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Illustration Essay Of Neglect Of The Elderly

For years, Rudy North woke up at 9 A.M. and read the Las Vegas Review-Journal while eating a piece of toast. Then he read a novel—he liked James Patterson and Clive Cussler—or, if he was feeling more ambitious, Freud. On scraps of paper and legal notepads, he jotted down thoughts sparked by his reading. “Deep below the rational part of our brain is an underground ocean where strange things swim,” he wrote on one notepad. On another, “Life: the longer it cooks, the better it tastes.”

Rennie, his wife of fifty-seven years, was slower to rise. She was recovering from lymphoma and suffered from neuropathy so severe that her legs felt like sausages. Each morning, she spent nearly an hour in the bathroom applying makeup and lotions, the same brands she’d used for forty years. She always emerged wearing pale-pink lipstick. Rudy, who was prone to grandiosity, liked to refer to her as “my amour.”

On the Friday before Labor Day, 2013, the Norths had just finished their toast when a nurse, who visited five times a week to help Rennie bathe and dress, came to their house, in Sun City Aliante, an “active adult” community in Las Vegas. They had moved there in 2005, when Rudy, a retired consultant for broadcasters, was sixty-eight and Rennie was sixty-six. They took pride in their view of the golf course, though neither of them played golf.

Rudy chatted with the nurse in the kitchen for twenty minutes, joking about marriage and laundry, until there was a knock at the door. A stocky woman with shiny black hair introduced herself as April Parks, the owner of the company A Private Professional Guardian. She was accompanied by three colleagues, who didn’t give their names. Parks told the Norths that she had an order from the Clark County Family Court to “remove” them from their home. She would be taking them to an assisted-living facility. “Go and gather your things,” she said.

Rennie began crying. “This is my home,” she said.

One of Parks’s colleagues said that if the Norths didn’t comply he would call the police. Rudy remembers thinking, You’re going to put my wife and me in jail for this? But he felt too confused to argue.

Parks drove a Pontiac G-6 convertible with a license plate that read “CRTGRDN,” for “court guardian.” In the past twelve years, she had been a guardian for some four hundred wards of the court. Owing to age or disability, they had been deemed incompetent, a legal term that describes those who are unable to make reasoned choices about their lives or their property. As their guardian, Parks had the authority to manage their assets, and to choose where they lived, whom they associated with, and what medical treatment they received. They lost nearly all their civil rights.

Without realizing it, the Norths had become temporary wards of the court. Parks had filed an emergency ex-parte petition, which provides an exception to the rule that both parties must be notified of any argument before a judge. She had alleged that the Norths posed a “substantial risk for mismanagement of medications, financial loss and physical harm.” She submitted a brief letter from a physician’s assistant, whom Rennie had seen once, stating that “the patient’s husband can no longer effectively take care of the patient at home as his dementia is progressing.” She also submitted a letter from one of Rudy’s doctors, who described him as “confused and agitated.”

Rudy and Rennie had not undergone any cognitive assessments. They had never received a diagnosis of dementia. In addition to Freud, Rudy was working his way through Nietzsche and Plato. Rennie read romance novels.

Parks told the Norths that if they didn’t come willingly an ambulance would take them to the facility, a place she described as a “respite.” Still crying, Rennie put cosmetics and some clothes into a suitcase. She packed so quickly that she forgot her cell phone and Rudy’s hearing aid. After thirty-five minutes, Parks’s assistant led the Norths to her car. When a neighbor asked what was happening, Rudy told him, “We’ll just be gone for a little bit.” He was too proud to draw attention to their predicament. “Just think of it as a mini-vacation,” he told Rennie.

After the Norths left, Parks walked through the house with Cindy Breck, the owner of Caring Transitions, a company that relocates seniors and sells their belongings at estate sales. Breck and Parks had a routine. “We open drawers,” Parks said at a deposition. “We look in closets. We pull out boxes, anything that would store—that would keep paperwork, would keep valuables.” She took a pocket watch, birth certificates, insurance policies, and several collectible coins.

The Norths’ daughter, Julie Belshe, came to visit later that afternoon. A fifty-three-year-old mother of three sons, she and her husband run a small business designing and constructing pools. She lived ten miles away and visited her parents nearly every day, often taking them to her youngest son’s football games. She was her parents’ only living child; her brother and sister had died.

She knocked on the front door several times and then tried to push the door open, but it was locked. She was surprised to see the kitchen window closed; her parents always left it slightly open. She drove to the Sun City Aliante clubhouse, where her parents sometimes drank coffee. When she couldn’t find them there, she thought that perhaps they had gone on an errand together—the farthest they usually drove was to Costco. But, when she returned to the house, it was still empty.

That weekend, she called her parents several times. She also called two hospitals to see if they had been in an accident. She called their landlord, too, and he agreed to visit the house. He reported that there were no signs of them. She told her husband, “I think someone kidnapped my parents.”

On the Tuesday after Labor Day, she drove to the house again and found a note taped to the door: “In case of emergency, contact guardian April Parks.” Belshe dialled the number. Parks, who had a brisk, girlish way of speaking, told Belshe that her parents had been taken to Lakeview Terrace, an assisted-living facility in Boulder City, nine miles from the Arizona border. She assured Belshe that the staff there would take care of all their needs.

“You can’t just walk into somebody’s home and take them!” Belshe told her.

Parks responded calmly, “It’s legal. It’s legal.”

Guardianship derives from the state’s parens patriae power, its duty to act as a parent for those considered too vulnerable to care for themselves. “The King shall have the custody of the lands of natural fools, taking the profits of them without waste or destruction, and shall find them their necessaries,” reads the English statute De Prerogative Regis, from 1324. The law was imported to the colonies—guardianship is still controlled by state, not federal, law—and has remained largely intact for the past eight hundred years. It establishes a relationship between ward and guardian that is rooted in trust.

In the United States, a million and a half adults are under the care of guardians, either family members or professionals, who control some two hundred and seventy-three billion dollars in assets, according to an auditor for the guardianship fraud program in Palm Beach County. Little is known about the outcome of these arrangements, because states do not keep complete figures on guardianship cases—statutes vary widely—and, in most jurisdictions, the court records are sealed. A Government Accountability report from 2010 said, “We could not locate a single Web site, federal agency, state or local entity, or any other organization that compiles comprehensive information on this issue.” A study published this year by the American Bar Association found that “an unknown number of adults languish under guardianship” when they no longer need it, or never did. The authors wrote that “guardianship is generally “permanent, leaving no way out—‘until death do us part.’ ”

When the Norths were removed from their home, they joined nearly nine thousand adult wards in the Las Vegas Valley. In the past twenty years, the city has promoted itself as a retirement paradise. Attracted by the state’s low taxes and a dry, sunny climate, elderly people leave their families behind to resettle in newly constructed senior communities. “The whole town sparkled, pulling older people in with the prospect of the American Dream at a reasonable price,” a former real-estate agent named Terry Williams told me. Roughly thirty per cent of the people who move to Las Vegas are senior citizens, and the number of Nevadans older than eighty-five has risen by nearly eighty per cent in the past decade.

In Nevada, as in many states, anyone can become a guardian by taking a course, as long as he or she has not been convicted of a felony or recently declared bankruptcy. Elizabeth Brickfield, a Las Vegas lawyer who has worked in guardianship law for twenty years, said that about fifteen years ago, as the state’s elderly population swelled, “all these private guardians started arriving, and the docket exploded. The court became a factory.”

Pamela Teaster, the director of the Center for Gerontology at Virginia Tech and one of the few scholars in the country who study guardianship, told me that, though most guardians assume their duties for good reasons, the guardianship system is “a morass, a total mess.” She said, “It is unconscionable that we don’t have any data, when you think about the vast power given to a guardian. It is one of society’s most drastic interventions.”

After talking to Parks, Belshe drove forty miles to Lakeview Terrace, a complex of stucco buildings designed to look like a hacienda. She found her parents in a small room with a kitchenette and a window overlooking the parking lot. Rennie was in a wheelchair beside the bed, and Rudy was curled up on a love seat in the fetal position. There was no phone in the room. Medical-alert buttons were strung around their necks. “They were like two lost children,” Belshe said.

She asked her parents who Parks was and where she could find the court order, but, she said, “they were overwhelmed and humiliated, and they didn’t know what was going on.” They had no idea how or why Parks had targeted them as wards. Belshe was struck by their passive acceptance. “It was like they had Stockholm syndrome or something,” she told me.

Belshe acknowledged that her parents needed a few hours of help each day, but she had never questioned their ability to live alone. “They always kept their house really nice and clean, like a museum,” she said. Although Rudy’s medical records showed that he occasionally had “staring spells,” all his medical-progress notes from 2013 described him as alert and oriented. He did most of the couple’s cooking and shopping, because Rennie, though lucid, was in so much pain that she rarely left the house. Belshe sometimes worried that her father inadvertently encouraged her mother to be docile: “She’s a very smart woman, though she sometimes acts like she’s not. I have to tell her, ‘That’s not cute, Mom.’ ”

When Belshe called Parks to ask for the court order, Parks told her that she was part of the “sandwich generation,” and that it would be too overwhelming for her to continue to care for her children and her parents at the same time. Parks billed her wards’ estates for each hour that she spent on their case; the court placed no limits on guardians’ fees, as long as they appeared “reasonable.” Later, when Belshe called again to express her anger, Parks charged the Norths twenty-four dollars for the eight-minute conversation. “I could not understand what the purpose of the call was other than she wanted me to know they had rights,” Parks wrote in a detailed invoice. “I terminated the phone call as she was very hostile and angry.”

A month after removing the Norths from their house, Parks petitioned to make the guardianship permanent. She was represented by an attorney who was paid four hundred dollars an hour by the Norths’ estate. A hearing was held at Clark County Family Court.

The Clark County guardianship commissioner, a lawyer named Jon Norheim, has presided over nearly all the guardianship cases in the county since 2005. He works under the supervision of a judge, but his orders have the weight of a formal ruling. Norheim awarded a guardianship to Parks, on average, nearly once a week. She had up to a hundred wards at a time. “I love April Parks,” he said at one hearing, describing her and two other professional guardians, who frequently appeared in his courtroom, as “wonderful, good-hearted, social-worker types.”

Norheim’s court perpetuated a cold, unsentimental view of family relations: the ingredients for a good life seemed to have little to do with one’s children and siblings. He often dismissed the objections of relatives, telling them that his only concern was the best interest of the wards, which he seemed to view in a social vacuum. When siblings fought over who would be guardian, Norheim typically ordered a neutral professional to assume control, even when this isolated the wards from their families.

Rudy had assured Belshe that he would protest the guardianship, but, like most wards in the country, Rudy and Rennie were not represented by counsel. As Rudy stood before the commissioner, he convinced himself that guardianship offered him and Rennie a lifetime of care without being a burden to anyone they loved. He told Norheim, “The issue really is her longevity—what suits her.” Belshe, who sat in the courtroom, said, “I was shaking my head. No, no, no—don’t do that!” Rennie was silent.

Norheim ordered that the Norths become permanent wards of the court. “Chances are, I’ll probably never see you folks again; you’ll work everything out,” he said, laughing. “I very rarely see people after the initial time in court.” The hearing lasted ten minutes.

The following month, Even Tide Life Transitions, a company that Parks often hired, sold most of the Norths’ belongings. “The general condition of this inventory is good,” an appraiser wrote. Two lithographs by Renoir were priced at thirty-eight hundred dollars, and a glass cocktail table (“Client states that it is a Brancusi design”) was twelve hundred and fifty dollars. The Norths also had several pastel drawings by their son, Randy, who died in a motorcycle accident at the age of thirty-two, as well as Kachina dolls, a Bose radio, a Dyson vacuum cleaner, a Peruvian tapestry, a motion-step exerciser, a LeRoy Neiman sketch of a bar in Dublin, and two dozen pairs of Clarke shoes. According to Parks’s calculations, the Norths had roughly fifty thousand dollars. Parks transferred their savings, held at the Bank of America, to an account in her name.

Rennie repeatedly asked for her son’s drawings, and for the family photographs on her refrigerator. Rudy pined for his car, a midnight-blue 2010 Chrysler, which came to symbolize the life he had lost. He missed the routine interactions that driving had allowed him. “Everybody at the pharmacy was my buddy,” he said. Now he and Rennie felt like exiles. Rudy said, “They kept telling me, ‘Oh, you don’t have to worry: your car is fine, and this and that.’ ” A month later, he said, “they finally told me, ‘Actually, we sold your car.’ I said, ‘What in the hell did you sell it for?’ ” It was bought for less than eight thousand dollars, a price that Rudy considered insulting.

Rudy lingered in the dining room after eating breakfast each morning, chatting with other residents of Lakeview Terrace. He soon discovered that ten other wards of April Parks lived there. His next-door neighbor, Adolfo Gonzalez, a short, bald seventy-one-year-old who had worked as a maître d’ at the MGM Grand Las Vegas, had become Parks’s ward at a hearing that lasted a minute and thirty-one seconds.

Gonzalez, who had roughly three hundred and fifty thousand dollars in assets, urged Rudy not to accept the nurse’s medications. “If you take the pills, they’ll make sure you don’t make it to court,” he said. Gonzalez had been prescribed the antipsychotic medications Risperdal and Depakote, which he hid in the side of his mouth without swallowing. He wanted to remain vigilant. He often spoke of a Salvador Dali painting that had been lost when Parks took over his life. Once, she charged him two hundred and ten dollars for a visit in which, according to her invoice, he expressed that “he feels like a prisoner.”

Rudy was so distressed by his conversations with Gonzalez that he asked to see a psychologist. “I thought maybe he’d give me some sort of objective learning as to what I was going through,” he said. “I wanted to ask basic questions, like What the hell is going on?” Rudy didn’t find the session illuminating, but he felt a little boost to his self-esteem when the psychologist asked that he return for a second appointment. “I guess he found me terribly charming,” he told me.

Rudy liked to fantasize about an alternative life as a psychoanalyst, and he tried to befriend the wards who seemed especially hopeless. “Loneliness is a physical pain that hurts all over,” he wrote in his notebook. He bought a pharmaceutical encyclopedia and advised the other wards about medications they’d been prescribed. He also ran for president of the residents, promising that under his leadership the kitchen would no longer advertise canned food as homemade. (He lost—he’s not sure if anyone besides Rennie voted for him—but he did win a seat on the residents’ council.)

He was particularly concerned about a ward of Parks’s named Marlene Homer, a seventy-year-old woman who had been a professor. “Now she was almost hiding behind the pillars,” Rudy said. “She was so obsequious. She was, like, ‘Run me over. Run me over.’ ” She’d become a ward in 2012, after Parks told the court, “She has admitted to strange thoughts, depression, and doing things she can’t explain.” On a certificate submitted to the court, an internist had checked a box indicating that Homer was “unable to attend the guardianship court hearing because______,” but he didn’t fill in a reason.

The Norths could guess which residents were Parks’s wards by the way they were dressed. Gonzalez wore the same shirt to dinner nearly every day. “Forgive me,” he told the others at his table. When a friend tried to take him shopping, Parks prevented the excursion because she didn’t know the friend. Rennie had also tried to get more clothes. “I reminded ward that she has plenty of clothing in her closet,” Parks wrote. “I let her know that they are on a tight budget.” The Norths’ estate was charged a hundred and eighty dollars for the conversation.

Another resident, Barbara Neely, a fifty-five-year-old with schizophrenia, repeatedly asked Parks to buy her outfits for job interviews. She was applying for a position with the Department of Education. After Neely’s third week at Lakeview Terrace, Parks’s assistant sent Parks a text. “Can you see Barbara Neely anytime this week?” she wrote. “She has questions on the guardianship and how she can get out of it.” Parks responded, “I can and she can’t.” Neely had been in the process of selling her house, for a hundred and sixty-eight thousand dollars, when Parks became her guardian and took charge of the sale.

The rationale for the guardianship of Norbert Wilkening, who lived on the bottom floor of the facility, in the memory-care ward, for people with dementia (“the snake pit,” Rudy called it), was also murky. Parks’s office manager, who advertised himself as a “Qualified Dementia Care Specialist”—a credential acquired through video training sessions—had given Wilkening a “Mini-Mental State Examination,” a list of eleven questions and tasks, including naming as many animals as possible in a minute. Wilkening had failed. His daughter, Amy, told me, “I didn’t see anything that was happening to him other than a regular getting-older process, but when I was informed by all these people that he had all these problems I was, like, Well, maybe I’m just in denial. I’m not a professional.” She said that Parks was “so highly touted. By herself, by the social workers, by the judge, by everyone that knew her.”

At a hearing, when Amy complained to Norheim that Parks didn’t have time for her father, he replied, “Yeah, she’s an industry at this point.”

As Belshe spoke to more wards and their families, she began to realize that Lakeview Terrace was not the only place where wards were lodged, and that Parks was not the only guardian removing people from their homes for what appeared to be superficial reasons. Hundreds of cases followed the same pattern. It had become routine for guardians in Clark County to petition for temporary guardianship on an ex-parte basis. They told the court that they had to intervene immediately because the ward faced a medical emergency that was only vaguely described: he or she was demented or disoriented, and at risk of exploitation or abuse. The guardians attached a brief physician’s certificate that contained minimal details and often stated that the ward was too incapacitated to attend a court hearing. Debra Bookout, an attorney at the Legal Aid Center of Southern Nevada, told me, “When a hospital or rehab facility needs to free up a bed, or when the patient is not paying his bills, some doctors get sloppy, and they will sign anything.” A recent study conducted by Hunter College found that a quarter of guardianship petitions in New York were brought by nursing homes and hospitals, sometimes as a means of collecting on overdue bills.

It often took several days for relatives to realize what had happened. When they tried to contest the guardianship or become guardians themselves, they were dismissed as unsuitable, and disparaged in court records as being neglectful, or as drug addicts, gamblers, and exploiters. (Belshe was described by Parks as a “reported addict” who “has no contact with the proposed ward,” an allegation that Belshe didn’t see until it was too late to challenge.) Family who lived out of state were disqualified from serving as guardians, because the law prohibited the appointment of anyone who didn’t live in Nevada.

Once the court approved the guardianship, the wards were often removed from their homes, which were eventually sold. Terry Williams, whose father’s estate was taken over by strangers even though he’d named her the executor of his will, has spent years combing through guardianship, probate, and real-estate records in Clark County. “I kept researching, because I was so fascinated that these people could literally take over the lives and assets of people under color of law, in less than ten minutes, and nobody was asking questions,” she told me. “These people spent their lives accumulating wealth and, in a blink of an eye, it was someone else’s.”

Williams has reviewed hundreds of cases involving Jared Shafer, who is considered the godfather of guardians in Nevada. In the records room of the courthouse, she was afraid to say Shafer’s name out loud. In the course of his thirty-five-year career, Shafer has assumed control of more than three thousand wards and estates and trained a generation of guardians. In 1979, he became the county’s public administrator, handling the estates of people who had no relatives in Nevada, as well as the public guardian, serving wards when no family members or private guardians were available. In 2003, he left government and founded his own private guardianship and fiduciary business; he transferred the number of his government-issued phone to himself.

Williams took records from Shafer’s and other guardians’ cases to the Las Vegas police department several times. She tried to explain, she said, that “this is a racketeering operation that is fee-based. There’s no brown paper bag handed off in an alley. The payoff is the right to bill the estate.” The department repeatedly told her that it was a civil issue, and refused to take a report. In 2006, she submitted a typed statement, listing twenty-three statutes that she thought had been violated, but an officer wrote in the top right corner, “NOT A POLICE MATTER.” Adam Woodrum, an estate lawyer in Las Vegas, told me that he’s worked with several wards and their families who have brought their complaints to the police. “They can’t even get their foot in the door,” he said.

Acting as her own attorney, Williams filed a racketeering suit in federal court against Shafer and the lawyers who represented him. At a hearing before the United States District Court of Central California in 2009, she told the judge, “They are trumping up ways and means to deem people incompetent and take their assets.” The case was dismissed. “The scheme is ingenious,” she told me. “How do you come up with a crime that literally none of the victims can articulate without sounding like they’re nuts? The same insane allegations keep surfacing from people who don’t know each other.”

In 2002, in a petition to the Clark County District Court, a fifty-seven-year-old man complained that his mother had lost her constitutional rights because her kitchen was understocked and a few bills hadn’t been paid. The house they shared was then placed on the market. The son wrote, “If the only showing necessary to sell the home right out from under someone is that their ‘estate’ would benefit, then no house in Clark County is safe, nor any homeowner.” Under the guise of benevolent paternalism, guardians seemed to be creating a kind of capitalist dystopia: people’s quality of life was being destroyed in order to maximize their capital.

When Concetta Mormon, a wealthy woman who owned a Montessori school, became Shafer’s ward because she had aphasia, Shafer sold the school midyear, even though students were enrolled. At a hearing after the sale, Mormon’s daughter, Victoria Cloutier, constantly spoke out of turn. The judge, Robert Lueck, ordered that she be handcuffed and placed in a holding cell while the hearing continued. Two hours later, when Cloutier was allowed to return for the conclusion, the judge told her that she had thirty days in which to vacate her mother’s house. If she didn’t leave, she would be evicted and her belongings would be taken to Goodwill.

The opinions of wards were also disregarded. In 2010, Guadalupe Olvera, a ninety-year-old veteran of the Second World War, repeatedly asked that his daughter and not Shafer be appointed his guardian. “The ward is not to go to court,” Shafer instructed his assistants. When Olvera was finally permitted to attend a hearing, nearly a year after becoming a ward, he expressed his desire to live with his daughter in California, rather than under Shafer’s care. “Why is everybody against that?” he asked Norheim. “I don’t need that man.” Although Nevada’s guardianship law requires that courts favor relatives over professionals, Norheim continued the guardianship, saying, “The priority ship sailed.”

When Olvera’s daughter eventually defied the court’s orders and took her father to live at her seaside home in Northern California, Norheim’s supervisor, Judge Charles Hoskin, issued an arrest warrant for her “immediate arrest and incarceration” without bail. The warrant was for contempt of court, but Norheim said at least five times from the bench that she had “kidnapped” Olvera. At a hearing, Norheim acknowledged that he wasn’t able to send an officer across state lines to arrest the daughter. Shafer said, “Maybe I can.”

Shafer held so much sway in the courtroom that, in 2013, when an attorney complained that the bank account of a ward named Kristina Berger had “no money left and no records to explain where it went,” Shafer told Norheim, “Close the courtroom.” Norheim immediately complied. A dozen people in attendance were forced to leave.

population age 65 and older increased by 188 percent, and the population 85 and older increased by 635 percent (Eberhardt et al., 2001, Hetzel and Smith, 2001). Over this same period, the life expectancy of people at age 65 increased from 13.9 to 17.9 years (Natonal Center for Health Statistics, unpublished data, 2001). These trends will likely be accentuated by the aging of the post-WWII baby boom generation. The U.S. Bureau of the Census predicts that by 2030, the population over age 65 will nearly triple to more than 70 million people, and older people will make up more than 20 percent of the population (up from 12.3 percent in 1990) (Population Projections Program, 2000).

It is heartening that large proportions of the nation’s older people are living without substantial disability. Among people age 75 and older in 1999, 70 percent described their health as good or excellent (Eberhardt et al., 2001). Inevitably, however, the aging of the population is also associated with increases in age-related diseases and disabilities. Of the estimated 12.8 million Americans reporting need for assistance with activities of daily living (ADLs—eating, dressing, bathing, transferring between the bed and a chair, toileting, controlling bladder and bowel) or instrumental activities of daily living (IADLs—preparing meals, performing housework, taking drugs, going on errands, managing finances, using a telephone), 57 percent (7.3 million people) were over the age of 65 (Administration on Aging, 1997). Dementia is present in approximately 5 to 10 percent of persons age 65 and older and 30 to 39 percent of persons age 85 and older (Rice et al., 2001; Henderson, 1998). Among people age 85 and older in 1999, 33 percent reported themselves to be in fair or poor health, 84 percent had disabilities involving mobility (unpublished data Natonal Center for Health Statistics, 2002), and 16 percent had Alzheimer’s disease (Brookmeyer et al., 1998).

Given the projected growth in the elderly population, long-term care for elderly people with disabilities has become an increasingly urgent policy concern (Institute of Medicine, 2001; Stone, 2000). The settings in which long-term care is provided depend on a variety of factors, including the older person’s needs and preferences, the availability of informal support, and the source of reimbursement for care. An increasing number of elderly people reside outside traditional home settings in highly restrictive institutional environments (such as skilled or intermediate nursing facilities) or in less restrictive community-based residential settings, such as assisted living facilities, board and care homes, and adult foster homes. Among the 34 million persons over age 65 in 1995, 5 percent were nursing home residents, and 12 percent lived in the community setting with ADL or IADL limitations. The number of nursing home residents increased between 1973–1974 and 1999 from 961,500 to 1,469,500 among those age 65 and older, and from 413,6000 to 757,100 among those 85 and older (Eberhardt et al., 2001). In 1999, another 500,000 elderly people were living in