Abuse of Vulnerable Older Adults by Designated Surrogate Decision Makers

Abstract Abuse perpetrated by designated surrogates has become highly visible nationally, yet no reliable data exist on its nature or extent. Because vulnerable older adults needing surrogate decision makers typically rely upon others for care, they may be unable to advocate for themselves and are susceptible to abuse. We prospectively gathered Adult Protective Services (APS) data from six geographically diverse counties on over 400 substantiated cases of abuse by perpetrators (53% non-surrogates; 47% documented or claimed surrogate) of vulnerable adults 65+ living in community settings. Most perpetrators (85%) were designated power of attorney, while approximately 8% were guardians, and 7% were representative payees; most perpetrators were family members. Polyabuse occurred frequently. Almost 25% of cases involved a prior substantiated APS report. This presentation highlights how surrogates perpetuate abuse and outcomes on older adult victims. Our findings inform practice and policy for better prevention, detection, investigation, and intervention in these challenging cases.


IDENTIFYING THE TRANSPORTATION NEEDS OF A RURAL AGING COMMUNITY: FINDINGS FROM A COMMUNITY ASSESSMENT
Community senior centers are tasked with providing aging adults services and programs, congregate meals, and transportation, set forth by the Older Americans Act. The overall function of senior centers is especially critical for rural communities, as rural communities are home to a greater proportion of older adults compared to metropolitan and low-density urban areas. To assess the current needs of the aging population in rural Northwest, OH, a total of 9 focus groups were held (N=45) as part of a larger mixedmethodological study. Through this work, older adults identified limitations of the current senior center transportation. A lack of transportation and accessibility of current transportation were noted as barriers to full senior center use. Findings from this study confirm disparities in rural transportation; a lack of transportation is a major obstacle to program completion. Recommendations address the unique challenges and needs for transportation services for in rural communities are presented.

PATHWAYS TO AND CONSEQUENCES OF SURROGATE DECISION-MAKING FOR OLDER ADULTS
Chair: Pamela Teaster Co-Chair: Cory Bolkan Discussant: Shawn Meyers With a burgeoning aging population, there is a growing need for surrogate decision makers, yet oversight of and guidance for them remains inadequate. People needing surrogate decision makers are an especially vulnerable population because they rely on others for care and/or are unable to advocate for themselves. Their vulnerability leaves them susceptible to elder abuse (e.g., physical, sexual, psychological abuse; active and passive neglect; financial exploitation), which affects approximately five million older Americans each year. Personal, financial, and societal impacts can be devastating and are estimated to cost billions annually. The issue of abuse, neglect and exploitation by surrogates has been highly visible nationally, evidence indicates that some surrogate decision makers perpetrate abuse. One purpose of this symposium is to discuss ways in which surrogates do and do not make decisions for older adults. Ramsey-Klawsnik and Burnett present data at the systemic level to illustrate how self-neglect sequelae can result in placement under surrogate decision-making authority of either well-intended or opportunistic others. Bolkan, Teaster, Ramsey-Klawsnik, and Gerow present findings from a six-state study on surrogate decision maker victims and perpetrators who were substantiated in Adult Protective Services cases. Zhao, Katz, and Teaster show, using a survey of M-Turk participants, how a general population makes and is comfortable with surrogate decisions. Discussant Shawn Meyers will pull together the findings by exploring their translation to judicial best practices for making determinations regarding surrogate decision makers and the effects of their decisions on the surrogate as well as collaterals. Abuse perpetrated by designated surrogates has become highly visible nationally, yet no reliable data exist on its nature or extent. Because vulnerable older adults needing surrogate decision makers typically rely upon others for care, they may be unable to advocate for themselves and are susceptible to abuse. We prospectively gathered Adult Protective Services (APS) data from six geographically diverse counties on over 400 substantiated cases of abuse by perpetrators (53% non-surrogates; 47% documented or claimed surrogate) of vulnerable adults 65+ living in community settings. Most perpetrators (85%) were designated power of attorney, while approximately 8% were guardians, and 7% were representative payees; most perpetrators were family members. Polyabuse occurred frequently. Almost 25% of cases involved a prior substantiated APS report. This presentation highlights how surrogates perpetuate abuse and outcomes on older adult victims. Our findings inform practice and policy for better prevention, detection, investigation, and intervention in these challenging cases.

SELF-NEGLECT: ONE PATHWAY TO SURROGATE DECISION-MAKING
Holly Ramsey-Klawsnik, 1 and Jason Burnett, 2 , 1. Canton,Massachusetts,United States,2. McGovern Medical School at UTHealth,Houston,Texas,United States Self-neglect, the most frequently reported allegation to Adult Protective Services (APS), involves profoundly harmful behaviors often due to functional or cognitive limitations, health problems, and insufficient resources that result in older adults insufficiently meeting their basic needs. Outcomes include high risk of illness, hospitalization and readmission, hospice and nursing home use, early mortality, and placement under surrogate decision-making authority of either well-intended or opportunistic others. APS staff are charged with assessing self-neglect and intervening to reduce client danger. A nationwide APS survey revealed program policies, procedures, resources, and needs affecting the client welfare. For example, 92% of APS programs have provisions for seeking guardianship for self-neglecting individuals, in 25% of programs staff serve as court-appointed guardians, and a wide variety of tools are used within APS programs to assess clients' mental capacity. Key study findings, implications, and recommendations will be presented.

A SCENARIO-BASED INVESTIGATION OF SURROGATE DECISION MAKING FOR OLDER ADULTS
Yuxin Zhao, 1 Benjamin Katz, 2 and Pamela Teaster, 3 1. Booz Allen Hamilton,Bethesda,Maryland,United States,2. Virginia Tech,Blacksburg,Virginia,United States,3. Virginia Tech,BLACKSBURG,Virginia,United States Surrogate decisions involve complex, challenging choices; surrogate decision-makers make treatment decisions for approximately 40% of hospitalized adults and 70% of older adults, and up to 95% of critically ill adults of any age. The purpose of our study was to understand how people make decisions for others and how surrogate decision making is linked to people's cognition, self-efficacy, and demographics, especially differences in acute (e.g., health and medical care, financial management, and end of life) versus general scenarios (spending time with family, contacting an insurance company on behalf of a family member). Participants were recruited through Amazon's Mechanical Turk. We collected data from 290 adult participants aged 18 years or older. On average, people reported a higher level of confidence in general versus acute scenario. The differences of confidence in scenario-based surrogate decision-making links to decision-makers' cognition, self-efficacy, the experience of decision-making, the experience of caregiving, and demographic factors.

PERCEPTION VERSUS REALITY: SUBJECTIVE AND OBJECTIVE NEIGHBORHOOD CHARACTERISTICS AND COGNITIVE FUNCTION IN REGARDS
Chair: Jessica Finlay Co-Chair: Philippa Clarke Discussant: Lisa Barnes Does the world shrink as we age? The neighborhood captures a spatial area someone inhabits and moves through on a daily basis. It reflects a balance between internal perceptions and abilities, and the external environment which may enable or restrict participation in everyday life. We frequently hear that older adults have shrinking neighborhoods given declining functional mobility. This is associated with declines in physical and cognitive functioning, depression, poorer quality of life, and mortality. Knowledge of the interplay between objective and subjective neighborhood measurement remains limited. This symposium will explore these linked yet distinct constructs based on secondary data analyses of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a racially diverse sample of 30,000+ aging Americans. Finlay investigates how someone's perceived neighborhood size (in number of blocks) varies by individual and geographic characteristics including age, cognitive function, self-rated health, and urban/rural context. Esposito's analyses focus on neighborhood size in relation to race and residential segregation. Clarke compares subjective perceptions of neighborhood parks and safety from crime to objective indicators, and examines variations by health and cognitive status. Barnes will critically consider implications for how older adults interpret and engage with their surrounding environments. The symposium questions the validity of neighborhood-based metrics to reflect the perspectives and experiences of older residents, particularly those navigating cognitive decline. It informs policy-making efforts to improve physical neighborhood environments and social community contexts, which are critical to the health and well-being of older adults aging in place.

MY NEIGHBORHOOD IS FUZZY, NOT HARD AND FAST: A MIXED-METHODS STUDY OF NEIGHBORHOOD SIZE AMONG AGING AMERICANS
Jessica Finlay, Joy Bohyun Jang, Michael Esposito, Sandra Tang, Anam Khan, and Philippa Clarke, University of Michigan, Ann Arbor, Michigan, United States In this exploratory sequential mixed-methods study, interviews with 125 adults aged 55-92 living in the Minneapolis (Minnesota) metropolitan area suggest that neighborhood boundaries are "fuzzy". Qualitative analysis of neighborhood perceptions identified race, mobility, driving status, social connections, housing insecurity, land use, urbanicity, and crime as key themes. Over 8,000 REGARDS participants (mean age 72) indicated how many blocks composed their neighborhoods (mean=9.9, SD=35.4). Linear regression models showed that being over the age of 85, white, less educated, lower income, less physically and cognitively healthy, and living outside of a metropolitan area significantly