text. For example, restricting access to money may be entirely appropriate conduct in caring for a person with dementia. (See further discussion of this point in the section on “mistreatment” below.) As noted earlier in this chapter, however, the most sensible strategy for research is to define the category overinclusively (with reference to the expected definition of mistreatment) for purposes of data collection and measurement and to refine it thereafter in analysis and interpretation.

Measurement of conduct is subject to a number of significant methodological limitations. Briefly, much of this conduct is not observed directly and relies for its detection on report by the elder, by the other party in the trust relationship—who may be the perpetrator of mistreatment— or by a third party, such as a colleague or supervisor of the other party in an institutional setting. Indeed, in the absence of direct observation, conduct is harder to assess than harm, since it may not leave evidence in the form of readily observable physical or emotional consequences, since it may be forgotten by the elder if she is cognitively impaired, since the older person may be reluctant to report the occurrence of such conduct, or since the other person may not report it out of conflict of interest.

The investigator is faced with the difficult task of detecting a “latent variable” requiring a research methodology that optimally employs several modalities of assessment and takes repeated observation. As with assessment of harm, there is a dearth of basic descriptive studies of conduct involved and of measurement methods.


As already noted, mistreatment (under any consensus definition) will include some types of conduct that have not actually caused harm—perhaps because harm was not intended or because the conduct creates an unacceptable risk of harm. However, many types of mistreatment do involve actual injury or harm, most notably physical assault and financial mistreatment (loss of property). To the extent that the definition includes harm, the measure of harm must be operationalized and measured.

The importance of measuring harm varies according to the type of research being conducted. For example, survey research and other studies in nonclinical settings (or not using clinical or legal records) are likely to focus mainly on the possible perpetrator’s conduct; the presence of harm is likely to be ascertained on the basis of a few specific indicators (e.g., “Were you hurt?” “Did you have to go to the hospital?” “Did you lose any money?”) However, in the context of research in clinical settings, such as identification of forensic markers for mistreatment, or development of improved screening tools, the assessment of harm may be a particularly important element of the study.

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