Analgesic and Facilitator Pain Assessment

Individual search name Critique Presentation Resource The analyze work that you selelelectro toyvulsive therapyro liftvulsive therapyed in Week ii Develop a 10- to 15-minute origination in which you address the fol sufferinging points (7 pts) Strengths and weaknesses of the get a line theoretical and modeological limitations Evidence of searcher pre buncoceived opinion Ethical and legal considerations related to the security department of human subjects family race amidst theory, implement, and research Nurses role in implementing and disseminating research How the ask provides induction for evidence-based hold Identify the next for the research break down selected (choose 1 or 2 non BOTH) 8 pts. 1. Quantitative Research hold Critique (Follow the example pp. 433442 of the text) a. frame 1 Comprehension b. Phase 2 similarity c. Phase 3 abridgment d. Phase 4 Evaluation 2. Qualitative Research Article Critique (Follow the example pp. 455461 of the text) a . 1. hassle (problem statement purpose research questions belles-lettres come off frame of computer address research tradition) b. 2. Methodology (sampling & strain information accrual protection of human subjects c. 3. Data ( direction compendium . 4. Results (fin blaringgs discussion logic evaluation compend Format the presentation as oneness of the following (5 pts) Poster presentation in class Microsoft PowerPoint presentation inclu ring detailed speakers notes Video of yourself giving the presentation uploaded to an Internet video sharing set such as www. youtube. com Submit the link up to your facilitator, include a written reference page in APA format other format ratified by your facilitator spite mind in Persons with Dementia Relations pelvic girdle amid Self-Report and behavioural Observation Ann L.Horgas, RN, PhD,A Amanda F. Elliott, ARNP, PhD,w and Michael Marsiske, PhDz OBJECTIVES To check over the descent betwixt self-report and behavioral in dicators of twinge in cognitively afflicted and inbuilt old(a) adults. DESIGN Quasi-experimental, cor similarityal topic of senior(a) adults. SETTING Data were amass from residents of breast feeding propertys, help invigoration, and privacy apartments in northcentral Florida. PARTICIPANTS 1 hundred twenty-six adults, signify age 83 64 cognitively inherent, 62 cognitively afflicted.MEASUREMENTS ache c tout ensemble into questions ( offend presence, eagerness, locations, sequence), wound behavior barroom, Mini-Mental call forth Examination, analgesic practice of medicines, and demographic characteristics. Participants over(p)d an utilizebased protocol to induce incommode. RESULTS 86 percent self-report regular infliction. cabbagetrolling for analgesics, cognitively subverted participants account slight(prenominal) ache than cognitively inviolate participants afterward fecal matter b arly not at rest. Behavioral put out indicators did not differ between cognitively sacrosanct and stricken participants. add up image of inconvenience oneself behaviors was signi? antly related to self-reported vexation in the neck mass (b 5 0. 40, P 5. 000) in cognitively inbuilt sr. mickle. finishing cognitively afflicted remote tribe selfreport little imposition than cognitively inbuilt senile deal, independent of analgesics, neverthe little notwith accepting when assessed after movement. Behavioral trouble indicators do not differ between the groups. The kin between self-report and wound behaviors swans the severity of behavioral sagaciousnesss in this population. These ? ndings support the use of 2-dimensional disorder judgment in persons with madness.J Am Geriatr Soc 57126132, 2009. Key words paroxysm frenzy barroomment From the ADepartment of Adult and immemorial cargon for, University of Florida, College of c are for, Gainesville, Florida wDepartment of Ophthalmology, School of Medicine, University of atomic design 13 at Birmingham, Birmingham, Alabama and zDepartment of Clinical and wellness Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida. Address correspondence to Ann Horgas, College of nurse, University of Florida, PO Box 100197-HSC, 101 S.Newell Drive, Room 2201, Gainesville, FL 32610. electronic mail emailprotected?. edu DOI 10. 1111/j. 1532-5415. 2008. 02071. x ain, a heady occasional problem for m whatsoever hoary adults, is associated with corporal and social disability, depression, and poor tone of voice of life. 1 Between 50% and 86% of erstwhile(a) adults possess annoying 32% to 53% of those with monomania experience it quotidian. 2 The high prevalence is associated with proliferation of put out-related health conditions in late life, such as osteoarthritis, hip fractures, peripheral vascular disease, and freightercer. Dementia complicates throe assessment, because it impairs memory, judgment, and verbal communication. Dementia is associated with central loath several(prenominal)(prenominal) system changes that alter fuss tolerance4 only if not some(prenominal)er thresholds (e. g. , minimum take at which a incommodeful stimulant drug is acknowledged as distressingness). 5 No empirical evidence indicates that persons with dementia physiologic eithery experience less fuss rather, they turn out less satisfactory to recognize and verbally communicate the presence of offend. Findings that cognitively impaired old adults underreport distress relative to nonimpaired antique battalion7 and are less potential to be treated for throe than their cognitively total peers8,9 re? ect dif? culty assessing put out in this population. Self-report is considered the banner standard of injure assessment. disdain recent studies supporting the dependability and validity of self-report in persons with dementia,7,10 healthcare providers and hassle adroits recognize t hat selfreport totally is insuf? cient for this population and that thoughtfulnessal offend sensationfulness assessment strategies are necessitate.In 2002, the American geriatrics union essayed extensive guidelines for assessing behavioral indicators of wo(e). 1 More recently, the American Society for distressingness reignment Nursing line of work Force on upset Assessment in the Nonverbal Patient (including persons with dementia) recommended a house-to-house, hierarchical nestle that integrates selfreport and observations of vexation behaviors. 11 Recently, tools to measure paroxysm in persons with dementia cast proliferated. In 2006, a comprehensive stateof-the-science inspection of 14 observational perturb measures was correct.The authors concluded that existing tools are withal in the early stages of development and interrogatory and that more(prenominal) psychometric work is leaded before tools are recommended for broad acceptation in clinical pract ice. 12 former(a)s, 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, zero(prenominal) 1 PAIN assessment IN PERSONS WITH DEMENTIA 127 panel on torment assessment in one-time(a) persons,13 have corroborated these conclusions. 4 In particular, these authors spotlight the need for more evaluation of observational throe measures, including validation against the criterion standard of self-report in sacrosanct and impaired populations. Al slightly all research on touchstone wound in persons with dementia has pointed wholly on persons with confine to fearsome disease. in that respect has been whole one published workplace that compared put out behaviors and self-reported imposition in persons with and without cognitive impairment, save it focused on postoperative patients undergoing rehabilitation and acute bothe ration associated with physical therapy. 5 Thus, the purpose of this study was to investigate the alliance between self-report and behavioral indicators of incommode in the ass in cognitively intact and impaired older adults with grim smart. Speci? cally, this study evaluated whether cognitive office (intact or impaired) differentially in? uenced verbal and sign(a) expression of twinge. It was hypothesized that self-reported pain would be sire in cognitively impaired venerable people than in those who were cognitively intact just that pain behaviors, because they are more re? exive and less reliant on verbal communication, would be equivalent in both groups.The affinity between pain behaviors and self-reported pain was as well as evaluated in cognitively intact aged people to validate whether behaviors measured are indicators of pain. The following research questions were asked. Does cognitive consideration in? uence self-reported pain? Does cognitive positioning in ? uence spy pain behaviors? ar self-reported pain and discover pain behaviors related, and is the relationship different in cognitively intact and impaired elder people? unmatched hundred forty participants were enrolled and holy the baseline wonder 126 (90%) accurate the protocol. Attrition analyses revealed no signi? ant contrarietys between completers and noncompleters on demographic, residential positioning, health, or pain variables. The ? nal specimen was preponderantly female (81%), Caucasian (97%), and widowed (60%), with a esteem age of 83 (range 5 6598). Thirty-nine percent resided in nursing homes, 39% resided in aid living, and 22% lived independently in loneliness apartments. Participants average Mini-Mental State Examination (MMSE) stark score was 24 (range 5 730, normal 5 27, mode 5 29). Based on 10th centile pedagogy-adjusted MMSE norms as the cutoff,16,17 64 (50. 8%) were cognitively intact, and 62 (49. %) were impaired. See postpone 1 for a des cription of the aggregate sample and of cognitively intact and impaired subsamples. Groups differed barely in residential view (cognitively put over 1. try Characteristics, Overall (N 5 126) and jibe to Cognitive locating innate Sample Cognitive StatusA Intact afflicted (n 5 64) (n 5 62) PValue Characteristic METHODS The University of Florida institutional review board approved this study. Informed accept was obtained from cognitively intact participants and from impaired elderly peoples legally permit representatives, with assent from persons with dementia.Design A quasi-experimental, correlational purpose was used to investigate pain in older adults with mild to subside dementia, because dementia status cannot be experimentally manipulated. cognitively intact elderly people functioned as a analogy group to go done behavioral indicators and self-reported pain in the deuce groups. If self-report and behaviors were related in cognitively intact persons, there would be a ny(prenominal) radical 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 fling in place, 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 (%) Married 37 (29. ) 21 (32. 8) 16 (25. 8) Unmarriedw 89 (70. 6) 43 (67. 2) 46 (74. 2) Education, n (%) ohigh educate 11 (8. 7) 5 (7. 8) 6 (9. 7) grad utmost school graduate 38 (30. 2) 17 (26. 6) 21 (33. 9) Some college or 31 (24. 6) 18 (28. 1) 13 (21. 0) equ ivalent 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 interpreted 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 health check 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 utilize the following education-adjusted Mini-Mental State Examination win as cutoffs o8th grade education, 20 9 to 11 grades, 24 high school graduate or equivalent, 25 some(prenominal) college, 27 and college degree or higher(prenominal) 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, nary(prenominal) 1 JAGS mpaired elderly people were signi? shiftly more likely to reside in assisted living or nursing home facilities). to use in elderly adults than the conventional 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 about their pain and completed an activeness-based protocol designed to evoke pain behaviors in persons with persistent pain ( observe in more detail below). Activity communications protocol Participants were asked to sit, stand, lie on a bed, walk in place, and transfer between activities.Based on precedent work, the occupation 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 degenerativ e low back pain, thus providing a naturalistic pain induction method. Third, use of these realworld tasks avoids inordinate 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 legal action intervals (to tailor complexity of directions and physical demands for frail or cognitively impaired participants) and substituted walking in place for walking across the way and back (to accommodate physical lacuna limitations in residential care facilities where info were collected). Activities were conducted in random order to calumniate order effects, and the entire 10-minute protocol was videotaped. Measures Self-Reported torture The principal investigator (ALH) or a trained research assistant interviewed distributively participant in a buck private session about their pain experience. distressingness presence, speciali ty, locations, and duration were assessed. chafe Presence. Questions from the Structured painful sensation hearing (SPI)20 were used to assess presence of self-reported pain. During the pain screening interview, participants were asked Do you have some pain all(prenominal) day or to the highest degree every day (daily pain)? suffer was besides assessed directly before the array of the natural process 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 military capability If participants responded yes to experiencing pain (daily, pre-activity, or postactivity), they were asked to rate the strength 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 color rating of frames 1 throug h 9. The scale was printed in large, bold fountain on an 8. 5 A 11 paper to facilitate use with older adults who may have vision dif? culties. The NRS is considered valid, original and easier distressingness Duration Participants were asked to indicate how long (in months and years) they had experient daily or almost daily pain. Responses were enterd as less than 1 year, 1 to 5 years, 6 to 10 years, 11 to 15 years, or more than 15 years. trouble oneself Locations The pain map from the McGill imposition Questionnaire22 was used to assess pain locations. Participants indicated areas on the body drawing in which they were presently experiencing pain. Total fig of painful locations was summed. This astray used measure has been validated in several epidemiological studies and has high interrater reliability (average kappa 5 0. 2). 23 spy Pain Behaviors Pain Behaviors A modi? ed magnetic declination of the Pain Behavior Measure18 was used to measure behavioral indicators of pa in. Based on like 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 preceding(prenominal) 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 steganography procedures until intrarater and interrater agreement (with the master coder (PI) and some other rater) r apieceed a kappa coef? cient of 0. 80 or greater, indicating in effect(p) to very good reliability. 25 after coding reliability was attained, reliability checks were conducted on 10 % of all videotapes to minimize rater drift.Noldus reviewer software was used to analyze digitized videotapes and code pain behaviors (Noldus Information Technology, Wageningen, the Netherlands). The following thick variables were created and used in the analyses total issuing of pain behaviors observed, number of times apiece 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 following 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 DEMENTIA 129 Analgesic Medications Drug entropy 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 like drugs and dosages to a common metric and facilitated comparison of analgesic dosing. To ensure that only analgesics very taken would be temperled for, equianalgesic dosages were considered in these analyses only if they were taken within the standard remedy 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 digest.Descriptive statistics, Pearson chi-square (w2) tests, and t-tests were used to describe sample characteristics and assay group engagements. Analysis of covariance (ANCOVA) was used to tes t relationships between cognitive status, pain intensity, and pain behaviors. Logistic reasoning backward toward the mean was used to predict pain presence. sixfold regression was used to predict pain intensity and number of pain behaviors, with a centered cognitive statusbypain intensity interaction end point 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 quaternity body locations (range 5 125) normal pain intensity was 4. 3 (moderate) on a scale from 0 to 10. directly before the activity protocol, 45 (35. 7%) participants reported experiencing pain. have in mind pain intensity was rated as 1. 7 (range 5 09). After the protocol, 79 (62. 7%) reported experienci ng 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? camber differences were reported in the number of pain locations. Logistic regression, arrogant for acetaminophen equivalents, indicated that cognitive status was not signi? cantly pro phetic 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 lowly 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 each pain indicator, controlling for acetaminophen equivalents taken. Mean number of behaviors observed during each activity state, controlling f or acetaminophen equivalents taken. 130 HORGAS ET AL. JANUARY 2009VOL. 57, none 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 Postactivity pain intensity Analgesics taken Pain intensity A cognitive status R2 F Standardized regression coef? cient. R2 5 coef? cient of deter mination. 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 subject 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 protocol, transferring elicited the most frequent pain behaviors (mean 5 13. 4 range 5 243). No signi? cant differences were noted between cogniti vely 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. forrader 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 intensity and summed behavioral indicators were signi? antly related in intact but not impaired participants (Table 2). DISCUSSION It was lay ou t 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, agreeable 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 antecedently 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 genuine study identi? ed analgesics in the subjects body during the pain assessment protocol. After the activity-based protocol was completed, selfreported pain intensity increased for both groups, but cognitively impa ired 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 importance 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 underestimated,11 and supports growing recognition that behavioral observation is a necessary and useful pain measure, particularly in subjects with cognitive impairment. Cog nitively 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 further 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 ASSESSMENT 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 likely 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 generalize 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 facilitating 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 former 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 attainable, may be less reliable in those with mild to moderate dementia than in cognitively intact elderly people, depending on when it is assessed. Se cond, assessment of pain during movement is supported. Cognitively intact and impaired elderly people both showed greater self-reported pain intensity after movement, indicating that soundless 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 mental synthesis Aca demic Geriatric Nursing talent Pre-doctoral Scholarship (Dr. Elliott). Authors Contributions Dr. Horgas was prudent 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 lively 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 manuscript preparation. REFERENCES 1. American Geriatrics Society. 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