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. Hartford Foundation Building Academic Geriatric Nursing Capacity Pre-doctoral Scholarship (Dr. Elliott). Authors Contributions Dr. Horgas was responsible for scienti? c oversight of all aspects of the study reported in this manuscript, including study design, data collection, data management, data analyses, and manuscript preparation. Dr. Elliott provided critical review of the manuscript and contributed to the design and study methods, data collection, and data coding.Dr. Marsiske provided critical review of the manuscript and contributed to the design and study methods, data management, and statistical analyses. All authors have approved the ? nal version of this manuscript that was submitted for publication. Sponsors Role The National Institute of Nursing Research sponsored this study but had no role in the design, methods, subject recruitment, data collections, data analyses, or man uscript preparation. REFERENCES 1. American Geriatrics Society. 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