U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

93–525 PDF 2004

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

(

SPECIAL COMMITTEE ON AGING 

LARRY CRAIG, Idaho, Chairman 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MIKE ENZI, Wyoming 

GORDON SMITH, Oregon 

JAMES M. TALENT, Missouri 

PETER G. FITZGERALD, Illinois 

ORRIN G. HATCH, Utah 

ELIZABETH DOLE, North Carolina 

TED STEVENS, Alaska 

RICK SANTORUM, Pennsylvania 

JOHN B. BREAUX, Louisiana, Ranking 

Member 

HARRY REID, Nevada 

HERB KOHL, Wisconsin 

JAMES M. JEFFORDS, Vermont 

RUSSELL D. FEINGOLD, Wisconsin 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

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) 

(1)

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. 

2

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. 

3

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. 

4

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 

5

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:]

6


93525.001
7


93525.002
8


93525.003
9


93525.004
10


93525.005
11


93525.006
12


93525.007
13


93525.008
14


93525.009
15


93525.010
16


93525.011
17


93525.012
18


93525.013
19


93525.014
20


93525.015
21


93525.016
22


93525.017
23


93525.018
24


93525.019
25


93525.020
26


93525.021
27


93525.022
28


93525.023
29


93525.024
30


93525.025
31


93525.026
32


93525.027
33


93525.028
34


93525.029
35


93525.030
36


93525.031
37


93525.032
38


93525.033
39


93525.034
40


93525.035
41


93525.036
42


93525.037
43

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. 

44

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.] 

45

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 homicidesuicides. 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. 

46

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:]

47


93525.038
48


93525.039
49


93525.040
50


93525.041
51


93525.042
52


93525.043
53

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 commuVerDate 0ct 09 2002 13:41 Jun 09, 2004 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6633 C:\DOCS\93525.TXT SAGING1 PsN: JOYCE
54

nity 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:]

55


93525.044
56


93525.045
57


93525.046
58


93525.047
59


93525.048
60


93525.049
61


93525.050
62


93525.051
63


93525.052
64


93525.053
65


93525.054
66


93525.055
67


93525.056
68


93525.057
69


93525.058
70


93525.059
71


93525.060
72


93525.061
73


93525.062
74


93525.063
75


93525.064
76


93525.065
77


93525.066
78


93525.067
79


93525.068
80


93525.069
81


93525.070
82


93525.071
83


93525.072
84


93525.073
85


93525.074
86


93525.075
87


93525.076
88


93525.077
89


93525.078
90


93525.079
91


93525.080
92


93525.081
93


93525.082
94


93525.083
95


93525.084
96


93525.085
97


93525.086
98


93525.087
99


93525.088
100


93525.089
101


93525.090
102


93525.091
103


93525.092
104


93525.093
105


93525.094
106


93525.095
107


93525.096
108


93525.097
109


93525.098
110


93525.099
111

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; CODIRECTOR, 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 

112

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. 

113

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:]

114


93525.100
115


93525.101
116


93525.102
117


93525.103
118


93525.104
119


93525.105
120


93525.106
121


93525.107
122

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 

123

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? 

124

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 

125

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 conVerDate 0ct 09 2002 13:41 Jun 09, 2004 Jkt 000000 PO 00000 Frm 00129 Fmt 6633 Sfmt 6633 C:\DOCS\93525.TXT SAGING1 PsN: JOYCE
126

tact 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 21⁄2 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. 

127

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. 

128

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 

129

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 

130

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. 

131

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? 

132

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 recVerDate 0ct 09 2002 13:41 Jun 09, 2004 Jkt 000000 PO 00000 Frm 00136 Fmt 6633 Sfmt 6633 C:\DOCS\93525.TXT SAGING1 PsN: JOYCE
133

ognition 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.] 

(135)

A P P E N D I X 


93525.108
136


93525.109
137


93525.110
138


93525.111
139


93525.112
140


93525.113
141

Æ


93525.114