likely to mislead or confuse the jury. In such a case, however, the jury still has to consider the witness’s credibility, and expert opinions may be introduced about the possible effects of the witness’s cognitive impairments (Melton et al., 1997, § 7.07).

There is now a large body of research on children’s credibility and competence as witnesses. Many studies have addressed child witnesses’ suggestibility and accuracy of recall (see Saywitz et al., 2002). Extension of this research to elders with dementia poses significant challenges, because the impact of the impairments to statements about victimization will be affected by medications, comorbidities, the experience of trauma, and the severity of the dementia itself. However, some of the methods used in research on child witnesses could be applied in studies of testimony by mildly or moderately confused elders.

Research assessing the capacity of older persons with cognitive impairments to provide accurate testimony is needed for improving the accuracy of case identification, not only in clinical settings, but also in legal settings, including prosecutorial decision making and formal adjudication.

Another impediment to accurate case identification is that many elders have conditions that are associated with physical frailty and other medical problems as well as psychological or emotional problems. For example, as many as 18 percent of seniors report depressive symptoms (although many of these are mild symptoms)—much higher than can be accounted for by mistreatment alone. Also, normal age-related changes make an elder more susceptible to serious consequences of seemingly minor illnesses. An older person with atrial fibrillation taking an anticoagulant may have easy skin bruising, and thus the presence of bruising will be less helpful than otherwise as a sign of possible mistreatment. This “fact” is clinically accepted and makes intuitive sense, yet no studies quantify bruising rates under normal circumstances, compared with cases of mistreatment. Fragile capillaries and thinner skin, both age-related changes, also make elderly individuals more susceptible to bruising. Quantification and standardization of mistreatment-related clinical observations are necessary to explore their utility in designating cases of mistreatment. Because so little is known about the signs and symptoms of mistreatment, it is easy to assume that an injury is due to a certain constellation of natural changes and illnesses rather than to mistreatment. There are no studies that help illuminate when to consider an injury as a marker of mistreatment. Retrospective studies may be a valuable tool in understanding markers, particularly in cases of ongoing abuse. If elders with severe injuries secondary to mistreatment are identified, one may be able to look at their histories and see if there were markers that would have made it possible to identify mistreatment at an earlier stage.

A critical step to advance the field is the development of a consensus around the determination of whether or not a case of mistreatment has



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