What can a primary care physician (PCP) do if an older patient with dementia is being financially exploited by caregivers and family members?

Reporting Financial Exploitation in Patients with Dementia

When a primary care physician suspects financial exploitation of a patient with dementia by caregivers or family members, they have a professional and often legal obligation to report these concerns to Adult Protective Services (APS).

Recognition of Financial Exploitation

Financial exploitation is a significant concern for patients with dementia who may have diminished capacity to manage their finances or recognize when they are being taken advantage of. Primary care physicians should be vigilant for the following warning signs:

• Unexplained withdrawals or transfers from bank accounts
• Sudden changes in financial documents (wills, power of attorney)
• Unpaid bills despite adequate financial resources
• Missing personal belongings or money
• Inability to afford housing, medications, food, or medical care despite adequate income
• Signatures on documents that appear forged or suspicious
• Caregiver reluctance to spend money on patient care needs
• Patient reports of missing money or possessions

Mandatory Reporting Requirements

Financial exploitation is considered a form of elder abuse that requires intervention:

• PCPs should be aware that many states mandate reporting of suspected elder abuse, including financial exploitation 1
• The American Geriatrics Society recommends that clinicians report suspected cases of elder abuse, including financial exploitation, to appropriate authorities 2
• Reporting is especially critical when the patient has cognitive impairment that limits their ability to self-advocate 1

Steps for the Primary Care Physician

1. Document objective findings

   • Record specific observations that suggest financial exploitation
   • Document statements from the patient and family members
   • Note any changes in the patient's financial situation

2. Assess cognitive capacity

   • Use validated tools like Mini-Cog or MoCA to document cognitive impairment 2
   • Determine if the patient has capacity to make financial decisions
   • Document the relationship between cognitive impairment and vulnerability to exploitation

3. Report to Adult Protective Services

   • Make a formal report to local APS agency 3
   • Provide specific details about suspected exploitation
   • Share relevant medical information about the patient's cognitive status

4. Consult with specialists

   • Consider embedding or consulting with APS specialists in your healthcare system 3
   • Seek guidance from elder law attorneys when appropriate
   • Involve social workers to help coordinate services and supports

5. Consider guardianship proceedings

   • If the patient lacks capacity and is at significant risk, consider recommending guardianship proceedings
   • Document medical opinion regarding capacity to manage finances

Preventive Measures to Recommend

For patients with early dementia, PCPs should proactively recommend:

• Appointment of a trusted person as financial power of attorney before capacity is lost 4
• Setting up direct debits for regular bills 4
• Creating advance care plans that include financial management 2
• Establishing joint accounts with trusted individuals with appropriate safeguards
• Regular financial check-ins with trusted family members

Barriers to Address

Several barriers may complicate reporting and intervention:

• Patient denial or lack of insight due to anosognosia 1
• Family resistance or hostility
• Cultural barriers regarding family financial management 4
• Lack of knowledge about reporting processes 3
• Limited resources for investigation and follow-up

Multidisciplinary Approach

The most effective response involves collaboration:

• Engage social workers to help with resource coordination
• Consult with geriatric specialists or geriatric psychiatrists
• Work with financial institutions that may have their own elder fraud protection units
• Coordinate with APS for investigation and intervention 3

Follow-up Care

After reporting:

• Monitor the patient's situation at subsequent visits
• Document any changes in financial circumstances
• Maintain communication with APS about case progress
• Consider more frequent follow-up appointments to assess patient welfare

Financial exploitation of patients with dementia requires prompt recognition and action. By understanding the warning signs and reporting requirements, primary care physicians can help protect their vulnerable patients from financial harm that directly impacts their quality of life, health outcomes, and ability to access needed care.