With her regular caregiver on vacation, the family of 96-year-old Sara believed that the agency-appointed replacement would have little problem picking up the reins. However, less than a week after the new caregiver started, Sara's grandson, David, got an urgent call from a neighbor telling him that something was not right at his grandmother's place. "The neighbor called me at 11 p.m. She said that all the lights were still on in my gran's apartment and that the front door had been left open," begins David, 31, who lives a 20-minute drive from Sara's Bat Yam apartment. "I raced over there and found my gran in a terrible state. She had been drugged with sleeping pills and was totally incoherent. I tried to help her into bed, but she kept falling over. Her apartment was a filthy mess, with trash and diapers everywhere." David, whose parents do not live in the country, helped his grandmother back to bed and then waited for the caregiver, a foreign worker from Russia, to return. "I had already decided that I was not going to let this woman into the house again after what she'd done," he recalls. "She came back at 1 a.m., with a strange man and the two started banging on the door and shouting to be let in. I refused to open the door and then I called the police." While the man ran away, the police eventually allowed the caregiver into the apartment to gather her things before David told her to get out and never come back. "She was either stoned or drunk," he says. "Either way, she was totally out of it. I still can't believe that someone could have done this to my gran. She is 96 years old and totally helpless." The next day, Sara's family contacted the manpower agency that had provided the replacement caregiver. "They had little sympathy," remembers David. "They just said that they'd never had complaints about the woman before and that they would send us another replacement. This time, however, my aunt who lives here met with the new woman before letting her start work. We learned our lesson." Sara, thanks to her family and vigilant neighbors, had a lucky escape, but Shoshana Birenbach was not so fortunate. On October 27, the 76-year-old was found strangled in her Holon apartment with her Moldovan caretaker being labeled by police as the prime suspect. Investigators believed that the caregiver had choked Birenbach to death, set her apartment on fire and then tried either to commit suicide or to flee the arriving emergency squads. WHILE experts working with the elderly note that Birenbach's case was extreme and that Sara's negligent treatment at the hands of a foreign caregiver is not a regular occurrence, they do admit that incidents of abuse against the elderly by their primary caregivers are on the rise. Data published last month by the Knesset's research and information department identified those considered most at risk as being older than 75, suffering from ill health and dependent on assistance either from family members or outside help. A survey conducted in 2006 by the University of Haifa's Department of Gerontology and School of Social Work found that close to 20 percent of those older than 60 claim to have fallen victim to one type of abuse or another, including physical, sexual, verbal, financial or restriction of freedom. Using a sample of more than 1,000 people, both Jews and Arabs, the survey also found that 28% believed they suffered from general neglect. In a more recent study conducted by the university, in more than a quarter of cases of abuse against the elderly, the perpetrator was the primary caregiver. The Industry, Trade and Labor Ministry estimates that more than 500,000 families currently employ a foreign worker to care for sick or elderly relatives and that there are 300 legal (and many more illegal) manpower agencies operating in this field. "The situation is absurd," says Shalom Ben-Moshe, director of the Foreign Workers Department at the ministry, which is responsible for supervising the agencies. He says that one of the main problems is that there are very few guidelines regarding whom the manpower agencies can hire and send out to work. "At this point, an agency can order a Nepalese worker from a village who probably doesn't even know how to write his or her own name, who has no experience in working in this field and certainly no nursing training, to come over here and work with the elderly or sick," Ben-Moshe says. He adds that the ministry is currently working on a new set of regulations that will change the entire process to resemble that of Canada, where all foreigners working as caregivers must have a nursing background. Unfortunately, the ministry's changes were supposed to have been implemented earlier this year but have been delayed for nearly three months because of a court petition brought by the manpower agencies. "The ministry wants to throw all the responsibility onto our shoulders," responds Shmuel Armon, who has run a private agency in Tel Aviv for the past 12 years and is active in Achioz, the National Association of International Manpower Companies, the driving force behind the legal proceedings. He explains that the ministry's directives will only serve to squeeze money out of the agencies and disband some of the smaller operations but will not actually protect the consumers. Armon also says that there is a severe shortage of trained nurses, with most of those who do have such a background heading to greener pastures such as the US and Britain. "Something definitely has to change here. There are some companies that are irresponsible and only care about making a profit, but the ministry needs to consult those professionals who are out in the field to figure out how to improve the situation," continues Armon, pointing out that one of the changes proposed is to insist the companies bring in a social worker to check up on the caregiver three or four times a year. "I don't think you can tell much from such a quick visit. I think one of the only ways is for families to install video cameras to monitor what is going on in the home on a daily basis, like what has been suggested for those who work with young children." FANNY YUV, deputy director of services for the elderly at the Welfare and Social Services Ministry, agrees that visits by social workers are not the answer. "There already are visits by social workers every once in a while," she points out. "However, someone who does not go in every day cannot notice critical changes in a person's behavior, those have to be monitored daily." Yuv says that most of the responsibility for making sure the elderly person is not being mistreated must lie with the family. "Family members and friends are in a better position to notice what is really going on with the elderly person," she says, acknowledging, however, that there is not always a family member free to check up on the relative every day. "If they can't come, they have to make a neighbor aware of the situation." She also believes that the family must check on the conditions and mental state of the worker - to ensure that he or she is receiving all their rights, is taking enough breaks and is satisfied with the work conditions. She cites the stresses that many foreign workers feel while far from their families and homeland. "It is very important for everyone to work on the relationship together," she says. At the Ministry for Pensioners' Affairs, the approach to the problem is slightly different. The new office, which only recently became a bona-fide ministry, has already set up a hot line for those experiencing abuse problems. "Obviously, the family is in more of a position to see what is going on with its relative more than an outsider," says ministry director-general Avi Bitzur. "However, there is also room for the state to improve its role and to check up with what is going on." He says there should be more stringent checks and balances for the foreign workers coming in and, in cases where there has been abuse, much stricter punishment. The subject will be discussed this week during a special session of the Knesset Committee on Foreign Workers. "There is a real problem here and it's growing," says Bitzur. "This subject needs much more government attention." "I realize that caring for an elderly person is a difficult job and I would never want to do it myself," observes David, Sara's grandson. "However, a person needs to be properly trained to care for an elderly person and that is just not being done here. There are too many loopholes. "We were just very lucky that my gran has close family members living nearby that contact her every few days and neighbors that go in to visit her every day or the results could have been much, much worse. I just wonder what happens to the many elderly people who do not have family members close by or even relatives that care about them. What then?"