volunteer in-home helpers. In addition, common physiological changes in the elderly complicate the assessment of elder mistreatment. Bruises and fractures and even death may be indicators of abusive assaults, but they are also common occurrences in frail and dependent elders due to spontaneous falls and tissue fragility. How do we know when a bruise is an indicator of abuse rather than an expected result of a person’s medical condition and functional status?
As is evident throughout this report, the context in which an injury occurs is often as important as the injury itself in screening for elder mistreatment. Instruments for screening and case identification would be likely to benefit from considering contextual risk factors as well as characteristics of the elder subject and characteristics of the trusted other. As an example, the places where elders reside and spend time may affect the risk for mistreatment. For those living in a skilled nursing facility or who are housebound, residential or institutional risk factors take on greater importance. Others may spend time in a variety of settings, such as senior centers or adult day care centers. The varied distribution of social environments may alter risk profiles and the performance of screening instruments. The sociocultural milieu in which elder mistreatment occurs is another potentially important contextual issue that has received little research attention. Understanding how variations in race, ethnicity, religious beliefs, and socioeconomic status affect the risk and occurrence of elder mistreatment is critical to improving screening and case identification methods.
Further complicating screening and case identification of elder mistreatment is the problem of cognitive impairment. Depending on the degree of impairment, different methods may be employed to elicit needed information. Some with mild impairment may be able to give a reasonably accurate history of neglect or abuse, but those with moderate or severe dementia may not be able to do so (see further discussion of this issue below). There is good evidence that mistreatment is a substantial problem among Alzheimer’s disease patients (Paveza et al., 1992). Screening and diagnosis must then be done via interviews of caregivers or others who are knowledgeable about the elder’s situation and via clinical evaluation of the patient. Screening the trusted other in these circumstances is an important research direction as environmental and social factors in elder mistreatment are ascertained.
As emphasized throughout in this volume, the range of behaviors subsumed under elder mistreatment is large, diverse, and multidimensional. While some cases are obvious and easy to designate, many are not, and the definitions of elder mistreatment should be the subject of research, as noted