ers. However, studies to identify protective factors from elder mistreatment should not be neglected.
A particularly critical need exists for studies of risk indicators and risk and protective factors for elder mistreatment in institutional settings. The available evidence reviewed by Hawes (this volume), combined with extensive professional and public concern about serious quality problems in long-term care (Institute of Medicine, 1996), suggests that a vast reservoir of undetected and unreported elder mistreatment in nursing homes may exist. Because nursing home residents as a class are both extremely physically vulnerable and generally unable either to protect themselves or report elder mistreatment they experience, the physical and emotional costs of elder mistreatment in such environments are likely to be very high. Prevention programs exist (see Pillemer and Hudson, 1993), but they have not been informed by rigorous risk factor research. Understanding the causes of mistreatment of this extremely fragile population is of the highest priority.
Research on risk and protective factors should be expanded to take into consideration the clinical course of elder mistreatment. Although longitudinal data are absent, it seems probable that elder abuse situations may follow a pattern similar to disease progression, which would include lead time prior to the manifestation of active signs and symptoms of elder mistreatment; periods of “remission” from elder mistreatment; and critical points in which elder mistreatment becomes more intensive or acute. Some have speculated that elder mistreatment typically increases in severity and intensity over time (Breckman and Adelman, 1988), but no empirical data exist that demonstrate this pattern or individual differences in progression. Clinical accounts suggest that elder mistreatment situations include cases that resolve on their own; cases in which mistreatment intensifies; and cases in which the situation remains abusive but stable. It is therefore both possible and important to identify risk factors for an increase or intensification in elder mistreatment.
For these reasons, cohort studies are of great importance in determining risk factors for elder mistreatment. Although prospective cohort studies would be ideal, the lengthy period needed for cases of elder mistreatment to develop is a deterrent. In the near term, retrospective cohort, or nested case-control studies using established study populations may be preferable, in which a preexisting data set is used and elder mistreatment measured at a later point (the technique used by Lachs et al., 1994, 1997a). There are a number of existing datasets involving elderly persons that could be used for such a purpose (for example, existing panel studies of caregivers could be assessed for incidence of elder mistreatment in a follow-up study).
Advances in measurement in risk and protective factor research are needed. The measurement of risk factors many times can be accomplished