• Government has no system to check for abuse by volunteers, who bear most of the caregiving burden in the U.S. And they don't get enough support, training or respite, which increases the chances of stress and harm to elders.
• Professional caregivers, such as nursing aides, get poor pay, benefits and inadequate training, which leads to high turnover, poor screening and bad care.
• The system to oversee professional caregivers has gaps. There is no national system for background checks, and state rules give some abusive caregivers a chance to again work in long-term care facilities.
• Communities will face shortages of professional caregivers due to expected changes in the work force, and their role will grow as the population of frail elderly balloons in the coming decades.
"I don't know how it can't be a crisis at this point," said John Schnabl, chairman of the Wisconsin Long-Term Care Workforce Alliance, a group of private and public organizations that advocates on behalf of caregivers.
Power, control, money
Case study
An 84-year-old farmer deeded his Dane County property to a daughter, son-in-law and their children when they agreed to return to the property to care for him as he aged. When he complained about not receiving proper attention, the family was verbally abusive and the son-in-law struck him in the face, said Dane County elder abuse investigator Scott Martin, who withheld the man's name because of client confidentiality rules. The conflict escalated. Eventually, the elder got a restraining order against the son-in-law, who bought a trailer and moved elsewhere on the property. The daughter and son-in-law fenced off large portions of the land, allowing the elder no access to the property except the driveway. During an argument about the fence, the daughter shoved her dad into his car and then to the ground.
Most caregivers in this country are volunteers, usually family.
About 20 percent of the U.S. adult population provides unpaid caregiving to an elderly family member or friend, research shows. The average volunteer gives 21 hours of help a week for 4.3 years. A study by the American Association of Retired Persons found the economic value of volunteer caregiving to be $350 billion in 2006 — more than the entire sum spent annually on Medicaid in the U.S.
The volunteer caregivers who end up abusing their family members elude detection because other relatives don't keep an eye on them. And sometimes, the elders won't speak up because they don't want to turn in their own relatives or they're afraid they'll end up in a nursing home.
Sometimes, abusive caregivers take the form of "new friends" who spot an opening and gain unrestricted access to a frail or isolated senior.
For years, abuse has often been linked to the tremendous stress that can come from being a caregiver. And that's still an important social problem, experts say, with volunteer caregivers reporting poorer health than others and effects on their jobs and leisure time.
Stress can cause volunteers to lash out, said Patricia Wilson, who cared for her late father and is now a family support specialist with the Alzheimer's Association. Even Wilson admits yelling at her dad before she became better trained. "It's very frustrating and stressful," she said.
Caregivers don't ask for respite, said United Way senior vice president Deedra Atkinson, whose organization has launched an initiative to train and support volunteers. "(They feel) it's their duty to take care of the spouse. It's especially true of populations of color."
Newer research suggests that elder abuse, like many other forms of abuse, is usually motivated by a desire for power, control or money.
Indifferent to suffering
Case study
The state added 20 more names to the Caregiver Misconduct Registry in August, the most recent posting. Over the summer, listings included: a caregiver who got upset with a client, forcibly grabbed her by the arm and took her to her room; another who made $950 in unauthorized purchases on a resident's credit card; and another who cursed at and threatened to kill a resident. About 10 names are added to the list each month and, since 1992, at least 1,560 names have been added to the registry.
Those who make a living delivering care are the primary lifeline to the most vulnerable elders, helping them perform a lot of basic functions to get through their days.
Like volunteers, experts said, most professional caregivers who abuse do so because they like having the power.
"Home health or institutional aides do not sexually assault patients, leave people helplessly on toilets while mocking them, or wheel them into freezing cold or boiling hot showers and laugh because they're stressed," said attorney Betsy Abramson, one of the state's leading authorities on elder abuse.
Caregiver training and workloads vary widely among agencies and facilities — the care ranging from poor to excellent.
"A lot of these people are poor, hard working and deserve the utmost praise," said Dane County Assistant District Attorney Ann Sayles, who prosecutes elder abuse cases.
Some caregivers are put in tough spots by unscrupulous corporations that put profits ahead of human suffering, said Dane County Circuit Judge William Hanrahan, a former state assistant attorney general who prosecuted elder abuse cases.
And some caregivers have no business in the health-care field, Hanrahan said. They lack the right temperament and patience, are abusive or exploitative opportunists, or are "simply indifferent to the suffering of others," he said.
Wisconsin requires checks of those working in long-term care facilities, but the state's list of crimes that would ban employment is shorter than one for those working with children or in foster homes. All employers don't routinely access FBI background information. And misbehaving caregivers can get back into assisted living facilities through a rehabilitation review process.
The state routinely inspects nursing homes only once every nine to 15 months and assisted living every two years or longer — a long time for a bad caregiver to do harm, experts said. Although the state responds quickly to complaints, elderly victims are often afraid to speak up because they are afraid of retribution, they said.
There's also no comprehensive, national system for checking out caregivers, though a system was recently proposed by U.S. Sen. Herb Kohl, D-Wis. Its prospects in Congress are uncertain, but in its first year, a pilot program used statewide in Michigan excluded more than 3,000 people with records of abuse or a disqualifying history.
'A dangerous combination'
Case study
In response to a September complaint, the state found that Alterra Sterling Neenah assisted living failed to adequately supervise residents, allowing an 88-year-old male resident with Alzheimer's to have sexual contact with an 85-year-old female resident with advancing dementia. The state ordered a correction plan and imposed a $350 fine.
There's a link between harm to long-term care residents and inadequate caregiver pay, staff levels and training, experts said.
"Serious problems are often caused by a dangerous combination — vulnerable or mentally disabled residents with significant health-care problems cared for by staff with minimal knowledge," according to a 2003 report by the National Citizens Coalition for Nursing Home Reform, a nonprofit in Washington, D.C.
Nursing aides often don't earn enough money to support their own families or get adequate health insurance or other benefits. Nursing aides, orderlies and attendants in Wisconsin made an average $24,240 last year.
"A lot of caregivers work two or three jobs just to make ends meet," said Schnabl of the long-term care workforce alliance. He added that many are on BadgerCare, the state's subsidized health-care program.
In addition, Wisconsin is one of a minority of states with training for certified nursing assistants at the federal minimum of 75 hours. Some care jobs require little or no training.
The strains on caregivers lead to turnover in facilities that range from 20 percent to 120 percent a year, Schnabl said. If caregivers leave jobs, some facilities ease screening, which erodes staff morale, lets some people with marginal backgrounds in, and puts patients at risk of harm or abuse, experts said.
The industry's inability to keep adequate, trained staff "is a huge issue," said Katherine Ryczek, a former certified nursing assistant at Meriter Health Center in Madison, a 120-bed nursing home, who is now studying to be a nurse at Edgewood College.
Ann Mederios, project manager for the workforce alliance, summed up the frustration of many: "For some reason, our society just seems to accept this as the way it is."
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