I wrote the essay "Primer for a Sociopath" after my dad was murdered by a private caregiver. I was trying to think as the murderer thought, listing all those items that an abuser would need to know and do to kill someone. What I learned from that exercise is that the task is relatively simple if the patient is elderly, ill, or both.

I am not a medical professional, but I have some basic knowledge of medicine and medical procedures. I cannot say for certain that the perpetrator of the crimes against my parents is a sociopath. However, to a layperson such as myself, any individual who would purposely take the life of another, especially if the victim cannot defend himself, can only be a sociopath.

Excerpt from "A Primer for a Sociopath"

In order to hide what you are about to do-cause the premature death of a patient-there are a number of tasks which you must complete. The following is a detailed list of items which you must remember if you are to carry through on your plan.

1. Relate your long work history in this field, not only when you are being interviewed for the position, but individually with each family member-talk about your extensive knowledge of medicine and illnesses. Speak emotionally about your mother's or other family member's illness and how you have been of assistance to that individual. Talk about other patients you have cared for, letting slip a few well-known names, but always speaking of your previous patients as though you were very fond of them. A show of tears is often effective.

2. It is helpful if you can relate how you were similarly afflicted as your prospective patient is-use your imagination for this task if necessary. In this way the family will believe that you know how the patient is suffering and that you are empathetic to the patient.[horizontal ellipsis]

Background

My dad died on May 11, 2005. He was a victim of elder abuse. His death was directly attributed to criminal abuse and mistreatment by the perpetrator. My mom was also abused; however, she survived the abuse. My sisters and I often visited our parents and helped with their care, but we did not know one of the caregivers was actively trying to end their lives. Because of the abuser's expertise and ease of killing, the police investigators now believe our dad was not the first victim.

My sisters and I worked with the police investigators and other law enforcement officials for 10 months following our father's death. The woman pled guilty to three counts of elder abuse and was sentenced to 1 month in the county jail and a 10- year probated sentence. If the convicted abuser violates the terms of her plea agreement, she will serve the remainder of her 10-year sentence in the state penitentiary. Because of the lack of physical evidence, this woman could not be indicted or convicted of murder. My dad would still be alive if we had been able to recognize the characteristics of someone who abuses elderly people.

Before my dad's death, my sisters and I had almost perfect lives. Growing up in my dad's large Italian American family was a wonderful experience for all of us. Not only did we have parents who loved us, we had aunts and uncles who regarded us as their own children, although they all had children of their own. My grandparents, who were Italian immigrants-and proud American citizens-doted on all of their grandchildren. Our large family remained close throughout our lives. We shared family celebrations, laughed, talked, helped each other, and even grieved together. Nothing we had experienced before my dad became ill could have prepared us for what happened to my parents after we hired caregivers.

About 10 years ago, my mom developed dementia, a condition that has robbed her slowly of her memories and her ability to care for herself. My dad took care of my mom by managing her diet and medications, helping her dress, and making sure she felt safe and loved. After my dad had brain surgery for a recurrent meningioma in May 2004, he was unable to care for my mom as he had before. My dad was even having difficulty taking care of himself.

My mom and dad wanted to remain in their own home as they aged, and my sisters and I tried to honor our parents' wishes that they would never move to a nursing facility. One of my sisters lived in the same city as my parents; the rest of us lived far away. Therefore, it was necessary to hire caregivers to assist our parents.

In the months following our dad's death, my sisters and I struggled to understand how this horrible tragedy could have happened, and how we had failed to recognize the abuse. We took every precaution when we hired caregivers, but we were blinded by this woman's ability to pretend that she was a caring and attentive person, and by her assertions that she provided the highest quality care.

Below is a list of suggestions that will help you hire a caregiver. Some of these items we knew and followed; some we learned through our devastating experience. Please be vigilant because your loved one's life depends on you.

Before You Hire Caregivers

1. Remember caregivers are not your friends; they are your employees. Do not share information about your family history or values. Someone who wishes to manipulate you can use that information to control you.

2. Adult Protective Services can provide information about licensed caregivers and about recognizing abuse. Even if a caregiver works for a home health agency, he or she can still be an abuser.

3. If you can afford some type of monitoring system, have it installed before hiring a caregiver.

4. Install caller ID to track incoming phone calls. The absence of phone calls from your close family members may indicate that the caregiver is speaking privately to them and manipulating the family.

5. Keep family disagreements private. Never stop talking to your siblings or other relatives, no matter how difficult it becomes. Find someone outside the family to mediate if necessary.

6. Tell the prospective employee that any abuse of your loved one will be prosecuted to the fullest extent of the law. If you witness or even suspect abuse, call police or Adult Protective Services at once.

Managing the Staff

1. Do not allow the caregiver to rearrange the home for his or her convenience. It can be a sign that the caregiver is taking control of the home.

2. Do not put one caregiver in charge of other caregivers. You are in charge; never relinquish any part of your authority.

3. Do not allow the caregiver to schedule visitation times for nursing services; the nursing service should make unexpected visits.

4. Make unexpected visits to the home, varying times and days.

5. Limit the value of gifts given to the staff on birthdays and holidays. (You must maintain a distance between yourself and the caregiving staff. Never consider the staff to be your friends because the mistakes and excuses of friends can be easily accepted. In a situation such as this, overlooking mistakes and accepting excuses can put your patient at risk.)

6. Never give or lend money to the caregiver. It is inappropriate for an employee to ask for your financial help, no matter the reason.

7. Photograph everything in the home and let the staff know of your documentation. Remove valuables before hiring the caregivers. If even simple items are missing, find another caregiver immediately.

8. Even though a medication schedule is available to the caregiver, you cannot be certain medications are being given as prescribed. Check to make sure the schedule has not been changed. Count pills periodically and watch for indications that the medications are not being given as prescribed. Fill the medication container yourself and keep any additional medications secure.

9. Caution the prospective employee about bringing other medications into the home. If unprescribed medications are being given to your loved one, call the police at once.

10. A caregiver who often complains about other caregivers or family members may be trying to manipulate you. The caregiver should be removed from the home immediately.

11. Monitor the interactions between the caregiver and patient. If the caregiver does not touch or speak to the patient affectionately or is unwilling to be touched by others, that individual may be a danger to the patient.

12. Do not assume another caregiver will relate improper care by a fellow caregiver. Most people are afraid to "blow the whistle" on coworkers.

13. When a caregiver states that supplies are needed, make sure the need is genuine. Ordering too many supplies may be a way of stealing from you. Be in charge of your own possessions.

14. Any caregiver who repeatedly seeks your pity about his or her personal life may be a person who cannot be trusted; such individuals could be sociopaths. It is often easy for a sociopathic individual to manipulate kind and caring people.

15. Do not trust the caregiver implicitly. Check out stories you are told. Anyone who lies, even about something insignificant, should be fired immediately.

16. When conditions with the patient are puzzling, always suspect the caregiver. Never assume the patient's body is failing.

17. The presence of bed sores is an important indication of poor care. Find out immediately who is responsible and fire that caregiver.

Working with Other Medical Personnel

1. Keep in contact with other caregivers, especially visiting nurses, by questioning them about what they have seen. If you do not live with your loved one, insist that the nursing service mail its reports to your home. Contact the nursing service weekly, in person or by phone.

2. Do not assume the doctor will routinely look for elder abuse. If the patient returns to the physician in worse condition than the previous visit, the doctor may assume that the patient is failing.

3. Medical professionals also often consider paid caregivers to be colleagues. Medical professionals may not question their colleagues' motives or activities.

4. You may be told by the physician that you are in denial when you argue about the patient's condition. Be persistent. You likely know more about the patient's life, personality, and health history than the doctor.

Other Personal Issues of the Elderly Patient

1. An elderly person is easily controlled by an abuser and will seldom speak of the abuse. Watch for signs of behavioral change. For example, a person with dementia may not be able to tell you what has happened, but their behavior may change. A change in personality or defensive posturing in your presence may indicate that the individual is being harmed.

2. Privacy is always an important issue, especially when a patient is bathed or using the bathroom. Never allow the patient to be totally uncovered when bathing. If you see a patient's privacy violated, this may be a tactic to humiliate or control the patient. Find another caregiver immediately!!

3. Check the patient's teeth daily. If teeth are dirty, the patient is not receiving proper care. Do not accept excuses.

4. Schedule private time with the loved one. Do not allow a caregiver to sit in on private conversations. If the presence of an abusive caregiver threatens the elderly patient, it may keep the patient from speaking to you about the abuse.

5. Look for bruises, which are one of many possible signs of abuse. Remember ugly, demeaning words are abusive, as is excessive padding for urinary accidents.

Summary

Abuse happens every day to elderly and disabled individuals either through ignorance or design. Protecting your patient or loved one requires you to be suspicious of everyone who has access to the patient, even other family members. It is the most difficult and demanding task you will ever undertake.

Our story is a long and emotional one. If you wish to read an account of our experiences, please visit my Web site at http://www.iannarino.us/elderabuse.