Red Sky At Morning: Stepping Into Adulthood Essay -- essays research

Red Sky At Morning by Richard Bradford, is a coming of age novel thatillustrates the maturing of a young man. In the spend of 1944, Frank Arnold, awealthy shipbuilder in Mobile, Alabama, receives his volunteer commission in theU.S. Navy. He moves his wife, Ann, and seventeen-year-old son, Josh, to thefamilys summer home in the village of Corazon Sagrado, high in the New Mexicomountains. Mrs. Arnold finds it impossible to cope with the quality of life in thelargely Hispanic village. Josh, more the son of his father than his mother, becomesan integral member of the Sagrado community, forging friendships with classmatesat Helen De Crispin school, with the towns resident artist, with ChangoLopez--macho bully turned model student--and with Amadeo and ExcildaMontoya, the couple hired by his father to care for their house. Josh narrates thestory of his fateful year in Sagrado and reveals the events and bulk whoinfluence his progress to maturity. Josh matures without the book into a youn gman who learns the understanding of change, responsibility, and duty.Josh stays strong through the changes he goes through and it helps himmature into the man he becomes. When his family moves to Sagrado he makesnew friends and adapts well to the new environment he is put into. Josh staysopen-minded when making friends at school. He gets to know many differentkings of people. Unlike his mother he doesnt judge people by where they live ortheir racial background. His mothe...

House of Mirth - The Nature of Nature Essay -- House Mirth Essays

House of Mirth - The Nature of Nature Nature, whether in the form of the arctic tundra of the North Pole or the busy street-life of Manhattan, was viewed by Naturalist writers as a phenomena which unavoidably challenged individual survival a phenomena, moreover, which operated on Darwins maxim of the survival of the fittest. This contrasted sharply with the Romantic view, which idolise Nature for its beauty, beneficence and self-liberating powers. In Edith Whartons The House of Mirth, Lily Bart attempts to survive within the urbane drawing-room society she inhabits. Although Selden uses Romantic nature imagery to describe Lily, throughout the raw such Romantic imagery and its accompanying meanings are continually subverted. By simply invoking different understandings and views of Nature, Wharton demonstrates that not only is Lilys ability to adapt to various environments isnt necessarily salutary, but also that flower imagery, used in an ironic fashion, captures perf ectly Lilys need for climates of luxury. It is Whartons image of a hot-house, however, which ultimately captures the ambiguous nature of what, to Wharton, truly is Nature. Lily, although a city-dweller, is described by Selden as one who is intimately connected with a benevolent, life-giving Nature. He exclaims, The attitude revealed the long slope of her slender sides, which gave a diverseness of wild-wood grace to her outline- as though she were a captured dryad subdued to the conventions of the drawing-room (13). Seldens notion of Lilys sylvan freedom and her interconnectedness to all things natural is echoed later in the novel, when Lily is every described as, or compared to, a rose, (167) an ... ...entury Literature 44.4 (1998) 409-27. Howard, Maureen. On The House of Mirth. Raritan 15 (1996) 23 pp. 28 Oct. 2002 <http//proxy.govst.edu2069/WebZ/FTFETCH>. Howe, Irving. Edith Wharton, a Collection of Critical Essays. Englewood Cliffs Prentice-Hall, Inc., 1962. Lindberg, Gary H. Edith Wharton and the Novel of Manners. Charlottesville University Press of Virginia, 1975. Lyde, Marilyn Jones. Edith Wharton, design and Morality in the Work of a Novelist. Norman University of Oklahoma Press, 1959. Miller, Mandy. Edith Wharton Page. 19 Nov. 2002 <http//www.Kutztown.edu/faculty/Reagan.Wharton.html>. Pizer, Donald. The Naturalism of Edith Whartons The House of Mirth. Twentieth Century Literature 41.2 (1995) 241-8. Wharton, Edith. The House of Mirth. (1905) bleak York Signet,. 1998.

Pancreas Transplant: A Cure for Diabetes?” :: Endocrine System

The article, Pancreas Transplant A Cure for Diabetes? written by Eli A. Friedman, M.D., explores the possibility of a cure for type 1 diabetes and the implications involving this experimental procedure. The article discusses current procedures and treatments that ar commonly used to control type 1 diabetes and highlights provisional treatments that evolved into pancreatic transplant surgery.The editorial explains that diabetes mellitus is the leading cause of irreversible renal failure, known more commonly as End Stage Renal Disease (ESRD). Diabetes mellitus can cause nerve, vascular and other businesss that can result in limb amputation and blindness. there are two types of diabetes long-duration, non-insulin dependent (type 2) and insulin-dependent (type 1). Type 1 seems to attract the most attention from Physicians and the media. Many of those that suffer from type 1 are children and young adults.Dr. Friedman underlines most of the most common existing treatments for type 1 d iabetes. Insulin is used to correct the imbalances in blood sugar and patients are required to reduce the amount of dietetical protein they consume. This type of treatment focuses on slowing the possibility of developing kidney disease and retinopathy. For many diabetics, the time will come when their damaged kidneys are no yearner sufficiently cleaning the blood and they must begin dialysis. When a diabetic reaches the ESRD stage, the likely option is kidney transplant. Dr. Friedman adds that a kidney transplant will not solve the problem and the disease will eventually progress without a pancreas transplant. The article stipulates that diabetes involves the pancreas as well as the kidney. The pancreas produces insulin, the hormone that regulates glucose. When the pancreas malfunctions, diabetes can result. The idea behind kidney/pancreas transplant is to replace the kidneys damaged by diabetes and to eliminate abnormal insulin production by providing a new healthy pancreas.

Cocaine and the Nervous System Essay examples -- Drug Drugs Coke Cocai

cocaine and the Nervous System All drugs have a negative effect on the nervous system, exactly few can match the dramatic impact of cocaine. Cocaine is one of the most potent, addictive, and unpredictable recreational drugs, and thus can cause the most grueling and irreversible reproach to the nervous system. The high risk associated with cocaine remains the same regardless of whether the drug is snorted, smoked, or injected into the users bloodstream. In appurtenance to the intense damage cocaine can cause to the liver, intestines, heart, and lungs, even casual use of the drug will impair the champion and cause serious damage to the central nervous system. Although cocaine use affects many components of the body, including vision and appetite, the most significant damage cause by cocaine takes place in the brain and central nervous system. Spanish explorers first observe southwestward American natives chewing the cocoa leaf, from which cocaine is derived, when they ar rived on the continent in 16th century. The South Americans chewed these cocoa leaves in order to stay awake for longer periods of time. Centuries after this initial discovery, Albert Neiman isolated cocaine from the cocoa leaf in 1860. Neiman used this source as an anesthetic. Over the ensuing years, cocaine use became increasingly common and was even sanctioned by doctors, who prescribed the drug to aid recovering alcoholics. Cocaine was even a key ingredient in such popular beverages as Coca- Cola. It was not until the long-term health problems associated with cocaine use emerged that the public established that the drug was harmful and highly addictive (2). Cocaine is a versatile drug which can be ingested in a variety of ways. In its purest form, coc... ...te an false high. Cocaine can cause serious damage to the nervous system, as it eats away chunks of the brain and increases blood pressure, heart rate and body temperature, oftentimes for the rest of the addicts lif e.Sources Cited1)Drug information Cocaine http//www.theantidrug.com/drug_info/drug_info_cocaine.asp2)Cocainehttp//faculty.washington.edu/chudler/coca.html3)The Effects of Cocaine on the Developing Nervous Systemhttps//cognet.mit.edu/login/?return_url=%2Flibrary%2Ferefs%2Fnelson%2Fn33%2Fabstract.html4)The Physical Effects of Cocainehttp//www.shesinrecovery.com/ habituation/cocaineeffects.html5)As a Matter of Facthttp//www.well.com/user/woa/fscoke.htm6)Crack and Cocainehttp//www.nida.nih.gov/Infofacts/cocaine.html7)Cocaine Brain Damage may be Permanent http//www.healthy.net/asp/templates/news.asp?Id=6376

News :: essays research papers

Partygoers find renewed meaning in holidaysSaturday, December 22 at the Brick Elks Lodge 2152 celebrating the render of Jesus topped the list of paying homage. Instead of the much popular getting presents and money, the party was payback to the members who volunteer. The party was for Elks children and grandchildren. Food, Entertainment and Santa Clause were available there. The Elks fundament onlyy help people by donation things such as wheelchairs, canes, and walkers for handicapped kids. They also give food during Thanksgiving and Christmas. Last month they even had a party for veterans. All together the Elks are a pretty nice organization of caring people.Bush expected to seek 15 billion more to beef up domestic securityOur President George Bush is planning to get 15 billion dollars for his 2003 budget. This money will account for police officers to luggage screening equipment. It may also include new communication equipment so hospitals can react faster if another terrorist attack were to happen. Congress wanted to use 20 billion for security in its 2002 plan, they even had it approved. Except approximately half of that money was used before the September 11th attacks. After the suppose of Union Address to Congress in January the president will release his 2003 budget plan.Dress up yogurt without adding fatten outYogurts with the labels "nonfat" and " petty(a) fat" are all good for you when you want to make some cut backs on what you eat. But you see there are still catches to eating all of these. Yogurt like many other foods doesnt just contain the fruits posted on the cover. Companies add many chemicals and concoctions used to make the yogurt taste better. This is fundamentally like mixing the fruits and then adding 7 teaspoons of sugar. Which can double the calories. They also add sweeteners and even artificial coloring. If you have tried nonfat or low fat yogurts then you know how terrible they taste. There is an alternative of c ourse. What you can do is cut up your own fruits and put them in the yogurt to call for some real flavor back. Which will keep it healthy and make it tasty.Many elderly people taking inappropriate medicationsA study taken by the Healthcare Research and Quality has come to believe that many elders have taken incorrect medications. Approximately 1/5 of 32 trillion elderly people who live by themselves used 1 of 33 medicines considered dangerous for the older society.

News :: essays research papers

Partygoers find renewed meaning in holidaysSaturday, December 22 at the Brick Elks Lodge 2152 celebrating the birth of Jesus topped the list of paying homage. Instead of the more popular getting presents and money, the party was payback to the members who volunteer. The party was for Elks children and grandchildren. Food, Entertainment and Santa clause were available there. The Elks basically help people by donation things such as wheelchairs, canes, and walkers for handicapped kids. They also give food during Thanksgiving and Christmas. Last month they even had a party for veterans. All together the Elks are a pretty nice organization of caring people.Bush expected to seek 15 billion more to beef up domestic securityOur President George Bush is planning to get 15 billion dollars for his 2003 budget. This money will pecker for police officers to baggage screening equipment. It may also include new communication equipment so hospitals can react faster if another terrorist attack w ere to happen. congress wanted to spend 20 billion for security in its 2002 plan, they even had it approved. Except approximately half of that money was used before the September eleventh attacks. After the state of Union Address to Congress in January the president will release his 2003 budget plan.Dress up yoghourt without adding fatYogurts with the labels " fat-free" and "low fat" are all good for you when you want to make some cut backs on what you eat. But you see there are yet catches to eating all of these. Yogurt like many other foods doesnt just contain the fruits posted on the cover. Companies add many chemicals and concoctions used to make the yogurt taste better. This is basically like mixing the fruits and then adding 7 teaspoons of sugar. Which can double the calories. They also add sweeteners and even artificial coloring. If you have tried light or low fat yogurts then you know how terrible they taste. There is an alternative of course. What you ca n do is cut up your own fruits and put them in the yogurt to bring some real flavor back. Which will keep it healthy and make it tasty.Many elderly people taking inappropriate medicationsA study taken by the Healthcare Research and Quality has come to believe that many elders have taken incorrect medications. Approximately 1/5 of 32 million elderly people who live by themselves used 1 of 33 medicines considered dangerous for the older society.

Behind the Sun

Behind the Sun (Abril Despedacado) was a thought-provoking and captivating work of art by Walter Salles, Sergio Machado and Karim Ainouz who collaboratively derived the invoice from an Albanian book (Broken April by Ismail Ka hardiness). Behind the Sun was set in 1910 in the Northeast region of Brazil. The movie unfolds with this line, This is the story of me, my brother, and a garment in the wind The line was narrated by a charming young boy, Pacu (com/english-4-b-calpac/Ravi Ramos Lacerda). He comes from a family of peasants, who grows sugarcane for a living.Pacus oldest brother had just been murdered at the get of the movie. The setting was miserable, to say the least. The opening of the movie only matched this misery in the setting by showing a gory sight of a blood-stained shirt. The shirt belonged to Pacus oldest brother, who was then the latest victim in their familys feud with the Ferreiras family. The two families had been warring over land and territorial issues. Tradit ion dictates that the Breves family should avenge the death of their family member, but not long before the stain has turned from red to yellow.When the blood on the shirt turns yellow, someone will die, Pacu narrated further. The surviving eldest son of the Breves family, Tonio (Rodrigo Santaro), did what he had to do, harmonize to their tradition &8212 he killed the eldest son of the Ferreiras family. Tonio matte up that the vicious cycle of killing and revenge, disguising as a noble tradition, had to end but he felt powerless to end it, so he allowed it to continue by killing the eldest son in the other family. As a result, he was following(a) in line to be killed.But the charming and much too adorable boy, Pacu, had a way of keeping Tonio alive. Pacu died for Tonio. He knew at a tender progress that sacrifice, an act of love, was the key to end the vicious cycle that their family was caught in. In relation to Brazilian notions of ethnicity, the deep set often mysterious-looki ng eyes of the Breves brothers were captivating. Ironically, the softness of their looks couldnt match with the ferocious tradition they keep. The film is a story about a strong family bond, so strong in fact, that one had to be prepared to die in revenge of the other.Moreover, one was willing to die to let the other live and move on. The photography and sequence of shots in the movie are absolute astound and even poetic in nature. It seemed that every beat of its music matched with every frame in the screen with grace and much respect to art. Their clothing was not far from imaginable, the family bonding was very plausible, considering how tight family bonding was (still is) in Brazil. If it were a movie set in this time and age, it wouldnt have been plausible, with all the killings.But it was in 1910, when a lot of things, like respect for life, have yet to be discovered. Certainly, the work of art from the sounds to the overall direction and cinematography helped in establishin g the depth and heft of the movie. Truth be told, Hollywood cannot create movie that is as profound as this without resorting to much gimmickry. What Behind the Sun producers did that Hollywood wont dare to try is to simply tell a tragic story in the most poetic way possible. It was a wonderful movie, overall. It was heavy in the mind, and it sure will not be easy to forget.

Avoiding the Alignment Trap in Intormation Technology Essay

An alarming pattern has surfaced in that many companies atomic number 18 concentrating on conjunctive and are finding that their performance is either declining or moving sideways. Companies are focusing on the wrong solutions with respect to their Information Technology problems, resulting in pixilated bottlenecks to growth. Companies need to learn how to break out of the trap and build IT organizations that allow for growth rather than obstruct it. Companies will need to be committed as doing so will require a continuous effort.The essential goal for these companies in order to succeed is to move IT into the upper-right quadrant, where they will be highly stiff and highly aligned, and where IT appears to be enabling growth rather than inhibiting it. In order to move in this direction, it is my recommendation that the companies begin by installing topical anesthetic electron orbit networks locally, as well as a central database stored on a server to connect to head office. Th is option is economically feasible, will improve local efficiencies and will allow the sharing of resources and records. I would also recommend that the companies begin feasibility testing to explore the implementation of an internal ERP system to support spheric operations in the near future. Doing this will help companies to keep up with the competition.Current SituationCompanies are disembowelting caught in an alignment trap whereas they are throwing large amounts of resources towards being highly aligned and non realizing the importance of being highly effective as well.There are quartet quadrants indoors which companies are being categorized with respect to their ability to be effective. They are being measured based on the ineffectiveness as far as completing projects on epoch and on budget, and the ineffectiveness of alignment to an important business organisation objective.The first of these quadrants is alignment trap. Despite being highly aligned, the companies in doors this group are less effective in completing budgets on time and within the budget. Charles Schwab & Co. is currently in this position and as a result, continues to spend money on projects and seeing no growth.The second quadrant is maintenance zone. Companies in this quadrant are less aligned to major business objectives but are maintaining below average levels of growth even though they are less effective and spending more in IT as a result. In this zone, IT is not performing well, is not valued and is segregated from the companys main functions. Management is budgeting enough to keep the system running, but IT is not providing any added value to the business. Third is the well-oiled IT quadrant which can be categorized as second best. In this group, companies are highly effective at livery projects in on time and on budget. They are more foc utilize on execution. Still, companies are less aligned meaning that their IT group does not full understand the priorities of the bus iness and where to spend the resources.Lastly, the IT-enabled growth quadrant is where all companies would like to be. This quadrant encompasses those companies who are not only highly effective at make IT projects successful, but are also highly aligned in relation to their business objectives. Examples of companies who have succeeded in this respect are Nestle, Wal-Mart, FedEx and Dell.The following are IT-related issues that organizations are currently facing as they attempt to align their business goals with IT technology Believing that alignment is the solution to their IT problems, companies are spending enormous amounts of money without settlement any problems. Various divisions are driving independent initiatives, each one designed to address its own competitive needs, resulting in complexity of IT systems (no standardization). As a result, be increase and the fragmented divisions make it harder for managers to coordinate across business units. Complexity in systems is making enhancements to systems and improvements to infrastructures more and more difficult to implement and emf benefits are left unused. Redundant applications that perform the same or similar functions. Outsourcing the wrong activities. Data in multiple information systems are viewed as scraps and producing inconsistencies (i.e. salespeople are promoting products that are discontinued) In companies similar to Charles Schwab & Co. for example IT staff response have become slow and expensive IT engineers are spending more time fixing bugs in the systems than ever before and several big and ambitious projects are overdue and preventing the company from being competitive.CriteriaThe following criteria will be used to evaluate each of the alternatives IT spending must be aligned with the companys growth strategies (need to reduce IT costs i.e. savings on software licensing costs where bleeding money, and head count). Must be shared ownership and shared governance of IT projects. Need to reduce complexity (or emphasize simplicity). Increase efficiency (doing things in a cost effective way with no duplication of time and effort). Economically feasible. IT infrastructure to support networked operations in multiple locations. Need to centralise and simplify the IT functions. Need high effectiveness to achieve an objective through the use of 1. simplicity (or reducing complexity) by implementing companywide standards, replacing legacy systems, building impertinent solutions on simplified and standardized infrastructure 2. right sourcing choosing the right source for a capability and maximizing effectiveness while minimizing cost and 3. accountability executives should get the information they need to measure the progress of IT and IT people should be held accountable for outcomes. IT needs to be reliable, without excess complexity, and needs to deliver projects consistently with desired functionality, time and cost. IT systems need to run smoothly an d reliably. IT functions such as architecture and infrastructure need to be balanced with respect to the needs of the entire organization and those of single businesses. Need a good governance structure so as to set parameters to keep an organization on track (i.e. no more than four new technology releases per year).

Talent Code

In The Talent Code, the process of building talents is described in depth. In order to create a adroit basketball team I will use principles from this book. Talent is not entirely dependent on genes and you are not a finished crossing (talent wise) when you are first born. Growing talent in shammers requires three aspects that are described in the book. First, recondite practice is required to learn the aptitudes necessary to acquire a skillful player. Deep practice is not about the amount of meter spent practicing, but the concentration and effort given in the time while practicing.Second, touchwood is required in order to have the energy and passion required to practice and develop into a good basketball player. Ignition is the responsibility of the private instructor, because he/she must call on primal cues in order to ignite the players. Thirdly, master coaching is required in order to present for the most out of each individual player. It is the responsibility of the coach to read each player and decide what style of coaching is most suited to chirk up and teach that player. Deep practice is perhaps the most important aspect in developing talent.Deep Practice is the best way to produce myelin. Skill and talent is a result of nerve fibers firing fast and smoothly and myelin helps to make these firings happen faster and smoother the more(prenominal) times they are fired. Deep practice in basketball place be done in multitude of ways. The main idea of this practice should be targeted learning. What is the target? The target is to amend in every aspect of the fundamentals of basketball dribbling, shooting, and passing. Deep practice requires the player to be contestd enough to make mistakes, correct those mistakes, and conceal improving.This is the most high-octane way to create myelin and improve overall skill and talent. Practice should be held not with the idea to practice for as long and hard as possible, but with the idea to practice ef ficiently. Drills should be broken up into chunks in order to learn each specific movement . This will target each specific nerve firing required for the action. Secondly an idea would be to practice each drill in slow motion. This will help to make sure the movements are existence done correctly so that the myelin is being used efficiently.Players should be one hundred percent focused on their drill. Deep practice requires a lot of energy that comes from inflammation. Ignition is the motivation that comes from primal cues that players are largely unaware of. These primal cues mostly come from our distinctly human personality trait that gears us toward future belonging. It is our desire to be a part of groups of people who are accomplishing something worthwhile. In order to get ignition from a basketball team they must be inspired to want to be like a certain player or team. Videos should be shown of those teams and players.The challenge should be set forth that in order to be li ke those teams and players a lot of hard work will be required. This should ignite the players into wanting to belong to that same exclusive group of players or teams. The coach has the most responsibility to inspire players into wakeless practice and ignition through Master Coaching. It is the coachs responsibility to build myelin circuits for each player based on their individual personalities. The coach must tell the player how to practice in order to develop the skill circuit to fire the right way.The coach must know how to coach and interpret each players learning style. Each player may require a different style of coaching in order to ignite them and get them to fire the correct way. Once a skill is taught the coach should increase the level of difficulty quickly in order to shock the player. This is the fastest way to grow skill and challenge the player into deep practice. Coach should point out errors honestly and correct them in order for continuous improvement and in ord er to make sure myelin is being applied correctly to the nerve circuits.Good coaching should help support which circuit should be fired at the correct time. In short, myelin is the key to festering talent. The only way to grow myelin is deep practice that comes from ignition from primal cues. Talent is not a fixed thing for human beings and it can be learned. There is a lot of improving that can occur no matter what the starting skill level of the player is. Talent is more about commitment and concentration on the task being practiced. This is the best way to fire nerves quickly and grow myelin so that they keep firing that way.

Analgesic and Facilitator Pain Assessment

Individual Research Article Critique Presentation Resource The research pick out that you selected in Week Two Develop a 10- to 15-minute presentation in which you address the following points (7 pts) Strengths and weaknesses of the find out Theoretical and methodological limitations Evidence of researcher bias Ethical and legal considerations related to the protection of compassionate subjects Relationship between theory, go for, and research Nurses role in implementing and disseminating research How the study provides certainty for evidence-based practice Identify the following for the research study selected (choose 1 or 2 no(prenominal) BOTH) 8 pts. 1. Quantitative Research Article Critique (Follow the example pp. 433442 of the text) a. Phase 1 Comprehension b. Phase 2 Comparison c. Phase 3 Analysis d. Phase 4 Evaluation 2. Qualitative Research Article Critique (Follow the example pp. 455461 of the text) a. 1. Problem (problem separatement purpose research questions l iterature review frame of reference research tradition) b. 2. Methodology (sampling & precedent selective information collection protection of human subjects c. 3. Data (management analysis . 4. Results (findings interchange logic evaluation summary Format the presentation as one of the following (5 pts) Poster presentation in class Microsoft PowerPoint presentation including detailed speaker systems nones Video of yourself giving the presentation uploaded to an Internet video sharing site such as www. youtube. com Submit the link to your facilitator, include a write reference page in APA format Another format okay by your facilitator disturb in the neck Assessment in Persons with Dementia Relationship Between Self-Report and behavioural Observation Ann L.Horgas, RN, PhD,A Amanda F. Elliott, ARNP, PhD,w and Michael Marsiske, PhDz OBJECTIVES To investigate the relationship between self-report and behavioural indicators of pang in cognitively damage and entire older adults . DESIGN Quasi-experimental, correlational study of older adults. SETTING Data were collected from residents of breast feeding residences, assisted existing, and retirement apartments in northcentral Florida. PARTICIPANTS sensation hundred twenty-six adults, mean age 83 64 cognitively intact, 62 cognitively impaired.MEASUREMENTS unhinge interviews ( put out presence, loudness, locations, duration), bruise behavior measure, Mini-Mental State Examination, analgesic medications, and demographic characteristics. Participants shaded an practisebased communications protocol to induce hurt. RESULTS Eighty-six percent self-reported regular smart. absolute for analgesics, cognitively impaired participants reported less distress than cognitively intact participants subsequently movement but not at rest. Behavioral imposition indicators did not differ between cognitively intact and impaired participants. Total reckon of annoying behaviors was signi? antly related to self-rep orted wound intensity (b 5 0. 40, P 5. 000) in cognitively intact fourth-year hoi polloi. CONCLUSION Cognitively impaired cured people selfreport less anguish than cognitively intact senior people, in certified of analgesics, but that when assessed after movement. Behavioral pain indicators do not differ between the groups. The relationship between self-report and pain behaviors supports the validity of behavioral judgings in this population. These ? ndings support the use of multidimensional pain assessment in persons with derangement.J Am Geriatr Soc 57126132, 2009. Key words pain lunacy measurement From the ADepartment of Adult and Elderly nursing, University of Florida, College of Nursing, Gainesville, Florida wDepartment of Ophthalmology, School of Medicine, University of aluminium at Birmingham, Birmingham, Alabama and zDepartment of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida. Address correspondence to Ann Horgas, College of Nursing, University of Florida, PO Box 100197-HSC, 101 S.Newell Drive, Room 2201, Gainesville, FL 32610. E-mail emailprotected?. edu inside 10. 1111/j. 1532-5415. 2008. 02071. x ain, a persistent periodical problem for many elderly adults, is associated with physical and social disability, depression, and poor quality of life. 1 Between 50% and 86% of older adults aim pain 32% to 53% of those with dementia experience it daily. 2 The high prevalence is associated with proliferation of pain-related health conditions in late life, such as osteoarthritis, hip fractures, peripheral vascular disease, and cancer. Dementia complicates pain assessment, because it impairs memory, judgment, and verbal communication. Dementia is associated with central nervous system changes that alter pain tolerance4 but not pain thresholds (e. g. , minimum level at which a painful stimulus is recognized as pain). 5 No empirical evidence indicates that persons with d ementia physiologically experience less pain rather, they appear less able to recognize and verbally communicate the presence of pain. Findings that cognitively impaired older adults underreport pain relative to nonimpaired elderly people7 and atomic spot 18 less likely to be treated for pain than their cognitively intact peers8,9 re? ect dif? culty assessing pain in this population. Self-report is considered the criterion standard of pain assessment. Despite recent studies supporting the reliability and validity of self-report in persons with dementia,7,10 healthcare providers and pain experts recognize that selfreport alone is insuf? cient for this population and that observational pain assessment strategies are needed.In 2002, the American Geriatrics Society established comprehensive guide logical arguments for assessing behavioral indicators of pain. 1 More recently, the American Society for wound escapement Nursing Task personnel office on Pain Assessment in the Nonverbal Patient (including persons with dementia) recommended a comprehensive, hierarchical approach that integrates selfreport and observations of pain behaviors. 11 Recently, tools to measure pain in persons with dementia have proliferated. In 2006, a comprehensive reciteof-the-science review of 14 observational pain measures was completed.The authors concluded that existing tools are fluid in the early stages of study and testing and that more psychometric wee-wee is needed before tools are recommended for broad adoption in clinical practice. 12 Others, including an interdisciplinary expert consensus P JAGS 57126132, 2009 r 2008, Copyright the Authors Journal compilation r 2008, The American Geriatrics Society 0002-8614/09/$15. 00 JAGS JANUARY 2009VOL. 57, NO. 1 PAIN ASSESSMENT IN PERSONS WITH dementia 127 panel on pain assessment in older persons,13 have corroborated these conclusions. 4 In particular, these authors highlight the need for more evaluation of observational pain meas ures, including validation against the criterion standard of self-report in intact and impaired populations. Almost all research on measuring pain in persons with dementia has center exclusively on persons with moderate to severe disease. There has been only one published study that compared pain behaviors and self-reported pain in persons with and without cognitive impairment, but it cerebrate on postoperative patients undergoing rehabilitation and acute pain associated with physical therapy. 5 Thus, the purpose of this study was to investigate the relationship between self-report and behavioral indicators of pain in cognitively intact and impaired older adults with persistent pain. Speci? cally, this study evaluated whether cognitive stipulation (intact or impaired) differentially in? uenced verbal and nonverbal expression of pain. It was hypothesized that self-reported pain would be lower in cognitively impaired elderly people than in those who were cognitively intact but that pain behaviors, because they are more re? exive and less reliant on verbal communication, would be equivalent in approximately(prenominal) groups.The relationship between pain behaviors and self-reported pain was also evaluated in cognitively intact elderly people to validate whether behaviors measured are indicators of pain. The following research questions were asked. Does cognitive status in? uence self-reported pain? Does cognitive status in? uence ascertained pain behaviors? Are self-reported pain and find pain behaviors related, and is the relationship different in cognitively intact and impaired elderly people? One hundred forty participants were enrolled and completed the baseline interview 126 (90%) completed the protocol. Attrition analyses revealed no signi? ant differences between completers and noncompleters on demographic, residential status, health, or pain variables. The ? nal sample was predominantly female (81%), Caucasian (97%), and widowed (60%), with a mean age of 83 (range 5 6598). Thirty-nine percent resided in nursing homes, 39% resided in assisted living, and 22% lived independently in retirement apartments. Participants average Mini-Mental State Examination (MMSE) raw score was 24 (range 5 730, medial 5 27, mode 5 29). Based on 10th percentile education-adjusted MMSE norms as the cutoff,16,17 64 (50. 8%) were cognitively intact, and 62 (49. %) were impaired. See Table 1 for a description of the total sample and of cognitively intact and impaired subsamples. Groups differed only in residential status (cognitively Table 1. Sample Characteristics, Overall (N 5 126) and According to Cognitive billet Total Sample Cognitive StatusA Intact Impaired (n 5 64) (n 5 62) PValue Characteristic METHODS The University of Florida institutional review board approved this study. Informed consent was obtained from cognitively intact participants and from impaired elderly peoples legally authorized representatives, with assent from persons with dem entia.Design A quasi-experimental, correlational design was employ to investigate pain in older adults with buggy to moderate dementia, because dementia status cannot be experimentally manipulated. Cognitively intact elderly people functioned as a comparison group to examine behavioral indicators and self-reported pain in the two groups. If self-report and behaviors were related in cognitively intact persons, there would be approximately basis to infer that the same behaviors indicated pain in cognitively impaired elderly people. Participants One hundred ? ty-eight older adults were screened for enrollment from 17 assisted living facilities, nursing homes, and retirement communities in north central Florida. Inclusion criteria were aged 65 and older, English-speaking, able to stand up from a chair and walk in get in, diagnosed osteoarthritis in the lower body, and adequate vision and hearing to complete the interview. Sex, n (%) Male 24 (19. 0) 12 (18. 8) 12 (19. 4) Female 102 ( 81. 0) 52 (81. 3) 50 (80. 6) Race, n (%) White 123 (97. 6) 63 (98. 4) 60 (96. 8) Black 1 (0. 8) 0 (0) 1 (1. 6) Other 2 (1. 6) 1 (1. 6) 1 (1. 6) Marital status, n (%) wed 37 (29. ) 21 (32. 8) 16 (25. 8) Unmarriedw 89 (70. 6) 43 (67. 2) 46 (74. 2) Education, n (%) ohigh school 11 (8. 7) 5 (7. 8) 6 (9. 7) potassium alum High school graduate 38 (30. 2) 17 (26. 6) 21 (33. 9) Some college or 31 (24. 6) 18 (28. 1) 13 (21. 0) equivalent College graduate or 34 (27. 0) 18 (28. 1) 16 (25. 8) more Residence Assisted living 49 (38. 9) 28 (43. 8) 21 (33. 9) Nursing home 47 (37. 3) 14 (21. 9) 33 (53. 2) Retirement apartment 30 (23. 8) 22 (34. 4) 8 (12. 9) Analgesics taken 579 ? 1,320 313 ? 699 853 ? 1,708 (in acetaminophen equivalents), mean ? SD Age, mean ? SD 82. 2 ? 7. 3 81. 9 ? 7. 83. 1 ? 7. 6 Number of medical 6. 7 ? 3. 1 6. 6 ? 2. 9 6. 9 ? 3. 4 diagnoses, mean ? SD .93 .59 .39 .84 .001z .02 .55 . 63 A Cognitive status was computed using the following education-adjusted Mini-Mental State Ex amination scores as cutoffs o8th tally education, 20 9 to 11 years, 24 high school graduate or equivalent, 25 some college, 27 and college degree or higher 5 27. 16,17 w Unmarried 5 never married, widowed, separated, or divorced. z Chi-square 5 15. 2, degrees of freedom 5 2, P 5. 001. t (124) 5 2. 22. SD 5 standard deviation. 128 HORGAS ET AL. JANUARY 2009VOL. 57, NO. 1 JAGS mpaired elderly people were signi? cantly more likely to reside in assisted living or nursing home facilities). to use in elderly adults than the traditional visual analogue scale. 21 Procedures Participants completed a brief screening interview to con? rm study eligibility and to ascertain cognitive status. Those eligible were interviewed somewhat their pain and completed an activity-based protocol designed to evoke pain behaviors in persons with persistent pain (described in more detail below). Activity Protocol Participants were asked to sit, stand, rest on a bed, walk in place, and transfer between activ ities.Based on foregoing work, the activity protocol had several strengths for use with this population. First, it simulates performance of basic activities of daily living, thereby enhancing ecological validity of the tasks. Second, it was tested in other studies, and activities were shown to induce pain in persons with osteoarthritis and chronic low back pain, thus providing a naturalistic pain induction method. Third, use of these realworld tasks avoids undue health or safety risks for elderly adults and eliminates potential bias associated with arti? cially induced (e. g. , laboratory-based) pain induction techniques. 8,19 The protocol was simpli? ed by using only 1-minute activity intervals (to reduce complexity of directions and physical demands for frail or cognitively impaired participants) and substituted walking in place for walking across the room and back (to accommodate physical space limitations in residential care facilities where data were collected). Activities wer e conducted in random order to decrease order orders, and the entire 10-minute protocol was videotaped. Measures Self-Reported Pain The principal investigator (ALH) or a trained research assistant interviewed each(prenominal) participant in a private session about their pain experience.Pain presence, intensity, locations, and duration were assessed. Pain Presence. Questions from the Structured Pain Interview (SPI)20 were apply to assess presence of self-reported pain. During the pain screening interview, participants were asked Do you have some pain every day or almost every day (daily pain)? Pain was also assessed immediately before the start of the activity protocol (Are you having any pain right now? (pre-activity)) and immediately after it (Did you experience any pain during these activities? (postactivity)).Response choices to all three questions were yes (1) or no (0). Pain Intensity If participants responded yes to experiencing pain (daily, pre-activity, or postactivit y), they were asked to rate the intensity using a numerical rating scale (NRS). The NRS was presented as a horizontal line with 0 5 no pain and 10 5 worst pain as anchors and equally spaced dashes representing pain intensity rating of numbers 1 through 9. The scale was printed in large, bold font on an 8. 5 A 11 paper to facilitate use with older adults who whitethorn have vision dif? culties. The NRS is considered valid, reliable and easierPain Duration Participants were asked to indicate how long (in months and years) they had experienced daily or almost daily pain. Responses were coded as less than 1 year, 1 to 5 years, 6 to 10 years, 11 to 15 years, or more than 15 years. Pain Locations The pain map from the McGill Pain Questionnaire22 was used to assess pain locations. Participants indicated areas on the body drawing in which they were currently experiencing pain. Total number of painful locations was summed. This widely used measure has been validated in several epidemiologi cal studies and has high interrater reliability (average kappa 5 0. 2). 23 Observed Pain Behaviors Pain Behaviors A modi? ed version of the Pain Behavior Measure18 was used to measure behavioral indicators of pain. Based on standardized behavioral de? nitions, occurrence of the following speci? c pain behaviors was evaluated rigidity, guarding, bracing, stopping the activity, rubbing, shifting, grimacing, sighing or nonverbal vocalization, and verbal complaint. Standardized de? nitions were adapted from previous work,18,19 modi? ed for use in this older, moreimpaired population, and pilot tested in a sample of nursing home residents with dementia. 4 This measure has adequate reliability and validity. 13 Pain Behavior Coding Independent raters, all registered nurses blind to participants cognitive status, scored the videotaped activity protocols. Coders completed extensive training in coding procedures until intrarater and interrater agreement (with the subjugate coder (PI) and anot her rater) reached a kappa coef? cient of 0. 80 or greater, indicating good to very good reliability. 25 After coding reliability was attained, reliability checks were conducted on 10% of all videotapes to minimize rater drift.Noldus Observer software was used to analyze digitized videotapes and code pain behaviors (Noldus Information Technology, Wageningen, the Netherlands). The following summary variables were created and used in the analyses total number of pain behaviors observed, number of times each behavior (rigidity, guarding, bracing, stopping, rubbing, shifting, grimacing, sighing or nonverbal vocalization, and verbal complaint) was observed, and total numbers of pain behaviors observed during each activity state (e. g. , number of behaviors while walking, reclining, sitting, standing, and transferring).Cognitive Status Cognitive status was assessed using the MMSE,26 an 11-item screening instrument widely used to assess general cognitive status in elderly adults. The follo wing MMSE scores served as the cutoffs to classify participants as intact or impaired less than 8th grade education, 20 9 to 11 years, 24 high school graduate or equivalent, 25 some college, 27 and college degree or higher, 27. 16,17 JAGS JANUARY 2009VOL. 57, NO. 1 PAIN ASSESSMENT IN PERSONS WITH frenzy 129 Analgesic Medications Drug data for each participant were coded according to the American Hospital Formulary Service system.All pain medications were identi? ed and converted to acetaminophen equivalents. 8,27 This standardized drugs and dosages to a common metric and facilitated comparison of analgesic dosing. To ensure that only analgesics actually taken would be controlled for, equianalgesic dosages were considered in these analyses only if they were taken indoors the standard therapeutic dosing window for each drug (e. g. , acetaminophen, every 46 hours) before the activity protocol. Data Analysis SPSS, version 15. 0 (SPSS Corp. , Chicago, IL) was used for data analysis.Des criptive statistics, Pearson chi-square (w2) tests, and t-tests were used to describe sample characteristics and examine group differences. Analysis of covariance (ANCOVA) was used to test relationships between cognitive status, pain intensity, and pain behaviors. Logistic retroflection was used to predict pain presence. Multiple regression was used to predict pain intensity and number of pain behaviors, with a centered cognitive statusbypain intensity interaction term to identify group differences standardized regression coef? cients (b) are reported in the results.RESULTS Self-Reported Pain The majority of participants (86. 5%) reported experiencing pain every day or almost every day. More than 65% reported experiencing pain for more than 1 year ( $ 40% indicated duration of 45 years). On average, participants reported pain in four body locations (range 5 125) usual pain intensity was 4. 3 (moderate) on a scale from 0 to 10. Immediately before the activity protocol, 45 (35. 7%) p articipants reported experiencing pain. dream up pain intensity was rated as 1. 7 (range 5 09). After the protocol, 79 (62. 7%) reported experiencing pain during the activities mean pain intensity was 3. (range 5 09). Relationship Between Cognitive Status and Self-Reported Pain Chi-square analyses were conducted to examine the relationship between cognitive status (impaired vs intact) and presence of self-rated daily pain and pain duration at baseline. The baseline pain interview was not always conducted on the same day as the activity protocol, and analgesic use before the interview was not assessed. Thus, initial analyses are descriptive only and do not control for analgesic use. At baseline, 77. 4% of impaired and 95. 3% of intact participants reported experiencing pain every day (w2(1) 5 8. 6, P 5. 003).Cognitively impaired elderly people also recalled shorter pain duration (w2(3) 5 16. 0, P 5. 001) than intact participants, but no signi? cant differences were reported in the n umber of pain locations. Logistic regression, absolute for acetaminophen equivalents, indicated that cognitive status was not signi? cantly predictive of pre-activity pain presence. Regression analyses, with pre-activity pain intensity as the dependent variable and cognitive status and analgesics as predictors, revealed no signi? cant difference between the two groups (Figure 1). Intact Impaired 16 14 12 Mean values 10 8 6 4 2 0 In te a * t ns y SR a re- cti v in Pa ng cing ing rbal aint sity pi b l n e ra uar ig Sh op rima Rub onv mp Inte B G R St G N al co ain P rb Ve activ tos SR b Pain indicators cin g n di g i id ty in ift g a tt Si g g g g g in din kin yin rrin l e n L sf a Wa St an Tr c Activity states Figure 1. Relationship between self-report and observed pain behaviors in cognitively intact and cognitively impaired elderly people (N 5 126). aMean self-reported (SR) pain intensity, controlling for acetaminophen equivalents taken. bMean number of behaviors observed for eac h pain indicator, controlling for acetaminophen equivalents taken. Mean number of behaviors observed during each activity state, controlling for acetaminophen equivalents taken. 130 HORGAS ET AL. JANUARY 2009VOL. 57, NO. 1 JAGS At the end of the activity protocol, cognitive status was signi? cantly associated with the reported presence of pain, controlling for analgesics (b 5 1. 2, P 5. 002) cognitively impaired elderly people were less likely to report pain. Impaired participants also reported signi? cantly lessintense pain than intact participants after the activity protocol (3. 8 vs 2. 6 F (1) 5 A 5. 0, P 5. 03).Paired t-tests indicated that pain intensity increased signi? cantly from start to end of the protocol for both groups (Figure 1). Table 2. Relationship Between Self-Reported Pain Intensity and Observed Pain Behaviors (N 5 126) Total Number of Behaviors Observed Model bA P-Value 1 Pre-activity pain intensity Analgesics taken Pain intensity A cognitive status R2 F 2 Postac tivity pain intensity Analgesics taken Pain intensity A cognitive status R2 F Standardized regression coef? cient. R2 5 coef? cient of determination. A Relationship Between Cognitive Status and Observed Pain Behaviors On average, 21. pain behaviors per person (range 5 350, median 5 21, mode 5 16) were observed during the activity protocol. ANCOVA models, controlling for analgesics, revealed no signi? cant differences in mean number of pain behaviors observed between cognitively intact and impaired participants (covariate-adjusted means 5 21. 8 and 21. 3, respectively F (1) 5 0. 08, P 5. 77). The number of occurrences of each of the eight behavioral indicators observed was summed. ANCOVA models, controlling for analgesics and using Bonferroni correction for multiple comparisons (P 5. 005), revealed no signi? ant differences between cognitively intact and impaired elderly people for any behavioral pain indicators investigated (Figure 1). Of the activity states observed during the prot ocol, transferring elicited the most frequent pain behaviors (mean 5 13. 4 range 5 243). No signi? cant differences were noted between cognitively intact and impaired participants in number of behaviors observed during any of the ? ve observed activity states. Relationship Between Self-Reported Pain and Observed Pain Behaviors Regression analyses were conducted to examine the relationship between elf-reported pain intensity and total number of pain behaviors observed, controlling for analgesics. Before the activity protocol, pain intensity was signi? cantly predictive of the pain behaviors sum score (b 5 0. 27, P 5. 002), but the relationship did not differ between cognitively intact and impaired participants. After the activity protocol, self-reported pain intensity was signi? cantly (and more strongly) related to number of pain behaviors observed (b 5 0. 40, P 5. 000), and the painby-cognitive status interaction was signi? cant (b 5 0. 22, P 5. 008). Thus, postactivity pain intens ity and summed behavioral indicators were signi? antly related in intact but not impaired participants (Table 2). DISCUSSION It was found that cognitive impairment diminishes selfreported pain assessed at rest but only when analgesics are not controlled. At baseline, cognitively impaired elderly people were signi? cantly less likely than cognitively intact elderly people to report pain, consistent with reports in the literature,7 but when analgesics were controlled for, these differences disappeared. This ? nding highlights the need to control for analgesics taken when making group comparisons, which to the best of the authors knowledge, has not been previously done.The few studies reporting medication use include drugs prescribed or number of doses taken 0. 27 0. 01 0. 09 0. 08 2. 9 0. 40 A 0. 03 . 22 . 18 6. 70 .003 . 99 . 30 . 02 . 00 . 75 . 01 . 000 (regardless of medication class), whereas the current study identi? ed analgesics in the subjects body during the pain assessment p rotocol. After the activity-based protocol was completed, selfreported pain intensity increased for both groups, but cognitively impaired elderly people reported less-intense pain than their intact peers. This ? ding supports the usefulness of the protocol to exacerbate pain in those with painful conditions and highlights the richness of mobility-based pain assessments. 12,14 This ? nding held even when the amount of analgesics taken by participants was controlled for in the statistical analysis. Behavioral indicators of pain observed during activities were equivalent across both groups. This ? nding contradicts previous work15 and may re? ect that medication use was controlled for and that the focus of the current study was on persistent pain, as opposed to more-acute, postoperative pain. This research con? ms that reliance on selfreport alone is insuf? cient to assess pain in older adults with dementia, because the pain experience may be underreckoningd,11 and supports growing recognition that behavioral observation is a necessary and useful pain measure, particularly in subjects with cognitive impairment. Cognitively impaired elderly people took signi? cantly more pain medication than their intact peers. The difference was approximately 500 acetaminophen equivalents, approximately the dose of one extra-strength acetaminophen tablet. This ? nding, which contradicts previous work,8,9 warrants moreover investigation.Post hoc analyses indicated that this difference was not attributable to residential status, number of medical conditions, or demographic characteristics. Thus, it may re? ect recent changes in prescriptive practice as a result of heightened focus on pain in older adults with dementia. Another important ? nding is the signi? cant relationship between self-reported pain intensity and observed pain behaviors in cognitively intact persons. This ? nding provided support for the validity of behavioral pain JAGS JANUARY 2009VOL. 57, NO. 1 PAIN ASSESS MENT IN PERSONS WITH DEMENTIA 31 indicators against the criterion standard of self-report, as least in cognitively intact elderly people, and is consistent with other researchers ? ndings. 28 Because there is no evidence that cognitively impaired elderly people experience less pain, it is reasonable to infer that pain behaviors are a valid indicator of pain in persons with dementia, although this assumption cannot be directly tested unless biological tests are developed. 12,24 Pain is subjective, and pain behaviors can be dif? cult to interpret, be subject to bias, and lack speci? city. 14,29 It has been uggested that some behaviors may indicate anxiety or generalized distress, not pain, in those with advanced dementia. 29,30 Thus, pain behavior measurements should be used in conjunction with selfreport, not as a replacement, and in the context of a comprehensive pain assessment. 14,30 Study strengths are that cognitively intact and impaired elderly people participated, thereby faci litating comparison of assessment strategies in persons of differing cognitive abilities, that a careful analysis of analgesics used during the pain assessment was conducted, and that persistent pain was focused on.Most related antecedent research has included only persons with advanced dementia and postoperative pain. The sample was limited, however, by being primarily Caucasian and by being restricted to individuals with mild to moderate dementia. This was likely because of inclusion criteria requiring that participants be able to rise, stand, and walk. Individuals with severe dementia are typically more immobilized and unable to follow directions, factors that would impair ability to complete the activity-based protocol in this study. Thus, generalizations are limited, and further study is needed.This study contributes several important ? ndings to the discourse on pain assessment in persons with dementia. First, it was con? rmed that self-reported pain, although still attainabl e, may be less reliable in those with mild to moderate dementia than in cognitively intact elderly people, depending on when it is assessed. Second, assessment of pain during movement is supported. Cognitively intact and impaired elderly people both showed greater self-reported pain intensity after movement, indicating that static assessment may underestimate pain.Third, results support the validity of behavioral pain assessment against the criterion standard of self-report and provide evidence of an association between summed pain behaviors and self-reported pain intensity. More work is needed to establish scale properties of pain behaviors in relation to pain severity before this approach can be translated to clinical practice. Fourth, ? ndings highlight the importance of carefully evaluating analgesics taken when measuring pain, since results indicate that cognitively intact and impaired elderly people with persistent pain are often medicated differently.This ? nding may re? ect a change in prescriptive practice that warrants further investigation. (Dr. Horgas) and a John A. 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