Page Ulrey 0:00

In emergency rooms who are, you know, social workers and nurses and doctors who are seeing some of these cases and not knowing if what they're seeing is criminal or not. And it's hard to report. It's it's a heavy lift to report. So they may say, Well, it's I'm sure they're doing the best I can. I'm not, I don't think this is something we need to report. And so you know, the case dies on the vine right there. Or we'll see someone who actually is alarmed about something and they call 911. And the dispatch person, also not trained on elder abuse, says, Oh, I don't think that's criminal. I think you need to call a civil attorney or, or call APS. And so then that case dies on the vine. And so there's all these different places where the ball is being dropped. And as a result, very often nothing is happening in response to what could be a really dangerous and deadly situation for somebody.

Dr. Regina Koepp 0:46

You just answered the next question, which is, so then what happens if it goes unreported and...

Page Ulrey 0:52

Yeah, nothing and so the abuse or neglect or exploitation continues and you know, the the elder may lose everything they have, they may die from the neglect, they may die from the abuse. Very, you know, we see a lot of really, really serious cases. And it's there's no question that the impact of any form of elder abuse, including financial exploitation is absolutely devastating. There was one study done by Mark lacs at Cornell Medical School that said that any form of elder abuse including financial exploitation, increases the risk of premature death in the elderly by 300%. Three times more likely to die of premature death if you're the victim of any form of abuse, and you're older.

Dr. Regina Koepp 1:36

I'm Dr. Regina Koepp. I'm a clinical geropsychologist, which means that I'm a psychologist who specializes with older adults and families. And this is the psychology of aging podcast, your go to resource for Mental Health and Aging.

Dr. Regina Koepp 1:54

This is Episode 68. The final episode in a four part elder abuse series. In today's episode, I interview Page Ulrey who's the senior deputy prosecuting attorney for the King County prosecutor's office in Washington State today pages on the podcast talking with us about the impact of elder abuse on older adults, barriers to reporting elder abuse cases, how we can improve the reporting system we each have a role. She'll describe some of the common elder abuse cases that she sees, and then gives lots of recommendations for mandated reporters and for loved ones who are concerned about an older adult, as well as for older adults themselves. Now, let me tell you a little bit about Page Ulrey. Page Ulrey is the Senior Deputy prosecuting attorney for the King County prosecutor's office. She graduated from Amherst College and Northeastern University School of Law. She began her career at the King County prosecutor's office in 1998. And in 2001, was appointed to the newly created position of elder abuse prosecutor in the criminal division. And that position she prosecutes cases of elder and vulnerable adult neglect, financial exploitation, sexual assault, physical assault and homicide. Paige conducts training and curriculum development on elder abuse, prosecution and investigation around the country and internationally. She has testified before the us senate Special Committee on aging and has twice spoken at White House conferences on Elder Justice. Let's jump into the episode with page every page.

Dr. Regina Koepp 3:36

Page Ulrey, thank you so much for joining me on the psychology of aging podcast. I know you're busy as a prosecutor, but your willingness to be here, it's gonna help a lot of people. So thank you so much for joining me today. Thanks for having me. I'm really excited to be here. Thank you. Can you share a little bit about what inspired you to specialize with older adults and elder abuse in your in your role or in your career?

Page Ulrey 3:59

Sure, I was I was happily working away in the domestic violence unit of the prosecutor's office. And unbeknownst to me, my my boss, who was our elected prosecutor at the time norm mailing, who is really kind of a legend in progressive tackling progressive issues, and really embracing change and novel ways of handling things. He was working on creating a position of elder abuse prosecutor in the office, and he asked me to do it, and I had no idea what I was getting into. But I, you know, I thought it sounded important and interesting. And so I said, Yes, so it was completely random, that I ended up getting involved in this.

Dr. Regina Koepp 4:40

Why do you suppose he chose you?

Page Ulrey 4:43

That's a great question. I don't know. I think I, um, I am a hard worker. I think I connect with people. He probably recognize that the job would require someone with a Lot of tenacity and sort of a willingness to sort of do whatever is is needed. And I think that define me at that or describe me at that time. So I, I don't know. But I was lucky that he chose me.

Dr. Regina Koepp 5:12

Can you just educate us about what a prosecutor is, and what a prosecutors role is an elder abuse cases.

Page Ulrey 5:21

So a prosecutor is someone who works for a either a city or a state or the federal government, who brings criminal charges on behalf of that, basically, of the city state or, or federal government, against somebody for violating a crime. So it's a very broad category of attorneys.

Dr. Regina Koepp 5:44

And then a role in elder abuse cases, is it unique? Or is it pretty standard?

Page Ulrey 5:50

It is very unique. When I when I was appointed to the position in 2001, there were only a very few elder abuse prosecutors in the country. We are very behind, as I'm sure you know, and how we respond to elder abuse. And so at that point, which in the early 2000s, very, very few prosecutors offices, were even charging these cases, were even bringing these cases. And beyond that there were incredibly few people who are dedicating themselves to elder abuse prosecution. So we we say that we were where we were with domestic violence like 40 years ago, that's where we are now, with regard to elder abuse, we've got a long way to go before we start responding to it properly.

Dr. Regina Koepp 6:30

So you said compared to domestic violence cases, elder abuse is currently where domestic violence prosecution was 40 years ago, what do we need to do to make that to catch up?

Page Ulrey 6:42

No, we need a lot of things we need dedicated and trained elder abuse prosecutors and detectives, prosecutors can't do it without having the law enforcement agencies to back them up and actually investigate the cases. And vice versa. Detectives who are dedicated to doing elder abuse cases, can't bring those cases unless there's a prosecutor there to prosecute them. We need much more funding for training and for community education on reporting and recognizing elder abuse. We just need a general increase in awareness and and alarm really about this, this issue is an alarming issue. And yet, very few people are even keyed into what it's about and to how often it's happening. So that means a lot of people aren't reporting it. A lot of people who are receiving those reports aren't trained in identifying these cases, and knowing when they're criminal and when they're civil. And so we just are, we are failing on many levels with regard to how to respond to it.

Dr. Regina Koepp 7:44

And multiple systems, not just one system is failing, exactly a collaborative effort to make sure that all of the reports are made and received and processed. And there's training at every level that's needed.

Page Ulrey 7:57

Exactly as we have people in emergency rooms who are, you know, social workers and nurses and doctors who are seeing some of these cases and not knowing if what they're seeing is criminal or not. And it's hard to report. It's, it's a heavy lift to report. So they may say, Well, it's I'm sure they're doing the best I can I'm not, I don't think this is something we need to report. And so you know, the case dies on the vine right there. Or we'll see someone who actually is alarmed about something and they call 911. And the dispatch person, also not trained on elder abuse, says, Oh, I don't think that's criminal. I think you need to call a civil attorney or, or call APS. And so then that case dies on the vine. And so there's all these different places where the ball is being dropped. And as results very often nothing is happening in response to what could be a really dangerous and deadly situation for somebody. Yeah, you

Dr. Regina Koepp 8:45

You just answered the next question, which is, so then what happens if it goes unreported? And

Page Ulrey 8:51

Yeah, nothing. And so the abuse or neglect or exploitation continues, and you know, the the elder may lose everything they have, they may die from the neglect, they may die from the abuse. Very, you know, we see a lot of really, really serious cases. And it's there's no question that the impact of any form of elder abuse, including financial exploitation is absolutely devastating. There was one study done by Mark lacs at Cornell Medical School that said that any form of elder abuse, including financial exploitation, increases the risk of premature death in the elderly by 300%, three times more likely to die of premature death if you're the victim of any form of abuse, and you're older.

Dr. Regina Koepp 9:33

Wow, I need to include that study on the show notes that is powerful. Will you say that statistic one more time? Sure.

Page Ulrey 9:42

Any form of elder abuse, including financial exploitation, increases the risk of premature death by 300%.

Dr. Regina Koepp 9:50

Oh my god. That's significant- that is more than significant.

Page Ulrey 9:55

And that the part of it that is the most striking to me is the financial exploitation part. Like it's not surprising someone would die of neglect or physical abuse. But the financial exploitation part when I first heard that statistic was was surprising to me. But now as I look back on my cases, and I think about it, I've just realized that it's true. We see so many victims of financial exploitation who just become so disheartened after they discover what's happened to them that they become ill and very often don't survive.

Dr. Regina Koepp 10:26

Oh, and mistrusting, I'm sure, and yeah, because the majority of abuse happens with people we know.

Page Ulrey 10:34

Exactly. So they they become distressing other people and also miss trusting of their own ability to perceive who is good for them and who's not good for them.

Dr. Regina Koepp 10:42

Yeah, so their self confidence and self assuredness is diminished. Exactly. This is heavy stuff.

Page Ulrey 10:52

Sorry, sorry, to be a downer

Dr. Regina Koepp 10:55

What are some of the most common elder abuse cases that you see?

Page Ulrey 11:00

Well, I, in general, in the office, our elder abuse unit focuses primarily on financial exploitation and neglect. But we also do some sexual assault cases and some physical abuse cases. So we're not seeing all of the cases that come in. We did a study with Department of Justice A number of years ago on our filed criminal felony level cases. And that study revealed that the majority of cases we see your financial exploitation involving victims 65 and over, and I think second most common is physical abuse. And then neglect and sexual assault are a very small percentage, not because they're not happening, but because I think there's even more issues with regard to reporting them.

Dr. Regina Koepp 11:43

And I think I heard a statistic that financial exploitation is the most reported type of abuse than any of the others. Is that your experience?

Page Ulrey 11:55

That is my perception. Yeah, it, you know, it probably is also the most frequent. But there's no question that, that we're seeing, you know, only a tiny fraction of the cases of sexual abuse and neglect that are happening as well. Well, there's just there's more, especially with neglect, it's really hard for people to understand, you know, whether what they're seeing is due to underlying disease and underlying complications someone might be suffering from, versus lack of proper care. And the other complicating factor for all of these types of crimes is that consent is the most common defense. I guess the one exception to that is physical abuse, but with regard to neglect, sexual abuse, and financial exploitation. The refrain that we hear all the time from perpetrators is this is what they wanted, this is what the victim wanted. And so that brings us to capacity does a person have capacity to be consenting to whatever the act is, that's an issue. And that capacity is just so important, not only to help us figure out whether they're consenting, but also just to make sure we understand what services they need, and obviously understand whether we should even be getting involved or not, because we have the right to spend our money, how we want to to have sexual contact with whoever we want to, to refuse medical care if we have capacity. So that's a really central question in many, many of our cases.

Dr. Regina Koepp 13:19

And capacity is so complicated, because it's determined for this point in time not determined in perpetuity, or indefinitely. And so, capacity can change and right. And it's so hard to get a sense of, especially if we're going to prosecute something, did they have capacity, then even if they don't have capacity now?

Page Ulrey 13:41

Exactly. And, and, and because of the lack of reporting, we often don't hear about these cases until long afterwards. So we're frequently frequently in a position of trying to figure out, you know, did this person have capacity two or three years ago? And that becomes even more complicated?

Dr. Regina Koepp 13:55

Yeah, I mean, it's, you know, capacity is a big conversation in regards to dementia, because of changes in the brain over time. And one of you know, it's so tricky, because even if a person has capacity to make medical decisions they might have might not have capacity to drive a car or manage their money. And, and what they say about somebody with dementia is once you see one person with dementia, you see one person with dementia, it's hard to generalize what it's like to be living with dementia. So to try to make a retroactive judgment about a person's capacities, incredibly complicated. Exactly.

Page Ulrey 14:34

And a lot of jurisdictions that I've worked with don't even have or use capacity evaluators. So all they're doing is looking back at the primary care providers records to see if someone had capacity at a particular time and that as you can imagine, is extremely just does not give you what you need in order to make a decision like that.

Dr. Regina Koepp 14:53

My mouth my jaw was dropping when you said that because for the people who are listening, because you know, I would be asked to do capacity evaluations from primary care, because sometimes capacity is pretty clear, when communicating with somebody of regarding certain things, like money or, but, but capacity around sexual intimacy or which is so nuanced and doesn't necessarily always require a verbal response. It's so much more complicated than just a primary care provider could assess in a 15 minute encounter with a patient I. And I just remember, I was embedded in a primary geriatric primary care clinic and then connected to one an outpatient mental health clinic for a geriatric primary care and a geriatric mental health clinic. And I remember providers, a physician saying, Can you do a capacity evaluation? And then I would have to say, on on what domain regarding what regarding finances regarding medical decision making regarding sexual decision making, what are you asking about? And and they would say, like, I don't know, tell me what all the options. So we need training there do? We do indeed.

Page Ulrey 16:15

And what happens in a criminal case, which is so difficult is that, that we will bring a case, this is actually a fairly common scenario, and it's usually a financial exploitation case, but we'll bring a case. And when we get the case, the person has dementia, but it's really unclear how impaired they are. And there's a consent defense that's raised. And so we're in the position of having to figure out if this person had capacity to consent to this complicated financial situation, or this this transaction, I guess, and we will get the primary care providers records and there's nothing in there, you know, or else there maybe is a mini mental state exam, status exam. That's it. So very minimal screening for dementia. And then we will go ahead and have a full blown capacity evaluation done. And lo and behold, the person has moderate, if not even more advanced, dementia, and they completely lack capacity to make financial decisions. And when we go to trial, what ends up happening is, the defense will call the primary care provider as a witness to reinforce their claim that the victim had capacity. And it's just a very awkward situation, and not one that I think is very comfortable for a doctor to be called into, and that kind of situation. But it's a great example of what happens when we're not we don't deal with these issues upfront and really work on doing better assessments and screening.

Dr. Regina Koepp 17:37

Yeah, and then that physicians sort of, you know, has to navigate managed care and the timeframes with managed care, and especially geriatricians do capacity much better. They do not only have more time with patients, so there is more room to do that, but and more training, like they're saying,

Page Ulrey 17:55

Right. But when they have 15 minutes, how do you do you know, the screening? And yeah, it's really an impossible request, I think.

Dr. Regina Koepp 18:03

Yeah. And often if people have diminished capacity, their family members there and has lots of questions. And so how do you really, you know, make the time for all of that it's an impossible position to even put the physician in the primary care provider that doesn't have the designated time and exactly like our system is not built to really handle this kind of situation? Yeah. Well, well, you're the person to help us understand how to make it better. So I'm glad that you're here and getting some insights. And I know, at the end, we're gonna have some tips for what people can do whatever role, you know how to how to be aware, and what you can do, if you're concerned, regardless of your role, or whatever role you're in, what do you suppose are some barriers to people reporting, even elder abuse cases?

Page Ulrey 18:48

I think there's a lot of concern on the part of professionals with regard to, you know, infringing on their patients or their clients privacy rights. And it's, it's so different than when you're talking about a child, you know, because obviously, there's no privacy interest, and you can report anything, and it's just a much easier thing to do. But when you're talking about someone who's in their 70s, or 80s, or 90s, who is making their own decisions, you know, to be working with them and say, Hey, sorry, I think you're doing something that is, you know, not okay, and I think you're being victimized, and I'm going to call Adult Protective Services or the police, it's a very, you know, intrusive thing to do. And if you have a relationship with that person, you may be afraid of that them, you know, not coming back to you, if you're a doctor, for instance, or you may be afraid of losing their business, if you're a financial advisor. There's just a lot of impediments that make it very, very difficult for people, especially if they're not really sure if they're right, so it's just easy to sort of say to yourself bad, you know, it's probably not I'm just gonna let it go and sort of see what happens. So there's just huge difficulties, I think, on the part of professionals, and then with regard to family members, I think there's a Fear of also angering the person, you know if it's your parent, your grandparent, or whoever alienating them or angering them. And if you know, you could be afraid you're going to lose their trust in you if you report something. And then there's also just a stigma, I think about being a victim, there's a stigma about having dementia and, and no one really wants to believe that this person that they love has dementia, and by sort of pulling that cover bad or pulling, you know, revealing that you could be having to deal with something that's very painful for you and for that person. So a lot of people would just prefer to kind of ignore whatever the problem is, and, and just hope for the best. But usually, that ignoring of those red flags, doesn't help things. And in the end, it ends up causing a lot more harm.

Dr. Regina Koepp 20:45

Yeah, back to that. 300%.

Page Ulrey 20:47

Right. Exactly. I think another barrier is that a lot of people don't get a good response from the system. Right. So like we were talking about earlier, a lot of people might report to APS and and not, you know, be happy with APS response, either, because APS decides there's nothing wrong or because APS maybe too aggressive and how they respond. And same with law enforcement, law enforcement may say, you know, this is civil, this isn't anything we can do or be aggressive. And in some jurisdictions, we're seeing a lot of very aggressive responses by law enforcement now with regard to elder abuse. So it's just a fear, I think, and a lot of inconsistency with regard to how the system responds when someone does report.

Dr. Regina Koepp 21:26

Hmm, that's very helpful. clarification. I mean, just these examples are so helpful. They're, they're triggering or sparking in me some examples of my own clinical work when I've had to report and yes, I had to report a case where a person with significant disability required full care was reporting emotional harm from their partner. And so I consulted with the team who was working with me and in his care, and and we all agreed, yes, it needed to be reported. And that helped to have a team that I could balance, you know, is this my own fear about how he's being treated? Or is this accurate? You know, what do you all think, is reporting this to me? Is he reporting that to you, and if we all had consent to consult on his care, and in terms of, you know, releases of information, we're all in the same care team. And it helped me so much to have this care team to say, yes, it's reportable, we need to record it. And when I was horrible for me and horrible for him, and he ended up not working with me anymore, I felt I had betrayed his trust. Naturally, when I told him, I would be filing the report, and I understood that it was a betrayal of his trust, and I, you know, apologized, and, and he didn't want to work with me anymore. And I understood, even though I was heartbroken, and to sort of finish out the story. Several months later, he did return to mental health care with somebody else, thankfully, not with me, which I understand. But, but he did return to mental health care. And I think that the transparency of how I what I told him my steps, and then I was terribly sorry, but but the team and I agree that we needed to report it, I think helped him to remain trusting enough of the mental health system that he could continue to work with somebody even though that person wasn't me. And but just it's so hard, it is incredibly painful. I think that another barrier that I hear from physicians and mental health providers is around does the person have to be have diminished capacity to be exploited? So if they're an adult, and they don't have a significant disability, you know, like a developmental disability, and they don't have dementia, but they're being financially exploited or, you know, maybe some other type of abuse or harm, is that reportable? And like if they're in an abusive partnership, romantic partnership, or they're being financially exploited, but there's no diminished capacity? How does that? You know, clinicians often sort of wonder about that, is that reportable? Yeah,

Page Ulrey 24:19

that's a great question. You know, it just depends on your state's mandatory reporting laws. Some states have require that anyone who is over 60, or over 65 is considered an elder and any abuse, neglect or exploitation of that person must be reported by mandatory reporters. other jurisdictions require a vulnerability. So someone could be 95, but not have any cognitive impairment or physical impairment and not be considered a vulnerable adult and therefore, it doesn't have to be reported. So that it really depends on your state's laws. I think most if not all states do have a law that says that reporting in good faith good You immunity. So even if you're wrong, like, my feeling is better to report and be wrong than not report at all. And even if you're if you're wrong, you're still going to be hopefully revealing a situation that someone can can do something about. And you're not going to be liable for doing that, as long as you make the report in good faith.

Dr. Regina Koepp 25:21

That's a helpful clarification. And for a reminder to folks to check your your jurisdiction for your own state rules around mandatory reporting for elders.

Page Ulrey 25:30

Exactly. The other thing that that we're lacking is coordination between disciplines. You know, these cases are inherently multidisciplinary. So we, in almost every case, we're dealing with capacity, like we've talked about, or we're dealing with medical issues or both. We may be dealing with financial issues, we may be dealing with social issues and housing issues and legal issues. And so you know, that bringing together disciplines to discuss a particular cases is a really important thing to do. And it's starting to become the gold standard for how we respond to elder abuse. So all over the country, multidisciplinary teams are being formed in different jurisdictions. And they, they usually consist of a geriatrician, a capacity evaluator, APS, law enforcement, a prosecutor, a financial analyst, somebody who might have expert expertise in mental health or developmental disabilities. And the idea of these teams is that they come together to staff difficult cases, and together to figure out what's the best path forward for this person. And it may be prosecution, it may not be it may be that the team decides this person actually has capacity, and that what they're doing is is, is their choice, and they're freely choosing to do this. So we shouldn't be intervening. It may just be services. There's a wide variety of different options. But there's no question that we make our best decisions when we're as informed as we can be. And having that multidisciplinary perspective, is how we are best informed to make good choices for people. And so that's really an important thing that is starting to happen around the country,

Dr. Regina Koepp 27:06

Even outside of the elder abuse discussion around determining sexual consent capacity. in long term care communities, the recommendation of the gold standard is a team approach to even outside of this judicial system. So staying if someone is living in a long term care community and starting romantic relationship, and maybe both members of that relationship, or maybe multiple members, many some people are polyamorous, you know, multiple members have dementia and diminished capacity. The standard is that a team is created to assess the person's capacity to consent, that it's not one person making that assessment regarding sexual decision making capacity in long term care with diminished capacity. And that's because we could, you know, it's so nuanced, the sexual interactions are so nuanced where we could be okay with one sex act with one partner, but not that same sex act with a different partner, we could be okay with one sex act with one partner, and then try a different sex act and not be comfortable. Right, but maybe comparable to something else. And so every every sort of moment in an intimate interaction, you know, we're giving consent or dissent, right. And so and so it's incredibly complex, and, and also very human, and the natural part of human expression more than spending money, so and so the team is the gold standard there as well. So I'm glad to hear that more and more teams are forming around around even these elder abuse cases.

Page Ulrey 28:48

That's fantastic. I didn't know about that. I think that's a really, really wonderful way to deal with a very complicated question. Yeah, great.

Dr. Regina Koepp 28:54

Well, and even just back to that, what seems straightforward, a person with severe disability being harmed by his spouse or partner, and, and that I really, what helped me so much to have a team. Even though I was a mandated reporter, I had to report on my own, just to have a team of people that I could say this is happening when they could help me kind of carry the weight of making this kind of a report that does affect a person's life on many levels. And just that's a heavy thing to carry.

Page Ulrey 29:25

For one person. Yeah. And then for the patient or the client to hear that the team talked about and we taught, we hashed it out. And this was the collective decision of the team, I think, might help them realize this isn't a personality problem, and sort of might help them trust your opinion more, you know, your collective opinion more. Yeah, yes, we had. I had started a neglect team Long, long ago when I first started doing this work because I started out just bringing neglect cases. And we also had a medical ethicist as part of our team, which was a really wonderful addition. We don't have one now, but I wish we did because I think that person can really add a lot to this conference. Asians.

Dr. Regina Koepp 30:01

Oh, yeah, I completely agree. Just I completely agree. Yeah, the more multidisciplinary, I think you can make a team, the stronger the outcomes.

Page Ulrey 30:11

Exactly. Exactly.

Dr. Regina Koepp 30:14

Now, speaking of neglect, so we've been talking about pretty overt cases like financial exploitation or sexual sexual harm or physical harm. What about neglect? So neglect is often overlooked as a as an abuse? Can you sort of tell us a little bit about what neglect cases can look like and how we can navigate those?

Page Ulrey 30:36

Sure, like, I am looking at the worst of the worst Virgina so so the cases that I see the neglect cases that I see are felony level cases. So usually the victim is severely injured, and often they're dead. So we will end up getting a case from law enforcement where the police will have been called out to a scene. And the elder or the person with with developmental disabilities is someone who's usually bed bound with a lot of medical issues. And the thing that makes it a neglect case is that there's a caregiver or someone's responsible for that care, their care, and that person has neglected their responsibilities and failed to provide them with proper care. And that lack of proper care, not their underlying conditions, but the lack of proper care has resulted in significant injury or death. Usually, these cases involve malnutrition, dehydration, pressure sores or bed sores, and resulted in death. That's the majority of cases that I see. So they're pretty horrific cases, when you look at the photographs, are you you know, for law enforcement when you got to the scene. But the issue for us criminally is, is making sure that this caregiver is someone who had the tools to care for this person, and who chose not to. And usually, the kind of case that we end up actually bringing charges in is the is a case where the person was financially motivated not to provide care. So it's that we need usually some motive, that's very, very evident, like, like money in order to bring a case like that, because most often, if there isn't a motive, it's because the person is neglected, because the caregiver is may have their own disabilities, they may be an adult child of the victim, and always they follow their parents wishes. And so when their parents said, leave me alone, they did. It may be that the parent really did want to die at home. I mean, there's a lot of different variations that that could make a case simply not be appropriate for criminal charging. But then occasionally, there's a case where it's very clear that caregiver did have the tools emotionally and mentally to, to provide care to this person. And they had a gambling addiction, or they had a drug addiction, and they chose to spend their money for themselves rather than for getting proper care for this person. And that's when it may be a criminal case. Well,

Dr. Regina Koepp 33:06

How often are these criminal cases? Tried? And what's the proper term found prevailed?

Page Ulrey 33:17

Resulted in a conviction? I mean, they're pretty rare still, I have brought, when I file charges, maybe in maybe 10 or 15 cases in my in my career. Most often we'll get a case and we'll decide it's not appropriate for a criminal charging. But once in a while, we see a case and we will bring it because it's very obvious this person suffered tremendously, and they didn't need to suffer have suffered like that. And then around the country, you know, there's I think there's I said, there's more and more prosecutors who are starting to bring these cases. But as far as neglect is concerned, that's still an area where a lot of people don't have the training or the resources to to investigate and prosecute those cases properly. And so we don't see a lot of prosecutions nationally of neglect.

Dr. Regina Koepp 34:09

Tell us what's the difference between civil and criminal cases?

Page Ulrey 34:13

So civil cases are cases that where someone either a family member or a victim themselves, files a lawsuit against a perpetrator or against someone who had a duty to them and ask for money in return for this breach of duty. So you might see an elder abuse you might bring a case against a very common scenario is a family member will bring a case against the nursing home or another long term care facility for neglect of their family member in the facility. That's probably the most common form of civil elder abuse case that we see. There are a lot of other cases that could be brought cases of financial exploitation or or physical abuse, but usually the person A trader doesn't have assets, not always, but usually, so if they don't have assets, you know, someone might a family member might reach out to a lawyer and say, Look, I want to sue this person who abused my mom, or exploited my mom. But then the lawyer investigates it, and the the exploiter or the abuser doesn't have any resources, they don't own their own home, they don't have insurance, there's nothing, there's no way they can get any money from that person. So the case the civil case ends there, because there's no point in suing someone unless you can get money from them. You may also be able to sue a financial institution, if they breach their fiduciary duty by, you know, handing allowing an exploiter to get money from, from the elder and appropriately. And then a criminal case is not brought by an individual. It's brought by a municipality or a state or local government or the federal government, where a crime has occurred. So if we, if we file charges as criminal cases, we are the state of Washington, the state of Washington is prosecuting this person for having committed this crime. And the remedy is not money, the remedy is treatment, jail time, prison time, no contact orders, maybe restitution sometimes if it's if there's if it's a financial case, we can get the court to order that they the offender, repay the victim. But usually the fender has spent the money and so that the victim never gets their money back. But so it's two different things. You're one is pursuing damages for a wrong, it's been done to you by someone who has a duty to you in some way. And the other is pursuing a punishment for someone who has committed a crime against you. That's the difference between civil and criminal. But the other thing that's important in a criminal case is that it's the state bring in the case, not the individual. So some, so prosecutors offices may bring a case, even if a victim says I don't want you to bring this case, because that's my son, and I love him. And then the prosecutor still has the power to do that. Usually, the prosecutor will and they should consult with the victim and see what the victim wants. But in some cases, the person presents such a danger to the community that the state has to prosecute them anyway. It just sort of depends on the situation. For our in my experience, we give a lot more deference to victims of financial exploitation than we do of neglect or physical or sexual abuse. So if a victim of financial exploitation says Look, that's my son, he's my only heir. He's I don't, he wasn't entitled to my money, but I really don't want him prosecuted. Because he's the only person I have left in the world, we may well defer to their wishes, or try to figure out treatment or something else that's less punitive than than jail or prison time.

Dr. Regina Koepp 37:40

That's a helpful clarification. Thank you.

Page Ulrey 37:43

You're welcome.

Dr. Regina Koepp 37:45

So now, what, what are the recommendations for I know, we gave some recommendations for mandated reporters that it's really important to look up in your jurisdiction, what the mandated reporting laws are for elder abuse. But what about for concerned family members or caregivers, if they're concerned about a loved one who might be exploited or being harmed? What, what should they do?

Page Ulrey 38:07

Well, I think, you know, I think they should act versus not acting, I think the regret that I have witnessed by family members is for not intervening soon enough. And for assuming things are okay, because the elder has told them to leave them alone, or has said, everything's fine. And they haven't looked further. So I think, you know, if it's financial exploitation and your family member, I would ask, talk to the elder about it, you know, really try to convince them that you, you know, you're not going to take away their rights, but you just need to sort of see what's going on and ask them if you can look at their financial situation. Ideally, if it's, if it's a responsible adult family member, they could become, get their names on their accounts, or just be allowed to have access to the parents account or the elders account. So they can just be checking periodically to make sure everything's okay. And then if they're not sure, and the elder is very reluctant to allow them to do anything, you know, it gets really complicated. I mean, I think in that case, I might call the police call APS and see if they're willing to help. If they're not, I might call an elder law attorney. There's a lot of really wonderful elder law attorneys out there. And in some cases that are kind of too nuanced, or where there's not enough information, they end up being the people who can help the most. And they can look into the situation and see if a protection order is appropriate or see if report APS or law enforcement is appropriate and help with that. And maybe help. There's in Washington and I think, in other states as well, you can get a protection order that just prevents the suspect or the perpetrator from having access to the elders accounts. So it doesn't cut them out of their life. It just prevents this potential exploitation from happening access. There's a lot of Yeah, there's a lot more sensitive response. As that can come through a protection order, and maybe then through bringing criminal charges. So that's and then you know, another option is just to is to talk to the elder themselves. As I've said, talk to other family members, really try to network about it within your own family if you can, and sort of collect your knowledge and your concerns, and then sit down with the elder and talk to them about it. And if they're adamantly refusing to respond to your questions, and for instance, if you think they're being scammed and it's not, the perpetrator is someone who, who clearly does not have a legitimate relationship with them, then taking much more proactive action is probably appropriate. Yeah, the scam, the scam question is a really big one, we have so many people calling us who have a family member who's who's caught up in a scam, and they're so often reluctant to come forward about it, because they're afraid if they report this to the family or to the police or anything, they're going to lose the chance to get this money that they're expecting to get back. So there's, or they'll be deemed to be incapacitated, and they'll lose their independence, or they'll end up in a nursing home. There's all these very legitimate fears on the part of older adults to revealing when they may be fit when they're being victimized. So kind of addressing those concerns with a family member and trying to work with them, is the first thing I would try. That's very helpful.

Dr. Regina Koepp 41:20

And what about for vulnerable older adults? What would you recommend for them? Because we don't want older adults, you know, I, I struggle with these, these are such essential conversations, and we're raising awareness is so important. Elder abuse is not the norm. The majority of older adults are not being exploited or abused. Yes. But what would you say to older adults who are vulnerable, who do rely on others, even if they can make their own decisions and and do have capacity? What would you recommend for them just to safeguard their their wellness and their sense of security?

Page Ulrey 42:00

I mean, one thing that's a big issue that we see is older adults putting their trust in a family member who has an addiction of some kind. It's amazing how many of our cases of financial exploitation involve people who are gambling or shopping addicts. So if you are the parent, or the grandparent, or the uncle or the aunt of someone who has an addiction like that, don't let them be your power of attorney, it's just a it's a recipe for disaster. So just making sure that person doesn't have access to your money, and isn't your bill payer is one really good preventative step I would take also talking to multiple family members, if you have them about being co power of attorney for you, or, you know, assuming joint responsibility so that there's eyes on each other, is another really good thing to do. And just reaching out to your community, you know, if about concerns you might have and and I think the more we accept the fact that abuse and neglect and exploitation happens, the less shame there is around it, and just realizing that if this is happening to you, you're afraid it's happening to you. It is not your fault. You know, there's so many people who I've talked to who've been victimized and they've said afterwards, I just felt so stupid. I was how can I be so stupid? And it's not you, it's them. They're the problem. And and don't be ashamed and just be proud and talk to other people about it and talk about your concerns and your fears. I think that's probably the most important advice I could give to somebody.

Dr. Regina Koepp 43:30

I love that. But yeah, but you don't hold the shame the perpetrator who the same belongs to not to you?

Page Ulrey 43:38

That's right. That's right.

Dr. Regina Koepp 43:39

Yeah. Do you have any other guidance for mandated reporters?

Page Ulrey 43:45

Just being aware of the fact that you're, I think in every state, you're going to be protected as long as you report in good faith. And then, you know, realizing that it's not your job to investigate, it's the job of the investigators. And if it's a case also, where you really are convinced something serious is going on and you report and you don't get a response. Don't give up and and call back and to ask for a supervisor. If it's the police ask for a sergeant. If the police say to you, sorry, this is civil, and someone's being financially ravaged by an exploitation situation. Look at your at the website for the local prosecutor's office and see if they have an elder abuse prosecutor or turn to someone else, a civil attorney who might be able to help you but just don't give up because if you think something's going on, you're probably right. And the more you can do, the better off the elder is going to be in the end.

Dr. Regina Koepp 44:37

Yeah, thank you. I was I was just thinking too, it can help to get if you do file with APS, the case number, so then when you follow up, you'll have the case number and the name of the person who took the case number, or whoever the case manager is that assigned to that case number two, I've talked to many a case manager assigned to a case number and had success following up in that way. So that can be a helpful path to navigating that APS system.

Page Ulrey 45:04

Absolutely, Regina. And the same is true for law enforcement, you also get a case number from law enforcement. And so you can call back and say I made this report last week, I haven't heard anything, can you tell me where it is and, and then if they say, Oh, it's civil, we can't help you then ask if you can talk to a sergeant, or someone higher up and see if you can appeal to them.

Dr. Regina Koepp 45:21

And that's especially important for documentation to and the medical record. And it can help the whole team to know that they can follow up as needed as well. So it just can smooth out the all the wrinkles in the system. Exactly back to that collaboration you were talking about.

Page Ulrey 45:38

Exactly. And also for people who are seeing someone in a clinical setting, taking notes about what you're seeing. And if there are statements that the elder makes to you, if you can take them down verbatim, that is really great. And the same with if there's a caregiver who you think is abusing or exploiting them, taking down any statements, they make verbatim, that your record is something that we can get into court, even if we lose the victim by the time of the trial, which happens rather frequently. But we can still prove a case oftentimes through statements that were made to you as a health care provider, because that's admissible as non hearsay. So that is really wonderfully helpful to us. Yeah, so anything like that is very, very important to us figuring out, you know, if someone had diminished capacity, or if, if there was a criminal incident involving them,

Dr. Regina Koepp 46:29

For the resources that you mentioned, around finding an elder care attorney and other reporting resources, I can put all of those in the show notes, I have them on. A few episodes ago, I did an elder abuse kind of resource episode. And so I'll make sure that all of those resources are here in the show notes around where to find an elder attorney, how to report if you're concerned, and even tips for long term care communities and, and when to call in an ombudsman, and all of those sorts of reporting, even in long term care.

Page Ulrey 47:03

Great idea, and the Ombudsman is really a wonderful person we didn't mentioned before, but such an essential player in the long term care setting. I think they're fantastic advocates for people.

Dr. Regina Koepp 47:12

One of the concerns that I hear from Long Term Care communities or personal care homes, are that if they bring in an ombudsman from the stage, that to help with, you know, to be an advocate for a resident, that that will look negatively on the long term care community in terms of like, and they're afraid of citations with the state to and maintaining their license to have a long term care community with the state. What are your thoughts about that? And what is the role of an ombudsman?

Page Ulrey 47:45

Well, it's very different from the role of the state licensing agency. And that will definitely reflect on their record and be public information if there's a finding made against the facility. But as I understand it, the Ombudsman is there as an advocate for the resident. And if the resident is in is so impaired, they can't consent when ombuds men being involved, then it would be that that person's representatives, their guardian, or their power of attorney, but they cannot release information unless they have permission from the resident or their representative. So it's highly confidential. So I don't think it would be, you know, a mark on the facility unless there was something reported to the state. And they're not mandatory reporters, they wouldn't be reporting to the state unless they had the permission of the resident, as I understand it, at least that's true in Washington State. So but more than anyone, they are this resource for the community and for family members, because they know what's going on at these facilities. And they will advocate for residents in a way that is just so important. I think it's just, we I can't emphasize enough what what key players they are to addressing abuse, neglect and exploitation in long term care facilities.

Dr. Regina Koepp 48:53

Can you explain a little bit about what an ombudsman is? So I know they're their resident advocate. And so what is their role as an advocate?

Page Ulrey 49:02

As I understand it, I'm really not an expert. But as I understand it, they field complaints from residents or their families, and then they advocate for them with the facility. So if someone is, you know, being exploited in a facility by a staff person, they'll reach out to the facility and they'll work with them to make sure the facility takes the proper action to stop the exploitation. And then I believe with the permission of the resident, they will then report if that's what the resident wants. So they they're trying to remedy whatever wrong is that the resident is experiencing, and it could be something as dramatic as exploitation but it also could be something as mild as just the food being lousy and the resident wanting decent meals at the place where they live or a privacy issues, you know, people not being treated respectfully or you know, interference and their their decisions that they make about who they're intimate with. All those kinds of things are things I believe that they will get involved with.

Dr. Regina Koepp 49:59

Yeah, That would be like my second career is to be an ombudsman.

Page Ulrey 50:03

And they have volunteer ombudsman. So a lot of the a lot of the states, maybe not all of them will, you know, train people to volunteer and to go into facilities and just spend a few hours a week or a month, helping be the eyes and ears of the, of the Ombudsman's office and those facilities.

Dr. Regina Koepp 50:20

And the Ombudsman's office is connected to the state. Is that right?

Page Ulrey 50:25

Right, right. That's correct. Not connected to DHS, or whatever your state licensing is called. totally separate from them. And, but there is one in every state, I believe. Yes, I think there's one in every state.

Dr. Regina Koepp 50:39

And they have some great resources. So I can also link to the state ombudsman website. They have great resources for families and older adults as well. Excellent. Yeah. Well, Paige already thank you so much for joining me today, you have just laid out so much wisdom and resources and recommendations. I'm hoping that that wasn't the people working in senior care and mental health will listen and take action when they see something that they're concerned about.

Page Ulrey 51:07

Thank you. Thank you so much. It's been absolutely wonderful. And I it's just such a pleasure and honor to be here. So thanks so much.

Dr. Regina Koepp 51:14

This was a really difficult episode in which Page Ulrey and I talked about elder abuse and exploitation, and the consequences of abuse and harm. Please take care of yourself and the people that you're caring for. We all have a role in preventing and ending elder abuse. So thank you for being here and doing your part. If you'd like to learn more about elder abuse and financial exploitation, there are three other episodes in this series that are linked to in the show notes. So check them out.

Dr. Regina Koepp 51:52

Alright, that's all for today. If you like this episode, be sure to subscribe and leave a review wherever you listen to podcasts. It really does make a difference. I'll see you next week. Same time, same place. Bye for now.