those things Dr. Rasta talked about, and then to have that kind of reactivity through alerts to report any suspected identity theft immediately. And so we have moved into a realm where we may have to initially, we would have thought we may not have to initiate these formal safeguards. All of them have some kind of a legal background. One is called durable power of attorney, where an older person with sound legal advice may wish to confer legal responsibility to a third party to ensure that in case of a future mental impairment, an appropriate person will have the legal authority to handle their affairs. So that's a durable power of attorney. Giving trust is created after consulting a lawyer and transfer the title into a trust of the property, into a trust, and place the financial management in the hands of a trustee. And if you get payments, especially from federal government, you could create a formal arrangement which would involve administrative appointment of somebody to manage an incapacitated person's income. But the most painful, the most challenging, sometimes the only resort, which is what we were thinking about in my patient's case as I was discussing with her daughter, is the concept of guardianship. This is obviously, yes, we think a solution of last resort, but you may have to get through this to protect a vulnerable adult when everything else fails. So three things should be in our minds when we pursue guardianship. One is you are quite convinced that the victim has been exploited. Second, through your assessments, the victim lacks the capacity. Third, the victim cannot be adequately protected through any alternate means. When all those three themes are satisfied, then guardianship should be pursued. So victim has been exploited, victim lacks capacity, and cannot be adequately protected through alternate means. These are the three areas. And then, just giving you a list of various agencies which are aware of these kind of scams. It's not like when you call somebody, they have no idea what you're talking about. So including Adult Protective Services, they become your strong allies. They can have much more of a reach in putting an end to financial abuse and financial exploitation. Sometimes you may end up having to call local law enforcement, there are long-term care ombudsmen, Federal Bureau of Investigation, Federal Trade Commission, State Insurance Department, Department of Financial Regulation, even Office of Inspector General, and other agencies like legal service agencies, and state senior Medicaid patrol, and United States Postal Inspection Service for mail fraud. So I'm just going to get back to you on those various agencies, but the point is, this is very much on the radar, on the horizon, and it won't be difficult for them to grasp the essence of what you're trying to say. As I said, it is a balancing act. Clearly, we want to protect the older adults from any kind of financial abuse. But then, if it is sort of initiate, all these things are initiated too early, then there is this concern about older adults losing their sense of autonomy and their control. So in conclusion, financial abuse of older adults is widespread, yet underreported. When we encounter victims of elder abuse, we could potentially be able to detect simultaneously occurring forms of abuse as well. The goal is to work together, to rely on a multidisciplinary healthcare team, including social workers and local reporting agencies, and even family members, so you could provide a coordinated, multifaceted support for the victim and can most effectively intervene. And then we have sort of taken you through a combination of methods, which includes developing a trusting clinical relationship, using clinical interview methods, and having the curiosity and the due diligence to do a deep dive into the patient's financial situation independence, trying to use a standardized screen for elder abuse, be comfortable with how to obtain capacity assessments and to obtain collateral information. And of course, the final kind of management formula may involve pharmacological treatment, counseling, professional and financial and legal services, in-home supports, utilizing community resources, safety planning. And our final, ultimate goal is, of course, to support our patients who find themselves as the vulnerable victims of financial abuse. Thank you again, and it's question and discussion time. And just to follow up, can people hear me okay with this? Mike? Good. Okay, perfect. So in the case of Mr. A., who is redeeming bottles and cans, what we ended up doing was not only filing an APS report, but we also worked on getting guardianship with his sister. And so it was quite an extensive process, but it was well worth it to get a better outcome for him, because he clearly was mismanaging his own funds. And just to echo what Vineeth was just talking about with the balancing act, about, you know, not leaning too far into overprotecting older adults, sometimes a capacity evaluation isn't just a capacity evaluation. It can really be an opportunity for negotiation and strategizing with patients. And the two gentlemen sitting next to me are geriatric psychiatrists. I'm a CL psychiatrist by background and with a special interest in geriatric psychiatry. And during fellowship, I really honed ability to do capacity evaluations. And if you're interested in collaboration with primary care as a career or a future career path, there's a lot of opportunities for that, to be able to take a look at capacity evaluations for older adults. Because right now, we're really facing a silver tsunami, right? So we have a rapidly aging population and limited resources to help them. And we're blessed in mental health with having a little bit more time that we can spend with our patients. Our appointments are generally much longer than those of primary care. So we can really be essential actors in helping to protect them. And with that said, going back to the concept of the balancing act, we don't want to necessarily take away someone's autonomy unless it absolutely has to be done. So the patient I met with last week to do the capacity assessment via video, I just noticed initially when I went into it, I was thinking, well, it seems like he's lost a lot of money. He's trusting fairly random people with all of his money. He must lack capacity. But that's not necessarily the sense I got. He was quite articulate and quite cognitively sharp. And the sense I got was that he would be somebody that I could reason with. And that's part of capacity, is can someone make flexible decisions. And when you present them all the information, can they send it back to you? And so that's really reading up on how to do a capacity evaluation, getting practice doing capacity evaluations. It's great. And it's something that generally people dread doing. When you get a consult at 4 o'clock, you know, this person is refusing to go to the skilled nursing facility. And can you come evaluate their capacity? You're like, oh, gosh. And then also, medical consultants often can do capacity evaluations asking for global capacity, which is no such, there's no such thing, also asking for competency, right? And so we don't assess competency. That's more in the legal realm, not the medical realm. So what you want to do is fine-tune the consultation question. What is the capacity about? In the case of my veteran, it was ability to manage finances. And I said, he does have the ability to make the decision. And his decision was he wanted to get a fiduciary. Now, could he change his mind? Yes. And if he's vacillating on what his decision is, then that's a different discussion, and it might need an all-new capacity evaluation, given that there's changing of his mind. But capacity is really, it's one moment in time about one question, and then you're getting as much information as you possibly can. If you're going to dare to say that someone lacks capacity to do anything, you have to give a why. So it can't just be the what they lack capacity. There also has to be a why. So if our first patient, Mr. A, it was the TBI causing the coma and then cognitive impairment throughout his life, which was leading to the poor decision-making. So that was the why he lacked capacity, not only to make financial decisions, but also to care for himself, because he was living essentially in squalor, hoarding cans and other useless items, and had poor hygiene. So there was the lack of self-care, and also the lack of capacity to make financial decisions. We talked a little bit about Real Housewives of Salt Lake City, and another TV program I'd recommend you to, actually, I'm not recommending you watch Salt Lake City Real Housewives. I'm going to take back that endorsement, but I did talk about that. But I'm going to talk about one that I would recommend would be The Billionaires, The Butler, and The Boyfriend. It's a Netflix series. It's a four-part documentary, and it's about a L'Oreal heiress, the wealthiest woman in the world, Lillian Betancourt. And I'm going to leave it at that, because I don't want to spoil, like, all the punchlines. But let's just say that it's relevant to the topic of our talk, and it might give you some more inspiration to dig deeper in your pursuit of understanding capacity. So good. Yep, The Billionaire, The Butler, and The Boyfriend on Netflix. And it's the L'Oreal heiress, so if you can't remember, if you just Google that, it'll probably come up. But it's excellent. And there's political corruption, romance, everything you could ever want out of a TV show, plus you can learn stuff from it, too, for your own practices. So good. Any questions from the audience? Please step up to the mic. Hopefully the mic works, just so everybody can hear. Either that or talk very loud. Thank you, and when you say the fragmented info, do you mean someone who has multiple providers? Yeah. Yeah. People outside of the actual network. Got it, got it. Yeah, and for me, that's a lot easier because at the VA, it's the highly coordinated network where we can get medical records from multiple sites, but then when it's providers from other institutions, that becomes a little bit harder. So I might defer that one to my colleagues here. Any thoughts on the trying to coordinate information from vast networks? From my experience, the best group of people would be the adult protection services because they have resources, they have case workers exclusively to look at these kind of abuse situation, and they have the capacity to approach the banks and other avenues where we don't have any ability at all. So I would totally, if you're suspecting it, you're mandated in some way to quickly let the adult protection services know, and quite often, these are the kind of cases they know timeliness is of the essence, and they'll try to work on it very fast. Excellent, and I would add that APS, a lot of times they will say they cannot find evidence of the exploitation. With that said, covering yourself from a medical legal standpoint, it's good to report. If you have a germ of an idea that someone's about to, that someone's getting exploited, it's best to document that you have done the report. And in Vermont, where I practice, it's right online, so it's a very easy thing to do. And then the other thing about whistleblowers, was that question in terms of concerned family members, like not healthcare providers? Yeah. Yeah. They can report to APS, absolutely, yeah. I think the only area we have found is during guardianship and clearly there there has been a lot of openness to consider advocating for the patient but still there will be situations where like you said it is profit-driven and then there may be family members who may be quite willing to challenge this move from our side so trying to look at it from our perspective of like there is clinical evidence to suggest cognitive impairment which is making them vulnerable to abuse the only way to go there has not been much of interest from their side to learn more about this as well because they feel like it might eventually prevent them from taking on cases Yeah, so great points. So about the patient never coming in again, there is a bit of an art to it that I try to do, which is a little bit of playing possum. So if I start to suspect something might be going on, it might be more frequent visits. It might be you're doing perfectly with going over with the patient and also the family separate. But I think you touched upon one of the themes of the talk, which is enmeshed relationships. So the patient is dependent on the family to take care of them. And the family is dependent on the patient for money. And there could be some maybe not the best activity going on in terms of the person helping themselves to too much of the money, so to speak. So there's just get really building that rapport and building that trust. That is the best thing. But there could this is not we're not immune to bad results. It could be just like I'm not seeing that doctor again. And again, that's a red flag. So if the caretaker is like doing like doctor shopping or they're and Ryan talked about it, if they're kind of boxing off helpers, then that is even a further reason to maybe investigation might be necessary. So it might get it might get I want to say more difficult before it gets easier. But as long as you have your mind on it and you're screening, that's a great thing. Absolutely, and the crisis that we're facing is the shortage of helpers. They're just as, for example, like at the VA, we have funding available for vulnerable adults to get the home health care, but then the agencies don't have the staffing to send somebody in. But, absolutely right, the home health care, because they see the people in the home so they can detect things that are going to be a lot easier to pick up if they're there for a few hours as opposed to just a half hour, an hour office visit with us. Thank you. And, yes, I agree also that this kind of material should be in training programs, and I have a couple influential educators here with me, so we'll, you know, continue to press that. Obviously, every state and every country has different laws, but at least understanding the big pictures of the legal aspects, I think, is very important. It's not just the mechanics of doing a patient exam, but it's like, what next? Have you had a case that you're thinking of when you're trying to, this sounds like learned experience. Is there one that stands out to you? Yeah, I can't really discuss here, so I don't really get, a little on my own. Gotcha. Okay. Fair enough. Yep, there are people that will take advantage of people, and sometimes, like Ryan said, they're not the personification of evil, and sometimes they are. Sometimes they're just people that are quite brazen with their thievery. That's wonderful, thank you for your comments and sharing the stories. And what you did there was eloquently described the role of consultation liaison psychiatrist. So we interface with primary care and internists and part of our job shouldn't be just to see patients that they call us about, but also should be educating them about these are the questions. And so, you know, from my own little corner of the earth in Northern New England, I've been trying to do outreach about this at the VA and at the universities I'm affiliated with at Dartmouth and UVM and I'm kind of doing, you know, a little tour, giving this talk just to raise that awareness. And I do feel the pressure of feeling like psychiatrists now have to save the world from this plague, but I think we can, I think we're up to the task. To my knowledge, yes. I haven't reviewed every talk, but I haven't heard of this, and there's not a whole lot of literature. In fact, a lot of my references, when I published the article, were from legal handbooks. Actually, my wife is an attorney, and she works in sex crimes, but she also has experience as a prosecutor in financial crimes. She found this huge book that had all kinds of examples of different scams, so that was really helpful for me in putting together this article. I was inspired by my clinical experience of seeing the patients, but then, the last couple of years, I dove deep into the theory behind how we can help. Really, my colleagues here did an awesome job of explaining these are the things that the people in this room can do to help the problem. I'm sure very often, like the case that we were just talking about earlier, and the scope of the problem is so much more than we even know, because I gave an estimate of this costs three billion a year, and it increases mortality to the level of people that have caregiver neglect, which, if you think about caregiver neglect, we're talking about cacetic people sitting in rooms with horrible, chronic medical illnesses, and the financial abuse is the same type of level of damage that those people are suffering from, who aren't getting fed, who aren't getting bathed, so it's really catastrophic. And then just the amount of shame and guilt that comes from this, and patients, again, because of the shame and guilt, they might not be willing to admit this, especially to a doctor they're meeting just for the first time, so that's why the screening question from I'd have to look up the reference for my paper but I remember it being for 65 and up yeah yeah but I think we can safely assume that it's like ten billion just just for elderly it because these are the things we we know about and and again the scammers are getting trickier like we're all aging and we're all kind of slowing down and the scammers are just getting much more sophisticated in their methodology so this isn't a scare tactic talk but it's more like a okay there's this problem and we just need to address it and that's really as psychiatrists I mean that's what we are we're problem solvers we have to be more creative so you know dig into the literature and figure out how you can help but I'm sure all of us show of hands do we have patients that are above 65 I looked it over and I'm you know a general psychiatrist and a CL psychiatrist and my panel is 35% at least over 65 so even though geriatric psychiatry the the fellowship numbers are dwindling our friends here were kind enough to do one to help us out with this but that the numbers are dwindling and but it needs more enthusiasm I'm trying to actually not only persuade some of my residents to do CL but also to do Jerry because there's just such a need and so there us as general practice psychiatrists are going to be doing geriatric psychiatry so the earlier we're more comfortable with it the better and I was very impressed by dr. Patton dr. will start putting the slides up and the article so one thing we could do is to send it to all our colleagues especially the primary care so there's a added level of awareness about what's going on because I think people may have heard stories and now we hear even more kind of tragic stories of people actually losing their lives over this this could be a trend which may be invisible but I think by making it much more palatable and increasing the level of suspicion and more could be done the the references in the slides and then it's just on the primary care companion for CNS disorders website so if you just google like my name rust ad and financial abuse of older adults it's it's funny that that's like the first thing that comes up for me is financial abuse of older adults I'm not sure I'm not sure I want that connection but nonetheless that that's how you can you can find it and just so everyone if anyone has any questions oh it's on the app wonderful and my email is James dot rust ad at VA gov so feel free to reach out and I'm hoping that you know this can be just the beginning of other people getting more interested and presenting posters and cases and we can go from there that will start will be happy to visit your town and give us that's right that's right we could take the tour to you actually the circus on wheels um there was another question Oh, that in America is writing your will like a popular, like pretty common thing? Sort of, but on the same, yes, yes and no. I have noticed that there's these, I'm blanking on what they're called, the advanced directives, right? And we're always encouraged to do advanced directives, not only for medical and psychiatric, but it would be nice to have like, you know, financial advanced directives as well. It's just hard to get us to do more documentation as providers, because I can speak from personal experiences, there's just a lot of documentation, but advanced directives are one, and encouraging people to, early on, like Vaneeth mentioned, early on in the process, even when maybe they just have mild cognitive impairment, or maybe they're completely structurally intact, you know, start to make those plans, and start to talk to your trusted advisors about how to plan for that. Right, and the younger generation doesn't answer their phone, but they sure as heck will answer direct messages, or someone DMs you or slides into your DMs, as the young folks say. People answer those kind of things, so it's very easy to catfish people electronically with AI, just using text kind of material, so that's a great point. I'm not sure about the, I don't know the answer to the, about the way the laws are written, but I would suffice to say states like Florida and Arizona that have huge older adult populations are where a lot of stuff is, is going down. Any thoughts on that? California, Texas? Was there a place with more safeguards, perhaps, relatively speaking, that you're aware of? Not, not that, not that I'm aware of. Is it possible to report when you feel that they're vulnerable, but then the state could decline to investigate? I wish that maybe, I'm not sure which state it is, but I wish that, Washington? I wish that they would trust the clinician's judgment on vulnerability a little bit more, because it seems like a lot of times, and this is definitely not a pro-lawyer audience, but it almost seems like we're deferring psychiatric decisions to judges in some ways, right? We're social workers, and it would be nice if our opinions, based on not only our training, but just the longitudinal knowledge of our patients, and that specific patient, I wish that would be taken more into account. Yeah, I would say Vermont is similar, it's quite civil liberties friendly, which is great. I mean, we mentioned that it's important to respect people's autonomy, and you don't want to take away their rights. That's the, like guardianship, like Vinita said, that's the exact end of the line kind of thing. So saying someone doesn't have capacity to make financial decisions, that has huge implications. And one of the things that can happen, unfortunately, is when someone's exploited, that can actually completely change their lives, because they might be able to live independently, and then when they get exploited, they might end up not being able to live independently anymore. They might be right on the balance between living independently and having to need state assistance. And so there's so many more implications than just the money that people are taking. There's like lifestyle implications, health implications, mortality, and morbidity implications. So the issue couldn't be more important. It really is a disease, and it needs to be talked about like one. I look at it, actually, I'm nothing if not pragmatic, and CL Psychiatry certainly encouraged that, and just personally, I'm an optimistic cynic, right? So all the points you mentioned about APS, I agree with. With that said, when you put document that you did the report, that's kind of a signal to other clinicians and other people that read the chart that something might be going on and this needs more attention. And fortunately, I do have some governmental power in that I can say, hey, this person needs a fiduciary. So if my agency is going to be paying their disability payments, I'd rather that it go to the patient than go to their friend like Steve that they met two weeks ago, right? So we have, depending on where you work and where you are, you could have more power to have an impact. But at least with the APS, it's a way to, A, cover yourself that you did want this investigated, and also, even if the result isn't what you get, at least it signals to other clinicians, hey, there's been three APS reports of this person in the last year. There probably might be some abuse or exploitation going on. So it all serves a function, even though it's not maybe the one we want. Good, well, it's 2.57, so we'll release everyone to enjoy the rest of the afternoons, but thank you so much. Thank you so much. For your participation. Thank you.

financial abuse

older adults

elder exploitation

scams

cognitive impairments

multidisciplinary approach

Adult Protective Services

legal power of attorney

financial vulnerability

emotional distress

reporting barriers

strategic intervention