Risk of financial abuse in elders should draw internists' attention

Internists' elderly patients face many risks, such as cardiovascular disease, falls, dementia, and financial exploitation. Physicians may not think as much about the last item on that list, but it warrants their attention, according to Mary Ann Forciea, MD, FACP, a geriatrician and clinical associate professor of medicine at the University of Pennsylvania in Philadelphia.

Dr. Forciea is also co-director of the Geriatric Education Center of Greater Philadelphia. In that role, she has participated in a new national program called the Elder Investment Fraud and Financial Exploitation Prevention Program, designed to educate clinicians about screening their elderly patients for vulnerability to financial abuse. Examples of abuse range from Internet investment scams to family members pressuring an elderly person to change his will.

Dr. Forciea recently spoke to ACP Internist both about the prevention program, which includes instruction by both geriatricians and financial experts, and more generally about internists' role in preventing the financial exploitation of their patients.

Q: Why should internists be concerned with financial abuse?

A: There are, obviously, increasing numbers of older people who are part of the primary care practice. Somewhere between four and five percent of them will report some kind of financial abuse. It's estimated that for every patient that admits that they are involved in a situation of financial abuse there may be three or four additional patients who are very reluctant to admit that.

There is also a growing body of evidence that suggests that patients who are financially abused are also the victims of other kinds of abuse, like physical abuse or neglect, and also have a higher rate of health problems than the general population of older people.

Q: Do you know which way the cause-and-effect works in that association?

A: Older patients who have multiple chronic diseases are more vulnerable to financial abuse. And there's also no question older folks who have been financially abused have higher rates of depression.

Q: What can physicians do about this problem?

A: The first step for a physician is to try to recognize whether a patient might be experiencing financial abuse.

There are a couple of different ways we might do that, especially those of us who are generalist physicians. Those can range from adding a couple of screening questions to your social history to including financial screening questionnaires in your pre-visit checklist that you do for new patients or annual wellness visits for older patients.

Questions you can ask a patient would be: Who manages your money from day to day? How's that going? Do you regret or worry about financial decisions that you've recently made? If they say yes, you might want to go to a slightly more detailed question set [which asks them to agree or disagree with statements] such as: I'm having trouble paying bills because the bills are confusing. I don't understand financial decisions that somebody else is making for me.

Once we recognize that something is going on, there are a variety of referrals that we can make to help people who are having these kinds of problems, since this is not usually something that we would handle ourselves.

Q: Where are the best places to refer patients?

A: Every county in the United States has what's called an Area Agency on Aging. These organizations coordinate all the federal, state and county programs for senior citizens in their area. These agencies generally have hotline or intake numbers that are available online or in the phone book or through [directory] information, and they can direct patients or families to a variety of resources.

In cases where there's a serious problem, [the physician] might want to report the patient to adult protective services. These are state or county organizations that are mandated to investigate reports of abuse, both physical and financial, of older patients, and they have the authority to act if they discover abuse.

If the situation is not that severe, families or patients may be directed to legal organizations that operate at low cost or standard fees. Or they can be directed toward attorneys who practice in elder law.

Q: Are there any other responsibilities of physicians relating to financial abuse of elderly patients?

A: The other part of this issue that comes up in the practice of a lot of primary care physicians is that someone else has already identified that there may be a problem and we, as physicians, get asked to help determine the financial decisional capacity of an older adult.

This involves doing a careful history. If there are no acute medical problems which might explain some confusion, look at whether there might be evidence of some cognitive impairment and how severe that might be. We can advise the family and often ultimately the courts about whether this person needs to have a financial guardian appointed, or even whether a durable power of attorney for a financial decision needs to be activated if the person has reached the point of an illness where they're no longer able to make good decisions for themselves. We can be the ones who identify a problem or we can be involved because we need to assess what is causing the problem and whether this is just a bad decision or a symptom of a larger illness.

Q: What are the obstacles to effectively handling this issue?

A: In general, primary care physicians are aware that this problem exists, but possibly not aware of how common it is. Secondly, I think a lot of physicians are uncertain how to proceed in asking patients about this area of their lives. Thirdly, they're not too sure about how to progress in advising patients to seek help if they identify something. These are three hurdles that need to be overcome through continuing medical education and support.

Q: Where is education on the topic available?

A: There's currently an ongoing CME program nationally that's being coordinated by the Geriatric Education Center at Baylor College of Medicine in conjunction with the securities and exchange commissions of many states, an outreach program aimed at primary care providers. It's a two-hour course with an information card that's available for physicians and nurse practitioners. It's a pocket guide about how to ask questions and how to refer people for help (available online. ) They are being offered all across the country.