The number of people age 65 and older will nearly double by the year 2030 to 71 million. An estimated 6 percent of people aged 65 or older have Alzheimer’s disease, a degenerative condition that may lead to dementia. Over time, some elderly adults may become physically or mentally incapable of making or communicating important decisions, such as those required to handle finances or secure their possessions. In addition, while some incapacitated adults may have family members who can assume responsibility for their decision-making, many elderly incapacitated people do not. The Census Bureau predicts that in the future the elderly population will be more likely to live alone and less likely to have family caregivers. In situations such as these, additional measures may be necessary to ensure that incapacitated people are protected from abuse and neglect. Several arrangements can be made to protect the elderly or others who may become incapacitated. A person may prepare a living will, write advance health care directives, and appoint someone to assume durable power of attorney, or establish a trust. However, such arrangements may not provide sufficient protection. Some federal agencies do not recognize durable powers of attorney for managing federal benefits. SSA, for example, will assign a representative payee for an incapacitated person if it concludes that the interest of the incapacitated beneficiary would be served, whether or not the person has granted someone else power of attorney. In addition, many states have surrogacy healthcare decision- making laws, but these alternatives do not cover all cases. Additional measures may be needed to designate legal authority for someone to make decisions on the incapacitated person’s behalf. To provide further protection for both elderly and non-elderly incapacitated adults, state and local courts appoint guardians to oversee their personal welfare, their financial well being, or both. The appointment of a guardian typically means that the person loses basic rights, such as the right to vote, sign contracts, buy or sell real estate, marry or divorce, or make decisions about medical procedures. If an incapacitated person becomes capable again, by recovering from a stroke, for example, he or she cannot dismiss the guardian but, rather, must go back to court and petition to have the guardianship terminated. The federal government does not regulate or provide any direct support for guardianships, but courts may decide that the appointment of a guardian is not necessary if a representative payee has already been assigned to an incapacitated person by a federal agency. Representative payees are entirely independent of court supervision unless they also serve their beneficiary as a court-appointed guardian. Guardians are supervised by state and local courts and may be removed for failing to fulfill their responsibilities. Representative payees are supervised by federal agencies, although each federal agency with representative payees has different forms and procedures for monitoring them. Each state provides a process for initiating and evaluating petitions for guardianship appointment. Generally, state laws require that a petition be filed with the court and notice be provided to the alleged incapacitated person and other people with a connection to the person. In nearly all states, the alleged incapacitated person is granted the right to be present at the hearing, and the right to counsel. Most states require clear and convincing evidence of a person’s incapacity before a guardian can be appointed. The court may appoint a family member, friend, attorney, a paid private professional, a nonprofit social service agency, or a local public agency to serve as the guardian. In many cases, both courts and federal agencies have responsibilities for protecting incapacitated elderly people, as shown in figure 1. For federal agencies, a state court determination that someone is incapacitated or reports from physicians often provide evidence of a beneficiary’s incapacity, but agency procedures also allow statements from lay people to serve as a sufficient basis for determining that a beneficiary needs someone to handle benefit payments on their behalf—a representative payee. SSA, OPM, and VA ask whether the alleged incapacitated person has been appointed a guardian and often appoint that person or organization as the representative payee. In some cases, however, the agencies choose to select someone other than the court-appointed guardian. Social Security officials sometimes designate the nursing home where the incapacitated person resides as the representative payee because it provides for direct payment to the nursing home, ensuring continuity of care for the incapacitated person. In many cases, guardians are appointed with a full range of responsibilities for making decisions about the incapacitated person’s health and well- being as well as their finances, but several states’ laws require the court to limit the powers granted to the guardian, if possible. The court may appoint a “guardian of the estate” to make decisions regarding the incapacitated person’s finances or a “guardian of the person” to make nonfinancial decisions. An incapacitated person with little income other than benefits from SSA for example, might not need a “guardian of the estate” if he or she already has a representative payee designated by SSA to act on their behalf in managing benefit payments. Sometimes the guardian is paid for their services from the assets or income of the incapacitated person, or from public sources if the incapacitated person is unable to pay. In some cases, the representative payee is paid from the incapacitated person’s benefit payments. Guardians and representative payees may have conflicts of interest that pose risks to incapacitated people. While many people appointed as guardians or representative payees serve compassionately, often without any compensation, some will act in their own interest rather than in the interest of the incapacitated person. Oversight of both guardians and representative payees is intended to prevent abuse by the people designated to protect the incapacitated people. While the incidence of elder abuse involving persons assigned a guardian or representative payee is unknown, certain cases have received widespread attention. The following are examples of abuse by guardians and representative payees provided by courts and federal agencies: A guardian and an employee of the guardian’s law firm brought a nursing home resident in New York a cake and flowers on her birthday and billed her $850 for the visit using hourly rates for legal services. Rather than using electronic direct deposit, a guardian in New York City appointed to protect an incapacitated person regularly traveled to their branch bank in another borough to deposit her monthly $50 Social Security check, charging her $300 per deposit. A company in Michigan acting as guardian for more than 600 incapacitated people committed felonies against them, including selling one individual’s home to a relative of a company employee for $500. A woman in the position of Public Fiduciary at the Gila County Public Fiduciary’s Office in Arizona served as guardian of incapacitated people and in that capacity embezzled and misused a total of at least $1.2 million of public funds. The county’s investigation concluded that “the Court’s lack of oversight contributed to the enormous loss of public monies.” A woman in Washington State established a nonprofit service organization that SSA designated as the representative payee for about 200 beneficiaries. One of her clients was a homeless man entitled to retroactive payment of benefits totaling about $15,000. She received the payment on his behalf, but used the money as her own, along with SSA benefits for others. She embezzled a total of approximately $107,000 of SSA benefits. A guardian and representative payee for veterans pled guilty to four counts of misappropriation after a joint VA and SSA Office of Inspector General investigation substantiated allegations that he had embezzled over $400,000 from the veterans’ estates. The head of a foundation in West Virginia serving as a representative payee for 140 people (including veterans and elderly people) embezzled over $300,000 from them over a 4-year period, consisting mostly of Social Security benefits. All 50 states and the District of Columbia have statutes providing for state or local court oversight of guardianship appointments, but court procedures for implementing these laws vary considerably. Generally, guardians submit periodic reports to the court, but courts’ procedures for reviewing reports vary, as do procedures for monitoring guardianships and the penalties courts impose when guardians do not perform their duties. Jurisdictional issues, such as courts in 2 states being asked to appoint a guardian for the same incapacitated person, sometimes complicate guardianship appointments. In addition, most state courts surveyed do not maintain information needed for effective monitoring and oversight of guardianships. State laws provide for court appointment and oversight of guardianships. Nearly all states require two kinds of reports: one regarding the personal status and well being of the incapacitated person and another regarding the accounting of the person’s finances. The personal status reports usually include information regarding the condition of the incapacitated person, although many states require more specific information regarding various aspects of the incapacitated person’s status. In many states, the laws require the report to include documentation of the need for continued guardianship. Many statutory requirements are very detailed and require a physician’s statement, a determination of the mental status of the incapacitated person, or in some instances, reports of any change in the condition of the incapacitated person. Other basic report elements may include living conditions, place of residence, and the number of guardian visits. Some states may allow courts to waive certain reporting requirements. Most states require that guardians submit a financial accounting and record of expenditures for the care of the incapacitated person on an annual basis. This document may list the assets and income of the incapacitated person, including bank balances, real property holdings, and detailed expenses associated with the care and housing of the incapacitated person. State statutes usually require court approval for the sale of real estate by a guardian. How often guardians are required to submit reports varies. Most states require guardians to submit personal status reports at least annually.