Forensic Skills Seek to Uncover Elder Abuse 

By Jane Gross, New York Time

September 27, 2008

Dr. Laura Mosqueda, seated, with Dr. Lisa Gibbs, right, are members of a team that investigates cases of abuse and neglect among the elderly (Monica Almeida/The New York Times)

The elderly man in the emergency room was covered with bruises, some purple and others fading to yellow. Despite signs of dementia, he told the same story over and over: His wife’s burly home health aide had beaten him. But the health aide and the wife insisted he had fallen. Now it was up to the members of Orange County’s Elder Abuse Forensic Center to decide which story was true.

As the man lay on a gurney, he was interviewed by a team from the center: a geriatrician, a social worker and an investigator from the sheriff’s office. The bruises on the man’s chest, they determined, were the result of being punched. There were bloody outlines of a shoe on the man’s leg. His clear, consistent story, and cognitive tests, persuaded the prosecutor to charge the aide with a felony.

At the center here, public health and law enforcement officials are learning to speak the same language and using the same forensic techniques as those popularized on the three C.S.I. television series to diagnose elder abuse and neglect. For decades, the techniques have been the state-of-the-art approach for investigating child abuse and domestic violence. But elder abuse has lagged far behind, suffering from a lack of financing, research and data.

Now change is in the air, and forensic techniques are just one of many new initiatives nationwide to protect the elderly. Geriatricians at the Baylor College of Medicine in Houston, for example, review county autopsy reports looking for suspicious themes. Bank tellers at Wachovia branches nationwide are learning to detect irregular transactions in the accounts of elderly customers. 

Congress is also expected to consider, before the October recess, the Elder Justice Act of 2006, which would create the first nationwide database on elder abuse, replacing inconsistent or unavailable data. The legislation, which has bipartisan support, also assigns a federal official to coordinate projects and technical assistance and helps replicate programs like Orange County’s.

The legislation moved from committee to the full Senate on a unanimous vote within days of a celebrity scandal involving elder abuse accusations against the son of Brooke Astor, 104, the grand dame of New York society. The accusations against Mrs. Astor’s son, Anthony D. Marshall, himself 82, include mismanagement of her fortune for his own enrichment and neglect as a result of cutting back on her care. Mr. Marshall has denied those accusations. 

Mrs. Astor’s situation is not exceptional. She is a member of the fastest-growing segment of the American population, those 85 and older. Half in that age group suffer from dementia and are often incapable of informed consent. The fact that the elderly control 70 percent of the nation’s wealth makes them tempting targets for greedy relatives or swindlers. 

Those are the circumstances that set the stage for most elder abuse, experts say. The most common form is physical neglect, like untended bedsores, dehydration or the reek of urine. A family member who is providing care, most often an adult child, is usually the guilty party. Greed is generally the motive, whether there is a multimillion-dollar inheritance or a monthly Social Security check at stake. 

All this was well known to the assorted professionals in Orange County, but before the forensic center was established, each had to improvise without easy access to others’ expertise. A social worker might need a public guardian to sort out conflicting claims from adult children over who had power of attorney. The social worker might also need advice from a detective about securing evidence, but calls to colleagues often went unreturned for weeks, and there was likely to be no doctor to consult because few were trained to detect elder abuse. 

Now, in Orange County, such professionals meet face-to-face at least once a week, with a doctor at the helm, and often speak daily. 

“It’s a no-brainer,” said Rebecca Guider, the director of adult services and assistance programs in Orange County. “Almost every case benefits from this approach.” 

Some 6,000 cases of elder abuse are reported annually in Orange County. In California, 100,000 reports were filed in 2003, accounting for 20 percent of the 500,000 reports nationwide. But there is widespread agreement among professionals that those numbers may be low. In a 1996 study, only one in 14 cases of physical abuse and neglect were reported and one in 100 of financial exploitation.

In Orange County, Craig M. Cazares, a deputy district attorney, reviews about 120 cases a year that are considered potential crimes, twice the number before the creation of the forensic team. Half of the cases are prosecuted, Mr. Cazares said, with a 90 percent conviction rate including plea deals. 

The team approach, he said, can lead to pitched battles because doctors and social workers “don’t understand that not everything they want to be criminal is criminal.” 

Nevertheless, Mr. Cazares added, “we can make borderline cases better” because of shared information and, most important, the medical expertise to assess physical injury and mental capacity. 

Confidentiality laws prohibit outsiders at team meetings at the Elder Abuse Forensic Center. But in interviews, members discussed three cases, one involving neglect, one abuse and one financial exploitation. 

In the neglect case a 60-year-old woman had been providing substandard care to her 96-year-old husband, who has heart disease and dementia and uses a wheelchair. After home visits by a physician, a social worker, a detective, a public guardian, a mental health expert and an array of outside social service agencies, no criminal charges were filed. 

When the team took the case, reported by a neighbor, the husband had an open wound on his thigh from a kitchen accident and showed signs of malnourishment. But Dr. Lisa Gibbs said the wife had not intended harm. “So we worked with her, educated her, sent in a lot of social services and she is trying to do a better job,” Dr. Gibbs said. 

In the abuse case, involving the elderly man in the emergency room, the home health aide first accepted a plea deal that would send him to jail for a year, but is now vacillating. If found guilty at trial, the aide could be sentenced to up to nine years in state prison. 

The financial exploitation case, a classic sweetheart scam, ended when Jennifer Mitchell was sentenced to four years in a state prison and her husband, Anthony, an accessory, was given 12 months in the Orange County jail. Ms. Mitchell, described by investigators as “an attractive young woman,” was convicted of defrauding three elderly men of a total of $300,000 by feigning romantic interest in them. Dr. Laura Mosqueda and Dr. Gibbs established that mental impairment, depression and isolation had made all three men vulnerable.

The couple was charged with multiple counts of financial abuse, which carry heavy prison sentences. But the judge offered a plea deal demanding full restitution.

“This case wasn’t about the sentence,” said Kenneth W. Johns, the deputy public guardian for Orange County. “These men needed their money back so they can be taken care of.” 

Some members of the team, including Kenneth Smith, a veteran investigator, say the typical abuser tends to be the “weak link” in a family, without a career or a home. The abuser often has mental health or substance abuse problems.

Mr. Smith said other family members were relieved to delegate the task of caring for an elderly person and turned a blind eye to incompetence and other factors that raised the risk of abuse, like the need for money.

Dr. Mosqueda fiercely objects to that stereotype, which ignores the stress on those taking care of the elderly. A police investigator may never encounter loving and attentive adult children driven to the brink, she said, because the police work at the margins of society, after other interventions have failed. 

Dr. Mosqueda said she saw caretakers in her office every day and asked them, directly, if they had ever yelled at or struck the person in their care or even been afraid they might. 

“If your mother has Alzheimer’s,” Dr. Mosqueda said, “and she’s belittling you all the time, screaming, asking the same questions over and over, and you have a husband and kids and a job, at some point you’re going to say, ‘If she asks me that same damn question one more time, I’m going to hit her.’ ”

Dr. Mosqueda continued, “ ‘I’m doing the best I can’ isn’t an excuse, but sometimes it’s really true, and it’s our job to know the difference and help families solve it so it doesn’t ever get to the team at the forensic center.” 

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