THE ELDER ABUSE PATHWAY
IN EAST CENTRAL IOWA
Brian Kaskie, Ph.D,
Associate Professor of Health Management and Policy
University of Iowa College of Public Health
Leonard A. Sandler, J.D., Clinical Professor of Law
Director, Law and Policy in Action Clinic
University of Iowa College of Law

U.S. Department of Justice Rural and Tribal Elder Justice Summit
Des Moines, Iowa
November 14-15, 2018

1

 Acknowledgements
This research report was prepared at the request of the United States Department of Justice.
We would like to thank the following individuals for supporting and contributing to this effort:
The Department of Justice:
Andy Mao, J.D.
Susan Lynch, J.D., M.P.H.
Jacob Schunk, Asst. U.S. Atty., Chief, Civil Division, Northern District of Iowa.
The Heritage Area Agency on Aging:
Jill Sindt, Associate Director
Select Participants:
Kiley Remington
Lauri Mitchell
Kim Bergman-Jackson
Dean Spina
Steve Ballard
Bruce Teague
Sofia Mehaffey
Brittnee Pruter
Project Team Members:
The University of Iowa College of Public Health
Brian Kaskie, Ph.D, Associate Professor of Health Management and Policy
Delaney Bounds, M.P.H. Candidate
Andrew Kuenstler, M.P.H. Candidate

The University Of Iowa College Of Law, Law and Policy in Action Clinic
Leonard A. Sandler, J.D.; Clinical Professor of Law; Director, Law and Policy in Action Clinic
Ojone Ameadaji, J.D.
Dominic Azzopardi, J.D. Candidate
Matthew Brown, J.D. Candidate
Casey Daley, J.D. Candidate
Jeremy Kulish, J.D. Candidate
Isiah Lyman, J.D.
Benjamin Martin, J.D. Candidate
Jared Manternach, J.D. Candidate
Evan McCarthy, J.D. Candidate
Daniel Moeller, J.D. Candidate
Willem Rasmussen, J.D. Candidate
David Segal, J.D. Candidate
Reid Shepard, J.D. Candidate
Samuel Stender, J.D. Candidate
Brian Talcott, J.D. Candidate

3

 Please address all inquiries to:
Brian Kaskie, PhD
Associate Professor of Health Management and Policy
University of Iowa
145 River St, N214
Iowa City, IA 52242
e: brian-kaskie@uiowa.edu
p: 319-384-3820

4

 Executive Summary
America is getting older. Compared to persons under the age of 65, older persons endure
unique, age-related challenges such as diminishing cognitive capacity, increasing physical
frailty, and social isolation. All of these can contribute to increasing older persons’
vulnerability and may lead them to become dependent on someone else, formally or informally.1
Regardless of cause, vulnerable and dependent older adults are 4 to 10 times more likely to be
victims of elder abuse than individuals without disabilities.2 All told, we identified five
different kinds of abuse, exploitation or neglect that can be experienced by older adults: Neglect,
Self-Neglect, Financial Exploitation, Physical and Psychological Abuse, Sexual Abuse and
Personal Degradation. When referred to generally, the blanket term “elder abuse” will be used,
encompassing all of these distinct types.
The lack of an adequate state-level response provided an impetus for the Elder Justice
Act of 20103 (EJA) which allocated federal funds for the prevention and detection of elder
abuse.4 As an extension of the EJA, the Centers for Disease Control and Prevention (CDC)
initiated an effort to improve the consistency of elder abuse definitions and surveillance from one
state to the next. A primary reason that standard definitions, as suggested by the CDC, are
important is because these definitions help determine how a case of abuse moves from
occurrence to resolution. Though specifics may vary by state, there is a general pathway that
cases of elder abuse should include: Public Awareness, Identification and Reporting, Intake and
Referral, Criminal Investigation, and Legal Remedies including Prosecution and Civil
Resolutions.
While the EJA certainly has advanced the public response, responsibility for
identification, investigation and prosecution of elder abuse largely remains with the states and
5

 Adult Protective Services (APS) agencies continue to be the leading public authority on these
matters. In an effort to learn more about contemporary state-level efforts to address elder abuse,
we conducted an in-depth exploration of Iowa’s east central corridor. Although the state of Iowa
appears to be active in its efforts to identify elder abuse, there is much more that could be done to
move these cases along the desired pathway. As it stands, an older Iowan who experiences some
form of abuse, exploitation or neglect has less than a 5.0 percent chance of any formal litigation
taking place after filing a claim. So, despite recent efforts to expand and improve implementation
efforts intended to protect older adults and deter perpetrators, this population continues to be
adversely affected by a lack of legal recourse.
To further illuminate the barriers and facilitators to improve the pathway, we examined
the public response to elder abuse in east central Iowa – a geographic area stretching nearly 50
miles from Cedar Rapids (population est. 100,000) to Iowa City (population est. 80,000).
Between June of 2017 and May 2018, we convened six meetings with public agents involved
with addressing elder abuse. We then supplemented information collected from these group
discussions with a review of current literature concerning elder abuse. We also located state
regulations and other data most relevant to elder abuse. Finally, in an effort to expand and
validate our initial findings, we conducted eleven key informant interviews with local public
agents involved with identifying, interviewing, investigating and prosecuting alleged cases.
This in-depth examination of the discrete points in the east central Iowa corridor
generated several insights and recommendations. Many of the impediments result from a lack of
funding, not a lack of motivation, commitment, or effort from the three pillars of the Iowa
system, Heritage Area Agency on Aging providers, Adult Protective Service workers, and law
enforcement. Key informants urge cities and counties to earmark tax dollars, victim assistance

6

 funds, and civil monetary penalty funds to pay for local pilot projects, including enhanced
multidisciplinary teams. Renewed focus could be placed on:
•

Dispelling myths and misconceptions surrounding elder abuse, including the individual
and societal harms it inflicts.

•

Making the public more aware of the local organizations and people involved in
identifying, reporting, responding to, and resolving incidents of abuse.

•

Acknowledging that no one person or organization can do it all alone, and encouraging
systems agents to begin changing their culture and protocols.

•

Involving additional social workers and therapists in the system to address the complex
family dynamics and relationships that are often at the heart of elder abuse.

•

Providing increased and easier access to persons qualified to assess an elder’s mental
health and capacity for making decisions.

•

Funding for state and county attorneys to increase prosecution: increase state and local level
specialized elder abuse units, and the state-wide training of special prosecutors to handle elder
abuse cases.

•

Providing funding for individuals or organizations who are willing and available to make
decisions for an elder, such as a financial or healthcare agent, guardian, conservator,
Social Security Representative Payee or other fiduciary.
We conclude this report by considering how these recommendations might be advanced

most effectively at state and local levels. The time has come for state and local jurisdictions to
take part in the implementation and dissemination of national standards supported by the EJA
and close the gaps that leave too many older adults victims of elder abuse or at-risk of the
undesirable and unnecessary consequences of being vulnerable and frail.

7

 Table of Contents
Acknowledgements.................................................................................................................... 3
Executive Summary .................................................................................................................. 5
Introduction ............................................................................................................................ 11
Risk Factors for Vulnerability and Dependence ................................................................................. 11
Public Efforts to Protect Older Adults from Abuse ............................................................................. 13

The Elder Justice Act......................................................................................................... 14
Terminology and Definitions of Elder Abuse – Elder Justice Act ....................................... 14
The Centers for Disease Control and Prevention Uniform Definitions ............................... 15
Terminology and Definitions of Elder Abuse – Iowa Law ................................................................... 16

Iowa Elder Abuse Law....................................................................................................... 18
Iowa vs National Standard ................................................................................................ 19
The Recommended Process for Addressing Elder Abuse..................................................................... 20

Public Awareness .............................................................................................................. 22
Identification and Reporting .............................................................................................. 23
Intake and Referral............................................................................................................ 23
Criminal Investigation ....................................................................................................... 24
The Elder Abuse Pathway in Iowa...................................................................................................... 25
Problem Statement............................................................................................................................. 26

Methodology ............................................................................................................................ 28
Meetings ............................................................................................................................................ 28
Literature Review and Research......................................................................................................... 29
Key Informant Interviews ................................................................................................................... 30
Outcomes........................................................................................................................................... 30

Public Awareness .................................................................................................................... 32
Public Awareness across the States .................................................................................................... 33
Public Awareness in Iowa .................................................................................................................. 34
Recommendations .............................................................................................................................. 35

Identification and Reporting .................................................................................................. 37
Identification and Reporting across the States .................................................................................... 37
Identification and Reporting in Iowa .................................................................................................. 38
Recommendations .............................................................................................................................. 41

Intake and Referral ................................................................................................................. 42
APS Intake and Referral across the States .......................................................................................... 43
APS Intake and Referral in Iowa ........................................................................................................ 44

9

 Recommendations .............................................................................................................................. 48

Criminal Investigation ............................................................................................................ 50
Criminal Investigation across the States............................................................................................. 53
Criminal Investigation in Iowa........................................................................................................... 54
Recommendations .............................................................................................................................. 55

Legal Remedies ....................................................................................................................... 57
Civil Proceedings .............................................................................................................................. 57

Criminal Prosecution across States ................................................................................... 59
Criminal Prosecution in Iowa............................................................................................ 60
Recommendations ............................................................................................................. 63
Civil Proceedings .............................................................................................................................. 64

Civil Proceedings Across the States ................................................................................... 64
Civil Proceedings in Iowa ................................................................................................. 66
Recommendations ............................................................................................................. 66
Multidisciplinary Teams ......................................................................................................... 68
MDTs across the States...................................................................................................................... 68
MDT in Iowa ..................................................................................................................................... 69
Recommendations .............................................................................................................................. 70

Discussion ................................................................................................................................ 72
Conclusions.............................................................................................................................. 76
References ............................................................................................................................... 77
Appendix A: CDC Uniform Definitions ................................................................................. 84
Appendix B: CDC vs Iowa Definitions ................................................................................... 86
Appendix C: Meeting Agendas ............................................................................................... 89
Appendix D: Best Practices .................................................................................................... 99
Appendix E: Consolidated Recommendations: ................................................................... 100
Appendix F: Interview Request Emails and Protocol ......................................................... 101

10

 Introduction
America is getting older. The life expectancy of an average American has increased from
69.7 years in 1960 to 78.7 years in 20156, and the population over the age of 65 surpassed 51.1
million in 2017.7 By 2050, the number of older Americans is expected to reach 98.0 million.7
The number of people age 85 and older is expected to more than double from 6.3 million to 14.6
million over the next two decades.7 Also, as individuals live longer, the proportion of older
adults (individuals age 65 and over) is increasing relative to younger populations.7 As of 2015,
older adults represented one in every seven Americans (14.9 percent) and, by 2050, persons over
65 may represent 24 percent of the total population. These trends vary across the states. In
Alaska, persons over 65 constitute only 10.4 percent of the population whereas they account for
19.9 percent of the Florida population.8 Older Iowans represent 16.4 percent of the state
population in 2016, accounting for 514,215 people.9 This demographic phenomenon, often
referred to as population aging, is unprecedented.

Risk Factors for Vulnerability and Dependence
Compared to persons under the age of 65, older persons endure unique, age-related
challenges such as diminishing cognitive capacity, increasing physical frailty, and social
isolation. All of these can contribute to increasing an older adult’s vulnerability and may lead
them to become dependent on someone else, formally or informally.10 Alzheimer's disease and
other forms of dementia constitute the most common causes of cognitive impairment, resulting in
short-term memory loss, difficulty communicating, and behavioral problems such as striking out
and wandering. An estimated 5.5 million people in the United States live with Alzheimer's or
another form of dementia, and the prevalence among adults 65 and older is estimated at 5.6
percent.10 63,000 Iowans age 65 and older, or 12.3 percent, are thought to be living with some
11

 amount of cognitive impairment including dementia of the Alzheimer's type, and 1,339 Iowans
died from the neurodegenerative disease in 2015.11
While Alzheimer's is a form of cognitive impairment, frailty is the consequence of
cumulative physiological decline. The prevalence of frailty varies widely, but incidence does
increase significantly with age.12 Estimates of frailty in community-dwelling older adults range
widely from 4.0 percent to 59.1 percent.13 Frailty is correlated with an increased risk of
hospitalization and/or at-home care, and significantly increases the risk of nursing home
placement and mortality.12 The inherent nature of frailty often leaves an older adult in a perpetual
state of vulnerability. Currently, 36.8 percent of older Iowans live with at least one type of
disability, 20.0 percent live with two or more, and many of these individuals may be considered
frail.9
Another condition associated with vulnerability and dependence is isolation.14 The U.S.
Census estimated that 28.0 percent of older adults lived alone in 2010.15 Although living alone
does increase the likelihood of feeling isolated, an older adult does not have to live alone to feel
isolated. Often, feelings of isolation arise from a person’s inability or the lack of opportunity to
develop or maintain positive relationships. The State Data Center of Iowa and the Iowa
Department on Aging estimated that 45.0 percent of Iowans age 65 and older were living alone
in 2016.9
There are other age-specific factors that increase an older adult's likelihood of being
vulnerable or dependent. For example, cultural ageism and age discrimination may contribute to
the devaluing of an older population. Wealthier older adults may be vulnerable to financial
exploitation. Adults living in poverty experience stressors and are often unable to afford
necessary services, potentially forcing them to choose between paying for food, medication or

12

 other essentials. This often compels the older adult to depend on unpaid, untrained, and
inexperienced caregivers. Regardless of cause, vulnerable and dependent older adults are more
likely to experience elder abuse.
Older persons who experience cognitive impairment, physical disabilities and isolation
are 4 to 10 times more likely to be victims of abuse than individuals without disabilities.2 In
addition, researchers have found that having a need for assistance in performing activities of
daily living and having a lack of access to community-based supportive services correspond
increases the likelihood of harm among older adults.16

Public Efforts to Protect Older Adults from Abuse
Historically, the identification, referral and resolution of elder abuse has been left to state
and local authorities, particularly state Adult Protective Services (APS) agencies. Most states,
facing other demands, made little effort to target programs and services to older adults –
including those programs to protect them from harm. In 1965, Congress recognized the lack of
an adequate state level response and passed the Older Americans Act. The act supported the
creation of the federal Administration on Aging (AoA), and a network of 56 state units on aging
and 629 area agencies on aging.18,19 One purpose in establishing the aging network was to
improve efforts to protect older Americans against elder abuse.18 The aging network supported
several efforts such as developing and disseminating education and training programs concerning
elder abuse.6 The Administration on Aging also dispensed grants to support local programs to
address elder abuse.
Between 1965 and 2010, only a few states delineated how their laws concerning theft and
fraud applied to older persons. Indeed, while APS agencies continued to serve all individuals

13

 over the age of 18, only a few focused efforts specifically towards older adults. This lack of
concerted activity across the states provided an impetus for the Elder Justice Act of 2010.3
The Elder Justice Act
As part of the Affordable Care Act of 2010, the EJA (Title VI, Subtitle H) sought to
improve and expand rights for older Americans. This act allocated federal funds for the
prevention and detection of elder abuse and neglect.4 It also established an Elder Justice
Coordinating Council to coordinate agency efforts to address elder abuse, as well as an Advisory
Board on Elder Abuse, Neglect, and Exploitation to increase communication, develop consensus,
and submit status and recommendation reports to the Elder Justice Coordinating Council related
to elder abuse.20 To promote elder justice, it authorized the creation of programs to enhance APS
and long term care ombudsman programs.20 To enhance APS efforts to address elder abuse, it
also created a grant for state demonstration programs to enhance training concerning the
detection and prevention of elder abuse.20 Finally, the EJA required long-term care facilities to
report any suspicions of elder abuse to law enforcement and institute penalties for failures to
report.9 To aid law enforcement in addressing reported cases, it authorized $25 million for a
training program for state and local government from 2011 to 2014.21
Terminology and Definitions of Elder Abuse – Elder Justice Act
The Elder Justice Act (EJA) is the primary source of federal law that governs elder abuse,
and the EJA created and defined five categories of elder abuse for the purpose of implementing
that statute. The categories are:
Neglect is the failure of a caregiver or fiduciary to provide the goods or services that are
necessary to maintain the health or safety of an elder.
Self-neglect is listed as a type of neglect in the EJA. It is defined as an adult’s inability, due to
physical or mental impairment or diminished capacity, to perform essential self-care tasks
14

 including obtaining essential food, clothing, shelter, and medical care; obtaining goods and
services necessary to maintain physical health, mental health, or general safety; or managing
one’s own financial affairs.
Financial Exploitation is the fraudulent or otherwise illegal, unauthorized, or improper act or
process of an individual, including a caregiver or fiduciary, that uses the resources of an elder for
monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful
access to, or use of, benefits, resources, belongings, or assets.
Physical and Psychological Abuse is the knowing infliction of physical or psychological harm or
the knowing deprivation of goods or services that are necessary to meet essential needs or to
avoid physical or psychological harm.
Sexual Abuse is defined in reference to federal criminal law. It reads “serious bodily injury shall
be considered to have occurred if the conduct causing the injury is conduct described in section
2241 (relating to aggravated sexual abuse) or 2242 (relating to sexual abuse) of title 18, United
States Code, or any similar offense under State law.”
The Centers for Disease Control and Prevention Uniform Definitions
As an extension of the EJA, the CDC initiated an effort to improve the consistency of
elder abuse definitions and surveillance from one state to the next. In 2016, the CDC released a
document labeled, “Elder Abuse Surveillance: Uniform Definitions and Recommended Data
Elements.” The document lists definitions used for each piece of legislation and puts forth
recommendations for universal language surrounding elder abuse. The CDC considers elder
abuse an important public health issue. Appendix A shows a selected list of recommended
definitions by the CDC. The definition of elder abuse recommended by the CDC is “an
intentional act or failure to act by a caregiver or another person in a relationship involving an

15

 expectation of trust that causes or creates a risk of harm to an older adult.” Exploitation is
defined as “the illegal, unauthorized, or improper use of an older individual’s resources by a
caregiver or other person in a trusting relationship, for the benefit of someone other than the
older individual. This includes, but is not limited to, depriving an older individual of rightful
access to, information about, or use of personal benefits, resources, belongings, or assets."
Neglect is defined as “failure by a caregiver or other person in a trust relationship to protect an
elder from harm or the failure to meet needs for essential medical care, nutrition, hydration,
hygiene, clothing, basic activities of daily living or shelter, which results in serious risk of
compromised health and/or safety, relative to age, health status, and cultural norms.”22

Terminology and Definitions of Elder Abuse – Iowa Law
Iowa, like other states, has enacted civil and criminal statutes relating to all facets of elder
abuse. These definitions differ greatly from the EJA because state laws are tailored to meet local
needs, priorities and resources. The state laws also need to mesh with existing laws, regulations
and policies on other subjects. There are two laws that address dependent adult abuse. Iowa Code
Chapter 235B covers dependent adult abuse in the community. Iowa Code Chapter 235E covers
dependent adult abuse experienced by people who live in facilities and other institutional
settings. Iowa recently enacted Chapter 235F, which protects “vulnerable” elders and allows
them and other individuals to file petitions for protective orders and other relief. Figure 1
provides an at a glance comparison of the laws and how they differ from the EJA definitions.

16

 Figure 1:
Elder Abuse
Financial
Exploitation

Physical Injury

Deprivation
Neglect
Denial of
Critical Care

Sexual Abuse or
Exploitation

Personal
Degradation

Other

235B Dependent Adult
Abuse Services
“Exploitation” of a dependent
adult which means the act or
process of taking un- fair
advantage of a dependent adult or
the adult’s physical or financial
re- sources for one’s own
personal or pecuniary profit,
without the informed con- sent of
the dependent adult, including
theft, by the use of undue
influence, harassment, duress,
deception,
false representation, or
false pretenses.

235E Dependent Adult
Abuse Facilities
“Exploitation” means a caretaker
who knowingly obtains, uses,
endeavors to obtain to use, or who
misappropriates, a dependent
adult’s funds, assets, medications,
or property with the intent to
temporarily or permanently
deprive a dependent adult of the
use, benefit, or Iowa Code §
235E.1 possession of the funds,
assets, medication, or property for
the benefit of someone other than
the dependent adult.

Physical injury to, or injury
which is at a variance with the
history given of the in- jury, or
unreasonable confinement,
unreasonable punishment, or
assault of a dependent adult

A physical injury to, or injury which is at a variance with the
history given of the injury, or
unreasonable confinement,
unreasonable punishment, or
assault of a dependent adult which
involves a breach of skill, care,
and learning exercised by a
caretaker in similar circumstances.
“Neglect of a dependent adult”
means the deprivation of the
minimum food, shelter,
clothing, supervision, physical
or mental health care, or other
care necessary to maintain a dependent adult’s life or physical
or mental health.
“Sexual exploitation”
means any consensual or
nonconsensual sexual con- duct
with a dependent adult which
includes but is not limited to
kissing; touching of the clothed or
unclothed breast, groin, buttock,
anus, pubes, or genitals; or a sex
act, as defined in section 702.17.
“A willful act or statement by a
caretaker intended to shame,
degrade, humiliate, or otherwise
harm thepersonaldignityofthe
dependent adult, or wherethe
person knew or should have
known that would be the effect of
the act or statement.”
Any of the above listed
maltreatments as a result of the
willful misconduct or gross
negligence or reckless acts or
omissions of a caretaker, taking
into account the totality of the
circumstances

The deprivation of the minimum
food, shelter, clothing,
supervision, physical or mental
health care, or other care
necessary to
maintain a dependent
adult's life or health.
Any consensual or nonconsensual sexual conduct with a
dependent adult which includes
but is not
limited to kissing; touching of the
clothed or un- clothed breast,
groin, but- tock, anus, pubes, or
genitals; or a sex act, as defined
in section 702.17.
NA

Any of the above listed
maltreatments as a result of the
willful or negligent acts or
omissions of a caretaker.

235F Elder Abuse
“Financial exploitation”
relative to a vulnerable elder
means when a person stands
in a position of trust or
confidence with
the vulnerable elder and
knowingly and by undue
influence, deception,
coercion, fraud, or extortion,
obtains control over or
otherwise uses or diverts
the benefits, property,
resources, belongings, or
assets of vulnerable elder.
Physical injury to, or injury
which is at a variance with
the history given of
the injury, or unreasonable
confinement, unreasonable
punishment, or assault of a
vulnerable elder by a
person not otherwise
governed by chapter 235E.
Neglect which is the
deprivation of the minimum
food, shelter, clothing,
supervision, or physical or
mental health care, or other
care necessary to maintain a
vulnerable elder’s life or
health by a caretaker.
The commission of a
sexual offense under
chapter 709 or section
726.2 with or against a
vulnerable elder.

NA

NA

17

 Iowa Elder Abuse Law
As noted above and in the chart, Iowa has three laws that address dependent adult and
elder abuse.
Iowa Code §235B Dependent adult
A person eighteen years of age or older who is unable to protect the person’s own
interests or unable to adequately perform or obtain services necessary to meet
essential human needs, as a result of a physical or mental condition which
requires assistance from another, or as defined by departmental rule.
Iowa Code §235E Dependent Adult
A person eighteen years of age or older whose ability to perform the normal
activities of daily living or to provide for the person’s own care or protection is
impaired, either temporarily or permanently.
Iowa Code §235 Vulnerable elder
A person sixty years of age or older who is unable to protect himself or herself
from elder abuse as a result of age or a mental or physical condition.
Chapter 235B details provisions regarding dependent adult abuse services in the
community, including the formation of multidisciplinary teams (MDT) to assess, monitor, and
coordinate the needs and services for victims of dependent adult abuse, information sharing
among service providers, procedures for the referral of cases, and the establishment of a
dependent adult protective advisory council. This council is made up of 12 professionals with a
variety of areas of expertise and is tasked with advising directors, evaluating state laws and rules
and providing recommendations, and handling recommendations and complaints regarding
dependent adult abuse services programs.26 235B also outlines the creation and maintenance of a
central state registry for dependent adult abuse information, who can have access to this
information, and how the information can be used.27
Chapter 235E.2 details procedures for identifying and reporting dependent adult abuse in
residential facilities such as nursing homes and elder group homes. It describes the responsibility
of the Department of Inspections and Appeals, which is separate from APS agencies, to receive

18

 and evaluate reports of dependent adult abuse, as well as the employee responsibility to report
cases to the department.28
Finally, Chapter 235F, enacted in 2014, instructs a vulnerable elder on how to file a
petition for an order of protection, temporary or permanent, against their abuser. From July 2016
through June 2017, 64 orders of protection were filed as a legal remedy for elder abuse.29 It also
specifies what penalties the court may order if the defendant is found to have engaged in elder
abuse. Penalties include restraining the perpetrator from living with or entering the vulnerable
elder’s home, restraining the abuser from exercising powers on behalf of the victim, and in the
case of financial abuse, ordering that the abuser may not control funds, or must return control of
the funds back to the victim.30
Iowa vs National Standard
It is worth noting that the definitions provided by the Iowa Legislature vary from the
definitions provided by the CDC. These definitional differences across jurisdictions have
negatively impacted national efforts to combat and trace elder abuse. This negative impact has
led to the CDC recommending uniform definitions. One reason for the recommendation is the
discrepancies between definitions across jurisdictions has resulted in methodological problems
for organizations seeking to collect and compare data from different sources. Moreover, because
the definitions vary, studies differ regarding how elder abuse is actually measured. By
implementing uniform definitions, data standardization efforts can begin. Furthermore,
incorporating uniform definitions will make it possible to more fully and accurately describe the
scope and nature of the elder abuse problem.
Appendix B places CDC definition recommendations side-by-side with existing Iowa
Code Chapter 235B definitions. The CDC definitions of elder abuse are succinct, while the Iowa

19

 definitions detail specific types of elder abuse. Second, the CDC definitions are more expansive
than the Iowa definitions. They emphasize the trust relationship between a caregiver or other
person and the older adult, whereas the Iowa definitions focus primarily on the actions that
constitute abuse. For example, the CDC definition of abuse states that the abusive behavior
involves “an expectation of trust that causes or creates a risk of harm.” Similarly, the CDC
definition of exploitation is the improper use of resources by someone “in a trusting relationship”
with the older adult, and the definition for neglect explicates failure to protect an older adult
within “a trust relationship.”
For purposes of this report, we are using five categories of “elder abuse” which
encompasses acts that might fall within other state’s definitions of abuse, exploitation, neglect,
self-neglect and other maltreatment.

The Recommended Process for Addressing Elder Abuse
Standardizing definitions and terminology, as suggested by the CDC, is important
because definitions dictate how a case of abuse moves and is tracked from occurrence to
resolution. Though specifics may vary by state, there is a general pathway that cases of elder
abuse should follow. Figure 2 shows the typical progression of this pathway, beginning with the
victim and ending with follow-through and resolution.
Figure 2:

20

 The National Adult Protective Services Association has also created a sample flow chart
available in Figure 3 that delineates this process from the APS perspective. This chart captures
the complexity of this process, which is often not linear, but instead involves multiple contact
points by various actors in the system.
Figure 3:

21

 Public Awareness
The first consideration involves public awareness. Members of the public must be aware
of what constitutes elder abuse so they can recognize it in their daily lives. Researchers from the
FrameWorks Institute examined public thinking, cultural understandings of experts, and
communications campaigns about elder abuse. They explored and compared public perception of
elder abuse, child abuse, and domestic violence. The report’s findings are rather sobering.
“Americans simply don’t think about elder abuse as a policy issue. This reality reveals
both a risk and an opportunity. The risk is policy inertia: Unless advocates against elder
abuse cultivate a more visible, more informed conversation about this issue, they will
struggle to advance the systemic solutions they are seeking. They also have an
opportunity: the rare chance to introduce an unfamiliar topic to the public and define it in
a way that shapes the public discourse. Discussions of violence and abuse against specific
social groups, such as women and children, have entered the public conversation in
unprecedented ways in recent decades. But elder abuse has not been part of that
discussion. So it is no surprise that elder abuse does not hold a prominent position on the
national political agenda. In short, advocates working to end elder abuse face a
communications problem.”
The question and challenge is how to translate their expertise to shift public attitudes and
change thinking, policies and practices. The task involves a set of choices about content, tone,
method, language and timing of communications with the public, lawmakers, and other
constituents. Crafting a message also requires a shift in perspectives and attitudes, and
FrameWorks researchers stated:

22

 “The frames that advocates advance will shape how this issue moves forward, and
whether Americans understand elder abuse as a private problem that can only be
addressed through individual action, or if they understand it as a preventable public
health issue.”
Identification and Reporting
The second step and consideration involves the identification of an elder abuse victim.
While anyone should ideally be able to identify and report suspected cases, certain individuals
are considered mandatory reporters. These individuals may include employees of financial
institutions, law enforcement officers, APS agency staff, aging specialists, healthcare providers,
social service providers, ombudsman, clergy, family, neighbors and friends. Once these agents
identify the signs of different forms of elder abuse, they also must be aware of where to report a
case.
Intake and Referral
After a suspected case of abuse is identified and reported, the formal intake process may
begin. Cases that fall under the state definition of elder abuse should be reported directly to APS.
However, many people (including mandatory reporters) do not know this, and often end up
calling the local Agency on Aging (AAA) or law enforcement. If the older adult is known to
meet the state definition of dependent or vulnerable, then the AAA or police will refer the older
individual to APS for a formal intake. If the adult is not considered to be dependent under the
law, as defined, the case is not likely to be referred to Adult Protective Services. At this point,
the AAA may offer services to the individual to resolve acute distress or lower future risk, or the
case may not receive any further attention because it considered to be a “family matter.” The
agency also may have to allocate resources to provide further assistance.

23

 Criminal Investigation
Once a case of elder abuse is referred to APS (or an AAA), an investigation can take
place. In particular, if APS or AAA staff suspect that the abuse constitutes a crime, they can refer
the case to law enforcement regardless of dependency status. Local law enforcement then
determines if the individual was subjected to a criminal or civil harm, the officer’s options are to
informally resolve the dispute with or without a warning, take no action, arrest or detain the
threat, remove the elder, contact service providers, contact APS, AAA, or healthcare providers,
and/or refer the case for prosecution. Most cases are referred back to the APS or AAA to
coordinate with other agencies and provide food, shelter, financial or other assistance and case
management.
Legal Remedies
The prosecution of an elder abuse case is initiated, if at all, after a criminal investigation
is opened by law enforcement. Strength of the evidence, severity of the claim, resources
available to the prosecutor, and the prosecutor’s knowledge base of elder abuse related statutes
are all factors that influence a prosecutor’s decision. In addition to the aforementioned factors,
both the prosecutor and the victim (if the victim is not labeled a dependent adult) retain
discretion in their decision to pursue prosecution. In addition, civil legal steps can be taken to
ensure the safety and well-being of an older adult. These civil options include guardianship
proceedings, court proceedings to authorize involuntary intervention, protective orders, change
of conservator or representative payee, civil commitment, powers of attorney, or civil lawsuits.
How these issues are addressed in the legal system depends on each state’s legislative
framework. Cases can be addressed through state elder-abuse specific laws, APS laws, social
services laws, or a combination.24

24

 The Elder Abuse Pathway in Iowa
In Iowa, as in all states, the public response to an older individual who may experience
abuse depends in large measure on how certain elements are defined. For example, in Iowa, the
regulations specify who are considered mandatory reporters, including “those who attend to,
counsel, or treat a dependent adult, including, “the staff of a community mental health center, a
peace officer, an in-home homemaker-home health aide, an individual employed as an outreach
person, a health practitioner, a member of the staff or an employee of a supported community
living service, sheltered workshop, or work activity center, social worker, or a certified
psychologist.” This inclusive definition would suggest the public (including mandatory
reporters) would be quite active in identifying possible cases of elder abuse. In contrast, the state
maintains a somewhat restrictive definition of dependent adult that does not include the concept
of being vulnerable or at-risk and also requires that dependency status be established before an
intake is completed. DHS has legal authority to conduct evaluations and assessments of alleged
dependent adult abuse that occurs in the community when it is alleged that the victim meets the
definition of being a dependent adult, and the victim suffers one or more of the categories of
abuse or neglect, and the abuse or neglect occurred as a result of the acts or omissions of a
responsible caretaker or of the dependent adult.
While there are many public agents empowered to identify and report possible cases, the
state APS agency may be limited statutorily as to who actually qualifies for a formal intake and
referral. Indeed, if one part of the state response is defined broadly while another is defined
narrowly, then efforts to address elder abuse may be limited or disrupted in unexpected ways.

25

 Problem Statement
Researchers have estimated that only 7.0 percent (1 in 14) of alleged acts of elder abuse,
exploitation or neglect are ever reported to aging service agencies, APS or law enforcement
agencies.2 According to a 2016-2017 Iowa DHS Dependent Adult Abuse Report, of 7,195 total
abuse allegations, only 2,971 (39.0 percent) were accepted for consideration by an APS worker.2
However, in most cases, the APS staff did not conduct a formal intake because the case did not
fit the definition in Iowa Code 235B that the alleged victim already be classified as a dependent
adult.4 In 2017, of the 2,877 cases that fit the Iowa definition of elder abuse, only 407 (14.1
percent) of the cases required follow-up action.28 One explanation for this statistic is that very
few older victims opt to take legal or other action against the perpetrator or request supportive
services.29
So, although the state of Iowa appears to be active in its effort to identify elder abuse,
there is much more that could be done to move these cases along the desired pathway. As it
stands now, an older Iowan who experiences some form of abuse has little chance of any formal
legal remedy. 29 Despite recent efforts to expand and improve implementation efforts intended to
protect older adults and deter perpetrators, this population continues to be adversely affected by a
lack of legal recourse. This is problematic. These older Iowans suffer, and they often experience
a number of adverse health outcomes that extend beyond the immediate trauma of abuse.
Victims of elder abuse have an increased risk of hospitalization and death. Victims are also more
likely to be placed in a nursing home and are at an increased risk of developing mental disorders
such as depression and anxiety.33

26

 In an effort to further illuminate the barriers and facilitators to expand and improve the
public response in Iowa, we examined activities concerning elder abuse in east central Iowa, a
geographic area including the two small metropolitan cities of Cedar Rapids and Iowa City,
including a population of more than 300,000 covering 1,000 square miles. We hope this
examination and portrait of local effort reveals practical policy and programmatic alternatives
that can be pursued locally and at the federal and state level. We also aspire to provide a
blueprint for other jurisdictions that seek to evaluate and better understand local pathways
addressing elder abuse.

27

 Methodology
Between June 2017 and May 2018, we examined the public response to elder abuse in
east central Iowa. In particular, we convened six meetings with public agents known to be
involved with addressing elder abuse. We used these meetings to learn more about their efforts to
identify and resolve cases of elder abuse; each meeting focused on a distinct point in the system,
starting with efforts to increase public awareness and ending with prosecution efforts being made
by local county attorneys (see Appendix C for meeting agendas).
We then supplemented information collected from these group discussions with a review
of current literature concerning elder abuse. We reviewed state laws, regulations, agency
manuals, reports and other data and materials. Finally, in an effort to expand on and validate our
initial findings, we conducted eleven key informant interviews with local public agents involved
with identifying, investigating, resolving and prosecuting alleged elder abuse cases. This study
did not constitute social science research and was not reviewed by the University human
subjects’ protection committee.

Meetings
The United States Attorney’s Office for the Northern District of Iowa and the Heritage
Area Agency on Aging sent out invitations to known public agents who were involved in some
aspect of addressing elder abuse among older adults in east central Iowa. Meetings were held
monthly from June through November of 2017, and each meeting addressed a distinct topic
related to elder abuse, including public awareness, identification and mandatory reporting,
assessment and referral of alleged cases, the role of law enforcement, and the role of county
attorneys.

28

 Each meeting addressed three objectives:
1. Participants described their role in dealing with elder abuse—discussing efforts ranging
from: (a) conducting public awareness and professional training, and progressing to: (b)
their role in the identification of elder abuse, (c) their role in reporting to an investigatory
agency, (d) their involvement with intake and referral, and description of services offered
to older persons, (e) engagement with investigations conducted by law enforcement, and
(e) their role in prosecution and other resolution of elder abuse cases.
2. Participants then discussed how well their individual efforts were supported, and
described how they moved elder abuse cases along the pathway. These discussions
specifically focused on how well cases were managed relative to what might be expected.
3. Participants offered suggestions about what would help them conduct their work more
effectively and discussed how they could better coordinate with the other public agents
who are involved with elder abuse cases.

Literature Review and Research
We reviewed relevant scholarship, public and private sector reports, and collected
publicly available data from Iowa APS and other agencies. Our goal was to identify points in
which local efforts matched up well with both the evidence base and best practices implemented
in other states. We also set out to identify where local efforts appeared to fall short relative to the
evidence base and best practices. A consolidated list of best practices is available in Appendix D,
while a consolidated list of recommendations for each step in the pathway is available in
Appendix E.

29

 Key Informant Interviews
In the spring of 2018, we enlisted key informants to better understand our findings. These
individuals were identified as local experts and represented such groups as the Johnson County
Taskforce on Aging, Older Iowans Legislature, Olmstead Consumer Taskforce, Iowa Disability
Advocates, Johnson and Linn County Bar Associations, as well as local probate, criminal
defense, and family lawyers.
The interviews typically involved three project members; one asked core questions, a
second asked follow-up questions, and a third created an abbreviated transcript of the session.
All interviewees were told their names and other identifying information would not appear in this
report. Altogether, the team completed 11 telephone interviews and received written responses to
the core questions from four individuals. All materials relating to the interviews, including the
protocols, core questions, transcripts, scanned notes, and lessons learned, are in secure files in
the University of Iowa College of Law Clinical Law Programs password-protected computer
system. Interview questions and protocol are available in Appendix F.
Based on the six meetings, review of research and literature, and key informant
interviews, we were able to develop an Elder Abuse Map. The map identifies key points in the
pathway and a list of the participants who are involved at each stage. See Figure 4.

Outcomes
In the remainder of this report, we present our findings. We focus on what we learned
about the elder abuse pathway in the east central Iowa corridor and each section features what
gained from research, what we observed as best practices across the country, and what we
learned about current efforts in the east central Iowa corridor. Each section ends with a set of
recommended policy alternatives.

30

 Figure 4:

Elder Abuse Pathways Systems Map

Setting nr MalIIealJnent Iden??caticn Intake 8: Fa Ilavr

. Regarding Criteria, Thrnugh
Raidence nr Threat Prncess. Relief Resulu?cn

 
  

   
  

   
  

 

   

. Financial Social Service Dependent Adult Fund. Shelter.
Flnai'lual Institutions or other Abuse Agency ?nancial CHIEF
Emlu?ah?n Previder Assistance
Direct Hun-
. Law Enforcement Law . 
Injunr, Harm, Management
?nllf??d ar Threat Adult Protective
at: or . -
mm mm" "enem- 
Ccmpetent Agency on
H-EIITTI cr Aging, Slate cr

Criminal Charges

Ha rassment LEI-til Prosecution

Licensed
cr

   

- - Mental Health
Institutmn Deprivaticn, cr Healthcare 
Neglect, Pruvider Mental ?ealth 
Denial cf Pramders Prcvuder nmlna nr I'Il?l
Service
Provider

Famlhr. Friends.
Elder Abuse
Civil Proceedings

 

Elder
Impaired 
Decisicn Depnvatien, Family, Friends,
Making Neglect, Neighbors
Denlal of
Critical Care

   



    

Guardian,

Conservator
Agent. Payne

State Inspections Rli?lituljcn er
and Appeals Private Attorney anate Mitt-tune?r Cm Lawsuit

c?F Inpatiert Menul

M?lb't'?hnmt "mam? State Substitute Aging 'alis? 51:? nr 13-9 Home
Rep-urters Decisicnmal-zer WADE-C 

 

. bud .
Ne Fixed s?mm

Residence Sexual Abuse
or Explaitaticn

 

D?'ier

 

31

Public Awareness
Creating public awareness is an important aspect of any formal effort to prevent disease,
decrease accidents, increase access to programs and services, and improve the lives of older
adults.33 Public awareness campaigns provide brief exposure to an issue and ultimately lead to
increased public discussion and an improved public response.34 Public awareness campaigns
have contributed to increasing early detection and diagnosis of breast cancer, decreasing the
number of individuals who engage in unprotected sex, and addressing the stigma attached to
persons with mental illnesses.35,36
The degree of public awareness concerning elder abuse appears to be much lower relative
to how often it occurs.37 For example, based on their experiences with younger population and
children, many people assume that elder abuse only consists of physical assault, and they may
not consider that older adults experience other types of abuse (emotional), harm (financial
exploitation) and neglect (including self-neglect). Public education also must highlight potential
signs and symptoms of abuse and neglect - as many may only consider more obvious signs of
abuse like bruises and overlook symptoms such as trouble sleeping, weight loss and bed sores.38
Arguably, the general public’s failure to recognize the types and signs of elder abuse may
be cultural. For example, when an older adult presents significant bruises, others can easily
dismiss these signs as a medication issue or, perhaps, an accidental fall. Many individuals simply
do not think such bruises might reflect physical abuse.39 An effective public education campaign
would lead people to consider that bruises on an older adult may be a sign of abuse, just as they
would on a child.40,41
Moreover, public education efforts must address the reluctance many people may have in
engaging in what often is considered a family matter.42 In particular, campaigns need to educate
32

 people about what could be done if and when a sign of elder abuse, exploitation or neglect is
observed. Rather than leaving this to the family, public awareness campaigns can highlight the
range of designated public agencies that may be able to assist. These include the local AAA,
APS office, or law enforcement-the public agencies most involved with older persons who may
be at-risk of or who are experiencing abuse or neglect.

Public Awareness across the States
Since 2005, June 15th has been declared World Elder Abuse Awareness Day, marked in
Washington D.C. with a Presidential Proclamation at the White House Conference on Aging.43
Following this, the International Network for the Prevention of Elder Abuse, with a mission of
“advocacy, education, and research for the protection of the human rights of older persons,”44
Elder Justice NOW, the National Crime Prevention Council, the Ageless Alliance and the Office
for Victims of Crime have supported initiatives to raise awareness and disseminate information
about elder abuse.45 The Ageless Alliance's mission is “turning voices into action to end elder
abuse” through grassroots awareness and advocacy efforts. Elder Justice NOW has created an
educational video with 100 stories to promote public knowledge and awareness. Finally, the
National Crime Prevention Council created promotional kits for Crime Prevention Month, in
October, to be given to communities to raise awareness.45
At the state level, Illinois has supported an extensive public education effort including
materials production (e.g., “Break the Silence” which is an elder abuse awareness toolkit) and
enlistment of advocates to assist with the campaign.22 For example, Governor Pat Quinn declared
July as Elder Abuse Awareness and Prevention Month and Hugh Satterlee, a Montgomery
county health department administrator, has painted old military vehicles with the slogan “break
the silence” to raise awareness and direct individuals to the toolkit.47

33

 Texas created a campaign called “It's Everyone's Business!,” administered by the Texas
Department of Family and Protective Services' APS.23 Texas's efforts stand out relative to other
states for specifically focusing on the role of its APS agency and implementation of elder abuse
and exploitation laws. To fund this campaign, the state relied on social service block grant funds
– which can constitute a considerable proportion of the funding for state APS agencies.48

Public Awareness in Iowa
In 1998, the Iowa Department on Aging administered “Community Conversations on
Aging” and identified gaps in the aging services network, including the need to improve elder
abuse identification and reporting.49 In 2006, the state convened Dependent Adult Abuse Forums
and resolved that increasing public awareness of elder abuse was a top priority. This included
providing continuing education and training for law enforcement, county attorneys, investigators,
community providers and stakeholders.50
In state fiscal year 2017, the Iowa Department on Aging received $248,871 in state
appropriations to support the Elder Abuse Prevention and Awareness program, as administered
by the Office of Substitute Decision Maker and the Managed Care Ombudsman Program.
However, because of revenue shortfalls, the use of funds was limited to supporting efforts by the
Iowa AAA’s to employ elder rights specialists, whose primary duties include assisting at-risk
older adults and families, developing personalized intervention plans, and referring older adults
to APS.51
In the east central Iowa corridor, the Heritage Area Agency on Aging (Heritage) has
dedicated website space to educating the public about elder abuse. Heritage also employs
specialists that are knowledgeable about local older adult services and offers regular Caregiver
Educational Sessions that provide legal information and stress reduction techniques for

34

 caregivers. Among other public awareness efforts, Heritage created a 30-second radio ad, which
ran on local media stations. Despite these efforts, our meetings and interviews suggest that public
awareness remains low; the public often does not understand the types of elder mistreatment and
its various symptoms. The public is most familiar with financial abuse, but there were
misconceptions that it was outsiders who posed the biggest threat to older adults, not friends and
family.
The lack of a public awareness about elder abuse is common among local health care and
other service providers as well. For example, as part of our meetings and interviews, one service
provider relayed how a complaint about an adult child using their parent’s money for personal
benefit was considered a domestic concern rather than abuse, as this provider considered abuse
to be something more visible. Indeed, when service providers were asked to provide examples of
elder abuse, many interviewees were quick to name the most difficult cases they have worked on
involving physical abuse instead of the more common, less visible types. Our interviews also
revealed the lack of knowledge concerning the different public authorities that should be
contacted in a suspected case of abuse or neglect. In one instance, an interviewee who frequently
works with older adults in the private sector noted that he does not know where to send clients
when he is not able to provide them with the relief they are seeking. Another interviewee who
serves older adults and is familiar with resources in the area did not know the full extent of
services that were provided by various organizations. These two examples are not unique and
underscore the pervasive lack of awareness about elder abuse in east central Iowa.

Recommendations
Our meetings and interviews revealed a pervasive shortfall of public awareness, but it
was not for a lack of motivation as much as a lack of funding. For example, the local AAA

35

 reported that they had tried to conduct educational programs in public locations, such as local
libraries, but simply did not have the resources to continue efforts in other locations or with
enough frequency. With additional resources, these agencies would be able to hire more
employees and devote more time to the educational aspect of elder abuse prevention and
detection, as Illinois and Texas have done.
Beyond increasing financial support for public awareness campaigns, elder abuse
prevention efforts could be elevated to those of child abuse prevention efforts. Nearly everyone
who works with children for an extended period undergoes training that teaches them to identify
signs of abuse. This training creates a culture that leads more people to identify signs of abuse
and not just dismiss them as family matters. In terms of funding, the Iowa Child Abuse
Prevention Program receives approximately $1.3 million annually to combat abuse.

36

 Identification and Reporting
People who may be expected to identify possible cases of elder abuse fall into two broad
categories: individual citizens including older adults themselves and mandatory reporters (or first
responders). The latter may include state licensed physicians, emergency room nurses, social
workers, police officers, and in some states, even letter carriers. However, as discussed in the
previous section, most individuals (including mandatory reporters) often are not aware of the
signs of elder abuse. As a result, most victims of elder abuse go unnoticed.52
Even when a mandatory reporter recognizes a potential case of abuse, they may not be
familiar with the appropriate referral process. Instead, the reporter may hand off the case to
another local authority such as an AAA or police department. In some cases, first responders
may not refer the case any further believing local agencies are sufficiently burdened with other
responsibilities. In other cases, they may determine the older individual will not derive a
sufficient benefit by referring a case for a formal intake. In other words, the process of
identifying and reporting possible cases of abuse and neglect often remains uninitiated.53
Finally, mandatory reporting laws can appear to conflict with privacy and confidentiality
laws. This sort of confusion concerning legal issues may correspond with fewer cases of elder
abuse being reported, even by those with a mandatory obligation to respond.

Identification and Reporting across the States
Elder abuse identification procedures are defined at the state level,54 and each state has
implemented its own variation of mandatory reporting procedures, shaped by who are designated
as mandatory reporters, what signs or evidence constitutes a suspected case of elder abuse, and
whether the suspected victim resides in a community or facility setting.54 Some states, such as
Illinois, published a list of those professionals who are mandated to report suspected cases of
37

 abuse. Illinois’s statute requires various professions, including those in social services, law
enforcement, education, coroners or medical examiners, religious practitioners who provide
spiritual treatment, HHS field personnel, and local fire department personnel. Other states uphold
less specific designations. The state of Delaware requires any person to report a case if they
identify an older adult who may be victim of abuse or neglect.54 States also have established
different time periods in which a report must be made by a mandatory reporter. The South
Carolina administrative code requires that a report must be submitted in writing or orally via
telephone within twenty-four hours or within the next business day, whereas the Oklahoma state
code is much less explicit, mandating that reports must be made “as soon as the person is aware
of the situation.”54
Maryland also has a guide to reporting abuse that is noteworthy, as it addresses child and
adult abuse together. This strategy of combining the two types of abuse into one guidance
document could elevate the importance of identifying elder abuse for mandatory reporters.
California has also created a similar guide for elder abuse specifically, titled “Mandatory
Reporter's Guide to Elder and Dependent Adult Abuse Reporting.” This guide details what
constitutes abuse and who the report should be made to in each case.55

Identification and Reporting in Iowa
Mandatory reporting for elder abuse in Iowa first went into effect in 1988.31 Currently,
under Iowa Code § 235B.3, a mandatory reporter is identified as:
“A person who, in the course of employment, examines, attends, counsels, or treats a
dependent adult, including a member of the staff of a community mental health center, a
peace officer, an in-home homemaker-home health aide, an individual employed as an
outreach person, a health practitioner, a member of the staff or an employee of a

38

 supported community living service, sheltered workshop, or work activity center, social
worker, or a certified psychologist.”
Chapters 235B and 235E provide criminal penalties for failure to report and provide for a civil
law suit and damage claim against the reporter who does not fulfill their duties. Chapter 235E
also requires certain mandatory reporters in facilities to report abuse within 24 hours, unlike
235B, which has no timeline or requirement. Failure to report is considered a simple
misdemeanor.
A report is mandated when there is reasonable belief that a dependent adult has suffered
abuse, and reports are made to the Iowa DHS. Although the Iowa code is rather detailed in the
legislation regarding who is required to make reports, it does not outline a timeline of how soon a
report must be made. Of 3,409 reports made in Iowa from July 1st, 2016 to December 31st, 2016,
2,037, or almost 60.0 percent of reports, were made by mandatory reporters. Of these 2,037
reports, 60.0 percent were rejected. This rejection rate is significantly lower than other reporter
types, including anonymous and permissive, which have rejection rates of around 80.0 percent.31
In conducting our meetings and interviews, we observed substantial variation among the
different types of mandatory reporters. On one hand, the reliable identification and reporting of
elder abuse was more likely to be made by a dedicated aging network service provider (e.g., case
workers from the Heritage AAA) or medical care providers. These individuals possess more
experience and are more likely to have completed continuing education that improves their
ability to identify signs and symptoms. However, outside of these professional service providers,
there appeared a lack of engagement with the identification of elder abuse. This likely
corresponds with a lack of experience and education, and some of these professionals (e.g.,
bankers, police officers) may hold misconceptions about elder abuse. For example, some of these

39

 professionals seemed less familiar with many common types and different signs of abuse and
were more likely to consider possible instances of elder abuse as family matters that do not
require a formal intake. Interestingly, some of these professionals seemed less likely to consider
older adults themselves as reliable sources, thinking many suspected cases may be related to an
older individual serving as an unreliable source of information (e.g., cognitively impaired). Such
perspectives are to the older adult’s detriment, as formal intake is delayed until abuse becomes so
egregious that it can no longer be overlooked.

Figure 5: Iowa Referrals by Case Type

40

 Recommendations
Expanding and improving the identification and reporting of elder abuse among
mandatory reporters can occur in several ways. First, definitions of mandatory responders should
be unified and clarified, and perhaps more importantly, their obligations and penalties for failing
to uphold these obligations need to be clarified as well. Second, these individuals should be
engaged in continued education and training efforts that mandatory child abuse reporters have
undergone, becoming experts in the variety of abuse experienced by older adults. For example, a
continuing education course for health professionals in Iowa, approved by the Iowa Department
of Public Health, titled “Iowa: Abuse of Dependent Adults” is available. This course should be
evaluated in terms of how effective it has been as it is required for mandatory reporters, and
covers definitions, characteristics of both perpetrators and victims, intervention options, and
responsibilities of mandatory reporters.87
Another way we can improve the identification and reporting of elder abuse among
mandatory reporters is to classify the failure to report as a serious misdemeanor with the
penalties listed from the Iowa Criminal Code Chapter 903.1. There are also surcharges imposed
by the court upon conviction or plea. In addition, mandatory reporters are exposed to other
liability or sanctions. For example, reporters who do not fulfill their obligations, such as social
worker, nursing, therapist, medicine, dentist, medical resident or intern, etc., might be subject to
sanctions, loss of license, censure, etc. by a professional or licensing authority. A final
recommendation to improve identification and reporting practices of designated reporters is to
implement policy that requires mandated reporters to file a suspected case of abuse within a
certain amount of time after becoming aware of abuse. This may reduce how some mandated
reporters forget to file a case and serves to ensure the needs of the older adult are met.

41

 Intake and Referral
Ideally, when an individual or someone who is a mandatory reporter identifies and refers
a possible instance of elder abuse, he or she will contact their state APS agency. Then, the APS
agent will determine whether or not the older individual meets the statutory definition of
dependent adult or otherwise qualifies for APS services. If so, the agent assumes responsibility
for conducting a formal intake. In addition, the agent can assume a role in providing assistance to
the dependent older adult, which may include removing the individual from their current place of
residence. Even when a claim of abuse is not substantiated, APS agents still may consider the
person at–risk and refer assistance or medical treatment to the older person. Furthermore, if the
agent has reason to believe that an act of elder abuse may have been perpetrated on a dependent
older adult, then the APS assumes responsibility for working with local law enforcement in
conducting a criminal investigation.
If the APS intake reveals the older adult does not qualify as dependent, then the role of
the agent becomes less clear. If the agent believes the independent older adult has experienced an
act of abuse or neglect, the APS agent still must refer the case to local law enforcement, but the
agent may not be as involved in addressing the older adult’s supportive service and other
immediate needs. In fact, when an older individual does not meet the APS dependency standard,
they often are formally removed from the APS process, and at this point, APS agents may or
may not refer the individual case to an AAA or other service provider.
It is also worth noting how APS services for older persons differ from those related to
cases of suspected child abuse. In some cases when APS tries to assist an independent older
adult, the victim may indicate that he or she does not want help and APS will not make a referral
to an AAA or other resource provider. Indeed, pursuant to the Patient Self-Determination Act of
42

 1989, the APS services provided to elder abuse victims are largely driven by the victim's right to
choose whether he or she wish to receive assistance.

APS Intake and Referral across the States
States vary in the standard of evidence needed to accept a claim of elder abuse,
exploitation or neglect. A 2016 report by the National Adult Maltreatment Reporting System
found that the majority of states, 62.0 percent, accept claims with a preponderance of evidence
standard, 16.0 percent of states use a credible, reasonable, or probable cause standard, while 6.0
percent use a “clear and convincing” standard. 14.0 percent of states had no standard of evidence
requirements. States also vary in whether there are standard assessment tools to measure the
necessary types of evidence. While 76.5 percent of states have a common instrument or tool for
APS workers, 23.5 percent of states left this decision up to each county or to the employee’s
discretion. Of 42 states that submitted data, it was found that 37.1 percent of reports received
were accepted for investigation, while 62.9 percent were not. Among the 17 of 21 states that
responded to data requests regarding victims, 37.5 percent of victims either received services or
were referred outside of APS for services.31
Figure 6: Evidence Required to Accept a Case Across States

Source: NAMRS Report, 2016

43

 APS Intake and Referral in Iowa
In Iowa, which uses a dependent adult standard, 2,791 out of 7,195 referred cases were
accepted by APS. This gives Iowa a 39.0 percent acceptance rate, with most rejections being
made “due to the allegation not fitting the definition of abuse found in Iowa Code 235B, or there
was not a caretaker or the adult was not defined as dependent.”17 When the dependency standard
has not been met, the APS agent may refer older adults to the local AAA which provides case
management as well as a variety of other services including caregiver support and nutrition
assistance.50 In these cases, the provision of services can hopefully reduce the ongoing risk
experienced by the vulnerable older adult. APS agents also may engage local law enforcement in
suspected cases of abuse, and may participate in a criminal investigation, regardless of whether
the dependency standard has been met. The Iowa Law and Services collaborative has bolstered
this communication by providing training for APS workers, community-based advocates,
criminal investigators, and the aging network.92
Figure 7: Iowa Total Accepted vs Rejected Allegations

44

 Arguably, Iowa's narrow definitions of “dependency” as “a person eighteen years of age
or older who is unable to protect the person’s own interests or unable to adequately perform or
obtain services necessary to meet essential human needs, as a result of a physical or mental
condition which requires assistance from another” and “dependent adult abuse” as resulting from
“the willful or neglect acts or omissions of a caretaker” has limited the number of cases that APS
can accept for a formal interview. For example, for a case to constitute abuse in Iowa, the victim
must be defined as a dependent adult or an adult that is under caregiver supervision and/or has at
least one mental or physical condition. This limitation is not always apparent to other service
providers in the network.
In one case example provided by a key informant, a resident in a nursing home who was
admitted for a knee replacement had a negative experience with a night nurse. The incident
involved yelling, withholding pain medicine and fighting about administration of pain medicine.
The resident informed the administrator of the nursing home who in turn reported the incident to
APS. However, APS determined that she was not a dependent adult because the victim was still
working and only at the nursing home temporarily for rehabilitation. This led to no intake and
the case was dismissed. Another key informant reported how a service provider noticed that an
older adult was confined to his recliner, unable to leave even to use the bathroom, and in need of
acute medical care. However, given how the older adult refused to be examined, the service
provider reported the case to APS as a case of self-neglect. APS determined “he was not a
dependent adult” and did not conduct an intake. Such examples underscore how local service
providers have come to question the value of reporting these incidents to APS agents, and this
disposition can lead to underreporting.

45

 Another concern with the intake and referral process involves the lack of follow-up with
those who present the case initially to the APS agent. One service provider shared how she
requested feedback on the progression of an individual case for her own records. In response,
APS sent a brief letter stating the case had been accepted for intake but provided no further
information. This lack of communication can become problematic in providing services to an
older person, as they may fall into the cracks or receive redundant service supports.
Besides a lack of follow-up, some have suggested that the APS determination process
lacks transparency. One interviewee, who often referred cases to APS for intake, has sometimes
been told that suspected cases of abuse were unfounded because the older adults “chose to live
this way.” This sort of decision seemed inconsistent with what the service provider observed—a
man who was immobile and required daily care for feeding, bathing and other activities of
independent living and appeared to be routinely neglected by his caregiver. When APS does not
respond or does not provide transparent reasoning for its decision, others may be less inclined to
engage APS to conduct an intake. Figure 8 shows the outcome of cases accepted for intake in
Iowa, while Figure 9 breaks this down further by case type.
Figure 8: Outcome of Cases Accepted for Intake

4%
15%
Founded
Unfounded

81%

Confirmed, not
Registered

46

 Figure 9: Outcome of Cases Accepted for Intake by Case Type

Total

Total Accepted

Total Rejected

1695

1194

1149
790

2889

852
514

371

424

1939
1223
Neglect

Self-Neglect

Exploitation

131
49

938
Physical Abuse

180
Sexual Abuse

From the APS perspective, agents experience some difficulty with navigating privacy and
confidentiality laws as well as processes concerning release of patient information. For example,
one agent explained that she has to have her clients fill out and sign several different release
forms to get the help that they need because each organization/party requires a different form.
Health, mental health, alcohol and substance use programs have different forms to populate
when requesting services, and what is required may vary depending on the entity asking for or
being asked to share. This can lead to APS agents not referring cases because of either an
unwillingness to take on the extra workload, or an inability to due to limited time and resources.
APS agents repeatedly commented on the lack of staff and other resources relative to their
workload regarding the intake and referral of elder abuse cases.
47

 Recommendations
We recommend expanding the definition of dependent adult in Iowa Code 235B to
include an individual age 60 or older who meets the definition of “vulnerable adult,” in the Iowa
Elder Abuse Act, Iowa Code Chapter 235F. This would allow for the statute and the agency rules
to cover a greater number of susceptible older adults. The current definition of dependent adult in
Iowa Code 235B is as follows:
“A person eighteen years of age or older who is unable to protect the person's own
interests or unable to adequately perform or obtain services necessary to meet essential
human needs, as a result of a physical or mental condition which requires assistance from
another, or as defined by departmental rule.”
Adding language to this definition that reflects the definition of “vulnerable adult” in
Iowa Code 235F would aid efforts to ensure the definition provided in 235B is not under
inclusive. Per 235F, the definition of “vulnerable adult” is “a person sixty years of age or older
who is unable to protect himself or herself from elder abuse as a result of age or a mental or
physical condition.” Including this language in 235B would protect two separate categories of
elder adults, those that are deemed dependent and those that are deemed vulnerable, thereby
expanding the statute’s coverage. The Iowa Code gives the Department of Human Services the
power to define elder abuse. Officials should consider revising the current definition using
agency rulemaking rather than or in addition to changing Iowa law.
Similarly, the intake assessment tools used by APS agents should facilitate referrals even
when a person is not determined to be dependent, and this would include a process to reply to the
person (or organization) that initially brought the case to APS. Minnesota, which uses a broader
vulnerability standard, rather than dependent standard, has a tool that delineates decisions by

48

 response priority. When it is determined that a case of vulnerable adult abuse has occurred, cases
are assigned a response priority level of 1, in which case cases must be responded to within 24
hours, or level 2, which has a longer response time of 72 hours.57 Minnesota has been using this
vulnerability standard since the 1980’s, when its vulnerable adult abuse laws were enacted. In
2009, these efforts were expanded upon with a strengthening of the laws in 2009.90
In addition, efforts should be put into place so that APS and other supportive services
agencies can work to identify and provide services to those who are vulnerable or at-risk for
elder abuse. This sort of preventative strategy may help lower the incidence of abuse and reduce
the need to involve law enforcement. Indeed, one key informant stated, “It is so traumatic to
have those things resolved through such formal means.” Following this, a mediation strategy
might be developed as part of the APS assessment process as a means to address the factors that
contribute to actual instances of elder abuse. Another individual stated, “If you give me a magic
wand, I would at least encourage, or maybe require, some sort of mediation or informal dispute
resolution in these cases.” Such an approach could both preserve family relationships and also
put less strain on already limited resources of APS, law enforcement and county attorneys.

49

 Criminal Investigation
Law enforcement may come into contact with alleged cases of elder abuse. Individual citizens
and first responders may contact law enforcement directly when a case of elder abuse is
suspected, and this most often occurs in cases of acute distress that require an immediate
response. APS also may refer cases to law enforcement for criminal investigation. If law
enforcement gathers sufficient evidence, then cases can be referred to the corresponding county
attorney for further investigation and possible prosecution. However, most criminal
investigations are referred back to APS for lack of sufficient evidence. Figure 10 diagrams how
this decision-making process can take place.
Figure 10: Law Enforcement Decision-Making Process

In determining which cases to pursue and, ultimately, refer to a county attorney, law
enforcement agents use a considerable amount of discretion. The greater the ambiguity in laws
and definitions surrounding elder abuse are, the more discretion these law enforcement officers
have.58 For example, Florida clearly explicates its definition of exploitation, stating that it
“occurs when a person who: 1. Stands in a position of trust and confidence with a vulnerable
50

 adult and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use,
a vulnerable adult's funds, assets, or property with the intent to temporarily or permanently
deprive a vulnerable adult of the use, benefit, or possession of the funds, assets, or property for
the benefit of someone other than the vulnerable adult; or 2. Knows or should know that the
vulnerable adult lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use,
the vulnerable adult's funds, assets, or property with the intent to temporarily or permanently
deprive the vulnerable adult of the use, benefit, or possession of the funds, assets, or property for
the benefit of someone other than the vulnerable adult; ‘Exploitation’ may include, but is not
limited to: 1. Breaches of fiduciary relationships, such as the misuse of a power of attorney or the
abuse of guardianship duties, resulting in the unauthorized appropriation, sale, or transfer of
property; 2. Unauthorized taking of personal assets; 3. Misappropriation, misuse, or transfer of
moneys belonging to a vulnerable adult from a personal or joint account; or 4. Intentional or
negligent failure to effectively use a vulnerable adult's income and assets for the necessities
required for that person's support and maintenance.” This detailed definition can lead to more
clearly defined roles than a general one. For example, in Kentucky, exploitation is simply
defined as the improper use of an adult or an adult's resources by a caretaker or other person for
the profit or advantage of the caretaker or other person.59
There are numerous reasons why law enforcement officers may elect not to pursue
criminal investigation and do not refer the case to the county attorney. In some cases, a police
officer may find evidence of abuse but decide not to refer to the county attorney because the
older adult (i.e., alleged victim) explicitly expresses no interest in filing a formal charge. Elder
abuse victims may prefer for law enforcement not to pursue criminal charges because they fear
the possible consequences. A survey of over 1,800 members of the New York State Coalition on

51

 Elder Abuse, conducted by the New York City Elder Abuse Center and Lifespan of Greater
Rochester, found that older adults often perceive a high amount of risk associated with involving
law enforcement. First, the perpetrator is often a family member and the victim does not want
their family member prosecuted. 85.7 percent of respondents reported concern that the
perpetrator, who is often a family member, would be arrested. The second reason is that family
members fear losing their housing. Of those surveyed in the study, 85.2 percent reported fear of
losing family support; and 69.9 percent reported fear of losing their housing.60
Beyond constraints imposed on law enforcement officials by the victims, the officials
also elect not to pursue further investigation due to their own limitations. In certain instances,
officers do not find a sufficient amount of evidence to refer for further investigation and possible
prosecution. The inability to collect sufficient evidence may be the result of improper training to
identify elder abuse, which is discussed below, or incorrect categorization of the claim by law
enforcement. In these cases, police officers may decide to refer the individual case back to APS
and encourage these agents to monitor the case for future referral.61 Police officers may also
classify the issue as a purely civil matter or family matter, which removes their jurisdiction and
does not require any additional third-party intervention. Police officers deciding not to refer a
case to the county attorney or APS is similar to the problem with investigating and prosecuting
spousal abuse.62
The lack of referral from law enforcement to a county attorney can be a problematic point
in the elder abuse pathway. Local law enforcement often complete little if any formal training
with investigating elder abuse and may not have a command of the type of evidence needed to
support an alleged case. Members of law enforcement also might not have the resources needed
to complete such training or complete a formal investigation. As such, they rely on

52

 contemporary, local attitudes that often support the notion how such cases are a family matter. At
best, they may refer alleged cases to APS or other social service agencies as alternatives to
prosecution when cases are still being investigated or there is not enough evidence to
prosecute.63

Criminal Investigation across the States
In 2015, the National Center for Victims of Crime released a presentation regarding best
practices for law enforcement involvement in investigating cases of elder abuse. The report
emphasizes the importance of witness observations, defendant statements, physical evidence and
documents to supplement the victim’s claims. It also details when civil versus criminal
proceedings should be considered, emphasizing the importance of prosecution as a resolution.64
The University of Southern California also has developed The Elder Abuse Guide for Law
Enforcement (EAGLE), a tool to help officers quickly identify and respond to cases of elder
abuse. The resources include how-to information on a variety of topics including recognizing
abusers, interviewing older adults, working with others to build a case, documenting bed sores, a
bruising identification chart, photography tips, state criminal statutes and state mandated
reporting. The tool also includes a first responder checklist and evidence collection checklist, as
well as a community resources locator personalized by zip code.65
Additionally, the US Department of Justice provides sample protocols for law
enforcement that are being used in California, Illinois, and Michigan. In Santa Clara County,
there are specific procedures for both patrol officer response and investigative follow-up for each
type of abuse that can occur. For example, for cases of neglect, self-neglect, or endangerment,
the guide asks responders to first consider factors such as: does the elder need medical services?
Can the person recognize and communicate basic needs? Is there a caretaker present? Next, the

53

 responder must collect evidence, including documenting physical evidence, obtaining statements,
and taking photos. Next, there are detailed procedures for behavioral indicators of the victim or
caretaker, filing reports, conducting joint investigations.63
In Santa Clara County’s guidance document, investigative follow-up procedures are
specific to type of abuse, including neglect, physical abuse, financial abuse, sexual abuse and
suspicious death/homicide.66 Similarly, San Diego County has an Elder and Dependent Abuse
Blueprint document that details what patrol response should look like to suspected cases of elder
abuse, and refers law enforcement to appropriate documents for each point in the process,
including interviewing, and documenting the scene, as well as specific guidelines for physical
abuse, financial abuse and neglect.74 At the state level, Illinois has a protocol document for law
enforcement response to cases of elder abuse. The document only provides a checklist for cases
of financial abuse, but does provide indicators for other types of neglect, as well as detailed
instructions for law enforcement in the investigative process.68

Criminal Investigation in Iowa
The State Administration for Community Living’s Aging Integrated Database found that,
in Iowa from 2006 to 2015, there have been 477 original charges of dependent adult abuse and
465 disposed charges.69
In 2015, to improve law enforcement efforts and other services, eight states, including
Iowa, received a grant from the Victims of Crime Act (VOCA) as part of their Enhance Training
and Services to End Abuse in Later Life Program. This program was authorized by 42 U.S.C. §
14041, and is permitted to appropriate $9,000,000 in funding to elder abuse prevention services
from 2014 – 2018. Awards ranged from $300,000–$400,000 over three years.70 The OVW has
annually awarded grants to state, county, and city agencies that aim to reduce elder abuse since

54

 2006. In addition to training programs for law enforcement agencies, other notable activities and
services that are mandated to be provided with grant funding include services for victims of
abuse that are 50 years of age or older, the establishment and/or continued support of community
multidisciplinary responses to victims of abuse, and training programs for health care
professionals and other relevant human services organizations.
The Iowa State Bar Association (ISBA) held a free public information session at the
ISBA headquarters in Des Moines on September 19, 2018 to discuss issues pertinent to older
Iowans. Presenting at the event were local ombudsman officers and attorneys. Topics of
discussion included healthcare directives, disposition of remains, power of attorney and living
wills. Attendees also had the opportunity to have their living will and/or medical power of
attorney forms notarized at the event.71 In 2017, ISBA also held a webinar on financial
exploitation. The event included an overview of abuse types, indicators and interventions for
financial exploitation specifically, and case studies to put this knowledge into perspective.88

Recommendations
Law enforcement efforts to investigate cases of elder abuse can be improved through
greater education and training, and such efforts may even go as far as conferring specialist
certification for select officers. Additionally, increasing support for law enforcement
investigations could allow for more effective investigation (e.g., plain clothing or unmarked car
details to reach out to victims with discretion) and case follow-up. Law enforcement also can
help remedy prevailing local sentiments that “family matters should stay within the family.”
Involvement of law enforcement should not stop following the resolution of an elder
abuse case. This is because there remains the potential for abuse following the initial abuse. To
ensure that future abuse does not occur, law enforcement should develop specialized police units

55

 that conduct routine follow-ups on cases of elder abuse. For example, while many police
departments in the Iowa City-Cedar Rapids Corridor have begun to train their officers in some of
the key signs of elder abuse, officers still face resistance when an elder is asked whether he or
she is being abused, as well as a reluctance to get involved with family matters. One of our key
informants theorized that small-town police officers and county sheriffs are less likely to respond
to elder abuse allegations than those in a larger city, because when everyone in town knows each
other, they would see it more as a family conflict rather than a potential police issue. Given these
complex interpersonal dynamics, law enforcement could be doing more to help identify elder
abuse when it occurs, and channel those reports into the right mechanisms of relief.

56

 Legal Remedies
Criminal Proceedings
The prosecution of an elder abuse case is initiated, if at all, after a criminal investigation
is opened by law enforcement. Like other crimes that fall within the prosecutor’s jurisdiction, the
prosecutor retains the ability to exercise prosecutorial discretion when electing to pursue a claim
of elder abuse. Strength of the evidence, severity of the claim, resources available to the
prosecutor, and the prosecutor’s knowledge base of elder abuse related statutes are all factors
that influence a prosecutor’s decision. In addition to the aforementioned factors, both the
prosecutor and the victim (if the victim is not labeled a dependent adult) retain discretion in their
decision to pursue prosecution. Although it’s difficult to advance, sometimes the prosecutor will
prosecute “on the facts” if the victim recants and there is other sufficient evidence.
Prosecuting a case of elder abuse can provide several benefits such as providing justice
for the victim, ending the abuse, protecting the victim through a protective order, offering
restitution to the victim, and providing a just sentence—including treatment programs—to the
perpetrator.72 Despite these benefits, prosecuting a case of elder abuse is not common. We focus
on three reasons that contribute to this phenomenon: 1. Lack of victim willingness to pursue
charges; 2. Knowledge and resource restrictions for prosecutors to pursue elder abuse claims;
and 3. Criminal penalties for elder abuse do not motivate prosecutors or deter potential
perpetrators.
Elder abuse prosecution is unique. Unlike cases of an alleged and verified child abuse,
the decision to prosecute a case of elder abuse largely falls upon the older adult so long as the
older adult is not considered dependent or vulnerable. That is, when an older, independent adult
has been subjected to a verified act of elder abuse, the decision to prosecute is voluntary and
57

 remains with the older adult.86 The practical effect of a voluntary prosecution system is that older
adult victims often decline to prosecute. Declining to prosecute is common because the older
adult often views the benefits of prosecution as antithetical to traditional risk-reduction strategies
(e.g., an older adult may live in the home of or be cared for by the perpetrator).72 Prosecutors
must weigh several considerations when deciding to prosecute alleged cases of elder abuse.
Among the more important considerations is the preservation or restitution of the victim’s
autonomy balanced against the state’s interest in seeking justice by prosecuting crimes against
older adults. Indeed, striking this balance is difficult and has resulted in most states delegating
the prosecution of elder abuse and neglect to local authorities to handle on a case-by-case basis.
Even when an older adult voluntarily decides to prosecute, prosecution efforts are often limited
by external constraints. State and county attorneys routinely face competing priorities and
limited resources that restrict their efforts to pursue cases of elder abuse.
The negative consequences of constrained resources extend beyond the ability (or lack
thereof) of prosecutor offices to pursue cases of elder abuse. Constrained resources may also
result in inadequate training of those parties involved in prosecution and adjudication efforts.
Competing priorities and limited resources also can lead to prosecutors only taking cases they
believe will result in conviction, leaving many potentially valid claims overlooked.73 There are
many reasons why a prosecutor may be less inclined to pursue elder abuse claims compared to
other claims. These include the perception that older witnesses are unreliable, the domestic
nature of many elder abuse claims, unfamiliarity with elder abuse law, and weak state penalty
guidelines. 35 As a result, state and county attorneys often refer alleged cases of elder abuse back
to state APS agencies.

58

 Criminal Prosecution across States
In all states, cases of elder abuse can be prosecuted through general criminal statutes
applicable to the abuse such as assault, sexual assault, theft, and fraud.77 Laws specific to elder
abuse, however, vary state by state. For example, Virginia and Texas, detail crimes against
family members as a distinct crime and classify it as a Class 1 misdemeanor.78 Other states,
including California, Connecticut, Indiana, and Florida, increase penalties for specifically
targeting an older adult.77 Several states including California, Missouri, Florida, and Nevada also
have included acts of elder abuse as distinct crimes in their criminal code and allow for criminal
prosecution, either in addition to or independent from civil remedies.77,80 California was one of
the first states to criminalize elder abuse with the enactment of Penal Code § 368, which gives
elder abuse “special consideration and protection,” something that had been previously instituted
for victims of child abuse.52 Similarly, Florida State Code 825.102 states that “A person who
knowingly or willfully abuses an elderly person or disabled adult without causing great bodily
harm, permanent disability, or permanent disfigurement to the elderly person or disabled adult
commits a felony of the third degree.” If the encounter caused “great bodily harm or permanent
disfigurement,” this results in a first-degree felony.80
Utilizing specialized elder abuse units is an effective means towards increasing elder
abuse prosecution efforts. However, only a minority of jurisdictions employ such units. A
national survey conducted by the American Prosecutor’s Research Institute found that 28.0
percent of local prosecutor’s offices had units dedicated to specifically prosecuting elder abuse.
These specific elder abuse units often have internal investigation units, which can work with law
enforcement to ensure that the number of cases of elder abuse that can be prosecuted are being
prosecuted.84 States with strong county-level elder abuse units include Florida, Arizona, and New

59

 York.86 A secondary benefit of these units, in addition to increased elder abuse related
prosecution efforts, is an increase in both education and outreach efforts, both within the aging
network and to the general public. Both groups of people are unfamiliar with aspects of legal
proceedings. Providing community-based training could allow these individuals to feel more
confident in their ability to recommend or move forward with prosecution and increase the
understanding of the process and relevant information.
Another way to increase elder abuse prosecutions is to increase criminal elder abuse
penalties. Several states have followed California’s lead and criminalized elder abuse to the same
level of child abuse. New York and Florida also stand out for establishing substantive penalties
for committing elder abuse. In New York, assault of a person over the age of 65 results in a
second-degree charge, which is a felony in the state. In Florida, a third-degree felony can result
even when the perpetrator does not cause “great bodily harm, permanent disability, or permanent
disfigurement.”86 California has also passed the Elder Abuse and Dependent Civil Protection
Act, which allows for fee awards to attorneys for taking cases of elder abuse. Increasing criminal
penalties to reflect the more severe approach taken in states such as Florida and California may
increase the number of cases that prosecutors are willing to take, leading to higher levels of
successful prosecutions.86
Criminal Prosecution in Iowa
In Iowa, depending on the nature of the abuse, elder abuse can be criminally prosecuted
under Iowa Code 235B or 235E. Charges under 235B and 235F may be initiated upon a
complaint by a private individual, an investigation by social service agencies, or upon direct
initiation of the county attorney or law enforcement agency. Available charges under 235B and
235E include wrongful communication, intentional serious injury, reckless serious injury,

60

 intentional physical injury, exploitation greater than $100, otherwise intentionally commits
dependent adult abuse, exploitation, and failure to report dependent adult abuse.
While the charging options are numerous, the criminal penalties associated with
completing a successful prosecution appear insufficient to motivate prosecutors or deter criminal
activity. Of the above listed charges, the highest possible violation is a class “C” felony. Class
“C” felonies are punishable by a prison term of up to ten years and a fine of $1,000 to $10,000.
(Iowa Code § 902.9.) Class D felonies, punishable by up to five years in prison and a fine
ranging from $750 to $7,500 dollars, and serious misdemeanors are also available criminal
penalties. As discussed below, elder abuse related criminal penalties in Iowa are significantly
less severe as compared to other states.
A 2016 study that surveyed dependent adult abuse prosecution in Iowa from 2006 to
2015 found that there were 368 cases prosecuted during this time span. The number of
prosecuted cases has increased in the last five years and has more than doubled from 2006 to
2015.69 The study found no significant correlations between county demographics or government
characteristics and prosecution rates. From 2006 to 2016, the average number of cases
prosecuted in a metropolitan area was 11.05, but only 1.86 in non-metropolitan areas. Polk
County had the highest prosecution rate compared with all other counties in Iowa, the highest
sheriff’s mean salary, as well as the densest population. The Polk County attorney’s office also
was the first office to create a specialized Dependent Adult and Elder Abuse Unit to prosecute
elder abuse crimes in 2002.
One explanation for these relatively low prosecution numbers is a lack of resources in
local prosecutor and county attorney offices located in less densely populated areas. This lack of
resources for local prosecutor offices was recently recognized and addressed in a 2017 Iowa Law

61

 and Services Together Report.75 It was announced in September of 2018 that the United States
Department of Justice Office on Violence Against Women awarded the Iowa Attorney General
Office a three-year grant to provide training and services aimed at ending abuse in later life.76
The training will cover the investigation and prosecution of abuse cases and resources available
to older victims. The audience for this training includes those involved in elder abuse efforts
such as law enforcement personnel, prosecutors and judges.75 A key component of this grant is to
provide training of the county attorneys across the state.75 To date, this is the only training
focused on elder abuse that is offered to prosecutors.
Resource and training deficiencies for prosecutors and law enforcement personnel are not
the only road blocks impacting an individual’s ability to pursue an elder abuse claim. Key
informants also noted a scarcity of available lawyers to represent or advise individuals from lowincome and fixed-income households. Many people interviewed said that middle-class families
are caught in a no-win situation; they earn too much to qualify for legal services and too little to
pay for a private attorney. A statewide hotline and website are available for the public and
includes materials on elder abuse. Representation is available through the hotline and a volunteer
lawyer program, but it is extremely limited in many respects.
The state of Iowa has taken affirmative steps to improve elder abuse prosecution efforts
across the state. In 2013, an Iowa Elder Abuse Task Force was created. This task force suggested
updates to the Iowa Code, using recommendations to create a comprehensive approach to elder
abuse prevention which was incorporated into the existing system. To address elder abuse that
occurs outside of a dependent adult context, they recommended an alternate definition to include
“those over 60.” The task force also recommended establishing a statewide elder abuse
intervention system.30 As it stands, the code does grant the Iowa judiciary to bring relief and

62

 resolution to elder abuse victims. Options for judicial resolution include the court appointment of
a guardian, the forced disposition of the defendant from the home of the vulnerable elder,
restitution of funds in the case of financial exploitation, and the filing of a protective order
barring the defendant from the vulnerable elder that ranges from one-year to a permanent nocontact order. The bill also provides a guideline for the civil penalties enforced in the case that
the defendant violates a court mandated order.
Recommendations
The first step in facilitating elder abuse prosecution at the local level is to ensure the state
code is sufficiently detailed to support criminal prosecution and civil remedies. Laura Mosqueda,
from the National Center on Elder Abuse, suggests a locally administered, case-based strategy
that addresses several critical elements: the victim, the abuser, and the specific context or setting,
and considerations must be made to ensure the victim’s wishes are met by social services
agencies.85 Currently, Iowa Code 235B and 235E outline the types of elder abuse related
offenses and charges available to prosecutors. However, as mentioned above, prosecutors are
only now receiving the training necessary to properly utilize these charging options.
Another way to improve elder abuse prosecution efforts is by expanding the use of
specialized elder abuse units, such as the specialized unit in Polk County, that provide the needed
expertise to move forward with cases.

Specialized prosecution units remove the constraints of

competing priorities and inadequate training. Their specialization in this arena make them
uniquely equipped to handle cases of elder abuse. Communities with strong responses to elder
abuse often have specialized prosecution unites. However, equally important, is that these
specialized units have sufficient resources to succeed.98

63

 To improve targeted elder abuse prosecution efforts, funding for state and county
attorneys must be increased. Increased funding can increase prosecution in one of two ways.
First, increased funding can increase the use of specialized elder abuse resources at the state and
county level. Second, increased funding can also provide training to specific prosecutors
throughout the state on how to prosecute cases of elder abuse.5 Increasing funding to provide
specific prosecutor training may be a better approach for smaller counties that do not have the
resources or caseload to sustain a dedicated elder abuse unit. For larger jurisdictions,
implementing or improving a specialized elder abuse unit can yield positive results. While it
appears that increased funding and attention towards the issue has been initiated with the United
States Department of Justice – Office on Violence Against Women grant, this increased effort
should be viewed as the first of many steps needed to address the problem.

Civil Proceedings
Many cases of elder abuse are resolved through one of the three main pillars of elder
abuse advocacy: agencies (APS), service providers (Heritage) and law enforcement. In addition
to these three main pillars, civil legal steps can be taken to ensure the safety and well-being of an
older adult. These civil options include guardianship proceedings, court proceedings to authorize
involuntary intervention, protective orders, change of conservator or representative payee, civil
commitment, powers of attorney, or civil lawsuits. How these issues are addressed in the legal
system depends on each state’s legislative framework. Cases can be addressed through state
elder-abuse specific laws, APS laws, social services laws, or a combination.24
Civil Proceedings Across the States
While the EJA has advanced the public response, responsibility for identification,
investigation, and prosecution of elder abuse largely remains with the states. APS continues to be

64

 the leading public authority on these matters. In 2012, the National Association of States United
for Aging and Disabilities (NASUAD) investigated how these agencies operate. Their report
found that APS administration occurs mostly at the state level, but as many as 10 states leave the
administration of APS to county and other local levels of government. Moreover, since the EJA
did not specifically address the configuration of these administrative structures, there remains
dramatic differences across states regarding the structure and operation of APS agencies. For
example, while all APS agencies serve people who live at home in the community, only 39.6
percent work in state mental illness facilities.25 APS agencies also vary in how soon an intake
must be acted upon. While some state agencies must act within 24 hours, others require action
within three business days.25 APS agencies also vary in terms of the services offered. In some
states, APS can provide guardianship services and victim services such as home-delivered meals,
medical services, in-home services, money management, counseling, and legal intervention.25 It
is worth pointing out that in a 2017 survey NASUAD found an increase in state efforts to
increase APS efforts that specifically address elder abuse.26
Though rarely sought after by victims of elder abuse, most states allow for civil remedies
under statutory and common law, which can offer both injunctive relief and monetary
compensation for damages. Expansion of civil remedies for elder abuse began in the 1970s. In
the 1990s California led the way for future legislation of other states with the Elder Abuse and
Dependent Protection Act, which allowed for civil remedies including compensatory damages,
pain and suffering damages, punitive damages, attorney’s fees and equitable relief.59
For example, Pennsylvania has strengthened its ability to combat abuse of guardianship
power by creating rules for guardianship proceedings. These changes include requiring that an
“expert” attest to the older adult’s incapacity, rather than deposition, standardizing the steps that

65

 a guardian must take regarding reporting and compliance, providing an avenue to object to
rulings of incapacity, and increasing requirements to qualify as a guardian, such as background
checks. These rules show promise in alleviating the abuse that can accompany such powers.
Civil Proceedings in Iowa
In Iowa, under Code 235F, upon a finding that the defendant has engaged in elder abuse,
a court can provide several avenues of civil relief. These avenues of relief include requiring the
defendant move from the elder’s residence, requiring the defendant to provide suitable
alternative housing for the elder, initiating a restraint against the defendant from further abuse or
entering the premises, or other relief the court deems necessary to protect the elder. Upon a
finding of financial abuse, under the same statute, a court may order the relief necessary to
remedy the financial exploitation.
A recent Iowa Supreme Court decision could provide additional avenues for those
seeking to prosecute elder abuse. The term “vulnerable adult” in 235F was granted additional
weight after Chapman v. Wilkerson, where the Iowa Supreme Court ruled that age alone qualifies
a person as a vulnerable adult under 235F when the person is “unable to protect herself . . .”
Incorporating the “vulnerable adult” language of 235F into the definition of “dependent adult” in
235B would allow for additional prosecution opportunities.
Recommendations
Continuing to expand civil proceeding options and availability for victims of elder abuse
will help fill the necessary void left by limited prosecution efforts. Iowa has taken the
appropriate steps with the passage of 235F and the Iowa Courts have assisted by providing an
expansive construction of the law. The lack of awareness and resources in this area and in other
areas remains problematic. The law is relatively new, and, few attorneys are available to help

66

 low-income families, and many other have not had experience in bringing claims under the Elder
Abuse Act. The Iowa Courts have developed forms that elders, family, and other concerned
people can complete and file. The forms are intended to be used by victims and their advocates,
and are similar to the forms and procedures used in domestic violence proceedings under Iowa
Code Chapter 236.

Increased availability and awareness on training opportunities for attorneys

on elder abuse related civil remedies would expand the network of available attorney’s. One
resource of note is the National Center on Law & Elder Rights. The National Center on Law &
Elder Rights offers free training curriculum for advocates, providers and lawyers in the legal and
aging network. Trainings are offered in eight areas: Health and Long-Term Services and
Supports, Economic Security, Advance Planning, Supported Decision-Making, Guardianship.
Elder Abuse, Consumer Protection, and Housing. Legal Basics Training occurs on the second
Tuesday of the month at 11am PT/2pm ET; Advanced Training occurs on the third Wednesday
of the month at 11am PT/2pm ET. Written materials accompany each training and are available
for download at https://ncler.acl.gov/Legal-Training.aspx

67

 Multidisciplinary Teams
Multi-disciplinary teams (MDTs) have emerged as a way to address the fragmentation
that occurs at each point along the elder abuse pathway, and often include a constellation of
providers, agencies, advocates who can offer a more comprehensive, multifaceted, and holistic
approach to problem solving. The goal of MDTs is to provide improved services, eliminate or
bridge gaps in the system, use scarce resources efficiently, and provide relief to the victim at the
earliest juncture possible, stop the abuse, prevent further abuse and restore a sense of safety and
security.97
Caseworkers benefit from the perspective of different players and professionals and learn
how to effectively and efficiently navigate clients – or have someone else navigate their clients –
through various bureaucracies, courts and programs. This collaborative approach is designed to
save critical time and resources by securing funding, program eligibility, shelter and health care
for clients in crises and in non-emergencies.

MDTs across the States
The MDT model is evolving as jurisdictions try to expand and enhance their efforts. For
example, New York State appropriated funds to establish the Elder Abuse Interventions and
Enhanced Multi-Disciplinary Team Initiative (E-MDT). That state’s offices of Aging and Victim
Services are coordinating the project, which began as a pilot and involved a self-reporting study
of incidence of financial abuse. The primary mission is to streamline investigations and
interventions to prevent financial exploitation of older adults. This is accomplished using a team
of forensic accountants, geriatric psychiatrists, and attorneys from community legal services.
These personnel supplement and complement other members of MDT.

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 One lawmaker in the District of Columbia is taking a different track to bolster local MDT
and elder abuse networks. He introduced the Elder Abuse Response Team (EART) Act of 2018,
which would establish a response team to coordinate the functioning of victim services, medical
forensic care, investigations, and prosecutions available to victims of all types of elder abuse
cases. The EART would develop uniform policies and procedures and standard protocols, which
are lacking in many, if not most jurisdictions. The team would conduct regular case reviews,
review abuse reports and investigations, develop case review protocols, and create standard
forms that would protect confidential and privileged information and safeguard.
The team would be comprised of directors or designated individuals from victim services,
aging, the police department, the U.S. Attorney, legal services organizations that primarily
represents people 60 or older, forensic nurse examiners, APS, community organizations, longterm care ombudsman, and other personnel. The legislation would require an unprecedented
commitment of time, resources, and personnel so far as we know. The bill was assigned to the
Judiciary and Public Safety Committee, which held a public hearing in September of 2018. A
recommended MDT structure is displayed in Figure 9 below.

MDT in Iowa
One of the authors attended and participated in an MDT meeting in Cedar Rapids, which
involved clients facing an array of legal, medical, social work and enforcement problems. The
team discussed each client at length. They developed a variety of approaches to protect clients.
The brainstorming and case-planning session involved a mix of landlord-tenant, domestics
relations, dependent adult abuse, and elder abuse laws; tracking down land records and property
ownership to obtain eligibility for public benefits; providing counseling for the elder and family
members; and finding a safe and secure place to live for the elders and people who posed

69

 potential threats. In the days following the meeting individual members discussed the clients’
predicament and exchanged ideas on how to address a separate piece of the puzzle. Not everyone
at the meeting learned how the issues were resolved. The MDT model acknowledges that no
single agency can do it all alone, and that each agency can help solve different pieces of the
puzzle.
The MDT model implemented in Cedar Rapids was not living up to key informants’
expectations for several reasons. First, teams and team membership changed with great
frequency. In addition to the barriers noted elsewhere in this report, many informants were
uncertain if an MDT existed in their community or continued to meet, which undermined their
confidence and attendance. Second, in addition to a sustained presence, the teams could benefit
from having a secure forum that would allow the group to communicate on a regular basis and
notify members if and how the issues have been resolved. This could be accomplished using a
dedicated website or secure cloud-based network, a listserv, or a phone tree, where people could
post questions and receive answers in a timely fashion. Third, but most important, is that the
local MDT do not have any funds. Participants from many different agencies volunteer their time
to be there. Some are able to do it on work time – but it is not a funded group. Grants for rural
counties to pay for mileage and space for a group to meet no longer exist according to one
interviewee, who said the region is fortunate that so many agencies care and choose to attend.

Recommendations
Creating a MDT in Iowa modeled after New York that attempts to streamline
investigations and prevention of elder abuse within the state would serve as a step in the right
direction. The composition of this team should include members of the community invested in
preventing elder abuse. An example of the recommended model is listed in the graphic below

70

 and illustrates the necessary elder focused approach necessary to create an effective MDT. To
create such a team would require legislative action and resources – two difficult hurdles given
modern political and fiscal restraints. Considering these restraints, the legislative model should
err on the side of caution when recommending funding and other resources be directed to the
initiative.
Figure 11:

Elder-Centered MDT

Healthcar
e
Provider

Family
Spouse
Children

Friend
Caretake
r
Stranger

Service
Provider

State
Agency

ELDER
Adult
Protectiv
eServices

Lawyer

AAA
Aging
Specialis
t

Law
Enforceme
nt
Responders
Prosecutor

Bank
Financial
Advisor

71

 Discussion
Our in-depth study of Iowa revealed strengths in the system, as well as areas that need
improvement. At the first stage in the pathway, important public education efforts in Iowa have
been led by Heritage. Despite these efforts, awareness remains low, both in the general public
and among identified reporters. Next, identification efforts in Iowa are strong among dedicated,
knowledgeable service providers, particularly those in the aging network. However,
professionals outside of the network have misconceptions surrounding what abuse is, as well as
confusion on where to report it. During the intake stage, Iowa’s “dependent standard” leads to
much lower accepted cases than other states. This doesn’t necessarily imply bad outcomes, but
when the dependency standard is not met, and referral is not appropriate, there can be
inconsistencies with a reporter’s findings and inaction on behalf of APS. At the criminal
investigation stage, complex interpersonal dynamics can arise. Because of pervasive
misconceptions surrounding elder abuse, inaction can result when the dispute is regarded as a
family matter. Further, though involvement of law enforcement can be desirable for the reporter,
it may not be what the older adult wants, and these wishes must be respected. Lastly, prosecution
of elder abuse in Iowa is low. Despite these low prosecution numbers, some counties, such as
Polk County, stand out in their commitment to prosecuting cases of elder abuse with dedicated
specialized units.
These findings in Iowa highlight broader, ubiquitous system failures that can be used to
identify and address issues in other states. The first of these is myths and misconceptions about
elder abuse. The public often perceives abuse as something committed by a malicious stranger,
while it can often be unassuming family members or trusted friends. Emotional abuse can be
difficult to detect, and bullying or arguments between frail elders can be a hidden form of
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 domestic violence, both unrecognized and underreported. When more subtle abuse is identified,
it can be disregarded as a family matter and inaction can result. These deep rooted, often cultural
misconceptions can be very difficult to change. Our findings show that success in shifting public
mindset in this area can come from key individuals elevating its importance, public educational
campaigns, and elevating the importance of elder abuse to the same level as child abuse. There is
also a problem of determining what a successful outcome in these cases is. The victim frequently
has a different idea of what constitutes a successful outcome than what the other parties involved
view as success.
Many of the shortfalls discussed above do not result from a lack of motivation or effort,
but a lack of funding. Funding can be especially low for public awareness, where the process
begins. Since funding is lacking in the first step of the process, it is difficult for ideal results to
follow in later steps. In situations where funding is allocated, it is often inconsistent, or budget
shortfalls can prevent full funds from actually being distributed. This can lead to an inability to
create robust programming, or a hesitancy to do so because of sustainability concerns. A lack of
funding creates system overloads, which can discourage collaboration. When resources are
constrained, workers can get bogged down in the day to day details of their specific role, rather
than looking at the big-picture interaction among service providers and how it can be improved.
Law enforcement may not decide to intervene in an elder abuse situation, when it can be
perceived as a minor domestic dispute and they have other pressing concerns on their agenda.
Similarly, prosecution of elder abuse can be low, as it can often fall to the bottom of a
prosecutor’s office to-do list. Becoming familiar with elder abuse laws, and the ways they can be
applied to achieve a successful outcome involves a steep learning curve for prosecutors, defense
attorneys, and attorneys who practice civil law. Overall, it is important to have sustained,

73

 adequate funding at each point in the pathway, as each preceding step influences the capabilities
and effectiveness of people involved in the next step.
Key informants said increased funding and personnel are critical to improving their
efforts to safeguard elders, furnish case management services, healthcare, food, shelter, and
clothing, and enhance their quality of life. They also acknowledge that funds are scare. For the
time being, efforts rely on existing funding sources or be more creative in obtaining support
elsewhere. One school of thought is to ask cities or counties to fund local pilot projects that are
designed to increase the effectiveness of the network, by funding MDT, hiring additional social
workers, creating focused educational campaigns and activities and the like. The pilot program
could prove its value by serving more people, reducing costs, or by achieving other successful
outcomes. The short-term infusion of funds would not drain government coffers, but could lead
to innovative models that cities or counties could adapt or adopt. Another school of thought is to
explore tapping into or creating a civil monetary penalty fund linked to victims of elder abuse, as
the federal government has done in Medicaid, Medicare, and other enforcement programs. For
example, Iowa or the Federal government could create a civil monetary fund with deposits from
penalties assessed against banks, credit unions, securities firms, and other financial institutions
who are found culpable of elder abuse. A third school of thought is to apply for grants from
private foundations, nonprofits, and businesses involved in research, education, prevention and
other aspects of abuse and neglect. For example, local companies and corporations with workers
whose parents are aging, or whose workforce is aging have an interest in funding and
establishing programs that work to promote elder care and address issues of elder abuse in the
community. These funds could be used alone, or in conjunction with the other funding sources
mentioned.

74

 After individuals in the system are properly trained and receive enough funding,
multidisciplinary teams can be used to help states bolster their elder abuse prevention and
detection efforts. Before multidisciplinary teams can be effectively utilized, each part of the
system must recognize its role, its strengths, and how it must collaborate with other stakeholders
to combine their efforts. In the Linn and Johnson county corridor, multidisciplinary team
meetings are held monthly in Cedar Rapids. These meetings provide a venue to present client
cases, exchange ideas, and coordinate the delivery of services, supports, and legal representation.
The Multidisciplinary Team Process allows for a more comprehensive, multifaceted, and holistic
approach to problem solving. Individual caseworkers benefit from the perspective of different
players and professions and find out how to navigate clients – or have someone else navigate
their clients – through various bureaucracies, courts, programs and, most important funding
sources and potential payers for medical, psychological, dementia, and other programs and
placements.
Finally, our analysis focuses primarily on a state-based approach to addressing elder
abuse in community settings, but issues at the federal level and abuse within residential settings
are also important to consider. Though federal legislation has been implemented, responsibility
for addressing elder abuse is still primarily a state issue and state level analysis provides the
greatest opportunity for improvement in law, regulation, funding, and practices. Further, our
analysis was centered at the community level, as this is where the greatest misconceptions and
complexities lie. Instilling a sense of common responsibility for addressing elder abuse in the
community will lead to a more committed public to recognize and address elder abuse in all
settings.

75

 Conclusions
This in-depth examination of the discrete points in the east central Iowa corridor
generated several insights and recommendations. For example, our meetings and interviews
revealed a pervasive shortfall of local public awareness that could be easily addressed by
elevating education efforts concerning elder abuse to even half of those dedicated to child abuse.
Definitions of mandatory responders should be clarified, and perhaps more importantly, the
incentives and penalties could be established as a means of advancing suspected instances of
elder abuse. The intake and referral process can be substantially expanded if Iowa expands the
APS definition of dependent adult to include a person age 60 or older who is “vulnerable” or “atrisk.” Similarly, the intake assessment tools used by APS agents should facilitate referrals even
when a person is not determined to be dependent. This would include a process to follow up with
the person or organization that initially brought the case to APS. Law enforcement (police
officers, sheriffs, deputies, etc.) efforts to investigate cases of elder abuse can be improved
through greater education and training, and such efforts may even go as far as conferring
specialist certification for select officers, and similar administrative and financial resources could
be directed toward the legal remedies of criminal prosecution and civil resolutions. Although this
grounded, local based research report focused on how Iowa and specific communities within the
state implement the Elder Justice Act, it can be used by other states and jurisdictions to identify
and address elder abuse in their areas as well. Other states and communities can refer to the
methodology described in this report to design similar studies for their own areas. They can also
refer to our findings and recommendations to identify common problems and suggested
recommendations to implement in their own jurisdictions. This report is designed to serve as a
template for future studies and reports across the country.
76

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Crime website: http://victimsofcrime.org/training/upcoming-training/2015/07/01/defaultcalendar/investigating-elder-abuse-law-enforcement-s-best-practices-for-a-positive-outcome
66.

ELDER AND DEPENDENT ADULT ABUSE PROTOCOL(Rep.). (2010, July). Retrieved
September 27,2018, from Santa Clara County website:
https://www.sccgov.org/sites/ssa/daas/aps/
Documents/daas_elder_dependent_adult_protocol.pdf

67. SAN DIEGO COUNTY ELDER AND DEPENDENT ADULT ABUSE BLUEPRINT 2018(Rep.).
(n.d.). Retrieved September 27, 2018, from San Diego County District Attorney's Office
website:https://www.sdcda.org/helping/elder-abuse-blueprint.pdf
68. Protocol for Law Enforcement: Responding to Victims of Elder Abuse, Neglect and(Rep.).
(2011, November). Retrieved September 27, 2018, from Illinois Department on Aging
website:https://www2.illinois.gov/aging/protectionadvocacy/documents/ea_lawenforcement.pdf
69. Daly, J. M., Xu, Y., &, G. J. (2017). Iowa Dependent Adult Abuse Prosecutions From 2006
Through 2015: Health Care Providers’ Concern.Journal of Primary Care & Community
Health,8(3), 153-162. doi:10.1177/2150131916688561
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from https://www.justice.gov/ovw/awards/fy-2015-ovw-grant-awards-program

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 71. ISBA PEOPLE’S LAW SCHOOL: OLDER IOWAN ISSUES. (2018, September 19). Retrieved
September 27, 2018, fromhttps://www.iowabar.org/events/EventDetails.aspx?id=671404
72. Jogerst, G. J., Daly, J. M.,, M. F., Dawson, J. D.,, G. A., & Ingram, J. G. (2003). Domestic Elder
Abuse and the Law.American Journal of Public Health,9(12). Retrieved September 27, 2018,
fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448164/.
73. Loewy, E. (2015, July 1). Investigating Elder Abuse: Law Enforcement “Best Practices” for a
Positive Outcome(Rep.). Retrieved September 27, 2018, from National Center for Victims of
Crime website: http://victimsofcrime.org/docs/default-source/Member Materials/investigatingelder-abuse.pdf?sfvrsn=2
74. CRIMINAL JUSTICE SECTION SENIOR LAWYERS DIVISION COMMISSION ON
DOMESTIC VIOLENCE COMMISSION ON LAW AND AGING REPORT TO THE HOUSE OF
DELEGATES(Rep.). (n.d.). Retrieved September 27, 2018, from AMERICAN BAR
ASSOCIATION
website:https://www.americanbar.org/content/dam/aba/publishing/criminal_justice_section_new
sletter/crimjust_policy_crimeselderly.authcheckdam.pdf
75. Elder Abuse, Neglect, and Exploitation: Legal Resources & Remedies(Rep.). (2016, September
19). Retrieved September 27, 2018, from Iowa Law and Services Together website.
76. Enhanced Multi-Disciplinary(Rep.). (2015, July). Retrieved September 27, 2018, from New York
State Office for the Aging website:https://www.acl.gov/sites/default/files/programs/201609/5_Elder_Abuse_NYSOFA_RB.PDF
77. Elder Abuse Laws: Basics. (n.d.). Retrieved September 27, 2018,
fromhttp://www.eldersandcourts.org/elder-abuse/elder-abuse-material-for-right-rail-menu-forelder-abuse/basics/elder-abuse-laws.aspx
78. Code of Virginia § 18.2-57.2
79. Elder Abuse and Criminal Law. (n.d.). Retrieved September 27, 2018,
fromhttp://www.lawfirms.com/resources/criminal-defense/criminal-offense/elder-abusecriminal-law
80. Code of Florida§825.102
81. Mosqueda, L., Burnight, K., Gironda, M. W., Moore, A. A., Robinson, J., & Olsen, B. (2016).
The Abuse Intervention Model: A Pragmatic Approach to Intervention for Elder
Mistreatment.Journal of the American Geriatrics Society,64(9), 1879-1883.
doi:10.1111/jgs.14266
86. Polk County Iowa County Attorney. (n.d.). Dependent Adult and Elder Abuse Unit. Retrieved
September 27, 2018, fromhttps://www.polkcountyiowa.gov/attorney/criminal-division/ majoroffensegeneral-trial-bureau/dependent-adult-and-elder-abuse-unit/
83. Elder Abuse and the Prosecutor’s Office,” National District Attorneys Association Official
Policy Position, Adopted March 2003.
84. Ulrey, P. (n.d.).Confusion on the Front Lines: The Response of Law Enforcement and
Prosecutors to Cases of Elder(Rep.). Retrieved September 27, 2018, from King County

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 Prosecutor's Office, Seattle, WA website:https://www.acl.gov/sites/default/files/programs/201609/Ulrey_White_Paper.pdf
85. Coble, C. (n.d.). What Are the Criminal Penalties for Elder Abuse? Retrieved September 27,
2018, fromhttps://blogs.findlaw.com/blotter/2017/03/what-are-the-criminal-penalties-for-elderabuse.html
86. Iowa Department on Aging Public Guardian Office. (n.d.). Retrieved
fromhttps://www.iowaaging.gov/programs-services/elder-justice-adult-protectiveservices/office-public-guardian
87. Iowa: Abuse of Dependent Adults - All Modules. (n.d.). Retrieved from
https://www.atrainceu.com/course-all/iowa-abuse-of-dependent-adults-125
88. Stiegel, L. (n.d.). Elder Abuse, Neglect, and Financial Exploitation. Retrieved from
https://www.americanbar.org/groups/law_aging/publications/bifocal/vol_38/issue_2_december2
015/elder-abuse/
89. Corbalis, B. (2018, October 19). New Orphans' Court Rules Bring Changes to Pa.
Guardianships. Retrieved from https://www.law.com/thelegalintelligencer/2018/10/19/neworphans-court-rules-bring-changes-to-pa-guardianships/?slreturn=20181007011316
90. Freeman, I. C. (n.d.). Statewide Elder Abuse Coalitions: The Possibilities and Perils of
Sustained Action. NAPSA Annual Conference, Phoenix, AZ, October 18, 2012.
91. Office of Public Guardian. (n.d.). Retrieved from https://www.iowaaging.gov/programsservices/elder-justice-adult-protective-services/office-public-guardian.
92. Iowa Law and Services Together (ILAST). (n.d.). Retrieved from
https://www.iowaattorneygeneral.gov/for-consumers/for-older-iowans/ilast-resource-manual

83

 Appendix A: CDC Uniform Definitions
TERM

DEFINITION

Elder Abuse

An intentional act or failure to act by a caregiver or another person in a
relationship involving an expectation of trust that causes or creates a risk
of harm to an older adult.

Older Adult/Elder

Any person whose chronological age is 60 years or older. Age 60 was
selected as the lower boundary for classification as an older adult because
it is the age of first eligibility for services furnished under the Older
American’s Act and for inclusion in activities and programs covered in
the Elder Justice Act.

Victim

Person on whom the abuse is inflicted or who experiences abuse.
Survivor is often used as a synonym for victim.

Perpetrator/Offender

Person or persons who inflicts or causes the victim to experience abuse.
Such persons must be in a relationship involving an expectation of trust.

Family (Informal) Caregiver:

Any relative, partner, friend or neighbor who has a significant personal
relationship with, and provides a broad range of Instrumental Activities of
Daily Living (ADL) /Activities of Daily Living (ADL) (defined below)
assistance for an older adult. These individuals may be primary or
secondary caregivers (i.e., persons who assist a primary caregiver) and
live with, or separately from, the person receiving care.

Formal Caregiver:

A provider associated with a formal service system, whether a paid
worker or a volunteer.

Legal Guardian

A person who has been appointed by a court to possess the power and
obligation to take care of and manage the property, well-being and/or
rights of a person who, because of status as a minor, understanding, or
self-control, is considered incapable of administering his or her own
affairs.

Physical Abuse

The intentional use of physical force that results in acute or chronic
illness, bodily injury, physical pain, functional impairment, distress, or
death. Physical abuse may include but is not limited to such acts of
violence as striking (with or without an object or weapon), hitting,
beating, scratching, biting, choking, suffocation, pushing, shoving,
shaking, slapping, kicking, stomping, pinching, and burning. In addition,
inappropriate use of medications and physical restraints, pinning in place,
arm twisting, hair pulling, force-feeding, and physical punishment of any
kind also are examples of physical abuse.

Sexual Abuse

Forced and/or unwanted sexual interaction (touching and non-touching
acts) of any kind with an older adult. This may include but is not limited
to forced and/or unwanted completed or attempted contact between the
penis and the vulva or the penis and the anus involving penetration,
however slight; forced and/or unwanted contact between the mouth and
the penis, vulva, or anus; forced and/or unwanted penetration of the anal
or genital opening of another person by a hand, finger, or other object;
forced and/or unwanted intentional touching, either directly or through
the clothing, of the genitalia, anus, groin, breast, inner thigh, or buttocks;
unwarranted, intrusive, and/or painful procedures in caring for genitals or
rectal area; or forced and/or unwanted non-contact acts of a sexual nature
such as forcing a victim to view pornographic materials, photographing
an elder for sexual gratification, voyeurism and verbal or behavioral
sexual harassment.

84

 Emotional/Psychological Abuse

Verbal or nonverbal behavior that results in the infliction of anguish,
mental pain, fear, or distress, that is perpetrated by a caregiver or other
person who stands in a trust relationship to the elder. Such behaviors may
have immediate effects or delayed effects that are short or long-term in
nature that may or may not be readily apparent to or acknowledged by the
victim. May include humiliation/disrespect, threats, harassment, and
isolation/coercive control.

Neglect

Failure by a caregiver or other person in a trust relationship to protect an
elder from harm or the failure to meet needs for essential medical care,
nutrition, hydration, hygiene, clothing, basic activities of daily living or
shelter, which results in a serious risk of compromised health and/or
safety, relative to age, health status, and cultural norms.

Financial Abuse/Exploitation

The illegal, unauthorized, or improper use of an older individual’s
resources by a caregiver or other person in a trusting relationship, for the
benefit of someone other than the older individual. This includes, but is
not limited to, depriving an older individual of rightful access to,
information about, or use of personal benefits, resources, belongings, or
assets.

Self-Neglect

A nationally accepted, uniform definition of self-neglect has not been
developed. Examples of existing definitions include:
– The behavior of an elderly person that threatens his/her own health and
safety. This behavior generally manifests itself in an older person as a
refusal or failure to provide himself/herself with adequate food, water,
clothing, shelter, personal hygiene, and safety precautions. This excludes
situations in which a mentally competent older person, who understands
the consequences of his/her decisions, makes a conscious and voluntary
decision to engage in acts that threaten his/her health or safety as a matter
of personal choice. (National Association of Adult Protective Service
Administrators and the National Center on Elder Abuse
– Meeting one or more of the following:
• Persistent inattention to personal hygiene and/or environment
• Repeated refusal of some/all indicated services which can reasonably
be expected to improve quality of life
• Self-endangerment through the manifestation of unsafe behaviors (e.g.,
persistent refusal to care for a wound, creating fire-hazards in the home)
(Pavlou & Lachs, 2008)
– Lack of self-care and inattention to personal hygiene, domestic
squalor, hoarding, apathy and disinterest for [one’s] condition, social
withdrawal, and stubborn refusal of help. (Clark et al., 1975)
– The inability of a person to understand the consequences of his or her
actions or inaction when the inability leads to or may lead to harm. There
are two components to self-neglect:
• The failure to provide for oneself the basic needs to avoid physical
harm or suffering.
• The inability to understand the consequences of that failure. (Oregon
Department of Human Services)

85

 Appendix B: CDC vs Iowa Definitions
TERM

CDC DEFINITION

IOWA DEFINITION

Elder Abuse/Dependent Adult

An intentional act or failure to act by a
caregiver or another person in a relationship
involving an expectation of trust that causes
or creates a risk of harm to an older adult.

Any of the following as a result of the willful
or negligent acts or omissions of a caretaker:
(a) Physical injury to, or injury which is at a
variance with the history given of the injury,
or unreasonable confinement, unreasonable
punishment, or assault of a dependent adult.
(b) The commission of a sexual offense
under chapter 709 or section 726.2 with or
against a dependent adult. (c) Exploitation of
a dependent adult which means the act or
process of taking unfair advantage of a
dependent adult or the adult’s physical or
financial resources for one’s own personal or
pecuniary profit, without the informed
consent of the dependent adult, including
theft, by the use of undue influence,
harassment, duress, deception, false
representation, or false pretenses. (d) The
deprivation of the minimum food, shelter,
clothing, supervision, physical or mental
health care, or other care necessary to
maintain a dependent adult’s life or health.
(2) The deprivation of the minimum food,
shelter, clothing, supervision, physical or
mental health care, and other care necessary
to maintain a dependent adult’s life or health
as a result of the acts or omissions of the
dependent adult. (3) (a) Sexual exploitation
of a dependent adult by a caretaker

Any person whose chronological age is 60
years or older. Age 60 was selected as the
lower boundary for classification as an older
adult because it is the age of first eligibility
for services furnished under the Older
American’s Act and for inclusion in
activities and programs covered in the Elder
Justice Act.

Dependent Adult:

Family (Informal):

A related or nonrelated person who has the
responsibility for the protection, care, or
custody of a dependent adult as a result of
assuming the responsibility voluntarily, by
contract, through employment, or by order of
the court.

Abuse

Older Adult/Elder/Dependent
Adult

Caregiver:

Any relative, partner, friend or neighbor who
has a significant personal relationship with,
and provides a broad range of Instrumental
Activities of Daily Living (ADL) /Activities
of Daily Living (ADL) (defined below)
assistance for an older adult. These
individuals may be primary or secondary
caregivers (i.e., persons who assist a primary
caregiver) and live with, or separately from,
the person receiving care.

A person eighteen years of age or older who
is unable to protect the person’s own
interests or unable to adequately perform or
obtain services necessary to meet essential
human needs, as a result of a physical or
mental condition which requires assistance
from another, or as defined by departmental
rule

Formal Caregiver:
A provider associated with a formal service
system, whether a paid worker or a
volunteer.

Physical Abuse

The intentional use of physical force that
results in acute or chronic illness, bodily
injury, physical pain, functional impairment,
distress, or death. Physical abuse may

Physical injury to, or injury which is at a
variance with the history given of the injury,
or unreasonable confinement, unreasonable
punishment, or assault of a dependent adult.

86

 include but is not limited to such acts of
violence as striking (with or without an
object or weapon), hitting, beating,
scratching, biting, choking, suffocation,
pushing, shoving, shaking, slapping, kicking,
stomping, pinching, and burning. In addition,
inappropriate use of medications and
physical restraints, pinning in place, arm
twisting, hair pulling, force-feeding, and
physical punishment of any kind also are
examples of physical abuse.

Sexual Abuse

Forced and/or unwanted sexual interaction
(touching and non-touching acts) of any kind
with an older adult. This may include but is
not limited to forced and/or unwanted
completed or attempted contact between the
penis and the vulva or the penis and the anus
involving penetration, however slight; forced
and/or unwanted contact between the mouth
and the penis, vulva, or anus; forced and/or
unwanted penetration of the anal or genital
opening of another person by a hand, finger,
or other object; forced and/or unwanted
intentional touching, either directly or
through the clothing, of the genitalia, anus,
groin, breast, inner thigh, or buttocks;
unwarranted, intrusive, and/or painful
procedures in caring for genitals or rectal
area; or forced and/or unwanted non-contact
acts of a sexual nature such as forcing a
victim to view pornographic materials,
photographing an elder for sexual
gratification, voyeurism and verbal or
behavioral sexual harassment.

Any consensual or nonconsensual sexual
conduct with a dependent adult which
includes but is not limited to kissing;
touching of the clothed or unclothed breast,
groin, buttock, anus, pubes, or genitals; or a
sex act, as defined in section 702.17.

Neglect

Failure by a caregiver or other person in a
trust relationship to protect an elder from
harm or the failure to meet needs for
essential medical care, nutrition, hydration,
hygiene, clothing, basic activities of daily
living or shelter, which results in a serious
risk of compromised health and/or safety,
relative to age, health status, and cultural
norms.

The deprivation of the minimum food,
shelter, clothing, supervision, physical or
mental health care, or other care necessary to
maintain a dependent adult’s life or health.

Financial Abuse/Exploitation

The illegal, unauthorized, or improper use of
an older individual’s resources by a
caregiver or other person in a trusting
relationship, for the benefit of someone other
than the older individual. This includes, but
is not limited to, depriving an older
individual of rightful access to, information
about, or use of personal benefits, resources,
belongings, or assets.

The act or process of taking unfair advantage
of a dependent adult or the adult's physical
or financial resources for one's own personal
or pecuniary profit, without the informed
consent of the dependent adult, including
theft, by the use of undue influence,
harassment, duress, deception, false
representation, or false pretenses.

Self-Neglect

A nationally accepted, uniform definition of
self-neglect has not been developed.
Examples of existing definitions include:

The deprivation of the minimum food,
shelter, clothing, supervision, physical or
mental health care, or other care necessary to
maintain a dependent adult’s life or health as
a result of the acts or omissions of the
dependent adult

– The behavior of an elderly person that
threatens his/her own health and safety. This
behavior generally manifests itself in an

87

 older person as a refusal or failure to provide
himself/herself with adequate food, water,
clothing, shelter, personal hygiene, and
safety precautions. This excludes situations
in which a mentally competent older person,
who understands the consequences of his/her
decisions, makes a conscious and voluntary
decision to engage in acts that threaten
his/her health or safety as a matter of
personal choice. (National Association of
Adult Protective Service Administrators and
the National Center on Elder Abuse
– Meeting one or more of the following:
• Persistent inattention to personal hygiene
and/or environment
• Repeated refusal of some/all indicated
services which can reasonably be expected
to improve quality of life
• Self-endangerment through the
manifestation of unsafe behaviors (e.g.,
persistent refusal to care for a wound,
creating fire-hazards in the home) (Pavlou &
Lachs, 2008)
– Lack of self-care and inattention to
personal hygiene, domestic squalor,
hoarding, apathy and disinterest for [one’s]
condition, social withdrawal, and stubborn
refusal of help. (Clark et al., 1975)
– The inability of a person to understand the
consequences of his or her actions or
inaction when the inability leads to or may
lead to harm. There are two components to
self-neglect:
• The failure to provide for oneself the basic
needs to avoid physical harm or suffering.
• The inability to understand the
consequences of that failure. (Oregon
Department of Human Services)

88

 Appendix C: Meeting Agendas
Meeting 1:
INVITATION
Illuminating the local EAN Pathway in east central Iowa
March 29, 2017

A number of local organizations, including the United States Attorney’s Office for the
Northern District of Iowa and the Heritage Area Agency on Aging, have been moving to bridge
the gap between the incidence of elder abuse and neglect (EAN) and public efforts to identify,
investigate, and prosecute cases of EAN. With so much new activity occurring in the past year,
we are eager to learn more about these efforts and determine how they are being coordinated.
With that aim in mind, Prof. Brian Kaskie, from the University of Iowa’s College of Public
Health, will be coordinating a series of monthly meetings with stakeholders and constituents to
illuminate and strengthen the EAN pathway in our area. We hope you will support that effort.
In particular, we are inviting you to attend a series of monthly meetings and help us meet the
following three objectives:

1. Map out the local procedural “pathway” relevant to EAN —charting efforts starting
from: (a) public awareness and professional training, and progressing to: (b) the
identification of EAN, (c) the act of making a referral to an investigatory agency, (d) the
involvement of law enforcement, and (e) resolution.
2. Determine how well EAN cases move along this “pathway” relative to what might be
expected and identify points where activity is higher or lower than expected.
3. Develop a local resources that can be accessed easily by the public as well as local
professional networks. These resources will illuminate the local “pathway”, highlight
activity along the “pathway”, and offer information about how to move suspected
instances of EAN along the “pathway”.
Each meeting will include individuals from the Cedar Rapids/Iowa City corridor who are
most involved in some aspect of educating, identifying, referring, investigating, adjudicating,
and/or resolving cases of EAN.
The first meeting, scheduled for Friday, May 5th from 2:00 to 3:30pm at the United
States Courthouse, Office of the United States Attorney, Third Floor, 111 7th Avenue SE,
Cedar Rapids. 3rd will provide an overview of this effort and then engage participants in
“story telling.” In particular, participants will be asked to discuss their experiences with EAN
(e.g., social workers can talk about how they identify EAN, local law enforcement can talk about
cases that have been referred to). The purpose of this story telling is to introduce individual
89

 participants to one another and also serve to illuminate the local EAN pathway.
We also will use this opening meeting to discuss the agendas for the remaining meetings
(to be held monthly on the first Friday) and solicit input about desired outcomes for this process.
For example, one deliverable could be to populate a local EAN website which provides
information specific to each step in the EAN pathway.
For further information, please contact brian-kaskie@uiowa.edu. Please also send an
RSVP to Prof. Kaskie to let him know that you can be there for the first meeting or if you would
like to be notified about future meetings.

90

 Meeting 2:
Illuminating the EAN Pathway in east central Iowa
MEETING 2 AGENDA
Federal Courthouse, Level 2
9:30 to 11:00am
July 7, 2017
The goal of this project is to illuminate public efforts to identify, investigate, and prosecute elder
abuse and neglect (EAN) within a local jurisdiction consisting of the Cedar Rapids-Iowa City
corridor located in east central Iowa. We propose to meet three objectives:
1. Map out the local procedural “pathway” relevant to EAN —charting efforts starting from: (a)
public awareness and professional training, and progressing to: (b) the identification of possible
EAN, (c) the act of making a referral to an investigatory agency, (d) the involvement of law
enforcement, and (e) resolution;
2. Determine how well EAN cases move along this “pathway” relative to what might be
expected and identify points where activity does not match what might be expected;
3. Prepare a white paper and other communication tools that reflect what was learned about the
local EAN pathway and highlight targets for growth.
Meeting 2
The second meeting (Friday, July 7th) will account for local communication campaigns, public
education and professional training efforts; identify local organizations and professionals most
involved with the initial identification of EAN and document their experiences subsequent to
identification. The workgroup will identify “best cases” in terms of communication, education
and training, and also select some of the most compelling examples of case identification. Last,
the group will determine if these efforts are sufficient relative to the expected prevalence of
EAN, and consider opportunities for improvement.
Homework for Meeting 2
- Read Georgia Report (attached), review website and video links (below)
- Identify examples of education and training:
- local public communications campaign concerning EAN;
- local public and professional education efforts;
- local professional training efforts (i.e., professionals receive credit).
- Generate examples of local identification of EAN including patterns of referral
- define a list of “front line responders” and relative roles
- Consider ideal communication, education and training efforts
- Assess current baseline activity relative what might be expected given EAN prevalence
Agenda Meeting 2
- Teachable moments
- Defining the front line
91

 - Best cases
- Effort assessment

- Agenda for Meeting 3

92

Meeting 3:
Illuminating the EAN Pathway in east central Iowa
MEETING 3 AGENDA
Federal Courthouse, Level 2
1:00 to 2:30pm
August 4, 2017
Meeting 2

Minutes

The second meeting (Friday, July 7th) reviewed local communication campaigns (mostly
consisting of radio spots), public education and professional training efforts (largely
implemented by the Heritage Area Agency on Aging though time-limited grant support); and
discussed the process involved with the initial identification of EAN.
One of the key issues that emerged concerned whether or not the older persons was defined as a
dependent older adult, as that status often determine how an agency responds to the initial
identification. For example, when someone refers a case of suspected elder abuse, some agencies
may not engage in a follow-up if the individuals is not already qualified as a “dependent adult.”
Another key issue concerned timing. In particular, there is a lack of information about what
happens when one person “hands off” information about a suspected case of elder abuse or
neglect, and what is the appropriate amount of time needed for a response.
As part of compiling the final report, members of the workgroup agreed to identify “best
examples” of communication campaigns as well as education and training efforts, and then make
recommendations for how such efforts can be enhanced and expanded. We will be creating an
on-line portal that can assist with that process to compile information.
We also continue to ask people to identify others that could be included in the group meetings or
individual interviews.
Homework for Meeting 3
•

Review attached documents reviewing the pathways concerning data collection and her
the tools used to identify and evaluate cases of elder abuse.

Agenda Meeting 3
•

Review process and methods for elder abuse identification
93

 •

What happens when that information gets passed along; what is an appropriate response
and how long should it take?

•

Best case examples

•

Missing pieces

•

Set agenda for Meeting 4

94

 Meeting 4:
Illuminating the EAN Pathway in east central Iowa
MEETING 4 AGENDA
Federal Courthouse, Level 2
1:30 to 3:00pm
September 1, 2017
Meeting 3

Minutes

The third meeting (Friday, July 7th) covered the range of front-line responders involved with
the initial identification of elder fraud, abuse and neglect, and identified particular organizations
and individuals to be contacted to learn more about their means of identification and reporting
patterns. For example, we distinguished processes followed by “mandatory responders” and
others, and distinguished processes involved with referral to the Heritage Area Agency on Aging
and other public entities including county and state program staff.
Three key issues emerged from the conversation. One concerned the decision to offer immediate
LTSS and other services to individuals, particularly those who self-neglect, as a means to
resolving the “acute” distress. A second concerned the processes involved when county and state
program staff are involved, especially in cases of determining “adult dependent status.” Last, we
talked about the “epidemiology” of elder fraud, abuse, and neglect – highlighting expected
incidence of presented cases, and discussing how many of these individuals are diverted from
further investigation because immediate distress was resolved through other means or the
individual refused assistance.
Last, we discussed how we will start conducting interviews with key informants upon
completion of the next two group meetings. And, of course, we asked attendees to identify others
that should be included in the group meetings or individual interviews.
Homework for Meeting 4
•

None!

Agenda Meeting 4
•

Review process and methods for referral to county staff;

•

Review process and methods for referral to state staff;

•

When do county attorneys get involved?

•

When to federal attorneys get involved?
95

 Epidemiology of referral processes

Set agenda for Meeting 5

96

Meeting 5:
Illuminating the EAN Pathway in east central Iowa
MEETING 5 AGENDA
Federal Courthouse, Level 2
1:30 to 3:30pm
October 6, 2017
Meeting 4

Minutes

The fourth meeting (Friday, September 1st) featured Cindy from the Linn County Department
of Public Health and Pam from the State Long-Term Care Office. We first talked about efforts in
Linn County to advance clinic care coordination efforts through a computer-based system that
would allow different agencies to link and share information more effectively.
We also discussed efforts to standardize definition of “dependent” as to assure older persons are
being evaluated and qualified in a fair and reliable manner. This also involves developing “rule
out” criteria. We also highlighted some of the key elements that are used to determine individual
status. For example, one telling indicator concerned the unauthorized or unexpected transfer of
land or other assets from an older adult to another family member or acquaintance.
Comments also focused on how county and state authorities processed cases, the time involved,
the feedback mechanism to reporting agencies, and current challenges faced as staff and
resources have been curtailed.

Homework for Meeting 5
•

Come up with the names and contact information for any person who we should include
in our interviews, which will begin in October and last until the end of the year.

•

Come up with questions you would wasn’t us to ask.

Agenda Meeting 5
•

Discuss process and methods for investigation by police and sheriff officers;

•

Discuss process and methods for case adjudication by county attorneys;

•

Discuss process and methods for when federal attorneys become involved;

•

What are the most critical resources needed for these organizations and individuals;
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 Discuss interviewing and other next steps

Set agenda for Meeting 6

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Appendix D: Best Practices
Pathway Point

Public Awareness

Identification and
Reporting

Intake and Referral

Investigation

Legal Remedies

Description

Further Information

Elder Justice NOW educational video with
personal stories

Elder Justice NOW

Illinois Break the Silence Elder Abuse
Awareness Tool Kit

Illinois Department on Aging

National Crime Prevention Council Crime
Prevention Month Kits

National Crime Prevention Council

Texas: “It’s Everyone’s Business”
Campaign

Texas: It's Everyone's Business

State Mandatory Reporting Statutes

Stetson MR Statutes by State

Maryland Guide to Reporting Abuse

Maryland Guide

California Guide to Reporting Elder
Abuse

California Guide

Minnesota “Vulnerability” Standard
Checklist

Minnesota APS Checklist

“Best Practices for a Positive Outcome”

National Center for Victims of Crime: Best
Practices

EAGLE Online Officer Support Tool

EAGLE

Santa Clara County, CA Protocol

Santa Clara County Protocol

San Diego County, CA Blueprint

San Diego County Blueprint

Illinois Protocol for Law Enforcement

Illinois Protocol

Virginia State Code: Crimes Against a
Family Member

Virginia State Code

California Penal Code 368:
Criminalization of Elder Abuse

Penal Code 368

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 Appendix E: Consolidated Recommendations:
Pathway

Recommendations

Point
Public
Awareness

Provide adequate resources to local Areas Agencies on Aging

Identification
and Reporting

Mandatory reporters of elder abuse should be trained and continually educated in a
similar manner as mandatory reporters of child abuse

Fund elder abuse prevention programs similarly to child abuse prevention programs

Definitions of mandatory reporters should be explicated
The obligations of mandatory reporters and the penalties for failure to uphold those
obligations should be explicated
Require mandatory reporters to file a case of suspected abuse within 48 hours
Intake and
Referral

Broaden the current code to include “vulnerable” or “at-risk” older adults, rather
than requiring an older adult to be classified as “dependent”
Intake referrals even if an older adult is not classified as “dependent” under current
law
Informal mediation to resolve cases of potential elder abuse without involvement of
law enforcement or APS

Criminal
Investigation

Increased support, education, and training for law enforcement officers; perhaps
conferring a “specialist certification” for select officers
Involvement of law enforcement should not stop following the resolution of an
elder abuse case; officers should conduct routine follow-ups on cases of elder abuse

Legal
Remedies

Criminalize elder abuse similarly to child abuse, such as in New York and Florida
Provide awards to attorneys for taking on cases of elder abuse, as seen in California
Train local prosecutors to be well-equipped to take on cases of elder abuse
Support civil proceeding options
Train attorneys on elder abuse civil proceeding options

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 Appendix F: Interview Request Emails and Protocol
Sample Email- To: Legal Professionals and List Serves:
Subject Line: Elder Abuse in the greater Iowa City/Cedar Rapids Area
We are writing to you and other lawyers who might have represented clients age 60 or older who
were being exploited financially or abused by family, fiduciaries or strangers.
Professor Brian Kaskie, from the University of Iowa’s College of Public Health, and I convened
a series of meetings in 2017 at the United States Attorney’s Office in Cedar Rapids with an eye
toward, among other things, mapping out the path elder abuse and neglect cases follow and
making recommendations to improve the network. The goal is to map out the path that elder
abuse and neglect cases follow and to make recommendations to improve the network. We
welcome your participation and the unique perspective and expertise you bring to the issue.
We are hoping you would help us out with about an hour of your time. We know your time is
valuable and promise not to waste it. To speed things along, we can send you the short list of
questions in advance, and then schedule an interview at your convenience. The interview can
take place at your office, or by phone or videoconference.
If you are interested, just reply to this email, send an email to law-legal-clinic@uiowa.edu or call
319---335-9023. If you know someone else who might want to participate, please forward this
email.
Thank you for your help. I look forward to hearing from you soon.
14 core questions:
1. How do cases of elder abuse and neglect come to your attention? What are the key
warning signs?
2. What types of cases come to your attention most often, and what specific incidents stand
out most to you?
3. How many instances of elder abuse and neglect do you handle each week, month, or
year?
4. What are your primary duties and responsibilities with regard to elder abuse and neglect?
5. What are your organization’s primary roles and responsibilities with regard to EAN?
6. What steps or actions do you take when you learn of suspected abuse or neglect? Please
walk us through the process one step at a time.
7. What other people and agencies do you work with or ask for help or referrals in cases of
elder abuse and neglect?
8. How are most of these cases resolved by you or your organization?
9. What do you consider a successful outcome?
10. What policies, forms, and systems do you use to keep track of cases and outcomes?
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 11. How effective is your organization in responding to, preventing, or resolving cases?
12. Other than more funding and staff, what could help you or your organization do a better
job?
13. What resources, supports, or policy changes would help fill gaps or remove barriers in the
local EAN network?
14. Is there anything we forgot to ask, you think we should know, or you would like to tell us
about?
Interview Protocol:
The lead researchers trained the law and public health students on interviewing
techniques and facilitated practice sessions using the 14 core questions and interviewing
protocols they developed. The first interview was a pilot session used to gauge the quality and
usability of the questions and protocol. We modified the materials and process in response to
suggestions from the interview subject and team members.

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