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A Case of Elder Abuse and Undue Influence: Assessment and Treatment From a
Geriatric Interdisciplinary Team
Sheena M. Horning, Stacy S. Wilkins, Shawkat Dhanani and Donna Henriques
Clinical Case Studies 2013 12: 373 originally published online 19 July 2013
DOI: 10.1177/1534650113496143
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CCS12510.1177/1534650113496143Clinical Case StudiesHorning et al.
Article
A Case of Elder Abuse and

Undue Influence: Assessment
and Treatment From a Geriatric
Interdisciplinary Team
Clinical Case Studies

12(5) 373387
The Author(s) 2013
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DOI: 10.1177/1534650113496143
ccs.sagepub.com
Sheena M. Horning1, Stacy S. Wilkins1,2, Shawkat Dhanani1,2,

and Donna Henriques1
Abstract
Elder abuse is a pervasive problem that can have lasting emotional and physical consequences,
increasing its victims risk of mortality. Healthcare providers are frequently involved in the
detection and intervention of elder abuse. Because of the complexity of these cases, applying
treatment interventions within an interdisciplinary care team has been recommended to
ensure older adults safety and welfare. Psychologists in particular are frequently relied upon
in these situations because of their expertise in cognitive, psychiatric, and capacity assessment,
as well as their ability to intervene in a variety of difficult situations. The following is a report
examining the case of Mr. B, who was a victim of elder abuse involving financial exploitation and
undue influence. Assessment and treatment interventions were used within the context of an
interdisciplinary care team, using a bio-psychosocial approach. A decision-tree model describing
the steps to take in assessing and treating financial elder abuse is proposed.
Keywords
elder abuse, undue influence, dementia, decision-making capacity
1 Theoretical and Research Basis for Treatment

Abuse, neglect, and exploitation of older adults are significant and pervasive problems in the
United States (Fulmer, Guadagno, Dyer, & Connolly, 2004; Lachs & Pillemer, 2004) and have
been associated with an increased mortality among victims (Lachs, Williams, OBrien, Pillemer,
& Charlson, 1998). The estimates of abuse and mistreatment range from 3% to 25% of the older
adult population depending on the type of abuse (Laumann, Leitsch, & Waite, 2008), with financial abuse and exploitation identified as the most common types of abuse (Acierno et al., 2010).
Although the exact legal definition of elder financial abuse and exploitation varies by state, it has
been broadly defined as the misuse or mishandling of an older adults finances, assets, or income
by another individual (Setturlund, Tilse, Wilson, McCawley, & Rosenman, 2007).
1VA
Greater Los Angeles Healthcare System, CA, USA

of California, Los Angeles, USA
2University
Corresponding Author:
Sheena M. Horning, Department of Psychology, VA Greater Los Angeles Healthcare System,
11301 Wilshire Blvd, Los Angeles, CA 90025, USA.
Email: Sheena.Horning@va.gov
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Clinical Case Studies 12(5)
Clinicians and healthcare professionals are likely to be the first to recognize the mistreatment
of older adults (Quinn, 2002) with psychologists in interdisciplinary care teams being identified
as especially important in the assessment and treatment of elder abuse (Wiglesworth, Kemp, &
Mosqueda, 2008). Psychologists are frequently consulted by geriatric care teams because of their
expertise in assessment and management of elder abuse, making them important in the clinical
care of these patients (Wiglesworth et al., 2008). Although several research and case studies have
highlighted and addressed the need for proper assessment and keys to the recognition of abuse,
less is known about interventions, treatment, and outcomes in situations involving this type of
patient care (Lachs & Pillemer, 2004). Because of the interdisciplinary nature of this type of
work, the recognition, assessment, and treatment of older adult patients at risk for abuse necessitate a team approach, (Jayawardena & Liao, 2006) with the psychologist on the team playing
an instrumental role (Wiglesworth et al., 2008).
Although physical signs of abuse and neglect may be easily recognized by a skilled physician
or healthcare worker, such as malnutrition or evidence of bruising, emotional and financial abuse
tend to be less transparent. A patients self-report of these types of abuse also tends to be unreliable, as patients may be unable to accurately report abuse because of dementia or may be unwilling to report because of a sense of guilt, shame, or even dependency on their perpetrator for
caregiving (Fulmer et al., 2004). Uncovering financial exploitation involves a thorough assessment, particularly among patients judged to be at greater risk, such as those with cognitive
impairment, the medically compromised, or those who are socially isolated (Fulmer et al., 2004;
Laumann et al., 2008). Determination of financial abuse is difficult as a person is free to make his
or her own financial decisions, such as giving financial gifts or monies away to charities or even
individuals as they so please. However, the person must act freely without duress and also have
the decision-making capacity to make these choices (Quinn, 2002). Therefore, if financial abuse
is suspected, assessment of the patients financial decision-making capacity should follow, as
well as an investigation of the patients susceptibility to undue influence.
Decision-making capacity may be diminished in older adults, usually because of a neurodegenerative disease and/or medical problems that interfere with ones cognitive functioning, such
as dementia or delirium. Decision-making capacity, therefore, must carefully be judged by a
clinician through the use of a thorough clinical interview, as well as through the use of neurocognitive tests (Moye & Marson, 2007). Generally speaking, judgment of capacity involves evaluating whether the patients physical and mental abilities meet the demands of a given situation and
whether the patient is able to appreciate the risks and benefits of the choices and outcomes
involved and express a choice (Guzman-Clark, Reinhardt, & Wilkins, 2012; Moye & Marson,
2007). Several standardized capacity interviews, as well as cognitive assessment tools, can be
used to aid in this process, such as the Financial Capacity Instrument (Marson et al., 2000), the
Montreal Cognitive Assessment (MOCA; Nasreddine et al., 2005), and the Independent Living
Scales (ILS; Loeb, 1996). Assessment of capacity is usually the first step in the determination of
financial elder abuse, as many state laws require a person to have diminished capacity to determine whether the abuse has been perpetrated (Hall, Hall, & Chapman, 2005).
In addition to questions of capacity, older adults may remain at risk for financial exploitation
if they are under undue influence. Although a legal construct, the concept of undue influence and
its involvement in elder abuse and exploitation is clinically well understood (Peisah et al., 2009).
Undue influence is a form of psychological or emotional abuse and manipulation perpetrated for
financial gain (Quinn, 2002), usually involving a significant power differential between the perpetrator and the victim (Kurst-Swanger & Petcosky, 2003). Hall et al. (2005) provide a comprehensive list of characteristics that predispose a victim to undue influence, including being of
advanced age, frailty, financial autonomy, medical or physical limitations, depression, and some
degree of cognitive impairment or dementia. Older women also tend to be disproportionately
affected by mistreatment and exploitation (Kurst-Swanger & Petcosky, 2003). Unfortunately, the
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Horning et al.
perpetrators of this type of abuse are commonly family members, close friends, or acquaintances
and may even reside with the victim (Moon, Lawson, Carpiac, & Spaziano, 2006; Quinn, 2002).
However, regardless of the relationship, the perpetrator often engages in a distinct set of behaviors to isolate and manipulate the victim to gain control over them and their finances. For example, they may socially isolate the victim, particularly from family members, thereby making the
older adult reliant on the perpetrator for social or even instrumental support. They may do this by
engendering suspicion in the victim, causing them to question the intentions or even concern of
other friends or family, which again furthers their reliance on the perpetrator (Hall et al., 2005;
Quinn, 2002). By offering some degree of caregiving to the victim, the perpetrators subtle
manipulations may be difficult for the victim to discern, especially if the older adult has any
degree of cognitive impairment and/or functional limitations. Even among psychologists, medical providers, and skilled clinicians, the perpetrator may appear to have the patients best interest
in mind. In reality, however, they are opportunistic, predatory, and are likely to cause psychological and even physical distress to the patient for the purpose of their own personal financial gain.
Therefore, careful observations of changes in the patients behavioral patterns is suggested, particularly noting older adult patients who make sudden or abrupt changes in their finances or
financial management, as well as those involved in a caretaker/care-recipient relationship with an
obvious power differential (Hall et al., 2005; Quinn, 2002). Because of the fact that victims are
often socially isolated, clinical providers with whom they have an ongoing and trusting relationship may be most likely to become suspicious of, and recognize, the wrongdoing (Quinn, 2002).
After an older adult patient has been assessed and mistreatment has been identified, the treatment interventions are recommended to be handled within an interdisciplinary care team
(Jayawardena & Liao, 2006; Lachs & Pillemer, 2004; Wiglesworth et al., 2008). Through an
interdisciplinary team approach, the expertise of each member (e.g., psychologist, physician,
social worker, case manager, nurse, etc.) can be used to efficiently and effectively intervene.
Team members should work together to form a treatment plan to assess the individualized needs
of the patient. Community-based organizations (e.g., adult protective services [APS]), law
enforcement, and long-term care ombudsmen are also typically contacted at the onset, if warranted (Kurst-Swanger, & Petcosky, 2003; Moon et al., 2006; Wiglesworth et al., 2008). As
mandatory reporters of abuse, clinicians should contact APS as soon as abuse is suspected (Luu
& Liang, 2005). In addition, team interventions may include the following, based on the specific
nature of the situation: setting up family meetings with the patients loved ones, even perhaps
with the perpetrator; assisting in the conservatorship process; contacting home healthcare services to provide increased assistance in the patients home; placement of the patient from unsafe
living environment to an assisted living facility (ALF) or more appropriate level of care; and
referring the patient for psychotherapy services to address any associated depression or adjustment-related concerns. According to Moon et al. (2006), the most common geriatric team interventions to ensure patients safety after elder abuse had been established were placement from
unsafe living environments to a live-in care setting (e.g., nursing home; ALF), followed by
arrangement of a conservator. In addition, caregiver interventions and education may also be
appropriate to assist the families in their care of the at-risk seniors (Schulz, Martire, & Klinger,
2005).
Clearly, the tasks of detecting, assessing, and intervening in situations of elder abuse require
the consultation and collaboration of many disciplines. However, as Wiglesworth et al. (2008)
suggest, the psychologist tends to play an instrumental role in this process because of their expertise in cognitive, psychiatric, and capacity assessment, and are frequently consulted by team
members in some stage of this process because of their specialized skills. Therefore, knowing
how to approach this daunting task and the common missteps that may occur is crucial for successful treatment and intervention. The following case example of the patient, Mr. B, who was a
victim of elder abuse and undue influence will be discussed. From the perspective of
376
psychologists on a specialized geriatric interdisciplinary primary care team (Geriatric Research,

Education, and Clinical Center, GRECC), our approach to the identification and assessment of
elder abuse, undue influence, and decision-making capacity will be addressed, as well as how we
approached and conceptualized his care through a bio-psychosocial framework and interdisciplinary treatment approach.
2 Case Introduction
Mr. B is an 89-year-old, divorced, Caucasian male veteran with 16 years of education. He is a
retired businessman. He has two adult children with whom he remains in contact. Mr. B resides in
a townhome in the Los Angeles area with his girlfriend. He is a long-term patient of the GRECC
outpatient primary care clinic of the VA Greater Los Angeles Healthcare System. Mr. B was referred
to the GRECC psychologist in 2012 by his primary care physician because of the concerns about
his cognitive functioning, anxiety, recent escalation of his depressive symptoms, and conflict within
his relationship with his girlfriend, who will be referred to using the pseudonym Diana.
3 Presenting Complaints
Mr. B was brought to the initial meeting with the GRECC psychologist by his daughter, Judy.
During the clinical interview, he endorsed several concerns over his cognitive functioning, specifically related to his memory, as well as periods of depression and anxiety. He stated that his
mind feels cloudy, and believed that he had dementia. He also repeatedly stated that he had
never felt so strange. For example, he explained that he often cannot recognize his daughters
face. As a result, he endorsed feeling scared and uncomfortable and was quite distressed over his
belief that his memory and health had been declining. In addition, Mr. B mentioned several times
that he could not recall who had brought him to the present appointment (his daughter), and was
unable to recall his daughters name. Mr. B reported that these problems began only over the past
3 months, although his medical record documented deficits in his memory beginning over the
past few years. In addition, Mr. B reported having frequent, severe headaches, which fluctuate
throughout the day. He also reported some difficulties with his balance, frequent falls, and periodic dizziness.
Mr. B explained that he resided in a home with his long-term girlfriend, Diana. He reported
that he and Diana had been together for many years, although their relationship was tumultuous
because of frequent arguments and Dianas fluctuating mood. While at home, Mr. B endorsed
requiring assistance with many of his instrumental activities of daily living (IADLs). He indicated that he received meals-on-wheels for his lunch and dinner and, at times, received some
meals prepared by Diana. Mr. B stated that he receives assistance with his financial management
from Diana as well (he stated that she pays all the bills), as he added her name to his savings
account and trust. Mr. B reported that he continues to shop, do laundry, manage his medications,
and engage in housework independently. In addition, Mr. B indicated that he continues to hold a
valid drivers license and endorsed driving short distances around his neighborhood.
Mr. Bs daughter, Judy, also reported that her father was having difficulties with his memory
and easily became confused. However, she stated that his difficulties fluctuated from day to day
and appeared to worsen if he had a headache. She also indicated that he appears anxious and
believed her father was stressed as a result of his living situation and relationship with his girlfriend. She also believed that her father had been noncompliant with his medications, specifically
hypertension medication, as a result of Dianas influence. She explained that her father was not
receiving the type of caregiving and support that he required and reported her concerns about
possible financial exploitation as well, perpetrated by Diana.
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Horning et al.
4 History
Mr. B was born in Ohio and moved to California during his adolescence. He was the second child
in a sibship of five and has three brothers and one sister. He was raised by his biological parents,
both of whom died at an early age. He graduated from high school and attended college at a
prestigious university, earning a bachelors degree in business management. Mr. B served in the
U.S. military from 1943 to 1948, where he worked in the intelligence department. After his military service, he worked as a businessman, participating in multiple business ventures, including
holding real-estate investments.
Mr. B was married twice and is currently divorced. His first marriage lasted 14 years, until his
divorce in the late 1960s. He remarried, but later divorced after 5 years of marriage. He has two
children, one son, Johnny, and one daughter, Judy. Mr. B resided in California in a townhouse
with his long-time girlfriend, Diana. He recently moved in with her within the last year after living in his own apartment nearby. He reported having a good relationship with his daughter and
son; however, his two adult children resided just outside the greater Los Angeles area (approximately 90 miles away).
Mr. Bs relationship with Diana was tumultuous, once described by him as a lovehate relationship. In 2002, Mr. B sought psychotherapy treatment through the Mental Health Clinic at the
VA, specifically requesting couples therapy to help resolve the conflict between himself and
Diana. At that time, he endorsed escalation of conflict, frequent arguments, and deterioration of
their relationship over the past several years. He also reported experiencing a depressed mood and
anxiety, with the onset of his mood symptoms appearing to temporally coincide with the stress
associated within his relationship. Mr. B did not continue with psychotherapy or couples therapy
at that time, which appeared to be due to Dianas lack of engagement in the process. However,
several years later in 2007, he again sought treatment through psychiatry at the VA. He endorsed
experiencing heightened anxiety, panic attacks, and depression, which were exacerbated by continued difficulties within his relationship. He explained that Diana was irrational, had mood swings
with bouts of anger, and they engaged in daily arguments and conflict. He also complained of
severe headaches, which were diagnosed as vascular or tension headaches, stress-induced, and
which occurred during arguments with his girlfriend. They also were judged to be related to his
uncontrolled hypertension given his refusal to take his hypertensive medication. His psychiatrist
began him on psychotropic medication and he was again referred to psychotherapy.
Mr. B began individual psychotherapy with a VA psychologist to help him cope with his anxiety and relationship difficulties. He reported that he felt he could not leave his relationship or
separate from Diana, as a result of feeling as if he had no one else to turn to for support. During
his treatment, he also had reported a physical altercation that involved Diana grabbing him in a
violent manner. As a result of this revelation, the psychologist at that time had again reviewed the
limits of confidentiality, and his requirement to report any suspected elder abuse. However, Mr. B
then acknowledged that he had been aggressively touched in the past by Diana but denied that
this had occurred within the past 5 years. Therefore, based on the psychologists judgment, an
APS report regarding elder abuse was not deemed appropriate. Mr. B continued in psychotherapy
for a period of 6 months.
In 2009, Mr. Bs care was transferred to the GRECC primary care outpatient clinic. At that
time, he continued to complain of anxiety and depression secondary to ongoing relationship difficulties with Diana. He complained of her verbal abuse, frequent arguments, lack of physical
intimacy, and her negative impact on his overall mood. He explained that his mood was happy
when he was not around her, as she constantly criticized him and would not allow him to talk
about anything. He also stated that he only remained with Diana because of his fear of being
alone. He also endorsed multiple somatic complaints, particularly tension headaches, dizziness,
and insomnia, which appeared to be exacerbated by stress. Mr. B had demonstrated a long history
378
of noncompliance with his hypertensive medication, as well as other prescribed medications, as

a result of his belief that medications would be detrimental to his health based on the advice of
Diana. Mr. B was referred to the GRECC geriatric psychiatrist and for a neuropsychological
assessment as a result of his ongoing mood disturbances, relationship difficulties, and his physicians concern over possible cognitive decline after he performed poorly on a cognitive screen.
He obtained a neuropsychological evaluation and was diagnosed with Cognitive Disorder not
otherwise specified (NOS) and Depression NOS, with significant impairments in nonverbal
learning and memory observed. At that time, Diana began taking over his financial management.
However, several months later in 2010, Mr. B separated from Diana by moving into his own
condo within the same complex to reduce conflicts between them and avoid her frequent verbal
rages. Diana remained financially supported by Mr. B. Although his mood had improved
because of living away from Diana, he moved back in with her shortly thereafter out of a fear of
being alone.
In 2012, after several years of being followed as a patient in the GRECC clinic for his primary
care, concerns regarding Mr. Bs emotional functioning, cognitive functioning, safety, and ability
to live independently were again reevaluated based on the expressed concerns of his children.
These concerns were brought to the attention of the GRECC psychologist who was consulted by
Mr. Bs primary care physician and his case manager. Mr. Bs daughter, Judy, had contacted the
GRECC team case manager based on her concern over her fathers well-being and his risk for
financial exploitation. She explained that she believed her fathers cognitive functioning had
deteriorated and, therefore, he was no longer making good decisions. She also expressed a belief
that Diana had prevented her father from taking his medications and, as a result, his medical
problems had worsened. Judy also reported her belief that her father was being financially
exploited. Judy had received a call from her fathers bank stating that Mr. B had attempted to
transfer over a quarter of a million dollars to Diana earlier in the year; however, because of the
banks concerns over this transfer, the transaction was held, which resulted in Mr. B writing a
check for approximately US$20,000 to Diana instead. Upon becoming aware of this information,
Judy began filing for conservatorship over her father to avoid financial abuse. Therefore, an
appointment with the GRECC psychologist was made to evaluate Mr. Bs cognitive abilities,
emotional functioning, and financial decision-making capacity, as well as to assist in individual
and family interventions to ensure Mr. Bs emotional well-being and safety.
5 Assessment
Mr. B arrived to his appointment accompanied by Judy. He presented as an older male, casually dressed and well groomed. He ambulated independently with a cane, but gait was observed
to be slowed and slightly shuffled. He reported his mood as depressed and anxious and his
affect was congruent. Speech was normal with regard to volume, rate, and prosody, although
he had word-finding difficulties. His thought processes were logical and goal-directed and no
inappropriate or unusual thought content was observed. Mr. Bs overall insight and judgment
appeared to be impaired. He denied any suicidal or homicidal ideation, hallucinations, and
delusions. In addition, as part of his clinic visit, Mr. Bs blood pressure was checked by the
GRECC nurse and found to be significantly elevated (163/82); therefore, he was seen by his
GRECC primary care physician immediately following his appointment and again started on
hypertensive medication.
Mr. B and his daughter underwent a clinical interview with the GRECC psychologist and
psychology intern. He endorsed multiple cognitive complaints, particularly memory impairments, as well as periods of anxiety and depressed mood. He also reported somatic complaints,
including severe headaches, frequent falls, and balance problems. Mr. B was also interviewed
regarding his psychiatric history, substance use history, medical history, occupational/education
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Horning et al.
history, and psychosocial history. In addition to the clinical interview, Mr. B was administered a
MOCA (Nasreddine et al., 2005), the Health and Safety and Financial Management Subscales of
the ILS (Loeb, 1996), and asked structured questions as part of an evaluation of his decisionmaking capacity for financial and healthcare management.
Cognitive Functioning
The MOCA (Nasreddine et al., 2005) is a brief assessment of cognitive functioning, assessing
visuospatial/executive functioning, attention, language, abstraction, memory recall, and orientation. Mr. Bs performance on the MOCA was compromised (13/30), performing significantly
below the threshold suggestive of cognitive impairment (26 points is within normal limits;
Nasreddine et al., 2005), especially given his high pre-morbid level of functioning based on his
occupational history and educational attainment. He missed points for visuospatial/executive
functioning, naming, attention, language, abstraction, delayed recall, and memory.
ILS
On a measure of his understanding of basic health and safety domains related to independent living (ILS; Loeb, 1996), Mr. B performed in the moderate range (ILS Health and Safety Subtest =
34/40; 38th percentile). He showed awareness of basic health and safety concepts, such as being
able to recall the emergency number 911, understanding reasons why taking care of ones body
is important, and acknowledging that one should seek medical assistance in a medical emergency. However, some of Mr. Bs responses to health and safety scenarios were vague, concrete,
and lacking in the necessary complexity required to fully address the situation. For example,
when asked what he would do if he unintentionally lost 10 pounds in 4 weeks, he was only able
to respond that he would eat more food. When asked what two precautions he could take to
protect himself when going out at night, he stated, be careful and watch what you are doing. He
was unable to identify any further specific strategies.
On a measure of the knowledge necessary for financial management (ILS; Loeb, 1996), he
performed in the moderate range (ILS, Financial Management Subtest = 27/34; 31st percentile).
Mr. B demonstrated basic knowledge of the information required for financial management. For
example, he was able to accurately fill out a fake check for a hypothetical telephone and gas
company bill and also complete a simple arithmetic problem. However, he was unable to complete more complicated arithmetic problems; for example, he was unable to set up or complete a
subtraction problem involving three amounts. In addition, his answers to more complicated
financial questions lacked in sophistication. For example, he was only able to provide one reason
for why it is important to pay bills (e.g., they will turn off your service), or why it is important
to understand and read documents carefully before signing them (e.g., you have to make sure
the amount is correct).
Decision-Making Capacity
Mr. B was asked a series of questions regarding his decisional capacity for healthcare and financial management. No barriers to his ability to communicate were noted at the start of the interview. Although he did exhibit some word-finding difficulties, his comprehension and expression
of spoken language was grossly intact.
Regarding his decisional capacity for healthcare, Mr. B was unable to provide an accurate
assessment of his current health problems or diagnoses, only stating that his health was deteriorating, he has an increase in headaches, and that his sleep isnt easy. Mr. B also indicated that
he manages his own medications, explaining that pills do more harm than good. Despite
380
having hypertension, he had been noncompliant with multiple hypertensive medications; he

failed to appreciate the risks involved in not taking his medications, or the connection between
his current physical symptoms (i.e., headaches) and the underlying condition (i.e., vascular).
Regarding his decisional capacity for financial management, Mr. B stated that his current source
of income was his savings account and social security. He was unable to provide complete
details of his assets and had to be reminded by his daughter, Judy. He also acknowledged that he
no longer managed his finances and that Diana, his girlfriend, controls them. Based on his
responses, Mr. B was found to lack decisional capacity for healthcare decisions and financial
management.
6 Case Conceptualization
Mr. Bs symptoms and clinical presentation were conceptualized using a bio-psychosocial framework. Specifically, the focus was on how his physical, cognitive, and emotional symptoms developed from psychological, biological, and socio-relational factors, and how these factors made
him susceptible to undue influence and elder abuse. With regard to his biological and physical
functioning, Mr. B was frail, experienced balance problems with gait disturbance, frequent falls,
had uncontrolled hypertension, and experienced severe headaches and cognitive impairment.
The degree of cognitive impairment exhibited in his 2012 evaluation demonstrated significant
decline from his previous cognitive testing (2010), particularly in learning and memory, as well
as executive functioning, and suggested evidence of dementia. He was diagnosed with Dementia
NOS. Neuroimaging evidence revealed that he had experienced a thalamic stroke and also generalized cerebral atrophy. Therefore, although his cognitive deficits were most probably associated with cerebrovascular disease due to uncontrolled hypertension, Alzheimers disease was
also a strong possibility and was unable to be ruled out at the time. In addition to his uncontrolled
hypertension causing cognitive impairment, his headaches had been diagnosed as vascular or
tension headaches, which were likely exacerbated by stress. However, Mr. B was under the
assumption that his medication would do more harm than good and thus he did not take his medications. Although he may have experienced relief from his headaches by taking his medications,
the daily influence of Diana that he should not be taking his medications, including his poor
executive functioning and memory, reduced his ability to make a good decision regarding his
own healthcare and comply with his physicians recommendations.
In addition to his cognitive decline and overall frailty, the interplay between the sociorelational and psychological factors was considered. Mr. B had been in a long-term relationship
with Diana. He did not live in close geographic proximity to either of his two children and therefore was relatively isolated from his family. Although he had expressed ongoing and chronic
difficulties within their relationship, which he frequently expressed resulted in depression, anxiety, and significant distress, he felt dependent on her. His dependency appeared to grow as his age
advanced, cognitive functioning declined, and his physical health worsened. He remained somewhat aware that he required assistance with his daily functioning and feared that he would not be
able to obtain that caregiving without her. He also became scared of being alone because of his
caregiving needs and lack of social relationships and companionship. Therefore, Mr. B continued
to live with her out of his dependency and fear of being alone, subjecting himself to constant
conflicts, arguments, and verbal abuse. He was able to recognize how damaging this relationship
was on his overall mood, particularly as he was aware that he felt happier during their moments
of separation. However, his overall dependency and cognitive decline reduced his ability to free
himself from the toxic relationship.
In terms of uncovering the financial exploitation and classification of undue influence, several
factors had to be evaluated. First, Mr. B was deemed to be at a high risk for financial exploitation
and had many of the risk factors that predisposed older adults to abuse. Based on the risk factors
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Horning et al.
for financial abuse outlined by Hall et al. (2005), Mr. B met the following: advanced age (89);
divorced; cognitive impairment; experienced depression/anxiety; was socially isolated from his
children; dependent on the abuser; lived with the abuser; and was financially independent. The
extent of Mr. Bs vulnerability, however, was not clear until he was assessed by the GRECC
psychologist and found to have dementia and lack decision-making capacity for financial
management.
Dianas behaviors and personality were judged to be quite characteristic of female perpetrators, as outlined by Hall et al. (2005). She had a caregiving relationship with Mr. B., isolated
him from others, and instilled a sense of dependency within him on her. For example, it was
revealed that she had suggested, on numerous occasions, to Mr. B that his children (Judy and
Johnny) did not love him or care for him. Judy had reported that she received phone calls from
her father crying, expressing this belief based on what he had been told. Although Diana presented herself as a support and partial caregiver for Mr. B, she likely did harm to his mental and
physical health by convincing him not to take his medications (i.e., antihypertensive), thereby
exacerbating his cognitive impairment and severe headaches. She was also noted as being relatively uninvolved in his medical care, as she did not attend any of his medical appointments
over a 10-year span. It was not until Judy had begun seeking conservatorship over her father that
Diana had finally accompanied him to a medical appointment. In addition, Diana was judged to
be emotionally unstable, frequently demonstrated emotional liability, and was verbally and,
possibly, physically abusive toward Mr. B. She also had a history of multiple unstable relationships, with reports that she had been married and widowed three times in the past. Financially,
she was reliant on Mr. B for support, as he paid her rent even when they lived apart. She eventually took over his financial management. However, it was not until Mr. Bs bank became suspicious of the attempted transfer of US$250,000 to Diana that the financial exploitation became
obvious.
7 Course of Treatment and Assessment of Progress

The course of treatment involved three stages: assessment, intervention, and follow-up care.
Because of the complexity of Mr. Bs case, multiple providers working as a team were involved
in his treatment to ensure his physical and mental well-being and safety. Treatment interventions
were aimed at first ensuring his safety and welfare and next improving his cognitive, physical,
and emotional complaints, such as through behavioral activation strategies (Kanter et al., 2010;
Logsdon, McCurry, & Terri, 2007). Caregiver education and family interventions were also used
to assist the patient and his children through this process.
The initial assessment involved not only the clinical interview and cognitive assessment but
also a thorough medical record review to establish Mr. Bs medical and psychiatric history, as
well as prior consultation with GRECC team members who had a long-standing relationship with
the patient. The GRECC interdisciplinary care team highlighted their concerns for the patient, as
well as their observations of the patients present difficulties. The integration of this information
was necessary to help facilitate the initial meeting with the GRECC psychologist and assisted in
the identification of Mr. Bs current problems, as described above under the section Assessment.
Through the initial clinical interview and cognitive assessment with the patient and his daughter,
elder abuse was discovered and the extent of Mr. Bs cognitive deficits and diminished decisionmaking capacity were brought to light.
After the assessment in which elder abuse and undue influence were indentified, the psychologist consulted with the interdisciplinary care team and the following treatment interventions were
used. The primary target of intervention became ensuring Mr. Bs safety and welfare. First, Mr. Bs
children were encouraged to intervene as communicated by the GRECC psychologist by moving
the patient to a safer living environment, as he was judged to no longer be able to live
382
independently. Mr. B did not return to his place of residence shared with Diana but was moved
by his family into an ALF that he had previously considered. Judy had already begun the process
of filing for conservatorship, which was further facilitated by the psychologist. In addition, the
GRECC team was on the cusp of filing an APS report of elder abuse; however, the family had
removed Mr. B from his home shared by Diana and took over his financial management.
Therefore, although filing an APS could have been completed, Mr. Bs safety was no longer
thought to be in danger at the time he was evaluated by the psychologist, as he was in the process
of being conserved and now in the care of his daughter. Next, Mr. B held a valid drivers license.
However, he was not judged to be safe to continue to drive and therefore he and his family were
advised to refrain him from driving. In addition, because of Mr. Bs diagnosis of dementia,
California state law required that his diagnosis be reported to the Department of Public Health.
Therefore, a confidential morbidity report was filed by the GRECC psychologist and primary
care physician to initiate a suspension of Mr. Bs drivers license unless tested by the Department
of Motor Vehicles and determined safe. Third, Mr. Bs children were supported in their desire to
file for conservatorship over their father. To facilitate this process, the psychologist worked
together with Mr. Bs clinical case manager and completed capacity assessment paperwork that
documented Mr. Bs cognitive impairments and his diminished capacity for medical, healthcare,
and placement-related decisions.
Two weeks after Mr. Bs initial intake and assessment, Mr. B and his family returned to meet
with the GRECC psychologist with treatment interventions focusing on psychoeducation regarding Mr. Bs cognitive abilities and behavioral strategies for improving cognitive and emotional
functioning. During this family meeting, Mr. Bs mood, current functioning, and adjustment to
living at the ALF were discussed. The family had reported that Mr. Bs ALF had been offering
him assistance with most of his IADLs. His medications were now being appropriately managed,
particularly his antihypertensive medications, and his headaches appeared to have remitted to
some degree. Mr. B also reported feeling comfortable and satisfied with his current living environment. He explained that he enjoyed his meals, was engaging in social activities with other
residents, and reported improvements in his mood. Mr. Bs affective state was observed to be
much improved compared with his previous presentation, which was reflected to him in the
meeting. Behavioral activation strategies for the treatment of depressive symptoms (Kanter et al.,
2010; Logsdon et al., 2007) were also explained to the patient and his family. In particular, the
importance of engaging in pleasant events, such as socialization, playing games, reading, and so
on, on ones mood was discussed and encouraged.
Feedback regarding the results of his cognitive assessment was also given to Mr. B and his
children, with his cognitive strengths and weaknesses being highlighted. Psychoeducation was
provided detailing the likely impact of Mr. Bs cognitive impairments on his daily functioning.
Several recommendations were also made to the patient and his family, including providing him
with strategies to help improve his recall. For example, Mr. B and his family were encouraged to
use organizational aids, such as daily calendars and notebooks, as well as to use verbal and visual
reminders, such as lists and alarms, to assist his memory. They were also recommended to create
a routine for his daily activities and to maintain a structured, consistent living environment to help
minimize memory and problem-solving demands. In addition, Mr. B and his family were reminded
of the importance of taking his antihypertensive medications and managing his vascular risk factors, such as through nutrition and exercise, to potentially prevent further cognitive decline.
Over the weeks thereafter, Mr. Bs daughter, Judy remained in telephone contact with the
GRECC psychologist for caregiver support. Judy was beginning to struggle with the burden of
her newfound role as the primary caregiver for her father and the continuing conflict that existed
between herself and her fathers girlfriend, Diana. The sadness and sense of loss regarding
accepting her fathers cognitive decline and personality changes were also acknowledged and
normalized. Judy also continued to have many questions regarding communication with her
383
Horning et al.
father given his memory deficits and was provided with recommendations to facilitate their interactions. For example, she was recommended to communicate using simple, straightforward
statements. She was also encouraged to ask about her fathers past or remote memories, which
were likely to have remained more intact than his recent ones. In addition, Judy was encouraged
to engage in self-care related activities to reduce her overall level of stress to prevent caregiver
burnout. After several telephone calls for supportive caregiver therapy, Judy appeared to have
adjusted to her role and felt more equipped to continue to provide care for her father. At this
point, Mr. B and his family continued to be followed by the GRECC interdisciplinary care team
but were no longer receiving direct services from the psychologist. Mr. B was judged to be in a
safe and stable living environment, apart from his girlfriend, and was no longer at risk for financial exploitation as he was conserved by his son and daughter.
8 Complicating Factors
At the time elder abuse and undue influence were determined, interventions were done swiftly
because of the coordination of the members of Mr. Bs interdisciplinary care team and his family members. However, in the course of his treatment and the weeks that followed, several
complicating factors arose, specifically regarding the continued relationship between Diana
and Mr. B. Although Mr. B remained rather content with the transition from his home to an
ALF, Diana did not cease her relationship with him. Although his daughter immediately began
the process of filing for conservatorship over him, an unanticipated clerical error was made by
the courts and therefore his conservatorship paperwork was on hold. This allowed Diana a
chance to continue to exert her influence in an attempt to financially exploit the patient. By
report of the ALF, she had stopped by on several occasions to continue to coerce Mr. B into
offering financial assistance. On one occasion, she took Mr. B to his bank to withdraw money;
however, the bank had been put on alert and refused to make any transaction. Diana also had
made plans to marry Mr. B during this small window of time that his conservatorship paperwork was on hold. When this announcement was made, the staff at the ALF was asked to ban
Diana from visiting the patient.
In addition, Diana continued to use coercive methods to sway Mr. B. For example, she frequently called Mr. B, leaving him highly agitated and upset after these conversations. She continued to report false statements about his children, making him believe that his children were
against him. She also wanted Mr. B to move back in with her; however, he refused, as he reported
being satisfied with his current living situation, particularly that he was provided daily meals.
Because of this constant upset, Mr. Bs depression temporarily worsened and he began experiencing suicidal ideation. His suicidal ideation was evaluated by his primary care physician, and
he was judged to be at a low risk as he denied any plans or intention. His depressed mood, anxiety, and thoughts of suicide coincided with interactions with Diana. Therefore, Mr. Bs family
decided to take further legal action and involved a family attorney to take legal action against
Diana if she did not stop her harassment, such as through a restraining order. Judy again contacted the GRECC psychologist for a letter of support. A letter documenting Mr. Bs diminished
decision-making capacity, cognitive impairment, and clinical opinion regarding the risk of harm
that Diana posed to the patient were outlined and faxed to the attorney. Diana eventually moved
out of town. Mr. Bs mood was reported as improved and his suicidal ideation had resolved. He
continued to engage in social activities at the ALF and his hypertension began to stabilize.
9 Access and Barriers to Care

Because of the severity of Mr. Bs cognitive impairment, he was not judged to significantly
benefit from traditional psychotherapies. Therefore, treatment interventions for his mood
384
involved pharmacotherapy and behavioral activation strategies, including involvement in

pleasant events and social activities (Logsdon et al., 2007). Caregiver support interventions
were used to help improve Mr. Bs mood, such as by providing education regarding how to
communicate and interact with Mr. B to avoid unnecessary agitation or exacerbation of his
affective complaints, as well as helping the children process their own emotions of anxiety and
sadness in adjusting to the caregiver demands and the changes taking place in their fathers
abilities.
10 Follow-Up
Mr. B continued to be followed by the GRECC outpatient program for his primary care.
Shortly after his move, Mr. Bs primary care physician made an at-home visit to his ALF to
monitor his medical problems and to determine his adjustment to his new residence. Several
safety recommendations were made to reduce his risk for falls. He continued to be seen at the
GRECC clinic for monthly medical checkups, as well as by the GRECC psychiatrist to monitor his mood and cognitive functioning. Although his mood appeared to fluctuate, his overall
mood had generally improved and his depression remitted to some degree. Pharmacotherapy
was also initiated, including antidepressants for his affective symptoms and memantine for
his cognition. In addition, his clinical case manager remained in contact with the patient, his
family, and his ALF to ensure that he remained safe and was receiving adequate care while at
the facility.
11 Treatment Implications of the Case

Mr. B demonstrates the interplay between psychological, social, and medical factors that made
him highly susceptible to financial exploitation and undue influence, further emphasizing the
necessity of the bio-psychosocial model in treatment approaches. As a result of his emotional
vulnerability, cognitive impairment, and the relational dynamics between him and his perpetrator, the psychologist played an instrumental role in the assessment of his current problems and
the facilitation of his treatment. Interventions aimed at his safety and overall well-being required
an interdisciplinary care team, as the literature on elder abuse suggests (Jayawardena & Liao,
2006; Lachs & Pillemer, 2004; Wiglesworth et al., 2008). Like others in Mr. Bs situation, older
adults who experience significant cognitive impairment and demonstrate diminished decisionmaking capacity are frequently unable to care for themselves independently and thus require
placement in a structured living environment or care facility, as well as an arrangement of a
conservator. Both of these are the most common interventions to suspend and further prevent
financial exploitation of older adults (Moon et al., 2006).
Elder financial abuse and undue influence can go on for many years undetected, as it likely did
in the case of Mr. B. In addition to being difficult to detect and discern, many clinicians fail to
broach the topic of finances or financial management with patients, likely because of a lack of
awareness regarding how to broach the topic, particularly if the patients themselves lack awareness of any wrongdoing. In addition, clinicians working with older adults may experience countertransference in working with their older adult patients (Genevay & Katz, 1990). For example,
clinicians tend to minimize the older adults limitations in handling their daily affairs because of
their own belief in personal independence and autonomy, particularly through older age.
Clinicians may also harbor negative biases and stereotypes toward assisted living or nursing
home placement because of their own beliefs that this is an undesirable outcome of aging
(Genevay & Katz, 1990). If clinicians are unaware of their own personal biases and countertransference toward working with older adults, they may be less likely to inquire about a patients
ability to live independently and may fail to intervene in a timely manner.
385
Horning et al.
Elder Abuse and Undue Influence

Is the older adult at-risk for financial exploitation as indicated
by the following risk factors?
Advanced Age (80+)
Female
Frailty or Physical Limitations
Social Isolation
Financial Independence
Depression
Cognition Impairment
(see Hall et al. (2005) for complete list).
Assess the elders financial

situation / management for signs
of abuse / or poor decisionmaking.
Have they been giving away
large sums of money to another
person or a charity?
Or
Have they made significant or
recent changes to their finances
/ assets? (i.e., changing will;
trust; adding names to bank
accounts or property, etc.).
Yes
No
No
Unless suspected,
do not evaluate for
elder abuse.
Assess for undue influence by a third-party.

Does the older adult rely on another person to
manage finances? If so, is this person using
the seniors finances for their own personal
gain?
Or
Are they financially supporting another
individual, such as a caregiver or relative? If
so, are there signs of undue influence or a
significant power imbalance?
No
If both are No,

then financial
exploitation is
unlikely.
(see Quinn (2002) for more details

regarding the signs of undue influence).
Yes
Yes
Assess for cognitive impairment. Assess for financial capacity.
Is there evidence of cognitive impairment?

Below threshold score on measure of global cognitive functioning (e.g., MOCA < 25;
Nasreddine et al., 2005).
Evidence of cognitive decline or impairment on neuropsychological evaluation.
Or
Does the patient lack decision-making capacity for financial management?
Impaired score on objective measure of financial management (e.g., ILS Managing Money
Subtest; Loeb, 1996); Lacks the basic skills for financial management (e.g., unable to write
a check, count change, complete simple calculations, etc.).
Demonstrates a lack of knowledge of information regarding their finances, financial
concepts, or their total income / assets; Demonstrates a lack of judgment to make financial
decisions (Moye & Marson, 2007).
Or
Has the older adult self-reported being a victim of financial exploitation or a scam with
financial losses?
No
If the older
adult has
capacity and is
cognitively
intact, then
financial abuse
is unlikely,
unless they
self-report.
Yes
Contact Adult Protective Services (APS) to report suspicion of elder financial abuse. *
*Laws regarding the reporting of elder abuse varies state by state. Refer to your local APS for details.
Other possible immediate interventions:
If the patient is considered at imminent risk, call 911 or the police and request a Health & Welfare check, and report the abuse.
If the patient resides in a residential care facility (e.g., nursing home), notify the ombudsmen and necessary care staff.
Figure 1. Decision tree for the detection and treatment of financial exploitation of older adults.
Note. Clinical judgment should always take precedence in the reporting of suspicion of elder abuse.
12 Recommendations to Clinicians and Students

The detection, assessment, and treatment of financial elder abuse and undue influence are complex and multifaceted processes. Figure 1 displays a decision tree to use as a framework to help
guide psychologists and other clinicians through the process from detection to intervention in
cases of elder financial abuse. In addition, the following are recommendations based on
386
the literature, as well as from lessons learned from the case of Mr. B. First, be aware of the risk
factors and signs of elder financial abuse and undue influence (Hall et al., 2005; Quinn, 2002).
For those who are at a high risk for abuse, clinicians may want to briefly evaluate their patients
ability to complete their IADLs, particularly financial management. Using an elder abuse screening measure may be useful to help structure the evaluation of abuse (Fulmer et al., 2004).
Although these tools may be helpful, clinicians should keep in mind that the self-reporting of
abuse tends to be unreliable, because of some older adults inability to accurately report abuse
because of dementia or dependency on their perpetrator for caregiving (Fulmer et al., 2004).
Therefore, clinical judgment should always be prioritized. Second, when possible, work within
an interdisciplinary care team to assist in immediate case management and treatment interventions (Jayawardena & Liao, 2006; Lachs & Pillemer, 2004; Wiglesworth et al., 2008). When
working as a sole practitioner, consult a colleague for additional support, or the older adults
primary care physician. Third, if elder abuse of any kind is suspected, call APS to report and to
ask for assistance. Finally, with consent from the older adult, contact family members or a close
friend to inform them of the situation. Consider holding a family meeting to discuss the need for
the following treatment interventions: placement options or in-home caregiving; conservatorship/power of attorney; caregiver support; psychoeducation about cognitive impairment; and any
other safety concerns. Dealing with elder abuse can be an overwhelming and frightening experience for the patient and the clinician. Therefore, having awareness of the steps necessary when
faced with these situations can assist clinicians in effectively and efficiently intervening to ensure
their patients safety and well-being.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies
Sheena M. Horning is a postdoctoral fellow at the West Los Angeles VA Healthcare Center with emphasis
in Geropsychology/Neuropsychology where she also completed her clinical internship. She attended the
University of Colorado at Colorado Springs earning her PhD in Clinical Psychology with emphasis in
Geropsychology in 2012.
Stacy S. Wilkins is a geriatric neuropsychologist at the Greater Los Angeles VA Healthcare Center with
the GRECC and GEM geriatric medical inpatient and outpatient programs. Dr Wilkins is also a Clinical
Professor at the David Geffen School of Medicine at UCLA in the Department of Medicine.
Shawkat Dhanani is a physician who is board certified in Internal Medicine and Geriatric Medicine. He is
the director of Geriatric Evaluation and Management Unit and the Associate Chief of Staff for Geriatrics
and Extended Care. His research interests are health promotion and improved functional status through
exercise.
Donna Henriques, RN, PhD, is currently the GRECC clinic associate/manager at the West Los Angeles
VA Healthcare Center. She is also involved in research exploring the improvement of focus and concentration in patients with Alzheimers Disease through response to continual stimuli.

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CCS12510.1177/1534650113496143Clinical Case StudiesHorning et al.

A Case of Elder Abuse and