About one in 10 older Americans experiences some form of abuse or neglect — something that’s often hidden in plain sight. Why and how do our social support systems fail older adults?

On this episode of Aging Forward, lawyer and elder justice expert M.T. Connolly talks about the situations in which elder abuse can occur, how society focuses on preventing aging instead of aging well, and shares her vision of community-based approaches for reducing harm.

Read the transcript:

Christina Chen, M.D.: It’s estimated that one in 10 older Americans experiences some form of abuse or neglect, and it’s often hidden in plain sight. We have a social support system that is lacking for older adults, and also for their caregivers, who often do not have adequate support or safety nets of their own.

This is Aging Forward – a podcast from Mayo Clinic about the science behind healthy aging and longevity. Each episode we explore new ways to take care of our long-term health, the health of our loved ones and our community, so we can all live longer and better.

I’m Dr. Christina Chen, a geriatrician and internist at Mayo Clinic in Rochester, Minnesota. And this episode, we are talking about elder justice and how to ensure that every year is lived with safety, dignity, and purpose.

We are so honored to be joined by M.T. Connelly, one of the nation’s leading experts on Elder Justice, and a recipient of the MacArthur Award.

M.T. is a lawyer and the architect of the Federal Elder Justice Act, founder of the Elder Justice Initiative, a bestselling author, and a leading voice behind community-based approaches aimed at reducing harm and restoring hope in aging. We are so happy to have you here, M.T.. Welcome to the podcast.

M.T. Connolly: Well, I’m so honored to be here with you today.

Christina Chen, M.D.: I’d love for you to help us understand what elder justice means, the definition of that, and why it’s such an important part of the healthy aging conversation.

M.T. Connolly: When we were first working on the Elder Justice Act, trying to come up with a definition, it became clear that it isn’t just freedom from abuse, neglect, and exploitation. As human beings, we have broader, more capacious hopes for ourselves than just not being abused or neglected or exploited. We want to have agency over our lives.

But we also want to feel like the systems that are available to us as we age really help promote not just health, but wellbeing, and that the systems help us age well and age with purpose and meaning. And too often that’s not the case.

I came to think of elder justice as a broader set of societal goals: both the ability to not endure abuse and mistreatment, but also having a society where that helps promote our ability to age well.

Christina Chen, M.D. And why does elder justice feel more important now than ever before?

M.T. Connolly: It’s a few things. Obviously, it’s the demographics: we have more people who are living deeper into old age than ever before. And deeper into old age often means deeper into vulnerability.

It used to be that we died while we were still more able-bodied and stronger. Now we can live longer, but we haven’t managed to contain all the chronic illness. That’s one thing where we are more dependent on others for care.

We don’t have a long-term care system that works particularly well. People are disproportionately dependent on family members and other informal caregivers, but mostly family members who are often totally unequipped to provide care: in terms of education, in terms of awareness, in terms of time, in terms of resources, in terms of being integrated into communities, or having the help they need. That’s another reason for Elder Justice.

Another thing is, and this is something we don’t understand that well, but the vulnerability to financial exploitation. Someone can seem like they’re completely fine and still be vulnerable to scams.

I mean, younger people fall prey to scams all the time. And AI and tech are making it more and more prevalent in ways that we don’t even know how to really prevent yet.

Then there’s increasing isolation. And here we’re sort of falling victim to our own cultural bias toward living alone. That independence equals living alone in your own house. That we’re setting ourselves up in many ways, and that living in community with other people is much better in terms of our capacity to ward off trouble.

If either as an individual we’re living alone, or as an older person and then a caregiver, they’re alone, that can set up all kinds of different troubles, such as isolation.

Christina Chen, M.D.: It’s interesting because you’re pointing to a lot of different sectors, or arenas: healthcare, social services, and financial safety nets.

M.T. Connolly: Aging doesn’t pick one lane. It isn’t just a health lane. It’s health, and it’s family, and it’s social services, and it’s financial, and it’s legal, and it’s housing. It’s all the things. You have to age well, have a basic understanding of how to think about all those different systems in a way that promotes healthy aging as opposed to undermining.

And also millions of people are living with these issues. Tens of millions of people are living with these issues, and they’re starting to come out of the shame and silence and starting to talk about them.

Christina Chen, M.D.: Let’s talk about that a little bit more. In your book, The Measure Of Our Age, you share that Americans have gained 30 years of life expectancy since the 20th century, but our systems, like the social, financial, and caregiving aspects, haven’t kept up, and it’s failed us in many ways. Can you explain what has happened there and what that gap looks like today?

M.T. Connolly: There’s this phenomenon called the Longevity Paradox. Essentially, we’ve moved Heaven and Earth as a society to live longer lives, and we’ve been astonishingly successful in that. In 1900, the average age was 48 and by 2000, the average age was 78.

That is an extension of years that is unprecedented in human history. But we don’t want to get old. We don’t want to be old.

Christina Chen, M.D.: Right.

M.T. Connolly: We have really put our heads in the sand in many ways in terms of how we live those much longer lives well. It happened, from an evolutionary perspective, incredibly quickly. We went from average ages of 48 to average ages of 78, which also, as you know, way better than I do, there’s what’s called heterogeneity or differences.

If you put 100 two-year-olds in a room, they all can do the same thing. If you put 100 92-year-olds in a room, some are going to be running marathons and others are going to be bedbound and have severe dementia and physical disabilities. There’s a huge range.

What’s happened is that we haven’t really built the systems we need for the people who are gonna need care, or to prevent problems as we age. A lot of it is due to the longevity paradox and also just our reluctance to think about aging.

We’re scared of it, we feel ashamed about it. We feel disgusted sometimes about it. And we want to be in denial. Much more effort goes into preventing aging, into trying to stave off the effects of aging, than to say, “How am I going to age well?”

If you look at the popular books or the popular media on this issue, it’s all about if you do these five things, then you’re going to live until 120. It isn’t if you live until 120 or if you live until a hundred, how are you going to do that? How’s your family going to support you? How are you going to support yourself? How are you going to pay for it? How do you protect yourself?

Christina Chen, M.D.: It sounds like you’re saying that we’re living longer, but then there are things that need to happen system-wise to make sure that we have that health span, so to speak.

As we’re talking about the state of aging in America and living longer and the prevalence of elder abuse, what forms does that usually take on?

M.T. Connolly: About one in ten people 60 and older in the United States fall victim to abuse, neglect, or financial exploitation. Those numbers go way up for people with dementia.

In general, verbal or emotional abuse and or financial abuse, followed by neglect, are the most common types.

And a lot of people underestimate the harm done by verbal or psychological abuse. Some studies suggest it’s even more harmful than physical abuse.

And when you think about it, if you’re at a vulnerable time of life and somebody’s telling you that you’re worthless, or they’re not going to help you unless you hand over all your money, or that they’re going to put you in a nursing home, you could see how that would be very damaging over time.

Christina Chen, M.D.: I’m just curious, your perspective, why do you think that happens? Why do we end up being harmful to each other?

M.T. Connolly: In terms of why we mistreat older people, it goes back to ageism. Because we feel a lot of antipathy about aging and often about older people. A lot of that’s based on fear. But it’s also based on profound age segregation, actually.

A lot of younger people don’t really have access to older people in their daily lives. Of course, then they are more alien or scarier. We haven’t done a great job as a society to protect vulnerable people. And we have increasingly eviscerated social support, and wait until there’s a crisis.

One of the problems is that we are more crisis-driven in the way that we respond. And we just kind of hope that people will muddle through, and then are shocked when something goes wrong. And then we say, “Oh, we have to investigate,” or “We have to prosecute,” when in fact we should be putting way more attention into prevention.

Christina Chen, M.D.: In our quest to make things better, we try to create these systems that are meant to protect older adults, like creating communities and nursing homes for the most advanced cases, guardianship, and adult protective services. But then sometimes that can make things worse, as well. Can you describe that paradox?

M.T. Connolly: Well, let’s talk about guardianship first. About 6 million older Americans have some form of dementia, and many more have something called mild cognitive impairment. When you have trouble making decisions in your daily life, that can have an impact on safety and well-being and also on economic security. Some people go through their money very quickly as cognition declines.

What we actually have as systems to help people who have some sort of cognitive impairment make decisions are either what’s called Powers Of Attorney or maybe Advance Directives.

Alternatively, if you wait too long and don’t have a Power of Attorney to make those kinds of decisions, then you have to go to court to appoint somebody who’s generally called a guardian– in some states, they’re called conservators – to make decisions that I am unable to make for myself.

Christina Chen, M.D.: Yeah.

M.T. Connolly: Lots of good intentions, but the question is what kinds of decisions can we make for ourselves? Because too often, guardianship is then used to take away all of our rights. Maybe I can’t make decisions about complex financial transactions, but I can make decisions about stuff that’s really, really close and intimate.

I can probably still say, these are the people I love the most. This is the person I wanna be romantically involved with. This is the person I want to live with.

But too often, what happens with guardianship is that it’s used to take away all of a person’s rights as opposed to figuring out what are the decisions that person can still make and how we use their ideas about how to live their own lives and their preferences in making those decisions.

And the data suggests that if you override people’s wishes about how they want to live their lives, it has really bad outcomes.

But the other thing that tells me is that we have really underestimated the profundity of that autonomy/safety balancing. There’s a wonderful expression that we want safety for the people we love, but autonomy for ourselves.

Christina Chen, M.D.: Hmm. I like that.

M.T. Connolly: We tend to over-correct for safety and underappreciate the importance of observing people’s wishes. But these are super, super complicated questions. Because there’s not just my desire and the risk I’m taking on, but the classic example of the car keys. If I am impaired as a driver, it’s not just my own safety then, but the safety of the community.

And these are really big questions that we haven’t really done a very good job addressing, and haven’t brought to bear the full ethical and philosophical expertise that we possess in helping families and professionals navigate them.

That’s guardianship. Sometimes it’s a shield protecting us, and sometimes it’s a sword used to take away our rights wrongfully.

Christina Chen, M.D.: Yes. You really have to have the person’s best interest in mind and really understand that person’s wishes well and carry it out well.

But when you’ve got a caregiver who is burned out, or there’s a lack of resources, I could see why it’s easy to find yourself in that situation of neglect or harm, even unintentionally.

And just from my own personal experience, a lot of our listeners are aware that my mother’s been sick lately. She declined very quickly in the past six months, and now she does have cognitive impairment, by definition dementia, because she can’t take care of herself. And I recently had to become her healthcare provider, power of attorney, and financial power of attorney with my husband.

And it was actually a very devastating experience for me to take that role on because she did all of that by herself before. And now I have that responsibility, a hundred percent. And if you don’t have your loved one’s best interest in mind, it’s so easy to take advantage.

M.T. Connolly: It’s such an important point. Medicare doesn’t cover nursing homes or long-term care, and most people don’t have long-term care insurance. When they do, it’s very expensive and often doesn’t cover what they need when they need it. And people are scared of long-term care facilities and want to stay at home.

As a result, there are literally more than 50 million people taking care of an older adult, a person 50 or older, an average of 24 hours a week, with extraordinarily little support or education.

Most people don’t even really know what dementia looks like. When the person asks the same maybe irritating question for the 15th time, and you’re doing your best, and you’re trying to take care of your kids, and you don’t have enough money, and you’re running out to try and get groceries or to help change diapers or whatever it is, you begin to understand how caregiving can lead to pressure cookers.

And that one form of prevention is really providing caregivers with much more support, education, respite, and the opportunity to take some time off. One of the people I wrote about was a woman named Anne who had taken care of her mother for more than 10 years. And first she took care of her mother in her mother’s house.

And then, when dementia got too serious. She moved her mother in with her, and she couldn’t lift her. And she was getting up again and again at night. And her mother would fall down the stairs and have really serious illnesses. And this went on for a decade.

Christina Chen, M.D.: Wow.

M.T. Connolly: For a decade. And she was so great. And at some point, she passed Laura Mosqueda, who’s the geriatrician that I wrote about, a note at an appointment saying, “Help me. I am overwhelmed.”

And it was on a hot pink card. And I came to think of that as a metaphor, because Laura was saying, “I missed her level of distress and her overwhelmingness.” And if this person, who was incredibly competent and loving, was this stressed out and overwhelmed, what about all the other caregivers who sometimes don’t even call themselves caregivers?

They’re just doing what they think is expected of them, and often, just exactly like your situation, fall into the position of caregiving very suddenly.

And it’s a huge, complicated work that we don’t respect enough and we don’t support enough.

Christina Chen, M.D.: What can friends or family who are not direct caregivers do to provide that support?

M.T. Connolly: Another aspect of wellbeing as we age is figuring out a good plan for caregiving, and that involves both good medical care, but also having a team around you. Because as we age, there are all kinds of issues that can come up.

There are medical issues, legal issues, financial issues, fighting with insurance companies, housing, transportation, and just being there. The thing that we too often miss is that caregiving is often really invisible. And we don’t recognize it as important work.

And so that leads to issues sometimes for the caregivers because it can become incredibly stressful if they end up having to carry too much of it or are not sufficiently supported or recognized.

Christina Chen, M.D.: Right. And for providers, we want to keep an eye out for caregivers who are burned out because that might be a warning sign or a risk of potential elder abuse or neglect, even unintentional, in the future. But what are some other warning signs or risks of elder abuse or exploitation we should be looking for?

M.T. Connolly: Well, just on the caregiver issue, Christy, because it’s such an important one. When medical providers routinely ask about diet, exercise, sleep, the data about caregiving are profound — that it has a profound impact on health: mental health: anxiety, depression, but also physical, health, heart disease, risk of stroke.

It increases the risk of mortality by 63%. That’s a huge health factor. And very few providers ask about it. And then the additional question of asking, “Well, how’s it going? Are you frustrated?”

And open up space for the conversation. And with older patients too, how’s it going with your daughter or with your grandson? And not to assume what the answer is because there’s a lot of stigma around it, including for older people and caregivers who feel a lot of stigma.

If things are not going well, and if it’s a super stressful situation, then to really listen and to ask the hard follow-up questions. Do you ever feel like you might hit your mom? Or, do you think somebody’s maybe using her money in a way that isn’t okay? Even just on that question, on the caregiving question, there’s a lot to do.

Christina Chen, M.D.: Any other red flags that members of someone’s support system, whether a community or a provider, should keep an eye out for?

M.T. Connolly: In terms of other signs, isolation is a huge risk factor. And conversely, social support is a really significant protective factor. For example, there are studies suggesting that if you have somebody with you to say, “Does this sound like it makes sense?” when somebody’s calling to say, “Oh, I’ve got a great deal for you,” or “Invest in this,” or, “You know, you have to call this number to make sure that they don’t do something weird on your computer.”

If you have somebody there with you to say, “Does that make sense?” That alone is a significant preventive factor.

If money is suddenly disappearing, flowing out of accounts, another thing to try to watch out for is having a trusted contact on your accounts, which is something that all financial institutions are permitted to do, but sometimes don’t do as a matter of course. That means that if suddenly huge chunks of money are leaving an older person’s account, they can call and say, “We’re concerned,” and then freeze the account, and do an investigation.

Another thing is to ask about fear. “Are you scared of anybody? Is anyone using your money in ways that you don’t feel comfortable with? Is anybody threatening you?”

One of my colleagues, David Burns, says, “It’s not a one-and-done. You have to build trust between the patient, the caregiver, and the provider. And it’s one of the things that is actually so problematic with the way that we structure the healthcare system because it doesn’t often allow time for conversations, which can be extraordinarily important to health.

Christina Chen, M.D.: Absolutely. I thank you for that. You actually taught me quite a few ways to just ask in a way that is vulnerable without being accusative. I really appreciated the question that you asked earlier, “Do you ever feel like hitting someone?”

It’s not accusing them, but it’s saying it’s asking about their emotions because it’s such an emotionally charged experience.

You’re not implying anything but asking about the negative emotions, like the fear and the worry and the anxiety that may lead you to do something that you normally would not do.

You are a co-designer of the RISE program, which stands for: Repair Harm, Inspire Change, Support Connection, and Empower Choice —  something of an alternative to our current adult protection services.

Tell me what you’re trying to address with the RISE program, and how it fills in gaps in our current social safety net.

M.T. Connolly: I learned a ton looking at some old data about adult protective services. When we initially had protective services, the focus was on protect, protect, protect, safety, safety, safety. And the data showed that people who had gotten those services had worse outcomes.

They died sooner and were institutionalized more often. It was worse for the clients, but it was better for the collaterals, meaning their families and the providers. Because people want a place to call. They want to feel like they’re doing the right thing. Mostly, the societal programs and attention to elder abuse is in making reports and doing investigations.

Christina Chen, M.D.: Right.

M.T. Connolly: Generally, adult protective services could keep a case open for 30, 60 days. That’s it. That’s the primary intervention. We don’t ask how we prevent it. And we don’t say what comes next. What we could do that Adult Protective Services couldn’t do is a really important part of the puzzle.

The other thing that’s super important is that for many older people, the top priority is to get help for somebody else. Say they have a grandson who has addiction problems, who also maybe lives with them or maybe is stealing from them, but they don’t want that person to go to jail. Or maybe they have a daughter who has severe mental health issues. Again, they want help for another person.

And often they have these really enmeshed relationships where maybe it’s a failure to launch, or the person is both a caregiver and the person who’s harming them. For older people, that is a very significant conundrum because we’ve said, okay, you have to report. And sometimes Adult Protective Services will then report to law enforcement or prosecution, and that’s not often what an older person wants.

Then that puts them in a position of not wanting to seek help because they’re scared of what might be the outcome. That’s why we built RISE, in the way we built it to inspire change using motivational interviewing to support connection by building social support around people — both informal supports. “Oh, okay, we’re going to try and make sure that the niece comes over once every two weeks, that your neighbor checks in on you once a week.”

And then formal support like Meals On Wheels or a senior center, or applying for Medicaid or whatever it is, and then empowering choice. For people who have some kind of cognitive impairment, making sure that they’re still in the driver’s seat in their own lives. Asking what is important to you, and then trying to fulfill those goals.

What we learned when we started crunching the numbers was that Adult Protective Services referred to their most complicated and intractable cases, the ones that kept coming into the system again and again. And that RISE reduced that recurrence rate by more than 50%.

I mean, we were utterly thrilled and kind of gobsmacked. Then, Maine wrote RISE into law as a funded part of the Healthy Aging Program. We also learned that it helped prevent elder abuse, and so then the Department of Health and Human Services gave us a grant in 2024 to replicate RISE in three new locations, which they then expanded to four new locations.

This model where adult protective services refer cases to RISE. But we’re also testing RISE in several other contexts, which we’re also super excited about.

Christina Chen, M.D.: No, I love it. That’s amazing. I wish we had a RISE program here. It just sounds like a very holistic model of support, creating that village model, so to speak, where everyone has a role. We’re creating that common ground of what the goal is, what comes next, and how we get to that goal, working collectively together.

And I wish we had that embedded into our systems, but obviously, we can’t. And for our listeners, whoever, whether it’s caregivers, professionals, or older adults themselves, is there any way we can maybe even replicate components of this in our own community?

Do you have any advice for some of us who can maybe help improve our current way of doing things with components of your RISE model?

M.T. Connolly: In terms of the core principles, probably the most important core principle is that it’s what we call person-led. The older person is in the driver’s seat of their own life. It’s their life. We should respect people’s wishes for their own lives to the extent possible.

And that’s something where we’ve gotten a little bit lost because we often feel like, as a health system or as social service providers or as a legal system, that we should be diving in there and telling people what to do as opposed to asking the leading authority on a person’s life, which is themselves. The other thing is that aging is a team sport.

Christina Chen, M.D.: Yep.

M.T. Connolly: We generally don’t age alone. In my own family, my father’s well being and by extension, the well being of all of my siblings and me, was totally entwined with the great care he got from my sister, Heidi who’s a doctor, lives close by and then my brother Danny, who lives in Minneapolis, who came down on weekends and is a lawyer, so he could help navigate some of the legal issues that come up with aging.

But in retrospect, I really wish that we had supported them both and especially Heidi better, and that also reflects a shortcoming in society relating to family caregiving, which is that we don’t do very much for caregivers to support them either in terms of education or respite care or compensation where it’s appropriate, or recognition for the work.

And if we have a system where the well-being of older people relies so heavily on caregiving — and right now there are more than 50 million people providing care for an older adult — we have to have a better way to support those people.

Christina Chen, M.D.: What can those of us who are far away do to support us if we’re, say, a child whose older parent lives on the other side of the country?

M.T. Connolly:  Helping to handle financial stuff, maybe you can fight with insurance companies over the phone from wherever you are. There are legal issues sometimes that come up that can be handled that you don’t need to be on site.

Even housing, like doing research. With my dad, he wanted to stay in his apartment, but for many people, moving somewhere else to get more care or to live in a community of people is a better option. That also requires a ton of research in terms of how much it costs for what, and getting on waiting lists, and for what kind of apartment or assisted living.

There are many, many questions, and I have friends who have Zoom family meetings on a regular basis to say, “Okay, who’s doing what?” And the parents are part of it. Sometimes the person who’s closest by is not an appropriate caregiver. Maybe they have mental health issues or substance use issues. Those are also really complex issues to navigate, as families that require a lot of thought.

Christina Chen, M.D.: We do have a closing tradition on our podcast. A question specifically for you. We love to get to know our speakers and how they approach healthy aging. You said that aging doesn’t have to mean decline, that safety, dignity, and joy are still possible. How do you personally age well?

M.T. Connolly: Oh, I love this question so much. In doing research for my book, I really wanted to understand what was going on at a deeper level with us and aging. And that took me into the neighborhood of how we make meaning of our lives.

And working on this chapter and doing research for this chapter has changed — not only the focus of my work, but how I live my life on a daily basis. Actually, it’s been a very profound set of lessons. Because we have this negative view of aging, but in fact, it’s this sacred trust.

We have the gift of time, of more time on the planet ourselves, and with the people we love. How do we make meaning of both our own lives and make meaning of the time we have left with the people we care about most?

Because all the noise can drown that out. What I wanted to do was think about concrete ways to make that happen. There are five of them, five steps. The first is connection and love to stay connected with the people you care about, especially with the people who are most important to you.

We should say, who are the people who mean the most to me? How do I stay connected? And then how do I stay in community with other people? And what is that?

What does that look like? And that is really clearly the most important thing that we can do to help us age well and meaningfully and to kind of double down on those relationships. The second is purpose.

We have this whole set of decades, often many of us, where we don’t really have a clear sort of clear map for how to live with purpose. And people do that in all kinds of different ways.

There’s a guy named Steve Cole at UCLA who has done studies looking at pleasure-seeking versus meaning — older people who volunteered with kids at risk improved their health dramatically. Doing things for others and having purpose in that way is really, really important.

Then there’s that third thing, which is a curiosity and creativity mashup — staying curious. From the time we come out of the womb, we’re curious. We’re trying to track the mobile and to our dying days, whether we have dementia or not. We’re curious about what’s happening, and so we have the capacity for creativity.

How do we realize that? My daughter and I have been doing watercolors on a regular basis. I’ve been going to listen to more music. How we reconnect with that part of ourselves is super important and very enriching.

 

 

 

 

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