[Senate Hearing 108-476]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 108-476
 
     CRIME WITHOUT CRIMINALS? SENIORS, DEMENTIA, AND THE AFTERMATH

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             MARCH 22, 2004

                               __________

                           Serial No. 108-31

         Printed for the use of the Special Committee on Aging



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                           WASHINGTON : 2004
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                       SPECIAL COMMITTEE ON AGING

                      LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama              JOHN B. BREAUX, Louisiana, Ranking 
SUSAN COLLINS, Maine                     Member
MIKE ENZI, Wyoming                   HARRY REID, Nevada
GORDON SMITH, Oregon                 HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri            JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois        RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah                 RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska                  EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania          THOMAS R. CARPER, Delaware
                                     DEBBIE STABENOW, Michigan
                      Lupe Wissel, Staff Director
             Michelle Easton, Ranking Member Staff Director

                                  (ii)




                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator John Breaux.........................     1

                           Panel of Witnesses

Commander Gary Gotham, USN, Woodbridge, VA.......................     3
Donna Cohen, Ph.D., professor, Department of Aging and Mental 
  Health, University of South Florida............................    43
Max Rothman, J.D., LL.M., executive director, The Center on 
  Aging, College of Health and Urban Affairs, Florida 
  International University.......................................    53
Constantine G. Lyketsos, M.D., MHS, professor of Psychiatry and 
  Behavioral Sciences; co-director, Division of Geriatric 
  Psychiatry and Neuropsychiatry, The John Hopkins University and 
  Hospital; on behalf of the Alzheimer's Association.............   111

                                APPENDIX

Material submitted by the Crisis Response and Intervention 
  Training Committee.............................................   135

                                 (iii)




     CRIME WITHOUT CRIMINALS? SENIORS, DEMENTIA, AND THE AFTERMATH

                              ----------                              



                         MONDAY, MARCH 22, 2004

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2 p.m., in room 
SD-628, Dirksen Senate Office Building, Hon. John Breaux 
presiding.
    Present: Senator Breaux.

    OPENING STATEMENT OF SENATOR JOHN BREAUX, RANKING MEMBER

    Senator Breaux. The committee will please come to order. 
Good afternoon to everyone, and thanks so much for our guests 
being with us, as well as our distinguished panel of witnesses 
this afternoon to talk about a very, very important subject 
that affects all of us in our country.
    The panel's testimony is going to be, I think, of great 
value to the committee as we work to address some of the 
critical challenges that our country is facing in providing 
proper mental health care to our Nation's seniors. In addition, 
I would also like to thank Chairman Craig for his support of 
this hearing.
    Our Nation confronts a pending wave of 77 million aging 
``baby boomers''. The purpose of this committee is to help this 
country rethink and to redefine how we age and continue to find 
ways to further enhance the quality of life for our older 
Americans and for their families.
    In the last Congress I initiated a series of hearings on 
ageism. To that end, this committee has examined various forms 
of ageism, this pervasive discrimination against seniors that 
permeates our health care system in our Nation. Last year I 
chaired several Aging Committee hearings that explored ageism 
in our Nation's health care system. We learned that medical 
ageism is pervasive. It can be found in the use of preventative 
screenings, in clinical trials for our valuable treatments, in 
the treatment of hospital-borne infections, and also in the way 
that mental health care is provided to our Nation's seniors.
    With respect to ageism and mental health care, we learned 
that older Americans have the highest suicide rate in America, 
a rate that is four times the national average. Even more 
disturbing, 75 percent of the suicide victims saw their doctor 
within one month of their suicide, but they were not treated or 
referred for treatment for their depression.
    Today, our committee will hear testimony about another form 
of ageism and mental health care for older Americans. We will 
examine dementia and the extreme level of tragedy that this 
condition can reach if it's left untreated by the health care 
system and misunderstood by law enforcement and judicial 
systems.
    This hearing will focus on a recent tragedy in Florida that 
exemplifies a growing problem evident across the Nation facing 
older individuals suffering from dementia. I would like to 
particularly thank several members of Mr. Ivan Gotham's family, 
who I understand are here in the audience today and who have 
been very supportive in the preparation for this hearing.
    I realize that it is an extremely difficult time for you, 
but I want to thank you for your support and also extend my 
sincerest condolences for the loss of your father. Your 
testimony may very well help prevent a similar tragedy from 
ever occurring anywhere else in the future.
    Although violent crimes committed by older Americans with 
dementia appear to be rare, we cannot be certain this is true 
because of the scarcity of the research and the data collection 
that is available. Nonetheless, we continue to see an 
increasing number of instances of severe violence that is 
associated with dementia. In fact, we have compiled a number of 
stories of this nature from around the country.
    We simply must find way to prevent even one unnecessary 
loss of life. This is particularly urgent, since it is possible 
to prevent these tragedies by encouraging more research and 
increased training for family members, for health care 
providers, for mental health care professionals, for law 
enforcement, and also for the court system.
    I prepared the charts over here to my right to assist 
individuals in recognizing the symptoms of potential violent 
behavior in older individuals with dementia who may need some 
professional intervention. Further, I recognize that we must 
continue to balance the needs of individuals with dementia with 
the need also, of course, to protect the public.
    I introduced the Positive Aging Act, which is S. 1456, to 
help seniors receive the mental health care that they need. It 
provides grants for demonstration projects to integrate mental 
health services for seniors into primary care settings. I also 
believe that the passage of the Elder Justice Act, which is S. 
333, will provide the necessary research, data collection, and 
the training to enhance our understanding of the care and 
treatment that is needed for seniors.
    Today we take another important step toward ensuring that 
seniors will have the mental health care that they need. I 
certainly look forward to hearing the testimony from all of our 
witnesses.
    I will introduce our first witnesses, who is Commander Gary 
Gotham of the United States Navy. Commander Gotham is the son 
of Ivan Gotham, who was killed in February in Ocala, FL. We 
thank you very much for being with us. As I said, your 
testimony may in a very significant way, help to prevent 
similar tragedies from ever occurring again. So, Commander, we 
are delighted that you are with us. I am very pleased to have 
the Aging Committee receive your testimony.
    You may go ahead and present it.

  STATEMENT OF COMMANDER GARY A. GOTHAM, UNITED STATES NAVY, 
                         WOODBRIDGE, VA

    Commander Gotham. Mr. Chairman, I want to thank you for the 
opportunity to come here today. It is an honor to speak before 
such a distinguished group of leaders in America about my dad, 
Ivan K. Gotham.
    I have provided a longer written statement and ask that it 
be included in the written record.
    Senator Breaux. Without objection, so ordered.
    Commander Gotham. In addition, I respectfully request that 
my sister's statement be included in the written record. It was 
provided to your office, sir. She is here today for the hearing 
and her written statement is very insightful.
    Senator Breaux. Without objection, it will be included.
    Commander Gotham. My name is Commander Gary A. Gotham. I 
have been in uniform for 23 years, honorably and faithfully 
serving the United States Navy and my country.
    I appear here today before the Senate Special Committee on 
Aging as a very humbled man. My father's death and the death of 
Deputy Brian Litz should cause us all alarm. It should serve as 
an example and case study for looking at mental health and how 
dementia patients are treated, or not treated, within the 
Medicare system by health care services, the police, and 
judicial system.
    The death of my dad and Brian could have and should have 
been prevented. What mattered most to my dad was liberty, 
freedom and dignity. He had given me and many other people so 
many gifts throughout life, ensuring his dignity as he departed 
this Earth was the smallest gift we could give him in return. 
But we were robbed of this familial responsibility.
    Respecting his freedom and liberty during the 3 weeks from 
January 12 through February 7, was our greatest challenge. He 
made it clear to all of us that he never wanted to be put in 
any kind of home. His home was in his house.
    In finding the error chain, we have focused on the events 
of January 5-12, 2004, when my dad was involuntarily confined 
to a mental health hospital under Florida's mental health 
statute, the Baker Act. Despite the 72 hour maximum stay under 
the Florida statute, he remained confined for 7 days. The 
Florida statute requires a hearing and court order to keep 
someone beyond the 72 hours. However, my dad did not have such 
a hearing.
    I contacted the elected Public Defender's office in 
Hernando County and they held no record of a hearing for my 
dad. He received no legal representation to discuss his civil 
rights and to explain why he was being kept beyond the 72 
hours.
    His diagnosis, severe dementia and delirium. His only 
aftercare was a follow-up appointment on January 29. My family 
was not aware of the true ramifications of his involuntary 
hospitalization until after he was shot and killed. The family 
was not notified that my dad was being held involuntarily. 
Despite the medical care that he had received from October 
through December from his primary care provider and other 
doctors, he was not identified as suffering from dementia or 
delirium. He was not even referred for counseling but, rather, 
was treated for depression with prescription drugs.
    We have pieced together the last 6 months of my dad's life. 
In July he spent a month with me to celebrate July 4, and his 
74th birthday. I had just returned from Operation Iraqi Freedom 
and he wanted to welcome us home. My dad had the highest pride 
in his kids. I left my shore tour at the Pentagon on September 
10, 2001, the day before 9/11, and headed to Japan in a tour on 
board the USS JOHN S. MCCAIN. For the next 18 months, we fought 
in Operation Enduring Freedom and Operation Iraqi Freedom, 
supporting the global war on terrorism.
    My dad and I spoke all the time about the 9/11 terrorist 
attacks. The tragedy of 9/11 was hard for him because he lived 
through the Japanese attack on Pearl Harbor. His brother fought 
in World War II. He was proud of the response from Congress, 
the President, and our military's actions.
    He returned to Florida and bought a house in Ocala, and 
spent Thanksgiving and Christmas with my brother. His spirits 
were excellent. He had recently been to the doctor for a 
routine check up on his prostate, was being treated for a 
blockage in his ear, and in December he had some work done on 
one of his eyes and had turned his hearing aid in for repair. 
He had redone his ``living will'', his last will and testament, 
and a power-of-attorney.
    I talked with my dad almost every day. He was my best 
friend. I thank God that we had the most remarkable 
relationship beyond just a father and son. We spoke often about 
the 2004 Presidential elections and he drilled me about the 
President's decision to go to war in Iraq. We spoke about the 
Democratic primaries and issues of drug prescriptions and 
Medicare reform. He remained lucid and engaging in our 
conversations.
    My birthday was on January 5, and I was not able to reach 
my dad for the next 7 days. I regained contact with him on 
January 12, the day he got out of Springbrook. He was not my 
dad any more. For the next 3 weeks, we all encountered a 
troubled mental state with my dad. He was lucid at times and at 
others he spoke of events that were unreal. He was paranoid, 
spoke of having a discussion with Jesus, thought his second 
wife and step-daughters had committed suicide. His sense of 
reality had faded away.
    In return calls to the police seeking help, I learned about 
the well-being check. That first week I called and requested 
they check on him. It went well. They called from inside his 
house, confirming that he was OK.
    My dad had a second incident with the sheriff on January 
24, and a deputy had been assisting my brother in providing 
contact information for senior services with the Department of 
Children and Families. We were trying to reach an agreement 
with my dad, that he would move to my brother's in 
Jacksonville, FL until he was stable again. Randy had contacted 
a lawyer to find out the mechanisms for us to take control over 
my father to get him some help.
    Before we could take these actions, my father was killed. 
On February 7, we lost my dad in an incredible turn of events 
that has crushed my life, my beliefs, and has saddened me to 
depths that no one should ever be burdened with.
    I called the Marion County sheriffs and requested a well-
being check. As I had done during that first call, I made sure 
that the dispatcher knew that my dad had a gun in the house, 
was having physical as well as mental problems and stability 
issues. I was adamant that I wanted to know that the police 
officer was told about the gun. I wanted to prevent a tragedy.
    That call went out from the dispatch at 12:07 p.m., and by 
12:32 my father, 74 years old and failing in mental health in 
ways we did not comprehend, shot and killed a sheriff's deputy, 
Brian Litz, who was 36 years old. Forty-two minutes later, in 
what is still shielded in confusion, misunderstanding, and 
lacking in truth, my dad, unarmed, was shot and killed in a 
blaze of gunfire from police and swat teams.
    There is no eloquence of words that can describe the depths 
of my personal grief, sorrow, and guilt that I feel in the loss 
of Brian Litz and my father. My dad was still giving to his 
family, his country, and the world. Brian was just starting his 
own remarkable journey in life.
    I knew my dad as a great man, an incredible father, a best 
friend, a legend. He handed down to me a puritan work ethic, 
hard work for God and country, family, love, church, neighborly 
kindness, freedom, respect for our parents and teachers, the 
military, our leaders, our service providers and police and 
firemen. These were the hallmarks of his teaching. He still 
cried during the national anthem when we went into a baseball 
game on July 4, 2003.
    I can't help but question the ability of the medical care, 
and especially Florida's mental health care system, in 
providing appropriate care for my dad. If we had been notified 
of the involuntary confinement, if he had been properly treated 
with follow-up care, if we had been there to take him home from 
the hospital, I know in my heart he would still be alive, and 
so would Brian.
    I can't avoid questioning the actions that resulted in his 
death. My attempt to seek out help from the Marion County 
Sheriff's office and to protect them and my father resulted in 
a police action and the use of lethal force that is beyond my 
comprehension. As a military man and a trainer in the uses of 
deadly force, even in combat, if I had directed or personally 
taken similar actions against an unarmed man, I would not be 
sitting here before the committee but would be sitting in 
Levenworth Federal Prison.
    I spent the last 2 years fighting the global war on 
terrorism and returned to America only to learn that terrorism 
had struck my dad in Florida. We're all searching for answers 
to understand these tragic events. My own quest for answers is 
to alleviate the tremendous guilt that I bear in the personal 
responsibility for the deaths of my dad and Brian. Some need to 
blame us; some need to blame the State mental health care 
system; others need to blame the misuse of Florida's mental 
health act, the Baker Act, with the elderly.
    I thank the committee for this opportunity today.
    [The prepared statements of Gary Gotham and Rorie Lin 
Gotham follow:]

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    Senator Breaux. Commander, thank you so very much for that 
very moving and very touching story, very tragic, and also very 
unfortunate. But again, we appreciate very much your being able 
to share it with the Congress, and hopefully contribute toward 
it not ever happening again to any other family. I think that's 
important.
    We are delighted to have back with us Dr. Donna Cohen, who 
has been with us before and has testified in hearings before 
the Aging Committee. She is a professor in the Department of 
Aging and Mental Health at the University of South Florida. We 
appreciate very much her being with us again.
    Dr. Cohen.

STATEMENT OF DONNA COHEN, PH.D., PROFESSOR, DEPARTMENT OF AGING 
   AND MENTAL HEALTH, UNIVERSITY OF SOUTH FLORIDA, TAMPA, FL

    Dr. Cohen. Thank you, Senator Breaux, for hosting this 
hearing. It's another indication of your great leadership in 
the areas of geriatric mental health care and elder justice 
issues, and your track record is one of great leadership.
    Gary, thank you for coming here with your family to talk 
about this terrible tragedy in Florida on February 7.
    I have spent the past 12 years studying these violent 
deaths among people with Alzheimer's disease, individuals with 
the disease who kill, family members stressed by care giving 
who kill their relatives out of desperation and depression. 
There are many instances of violent deaths among the dementia 
community.
    As you put it so well in your Elder Justice bill introduced 
last year, with a companion bill in the House, we do not have 
good data to survey the incidence and prevalence of abuse and 
neglect, and homicide is one of the most powerful forms of 
abuse that can occur.
    In my preparation for this hearing, I did do a search, 
using a newspaper cutting service which I have used before, 
which has been validated against medical examiner records, and 
we do have some preliminary data on the prevalence. But before 
going into this, I would like to add the voices of the 
community to the voices of the family of Ivan Gotham.
    Among the hundreds of these sad tragedies that we have 
investigated, we were able to bring to this hearing a 911 call 
from January 11, 2001, in Jacksonville, FL, where Mr. Gotham's 
brother resides. This was a case where a man with dementia shot 
and killed his daughter and son-in-law, who lived next door, 
killed his wife by chasing her across the street behind a 
dumpster that was in the back of a school yard with an 
aftercare program, quite active, before shooting himself.
    I ask if I may play this brief introduction.
    [Transcription of 911 call:]
    911: Sheriff's office.
    Caller: Yes, ma'am. We have a man out behind our house 
shooting people.
    911: He's shooting people?
    Caller: Yes, ma'am. There's one laying down on the ground 
and he's chasing another one back behind the park.
    911: Somebody has been shot?
    Caller: Yes.
    911: What's the address? What is the address?
    Caller: It's a trailer on school ground. He just fired 
another shot. We heard three shots.
    911: OK. Give me a description of him.
    Caller: Hannah, what's he look like?
    911: Is he a white male or black male?
    Caller: He's a balding man, probably in his fifties.
    911: Is he a white or--a white male?
    Caller: Yes.
    911: What color shirt and pants does he have on?
    Caller: What color clothes? Oh, my god, he just killed her.
    911: OK, ma'am. I need a description of him.
    Caller: Navy blue.
    911: Blue what?
    Caller: He's shooting himself.
    911: He just shot himself?
    Caller: Oh, my god, he's going to shoot himself in the 
mouth.
    911: Ma'am?
    Caller: Yes.
    911: OK. Who did he shoot?
    Caller: We don't know.
    911: OK. There's somebody laying on the ground, and didn't 
he just shoot himself?
    Caller: We don't know.
    911: OK. Well, give me a description of him. What does he 
have on?
    Caller: What does he have on? All blue.
    911: He has one all----
    Caller: Navy blue.
    911: Where is he? Is he behind your house?
    Caller: Yes, ma'am. He's behind the house. He's got the gun 
in his mouth. He's walking toward my house. Please hurry. I 
have children here.
    911: OK. Do you know where the person on the ground is shot 
at?
    Caller: I don't know. I don't know.
    911: OK. Has he shot himself?
    Caller: No. He's walking around with the gun in his mouth. 
He's shot two people.
    911: He shot two people?
    Caller: Yes, ma'am. There's one laying on the ground. Oh, 
my god, he's loading the gun. Please hurry.
    911: OK, ma'am. I've got police and rescue on the way, but 
I just need you to continue to talk to me.
    Caller: Pardon me?
    911: OK. What is he doing now?
    Caller: What is he doing now? He's loading the gun. I 
can't----
    911: He's loading the gun?
    Caller: Yeah. I can't see him. My mother-in-law and my 
husband are watching. Oh, my god, just another shot, two more 
shots, four more shots.
    911: Four more shots?
    Caller: Five more shots. Kevin, no! He shot himself? [End 
of transcription.]
    Dr. Cohen. Mr. Hurley shot himself. The city of 
Jacksonville is still stunned by this event in 2001.
    One of the important points I would like to offer to the 
committee is that, even though these things probably are 
relatively rare compared to other forms of elder abuse, they 
have a long-lasting impact on families and communities.
    I was surprised that we know so little. We have a mechanism 
for collecting data out of the Department of Justice, the 
National Incident Based Reporting System for Crime Statistics, 
but it only codes the offender's age and the relationship to 
the victim. There is a great deal of information about the 
victim.
    The Centers for Disease Control, with funding from the 
Federal Government, has been implementing a National Violent 
Death Reporting System based upon about 5 years of pilot 
studies with 13 sites coordinated by the Harvard School of 
Public Health. I spoke with every single one of those sites, 
including the key individuals at Harvard, and they were the 
first to admit that they have very comprehensive data on the 
victims of suicide, homicide, and homicide-suicide, but even at 
the best sites, they don't even have 50 percent of information 
about the homicide offenders.
    The sites that have the least data have maybe 10 percent of 
the information about the homicide offenders. For victims, they 
code for mental health antecedents, but do not separate out 
dementia.
    Within State systems, we do have a reporting mechanism for 
resident violence in long-term care, but no State in the United 
States records deaths on residence violence. So, sadly, our 
current State and national systems for recording this 
information are neglecting to provide us the codes to answer 
the questions that you pose to us.
    We did a newspaper surveillance of the United States 2 
years retrospectively and found that there were ten incidents 
where someone with dementia killed another person. Ninety 
percent involved men, 90 percent were at home, 20 percent were 
homicide-suicides. The previous study we did showed that half 
of them occurred in long-term care. I submit that a newspaper 
surveillance study is not a scientific study, but it gives us 
an indication of the need to do further research on this.
    One of the issues for law enforcement, for the Alzheimer's 
association, for health and mental health professionals, is the 
assessment of violence. Predicting violence is like predicting 
the weather. We have many programs and mechanisms to do this, 
but it is very difficult. The psychiatric literature tells us 
that there are ways of assessing dangerousness, and from my 
experience in the past 10 or 12 years, along with some studies 
that have been done in Europe as well as the United States, we 
know that there are some antecedent factors. We don't know if 
they are risk factors, but as you have aptly summarized, they 
are potential risk factors. Since they are there for the view 
of the public, I won't go over them.
    Precipitating factors are very difficult to identify, and 
the literature really supports what Commander Gotham said. You 
have individuals who are fearful, who have had experiences of 
being scared in the past, and they have catastrophic reactions. 
You and I would be afraid if an officer came to our door, and 
we really didn't know what they were there for.
    Someone with dementia, like Mr. Gotham, clearly scared--and 
I know from the family stories, this is a very compelling 
story. I echo what you said. I hope that this story will bring 
about some change.
    There are many legal and policy challenges, which some of 
my colleagues will be talking about here today, one of them the 
major legal challenges to law enforcement, but also the 
judiciary, prosecutors, and defense attorneys.
    There are model programs, and I think you will hear about 
one from my colleague from Johns Hopkins and from my colleague 
from Florida International University.
    I have made several recommendations to you, Senator Breaux, 
and I will echo the themes that were in your bill, the Elder 
Justice bill, of the need for more lethal violence research, 
for surveillance, education and training for law enforcement. 
The Department of Justice does fund some of this, and your bill 
provides a mechanism to further this.
    The development of programs like Crimes Against the 
Elderly, which are actually programs within law enforcement, 
actually provide officers training on a daily basis, so that we 
can have a better educated law enforcement program.
    We need education and training for health care 
professionals. We also need the consideration of State laws 
about allowing persons with dementia to possess firearms. A 
case in Eugene, OR where a man with dementia killed his wife 
and another man with dementia has led the State of Oregon to 
consider this kind of legislation. Minnesota has begun to 
consider this kind of legislation, but we get into issues of an 
individual's civil rights.
    In conclusion, Senator Breaux, and the committee and 
audience, lethal violence by dementia may be rare, but as you 
said, we need to understand this. Violence by formal and 
informal caregivers is probably more common, but the 
circumstances have a common denominator: the need to identify, 
intervene, and prevent the abuse, the injury, and the 
unnecessary death of Detective Litz and your father, Mr. 
Gotham.
    Thank you, sir.
    [The prepared statement of Donna Cohen follows:]
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    Senator Breaux. Thank you very much, Dr. Cohen, for a very 
thorough and extensive statement. It was very informative.
    Our next witness is Mr. Max Rothman, who is executive 
director, the Center on Aging, Florida International 
University. We welcome you, Mr. Rothman, and we are pleased to 
receive your testimony.

 STATEMENT OF MAX B. ROTHMAN, J.D., LL.M., EXECUTIVE DIRECTOR, 
   THE CENTER ON AGING, COLLEGE OF HEALTH AND URBAN AFFAIRS, 
                FLORIDA INTERNATIONAL UNIVERSITY

    Mr. Rothman. Thank you very much, Senator Breaux.
    I have been asked to address challenges facing the 
judiciary in response to the growing incidence of crime among 
elders with dementia and mental health conditions. In fact, 
quite little is known about the impact older people will have 
on the courts. There has been limited effort to examine the 
implications of aging on judicial administration, access to the 
courts, appropriate jurisprudence for elders who perpetrate 
crime, or resolution of underlying issues.
    There is little evidence that courts in general have 
addressed these issues, other than to achieve compliance with 
ADA requirements. We need to understand more about the complex 
reasons that lead older people to the courts, how courts 
respond, and what policies, resources and administrative 
actions are required in the future.
    The demographics of aging and the special needs of elders 
will impel judicial systems to accommodate larger numbers. 
Diversity of race, ethnicity, language, culture and education 
will overlay increasingly complex physiological, psychological, 
and social profiles.
    There will be more victims, arrests, and incarceration for 
violent crimes like domestic violence and sex offenses, as well 
as nonviolent crimes of theft and drug related offenses. 
Misdemeanors, shoplifting, trespass, also will increase. These 
may well involve people with dementia, mental illness, 
substance abuse, and complex medical conditions.
    Now, based upon data from our current research on judicial 
responses to an aging America, we do not believe that most 
jurisdictions are addressing issues of aging. However, site 
visits that we have made corroborated the identification of 
many similar concerns on the part of judges, court 
administrators, and health care professionals.
    The philosophy of therapeutic jurisprudence and the 
expansion of problem solving courts reflect emerging trends and 
best practices in related areas. They share common goals of 
improved access, closer ties to the community, and more 
effective use of available services to reduce recidivism.
    Elder justice centers in West Palm Beach and Tampa, FL 
share a common mission to remove access barriers to the system 
and to enhance linkages between elders and courts as well as 
with legal, health, and social service systems. Although Tampa 
focuses on victims and West Palm Beach on offenders, both serve 
as offices of the courts, not as independent advocates.
    Mental health court judges are specially trained and 
sensitive to the situations of these victims and offenders. 
Their broad perspective emphasizes health and treatment, 
coordination with community resources, and monitoring offenders 
to ensure future accountability.
    Now, as we have heard, services are quite limited, 
especially for those with special needs in most communities. 
Most providers are not closely linked to the courts or to law 
enforcement. If victims and offenders end up in guardianship--
an area that's been labeled the next ticking time bomb for the 
courts by the President of the National Judicial College--they 
face a lack of well-trained guardians and little accountability 
for delivery of services or financial management.
    Some preliminary conclusions from our research are in 
order. Leadership of the Judicial branch is going to be 
essential. Elder justice centers and perhaps elder courts 
represent models for replication. Professional staff, working 
for the courts, can establish community linkages and boundary 
spanning.
    The judiciary, the bar and law enforcement need education 
about the complex profiles and issues of aging. Standards of 
accountability and guardianship are typically nonexistent. 
Services for older victims and offenders with dementia and 
mental illness are very limited. Information and data on elders 
is not routinely collected by the courts or used to identify 
recurrent problems.
    In summary, issues of an aging America have not been 
identified as a judicial priority and addressed with passion 
and innovation.
    Thank you very much.
    [The prepared statement of Max Rothman follows:]
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    Senator Breaux. Thank you, Mr. Rothman, very much for your 
statement. It was very helpful and informative.
    Our final witness is Dr. Constantine Lyketsos.

 STATEMENT OF CONSTANTINE G. LYKETSOS, M.D., MHS, PROFESSOR OF 
 PSYCHIATRY AND BEHAVIORAL SCIENCES; CO-DIRECTOR, DIVISION OF 
  GERIATRIC PSYCHIATRY AND NEUROPSYCHIATRY, THE JOHNS HOPKINS 
     UNIVERSITY AND HOSPITAL; ON BEHALF OF THE ALZHEIMER'S 
                          ASSOCIATION

    Dr. Lyketsos. Thank you, Senator Breaux. Let me begin by 
thanking you and the Senate Special Committee on Aging for 
holding this very important hearing and for inviting me to 
testify.
    I am delighted to be testifying today on behalf of the 
Alzheimer's Association and want to once again acknowledge 
their staunch advocacy for people with Alzheimer's and their 
families.
    I am a physician. I am also a researcher and clinician in 
the Alzheimer field, and apropos to today's meeting, it is 
noteworthy that, with my fairly limited clinical practice, I 
have already been in the past week involved in two similar 
cases, although not to this extent, obviously, involving 
violence of people with Alzheimer's disease.
    The topic that brings us here today is the psychiatric and 
other behavioral features of dementia. The public usually 
thinks of Alzheimer's as a condition that only affects memory. 
Since this is a widespread disease of the brain, it should be 
no surprise that upwards of 90 percent of people with 
Alzheimer's develop psychiatric and related behavioral 
features. Doctors Cohen and Rothman, and especially the Gotham 
family, have very eloquently brought to life the sorts of 
issues we're talking about.
    Now, let me address a few questions that revolve around the 
issue. First, how common are the psychiatric and behavioral 
symptoms of dementia and what is their cause. I reiterate, that 
as our research has shown at Hopkins that over 90 percent of 
Alzheimer's patients develop psychiatric and belated behavioral 
features. Among the most troubling that we're heard about today 
include depression, delusions, hallucinations, delirium and 
agitation. Physical violence is exhibited by about 15 to 18 
percent, every year. When you multiple this by the number of 
people with dementia alive today, you appreciate how big the 
numbers really are.
    The vast majority of such violence occurs against care-
givers, is short lived, and does not result in significant 
injury. Most of the time we probably never hear about it. 
Occasionally violence gets out of hand and we hear about the 
cases that we heard of today. Typically, violence gets out of 
hand when currently available treatments are ineffectively 
applied.
    Turning to the cause of the symptoms, the primary cause is 
the brain damage brought about by Alzheimer's or other 
dementias. The disease damages brain centers that regulate 
mood, the ability to perceive the environment, and the ability 
of the patient to control his behavior and his impulses.
    With regard to violence specifically, just as with any 
behavior, it is affected by many factors, sometimes many 
contributing at once. Both patients and environmental factors 
play a role. Brain damage is the major patient factor, but 
there are important environmental factors, such as lack of 
structure, changes in routine, and what we refer to as 
unsophisticated caregiving.
    Well, how good are the treatments that we have available at 
present? Current treatments consist of prevention, removal of 
provocations, rapid response to early symptoms, psychiatric 
hospitalization, and use of certain medications.
    Prevention focuses on putting into place good dementia care 
practices for all patients. Involvement of the family is a 
critical aspect of good dementia care. Certain medicines have 
been shown to reduce some of the symptoms, but medicines carry 
significant risks. Yet, in the hands of seasoned clinicians, 
treatments are successful in reducing these symptoms to a 
manageable level well over 80 percent of the time. In fact, 
these are some of the most treatable symptoms of Alzheimer's. 
Yet, in many cases success is not complete and these symptoms 
can trouble patients and care-givers for many years. Obviously, 
we have a lot more to learn about how to treat the symptoms.
    How does our health care system fall short in treating 
these aspects of the disease? Let me try and summarize that in 
four points:
    First, the system fails to detect the symptoms. Second, it 
fails to disseminate the currently available treatment know-
how. Third, it doesn't pay adequately for the care of patients 
with these symptoms. Fourth, we do not have enough well-
equipped treatment settings that can effectively manage these 
symptoms.
    Detection rates for dementia itself--not just the symptoms 
but the dementia itself--is unacceptably low. Only about 30 
percent of people with dementia are given this diagnosis in the 
primary care setting, and only about half to two-thirds in the 
other major care setting for dementia people long-term care, 
which includes both assisted living and nursing homes. These 
are major missed opportunities to intervene early and prevent 
severe behavior problems.
    While the know-how for preventing and managing these 
symptoms is rather good, this knowledge has not been 
transferred to the settings where they are cared for. Part of 
the problem is that costs associated with treating these 
symptoms are very high, and Medicare reimbursement structures 
are not conducive to clinicians getting paid adequately for 
managing these symptoms.
    I will briefly turn to talking about what research is 
needed to improve treatments. Research obviously is an 
essential part of battling and conquering Alzheimer's, and the 
ultimate goal must be to find treatments that will cure, 
prevent, or delay the brain disease itself. At the same time, 
we must focus our energies on improving the care of the 4.5 
million people with Alzheimer's who are currently alive, and of 
their caregivers, and of the many more patients who are going 
to arrive on our doorstep in the next 20 to 30 years.
    It is critical that we dedicate adequate resources to the 
care research effort. In the interest of time, I will not make 
additional remarks about treatment research, but my written 
testimony has several additional examples.
    What are some of the community responses that we've seen to 
this issue? Well, the Alzheimer's Association has been the 
leader in this effort through it's nationwide chapter network. 
In my written testimony I highlight several examples. Let me 
just bring one to life today.
    In Wisconsin, when mandatory arrest in domestic abuse cases 
became State policy, the Alzheimer's Association enlisted 
community service providers, adult protective services, local 
enforcement agencies and the Governor, to develop a community 
response to cases involving persons with dementia. As a result, 
all police officers in the State receive mandatory training in 
dementia care. Further, nursing homes and community based 
residential facilities have been recruited to provide temporary 
placement as an alternative to jail when a violent person with 
dementia needs to be removed from the home. Mr. Richard Langen, 
a retired police lieutenant who spearheaded the Wisconsin 
program, is in the audience today.
    Let me leave you with a few conclusions. Ultimately, the 
management of a person with Alzheimer's and behavioral symptoms 
who is at risk for violent behavior will depend upon direct 
response from physicians, law enforcement personnel, long-term 
care providers, and community agencies. But Congress and the 
Federal Government have a lot to say about making these 
responses possible.
    My specific recommendations are: (1) provide adequate 
funding for the essential research and understanding, managing 
and treating behavioral symptoms in persons with dementia, 
research that will be jeopardized unless funds are added beyond 
the President's budget for Alzheimer research at the NIH. (2) 
continue support funds through the Department of Justice for 
the Safe Return program. (3) maintain funds and the quality 
requirements attached to those funds for State Medicare long-
term care program. (4) and this is probably the most 
important--change Medicare reimbursement policy to provide 
payment, not just for evaluation and diagnosis, but for the 
ongoing management and care coordination for beneficiaries who 
have Alzheimer's disease and related conditions that might 
require such medical care.
    Thank you, Senator.
    [The prepared statement of Dr. Lyketsos follows:]
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    Senator Breaux. Thank you very much, Dr. Lyketsos, for your 
presentation. I thank everyone for being with us. I think your 
statements speak for themselves and they have been very helpful 
and very illuminating. Hopefully, it can lead to Congress 
having a greater awareness of the problems we are talking 
about.
    Commander Gotham, why was your father initially confined as 
he was under the Baker Act? Was there a specific complaint by 
someone? How did that happen?
    Commander Gotham. On the evening of January 5, 
approximately 10:30 at night, he had gone to a woman's house 
that he had met on the Internet for a date. He had gotten lost 
and was in an unfamiliar neighborhood and had gone to the wrong 
door.
    He also suffered because of his prostate from bladder 
control and had told me that he gotten out of the car to 
urinate and had forgot to zip up his zipper. So when he went to 
the door, the gentleman did not know who he was, his zipper was 
unzipped, and he did not like the responses he was getting from 
my father and called the police.
    When the police responded, my dad had left his car in this 
man's driveway and was walking away with his dog. The police 
approached him and he was able to respond where he lived, but 
was confused about where he was and didn't know how to get back 
to his car or the house.
    Senator Breaux. Was he on any kind of medication at the 
time or in treatment for dementia?
    Commander Gotham. No, Senator. The only thing he had had 
was in November, where his primary care provider felt that his 
depression was bad enough that she had put him on Paxil. He had 
taken himself off of that at the same time his primary care 
provider had moved on, mainly because he said he was suffering 
from hallucinations on the medication, at the dosage.
    Senator Breaux. After they picked him up and incarcerated 
him for this period of time, was he seen by a doctor or anyone 
during that period, to find out what the problem was that he 
was suffering from?
    Commander Gotham. We're in the process now, working with 
the assistant state attorney, to get the Springbrook Hospital 
records. He was actually seen by two facilities. The first 
facility in Marion County, because of his Medicare insurance, 
refused treatment for him. He had to be taken down to 
Springbrook in Hernando County. He was seen there. We have not 
seen the complete medical report, but he is required under the 
statute to be seen both physically and mentally within 24 
hours, and then at the 72 hour mark he was required to either 
be brought before a hearing and a decision made if he was not 
able to make his own decisions about his treatment, that a 
court could order him placed involuntarily for extended 
treatment up to 6 months.
    Senator Breaux. Was the family notified at any time when he 
was picked up, or how long was it before the family was 
notified?
    Commander Gotham. It was not until January 12, and it was 
due to his two neighbors that had worked with the hospital, 
trying to find out why they were keeping him. They went into 
his house because he had actually left his dog that he had with 
him that night with one of the neighbors. The police went back, 
got that neighbor, and brought her back to the car, took the 
dog and the car. So she had gone in my dad's house with one of 
the other neighbors, and they had e-mailed me. But that was on 
January 12.
    This was the first time that we knew my dad was in the 
hospital. It took about a week before----
    Senator Breaux. They picked him up on what date?
    Commander Gotham. On January 5.
    Senator Breaux. So from the 5th to the 12th, the family had 
not been notified?
    Commander Gotham. That's correct, sir.
    Senator Breaux. If you pick up a juvenile, I think the law 
requires that you notify the parents, that you have picked up 
the juvenile for misbehavior and incarcerated them.
    Did they say they attempted to find the children or any 
family members so that they could let you know they had this 
gentleman who was picked up for what they would call abnormal 
behavior? Were they trying to contact the family members to let 
them know?
    Commander Gotham. No, sir. Springbrook Hospital was very 
reluctant to discuss much with me. The police basically, once 
they turn the individual over to the medical community, they're 
off the hook for anything.
    He did have a yellow piece of paper in his wallet with all 
of our phone numbers on it. There were two immediate locations 
in the house where he had all of our phone numbers. But there 
was no attempt to contact the family.
    In reading the statute, it does say that the second person 
to be notified would be a subordinate, like a son or a 
daughter, if he didn't have a spouse. But they did not answer 
any of my questions. It took me contacting the assistant state 
attorney to even have his medical records released to us, and 
we still don't have those.
    Senator Breaux. How long was it from the time that the 
police picked him up before he was turned over to medical 
authorities, do you know?
    Commander Gotham. It looks like he was picked up about 
10:30 at night, and he was not taken to Marion Citrus, the 
first facility, until after midnight. Because they refused him, 
he was driven to Hernando County, which I drove that actual 
route and it took over an hour to reach the Springbrook 
Hospital. So he would have gotten there between 1:00 and 2:00 
in the morning.
    Senator Breaux. But apparently the police, after they 
picked him up based on this complaint, attempted to bring him 
to a medical facility, the first one turned him down, and they 
got him to the second one within a matter of hours?
    Commander Gotham. I believe the total time was probably in 
excess of 2 or 3 hours. I don't know exactly yet. But the 
officer that actually initiated the Baker Act spoke with my 
brother. She had worked with my brother several times about 
getting the gun out of the house and things to do with my dad. 
She explained to my brother that she did have his best 
interests in mind, that she did want to try and provide him 
some help, but under the Baker Act, she said she had stretched 
the criteria that applied to my dad but felt he needed some 
kind of help.
    Senator Breaux. The incarceration that he had during this 
first period was at the hospital facility?
    Commander Gotham. That's correct. I have actually been down 
at the facility and walked around inside of it. It is a 
treatment facility recovery for drug and alcohol abuse. The 
average age appeared to be--I saw probably 60 patients as I 
walked around in the facility, and the average age was probably 
48 to 55 years old. There were young people there, semi-private 
rooms. It did not look like it was very supervised in terms of 
being able to walk out of your room, and walk the common areas.
    It is locked. You are restricted in certain areas that you 
have access to leave the facility.
    Senator Breaux. So after he was there for a period of time 
of about 7 days, then they released him. Did they diagnose that 
he had dementia at that time and say, look, we recommend that 
he take the following medications; we're releasing him and 
here's the prescription for what he should be on?
    Commander Gotham. We have seen one discharge paper. He was 
given three medications. Two of them were for high blood 
pressure and one was for cholesterol. He was on those 
medications, or a derivative of them, prior to going to the 
hospital.
    He was diagnosed with dementia and severe delirium. He was 
not given any medical prescription drug for those conditions. 
He was given one follow-up appointment on January 29, to go to 
the Marion Citrus mental health facility.
    Senator Breaux. So at no time after this first period was 
he under any kind of treatment or on medication for dementia or 
delirium?
    Commander Gotham. Absolutely not, sir.
    Senator Breaux. Tell me what happened that brought him to 
make the call the second time to the sheriff's department to 
check on him. What happened there?
    Commander Gotham. On that morning, a Saturday, I was 
actually supposed to go down and visit him. But because of my 
job, I had to brief a flag Officer on a Sunday. My sister 
called me that morning and my dad's phone was disconnected. She 
was leaving for work, so I called and confirmed that his phone 
was disconnected. I called my brother, Randy, who lives in 
Jacksonville, about 2 hours away, and he----
    Senator Breaux. Your sister lives where?
    Commander Gotham. In California.
    Randy was about 4 hours away from seeing him because he had 
two meetings to go to that day before he would see my dad. I 
said I was concerned about it and should we do another wellness 
check, since the first one had gone OK. We made the decision to 
do that.
    That is when I contacted the sheriff's dispatch and talked 
with the dispatch about having them do another well-being check 
on my dad.
    Senator Breaux. When was the first wellness check done? Was 
that after the incident when he was picked up and brought to 
the hospital?
    Commander Gotham. Yes, sir. That first week after the 12th, 
when he got out of the hospital, because there was such a 
dramatic change in my dad--he was talking about things that 
just were not real. In my process of contacting the sheriff and 
verifying information because he thought my step-mom had 
committed suicide. I was asking them how to get help. They said 
``Well, we have something called the wellness check.''
    So I did that the first week, from the 12th through the 
17th, and then it was not until February 7, that I made the 
call for the second wellness check.
    Senator Breaux. What generated the need to make that second 
wellness check again?
    Commander Gotham. Because we couldn't get in touch with 
him. His phone had been disconnected, and my brother was not 
going to see him until later that night.
    Senator Breaux. When that second wellness check commenced, 
can you tell us the details, to the extent you know what 
happened from the report? I mean, I take it that's a physical 
check, that the sheriff's department comes up to the house, 
knocks on the door to see if everything is all right.
    Commander Gotham. Yes, sir. Actually, I am incredibly 
familiar and too familiar with the details. I was kept on the 
phone through the entire event. Because I had warned them about 
my dad having a gun in the house and warned them about his 
mental condition, they actually made the call for two officers, 
a primary and a backup.
    The backup arrived on the scene first. What we know from 
eyewitnesses, neighbors who both saw it and actually took 
pictures of it, is that it quickly got into a verbal 
confrontation between this officer and my dad. In listening and 
reading the transcript of the 911 dispatch call, he said that 
my dad did have a gun in his hand. This officer drew his weapon 
and approached the house, in addition calling for a SWAT 
negotiator and other backup officers.
    About this time the second officer arrived on the scene, 
too. The first officer was maneuvering around the house and was 
crouched underneath one window and was approaching a second 
window, and based on the ballistics and the FDLE report, my dad 
had positioned himself behind the couch, underneath the window, 
and was looking up at an angle to the window at the same time 
that this officer then was looking down and into the window. My 
dad fired two rounds and struck the officer in his neck and 
tore his jugular vein and his aorta. The bullet actually 
traveled down through his aorta.
    After that, it appears that my dad had placed the gun on 
the table and had been running or moving inside the house as 
additional officers and SWAT team members had arrived on the 
scene. They had the house surrounded. They were attempting to 
decide to make a rescue or a recovery. A sergeant was placed in 
tactical control, even though there was another senior officer 
there. He had actually approached Brian Litz, who was on the 
ground, and had signaled to everybody that it was now a 
recovery, that Brian was obviously dead.
    He then changed his mind and decided that he did not like 
him being there on the ground and wanted to continue with a 
rescue, as if Brian was alive.
    As the SWAT team arrived on the scene, a two-man team, one 
of them placed a shield over the window that my father had 
fired out of. He has a window in that shield and he maintained 
eye contact with my dad, as well as another officer that 
maintained eye contact with my dad.
    It appears--and there is some conflict in the testimony and 
the statements by several of the officers--that they were able 
to get Brian Litz away from the house, carried him or dragged 
him about 25 feet, and then all the way down a driveway about 
50 feet, and then the shooting started happening at the scene 
from multiple directions from both handguns and from shotguns.
    At no time did they see a gun in my dad's hand. They said, 
``Well, we were screaming at your dad to show his hands, to put 
himself on the ground,'' to pay attention to them. At one point 
one of the officer's statement was that my dad was, in fact, on 
the ground, was kneeling in the house.
    The officer that had the shield clearly could see my dad 
but couldn't see his hands, is what he is describing. One of 
the other officers made the decision that he felt the movements 
of my dad somehow threatened the rescue, even though apparently 
by the statements the shooting started after the officer had 
been completely removed.
    Senator Breaux. All the officers were outside, just 
shooting into the house?
    Commander Gotham. That is correct, sir. One of the officers 
that actually fired the lethal round at my dad came in through 
a screened-in carport and then broke the glass and stuck his 
shotgun in through the house. My dad had been running from one 
side of the house to the other as they were firing different 
weapons at him, missing each time, miraculously, 74 years old 
and running like that. Then as he came back toward the kitchen 
where this officer was, the description is that either he tried 
to push the gun out of the way or grab the barrel and the 
shotgun went off and it fired a 12 gauge lethal shot and two of 
the pellets entered, one in his heart and one in his lung.
    Senator Breaux. Had your dad had any experience with 
weapons? Had he been in the service or anything before?
    Commander Gotham. He was in the Navy, but he was only there 
for about 2\1/2\ years. He had traveled on the ocean in a 
sailboat with my older brother. I insisted, because of piracy 
on the high seas, that both he and my brother have weapons in 
the boats.
    Senator Breaux. He didn't have combat experience in the 
military, though?
    Commander Gotham. No, sir. In fact, the gun that was used 
in this incident which he had, because he had traveled in an RV 
in America, he had never even fired that particular gun. That 
was the first day that it was ever even fired.
    Senator Breaux. I hate to ask you to speculate, but to the 
extent you know, where do you think the system broke down from 
the time that you called to make the second check on your 
father? Where do you think the system broke down in order to 
have the tragic results that occurred?
    Commander Gotham. I think there is three key areas. One is 
that the family was not notified of the initial Baker Act, and 
the fact that he was kept there for 7 days. I wouldn't want to 
be kept for those 7 days like that, confined like that.
    Second is that there was nobody there to receive him. They 
just let him go from the hospital. They took him home and 
dropped him off. No family was notified, no safety net, nobody 
to be there with him to help him, no counseling appointment for 
2 weeks, until January 29.
    The other key for me is the distinction between the two 
officers that made the wellness checks the officer from first 
time the officer that not only had Baker Acted him on the 5th, 
but had another incident with my dad on January 24. She had a 
certain ability about her, that she said when she approached 
the house on the 29th, my dad was clearly agitated, clearly was 
feeling that she was there to take him away again. He did not 
want to be taken. She was able to talk to him, get him to calm 
down, and they had a pretty good conversation on the 24th.
    I contrast that to the events that happened on February 7, 
where it is clear that a confrontation happened within seconds 
of that officer arriving, based on eyewitness accounts, and 
then it progressed from there, starting off with an argument to 
then having weapons drawn and shots being fired.
    Senator Breaux. It seems that you're expressing a feeling 
that they had taken your dad away under the Baker Act and 
incarcerated him for 7 days, and then they came back to the 
house a second time to do a wellness check. He was agitated and 
sort of felt they may have been coming back to take him back to 
the place where he would have been confined. Then the second 
time they came back again to do a wellness check. I guess 
you're speculating that your dad probably thought they were 
coming back to take him back again to the place where he had 
been confined before for 7 days.
    Commander Gotham. Yes, sir. On the first wellness call, 
actually my dad and I joked about it, that here was his son, 
his youngest son, calling the cops on him, as if we were joking 
back and forth. So it was not that big a deal with him on the 
first one.
    In hindsight, and in listening to the police officers and 
then all of us talking, it's like suicide. It is clear that all 
the indicators were there, but we did not have all the pieces 
of how scared he was about the police. His neighbors talked 
about conversations they had had with my dad, saying ``I never 
want to go back to that facility''. These were not things that 
I knew on the morning of the 7th. Had I known all these things, 
I would have done something different than calling the police. 
I just did not have an idea of the extent that he had, No. 1, 
interacted with the police, did not know the full extent about 
this involuntary incarceration, and didn't understand just the 
extent of how his mind had deteriorated.
    Senator Breaux. Well, this is a tragic story. I'm just 
concerned that the potential of this occurring in the future is 
very, very high because of the larger and larger number of 
people that are becoming more elderly as we live longer and 
longer, and also because of the necessity for families to be 
located throughout the United States.
    I mean, you're in Washington, one child is in Jacksonville, 
far away, and another one was in California, all looking after 
their families and earning a living. That's very common. You 
just can't run next door and check on mom and dad any more.
    My father lives in Louisiana by himself, and I can't just 
knock on the door and say ``how you doing?'' So it's very, very 
typical that these family arrangements are such.
    Dr. Cohen, in listening to the situation, what do you think 
could have been done differently? I guess I'm again asking 
where was the breakdown. I'm surprised that he was released 
after being picked up the first time under the Baker Act with 
no medication being prescribed for dementia and delirium. They 
gave him, I guess, cholesterol medicine and high blood pressure 
medicine. But it seems today, with the miracles of medication 
that we're finding, that there are medications that can be of 
assistance. That struck me as being unusual.
    Where do you think it could have gone differently and 
preventing this tragic event from happening?
    Dr. Cohen. Well, building on the themes of Dr. Lyketsos' 
testimony, and with the knowledge of the limited details, all 
the vivid details from the Commander, the breakdown was in the 
involuntary commitment and the enforcement, the process and the 
discharge.
    The Baker Act in Florida, implemented in the Seventies, was 
a model of its time, one of the first in the Nation. In the 
Nineties--and I was actually a part of this research effort--
older people were being Baker Acted and voluntarily committed 
multiple times in several parts of Florida----
    Senator Breaux. How often is this used in Florida?
    Dr. Cohen. How often is it used?
    Senator Breaux. Yes. Not the exact number, but is it used 
frequently, infrequently, or is it unusual to have a person 
Baker Acted?
    Dr. Cohen. It is used frequently to deal with individuals 
who have a mental illness and are a danger to themselves and 
others. In the Nineties, we found----
    Senator Breaux. Regardless of age?
    Dr. Cohen. Regardless of age. In fact, sadly, the discharge 
issues that we had, the issues you have in the use of the Baker 
Act, with children and adults being kept for longer periods of 
time until a hearing can be held, and the problems in the 
discharge, also occur with four, six, and 8-year-olds, 10-year-
old children.
    The Baker Act, in many areas of Florida, is used 
appropriately. In Hillsborough County, where the University of 
South Florida is located, we have very specific criteria about 
the receiving facilities. Your dad was taken to one facility 
and then moved on to another, as I understood your comments.
    The use of the Baker Act now in many parts of the State is 
appropriate.
    Senator Breaux. It seems to me that I think the first thing 
is the requirement of the Act, according to Commander Gotham, 
would be that when you have a person who is picked up alone in 
a house, and Baker Acted into a facility, the first thing I 
would want to do, after assuring of their safety, is to find 
out who they are. I mean, is there a son or a daughter. Who is 
this person connected to. If it's a child, you say where's the 
parents. If it's an elderly person, where's the children, 
where's the guardian, to start immediately trying to find out 
where the family is, to let them know that their dad or 
grandfather, mother or grand-mother, has been picked up for 
irrational behavior. That's a requirement of the Act, right?
    Dr. Cohen. That's correct. Indeed, from talking with the 
Gotham family prior to the hearing, the wallet was recorded as 
being on your father's body when he was brought in. There is a 
piece of paper with the names, the relationship, and the phone 
numbers of the children. That was a significant deviation from 
the appropriate admission of this gentleman.
    Also, sometimes there's a difficulty in scheduling a 
hearing within the 72 hours, and sometimes individuals are kept 
longer. But my understanding is they lost his paperwork and, 
therefore, a hearing was never called. So as you look at the 
details--and I'm just learning these details as you do--there 
were violations of the Baker Act at this point.
    As was said, we do have medications that can be effective 
in controlling this condition. Your dad wasn't seeing primary 
care physicians. There should have been in the discharge some 
appropriate follow up with his primary care. The police picked 
him up and he was taken over to the facility. They have the 
responsibility to reconnect him with a system of care. It's not 
like there weren't neighbors around who knew, not only that he 
was seeing other physicians, but also knew the family could be 
involved to provide this information. So I think there was a 
significant breakdown in the implementation of the Baker Act.
    I know that our State legislature prior to this has been 
concerned about some of these difficulties.
    Senator Breaux. Commander, how did you ultimately find out 
that he had been incarcerated under the Baker Act?
    Commander Gotham. In the days after he was killed, I was 
able to get copies of the police report from the 5th, from the 
newspaper, the Ocala Star Banner.
    Senator Breaux. But you knew about it before then, didn't 
you?
    Commander Gotham. My dad and I talked about it, but his 
details of what happened, other than he was in a hospital, were 
very sketchy for him to say, to talk with me about.
    There are two things I would like to share with you, 
Senator. The 2003 report required in the State of Florida for 
the Baker Act had over 120,000 Baker Act incidents, of which 9 
percent of those placed were 65 and older.
    Senator Breaux. Ninety percent?
    Commander Gotham. Nine percent of 120,000.
    Senator Breaux. Only 9 percent.
    Commander Gotham. Yes, sir.
    Senator Breaux. Again, no one ever contacted you to let you 
know that your dad had been picked up, or your other brother 
and sister were notified by authorities that he had been picked 
up under the Baker Act? It was your father who told you 
ultimately?
    Commander Gotham. That is absolutely correct. It was the 
neighbor, on January 12, who e-mailed me and said your dad has 
been in the hospital for the past 7 days; you need to give him 
some help.
    When I started calling around to my brothers and sister, 
saying ``Does anybody know what the heck's been going on, the 
answer was no.'' None of us knew. I was able to establish 
contact on that very day, the 12th, with my dad.
    He did tell me that he had been in a hospital. He explained 
to me the incident that had happened. I think he was very 
embarrassed about his zipper being down, or whatever the 
details were that happened. He had explained to me why he was 
kept beyond the 72 hours, that there was a paperwork problem, 
that he should have been just in and out. It was tragic for 
him. He was having a very difficult time being able to tell me 
what happened. I did not know those details, what the Baker Act 
was, that he was in a mental hospital and not a regular 
hospital. I had felt that he probably had had a stroke and was 
in an actual hospital being treated for another stroke.
    Senator Breaux. Mr. Rothman and Dr. Lyketsos, you both have 
heard the Commander's testimony and what I asked of Dr. Cohen. 
Do either one of you have any comments before I ask you some 
specific questions, in general about the situation?
    Mr. Rothman. I am aware that in Palm Beach County, there is 
a group of Alzheimer's providers that are working to address 
the very issue that's been described with respect to the Baker 
Act, in that it's inappropriate for people with Alzheimer's or 
dementia anyway. They do not have access to services that are 
dementia-specific, as I understand it.
    Dr. Cohen. Right.
    Mr. Rothman. So a group in Palm Beach County is currently 
trying to work with the State of Florida to address that issue.
    The other thing that comes to mind is that, in this 
particular case, had his father ever come to the attention of 
the courts, if he had not been in Palm Beach County, I doubt 
anyone would have responded any differently than anyone else 
did in this process. Perhaps in Palm Beach County, where there 
is an Elder Justice Center that does get involved with 
offenders, particularly those who are placed in jail, they do 
go in and try to identify what underlying causes exist in a 
particular case and make an appropriate recommendation to the 
judge for assessment and potential follow-up services.
    Senator Breaux. Who does this in Palm Beach County? What 
association?
    Mr. Rothman. Well, it's called the Elder Justice Center. 
It's an office of the court. It functions under the authority 
of the judicial administrator for the jurisdiction. They do 
send, on a regular basis, their staff into the jail to see an 
older offender, 60 and above, although most of the people they 
see I understand are over 70, and they will make a 
recommendation to the judge at the first hearing, that there 
should be an assessment and potentially there should be 
services provided in a given case, that it would or would not 
be appropriate to keep that person in jail pending further 
hearings, and----
    Senator Breaux. It seems like there should be a referral, 
that when a person picked up under the Baker Act is released 
from custody, there should be a referral to some agency or some 
medical doctor, to say that Mr. so and so was picked up and we 
evaluated him and let him go, but here's what our concerns are.
    Dr. Lyketsos. Senator, I just wanted to comment that the 
events prior to February 7, are very familiar to me. This is a 
very common issue.
    I want to emphasize a piece that the Commander did not 
bring out, which is that his father had seen his primary care 
doctor in November and was being followed for prostate 
problems, and yet it was not detected that he had dementia. I 
would therefore like to move the timeframe much earlier and 
wonder about whether a lot of this could have been managed 
within the health care system much earlier without having this 
level of escalation.
    Senator Breaux. That's the whole series of questions I 
wanted to get to you about, and that is a lack of trained 
medical professionals and the area of recognizing dementia. Too 
many times we hear the report that well, he or she is just 
getting old and they're supposed to act like that, not 
recognizing there is a dementia problem or the advent of 
Alzheimer's or the advent of vascular dementia or some other 
problem that really is a serious medical problem that may be 
able to be handled differently, other than just letting them go 
and saying``Well, he or she is just old, and old people are 
supposed to act like that.''
    I note that at Johns Hopkins you are a professor of a 
department that most medical schools don't have. Most medical 
schools have very little training in geriatric specialties for 
general practitioners. There are very few specialty programs at 
all.
    So what should we do about that?
    Dr. Lyketsos. It's a very complicated answer.
    One thing would be to create incentives in the primary care 
setting, so that dementia can be recognized and treated better. 
For example, primary care physicians--and I've had this 
conversation with several of them over the years--don't feel 
that there is much reason to detect dementia because it 
alienates patients, they don't get paid for it, that family 
members----
    Senator Breaux. Any time you diagnose an illness, it 
probably alienates the patient who doesn't want to hear they 
have cancer, for instance, but you don't not tell them that 
because it may alienate their affections.
    Dr. Lyketsos. That's usually my answer to that. What I 
actually add is that their role in prevention of this kind of 
incident, or even a much smaller level of severity of this, 
which ends up being fairly common, is really important.
    Senator Breaux. In the Medicare bill that was just passed 
and signed into law we provide for the first time, in essence, 
a baseline physical for someone coming into the Medicare 
program. This is so that the person who becomes eligible for 
Medicare will at least be entitled to a baseline physical, 
conducted by a medical professional, to give them a baseline 
study of what the problems are that this person is 
experiencing, or what are the potential problems if they in 
fact are not treated properly in the future, instead of waiting 
for someone to be on Medicare for 10, 12, 13 years before they 
ever see a doctor for the first time.
    If you're 65 and you have your baseline physical and 
Medicare is going to pay for it, so you go do it, can that type 
of physical provide any helpful information in determining 
whether someone is on the advent of dementia?
    Dr. Lyketsos. Yes, it can. It's possible to incorporate in 
the physical exam assessments of cognitive state that would 
determine whether someone has early dementia or not. In fact, 
what we refer to as the very old, over age 80, it is probably 
critical that everyone have a cognitive assessment. Something 
called the mini-mental state is probably the most quoted method 
of doing that. But there are many others. Primary care 
physicians, as a rule, do not incorporate that sort of an 
assessment within their physical.
    Senator Breaux. Do we find in the medical profession that 
these incidents of violence among dementia patients is all of a 
sudden, where someone snaps and creates a violent act, or is it 
more of a gradual movement toward increasing violence which may 
ultimately lead to real serious violence?
    Dr. Lyketsos. The vast majority are of the latter kind, 
with a gradual increase. Occasionally there is the big snap, 
but that's very uncommon. It is therefore possible to recognize 
this sort of thing coming on most of the time.
    Senator Breaux. Mr. Rothman or anybody can comment on this, 
but is there any requirement that a physician report to law 
enforcement officers when they are treating a person for 
anything, but particularly for dementia that, in that doctor's 
professional opinion, may lead to potential violence?
    Dr. Lyketsos. As far as I know--it's likely to State 
dependent. But as far as I know, this would come under the 
Tarasoff type rules that exist within a given State. So in 
Maryland, for example, I could only breach confidentiality if I 
know the specific person that is being threatened by the 
patient. As a rule, I don't.
    But to step back before we even get there, probably the 
most critical involvement early on is the family. What one does 
with early dementia detection in primary care is involve the 
family in the care of the person and put into place alternative 
decisionmaking routes that often involve the family, so that 
when you have an escalating crisis, you have other people 
involved in decisions about moving out of your home, about 
removing guns from the home and so forth, the kinds of things 
that would have been preventive interventions in the Gotham 
case.
    Senator Breaux. Dr. Cohen.
    Dr. Cohen. Just to go back to your comment about the 
Medicare reimbursing for a physical, Medicare does not 
reimburse for time that physicians spend with family members. 
Along these lines, when it comes to evaluating the patient, I 
think that we need more reimbursement for family time.
    Also, a physical exam does not necessarily----
    Senator Breaux. If I was a smart doctor, I would just bill 
the whole thing as advising the patient while I was talking to 
the children.
    Dr. Cohen. Some of them do that.
    Senator Breaux. I would think some of them could figure 
that out pretty quick.
    Dr. Lyketsos. Doctors are scared of felony charges.
    Dr. Cohen. Exactly. [Laughter.]
    Senator Breaux. They're also very clever.
    Dr. Cohen. The physical exam doesn't include the 
psychiatric exam. Again, the primary care community is not 
trained in the recognition of depression, as has come up in 
other hearings, or other psychiatric problems.
    Senator Breaux. That's why I asked the question, whether it 
would be recognizable under a normal physical exam. It's really 
questionable.
    Dr. Lyketsos. I think the primary care physicians should 
change their practice, what I would rather approach this as, 
and incorporate this in the physical exam.
    Senator Breaux. If they had the training, which we don't 
provide in most medical schools, they could probably recognize 
it more than ``he's just getting old and is supposed to act 
like that.''
    Dr. Cohen. That's correct.
    Senator Breaux. The lack of information I think is really 
key. I think a part of the Elder Justice Act, which we're 
trying to get through the Congress, is in order to try to 
provide greater information so that we can make more rationale 
decisions and more intelligent decisions.
    Commander.
    Commander Gotham. Senator, if I could, one of the dynamics 
of this that was somewhat shocking to us is that we had found 
out that my dad had turned in his hearing aid, one of two 
hearing aids, in December. The woman that worked with my sister 
in describing that had talked about how patients with one or 
two hearing aids out, that their loss of hearing can lead to 
states of confusion and misdiagnosis. It calls into question 
some of the actions of police.
    My dad clearly only had one of two hearing aids in that 
day. Yelling at him, and yelling from multiple directions, and 
with a dog in the house, you're not going to get any kind of 
response from somebody like that.
    Senator Breaux. Like I always say, at least you got your 
dad to wear a hearing aid. I have not been successful in 
getting my dad to do that.
    All right. This has been a very informative hearing. It 
will be a matter now of the public record of the Senate Aging 
Committee and the U.S. Senate. We will make sure that the 
proper people who are in positions, myself included, who make a 
difference in these areas will have the benefit of what was 
said and your testimony. I appreciate it very, very much, 
particularly you, Commander, and your family here in the 
audience, for being with us. You're making a real contribution, 
so that the tragedy that you have experienced is not to be 
repeated in the future, hopefully, if we do the right thing. So 
we thank you in particular for that contribution.
    With that, the hearing will be adjourned.
    [Whereupon, at 3:20 p.m., the committee was adjourned.]

                            A P P E N D I X

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