Pleasantville Essay

When David and Jenifer are tolerated to Pleasantries and are forced to play the part of Bud and Mary-sue the whole routine/script goes out of whack. We see Davit's fantasy at the start were the director has used a close up shot of David talking to the girl of his dreams. As the camera zooms out, It becomes obvious that he was Imagining talking to her the director uses this to portray Davit's character. From this we see that he Is a loner and Is socially awkward. To David this perfect world Is his reality.David knows everything bout Pleasantries all the characters the script everything there is to know. It almost seems to be a religion to him. For Jenifer this is only a fantasy and she doesn't like it she wants to bring her reality to this fantasy world. Change Change is commonly seen throughout the film and is represented in many ways. We not only see change In the characters but In the environment around them. The first sign of change we see Is the red rose that bud sees after his d ate with Mary-sue the director uses this to show the audience that everything Is about to change.The director also use costumes to show the change In Pleasantries, teenagers In Pleasantries start to wear more modern clothing that are bright and colorful. The director also introduces rain and fire to Pleasantries, which are all new experiences for people in Pleasantries. When the director introduces rain The main characters in the film change in some way through the film. Jenifer is a teenage girl trying to be cool by smoking and getting with guys. When Jenifer is tolerated to Pleasantries we e change as the film progresses.We see a glimpse of change in Jenifer when she picks up the glasses to read the book. Moments later as we see the camera move across we see the photograph of her wearing glasses. Another sign of change is when Margaret starts baking cookies for bud Instead of Whaley. When we see Bud and Margaret on their date at lover's lane we see Margaret pick an apple from a tr ee, the apple symbolizes the corruption of the real world. The forbidden fruit. The people in Pleasantries have very little knowledge. We see an example of this when Mary-sue ask, â€Å"What outside Pleasantries† Everyone looks at her as she was stupid.The teacher replies â€Å"Mary-sue you know better than that it goes around in a circle†. We also see another glimpse of there lack of knowledge when the tree catches on fire. When we see the tree on fire the director portrays both the people of Pleasantries and the tree on fire to show their confused and intrigued faces. When bud is at the fire station yelling â€Å"FIRE† the fire fighters are all confused it wasn't until e said â€Å"cat† that the fire fighter got into action but when they got there they didn't know what to do.In the end bud saves the day putting out the fire. The tree on fire is a major event in the film this is when the people of Pleasantries what to know more. We see an example of chan ge and knowledge when David was saying the ending to a book as he was saying what happened the black pages in the book started to fill. Creating new knowledge soon after all the books in Pleasantries were filled and everyone was at the library reading and gaining new knowledge. By Dylan South

Mary kay reference sheet

The irony with the youth of today's generation is that even when they become romantically involved with a certain person or a certain project, they eave the abnormal ability to disengage from that entanglement in an instant. II. Preview Statement: The issue our society is suffering from mainline Ill. Preview Statement: In the modern society, one of the major social constrains to this particular issue has to do with liberty-I am going to discuss this ‘V.Preview Statement: [Environmental factors are also a constraint in the development of creating loving and decent adults. Body: [About 85% of speaking time. ] l. Our society is suffering from the condition of anomie, which is a situation in which society doles out very little ethical guidance to individuals, and allows a great amount of self-regulation. A. The recognition of should not go unnoticed. It is important we effectively educate our pupils to appreciate spiritual truth, spiritual fruits, beauty, and each other. 1 .Prevent ion measures should be taken against individuals from becoming underdeveloped and self-centered in their pursuits of selfish desires. 2. These slackers' concept of sex is all about lust and not love, marriage and babies. Our education must prevent individuals from becoming meaningless members who sole purpose is to consume with relentless voracity. . Proper values and education are vital, and students should also be surrounded by the right people as role models. B. Woodrow Wilson sums this up perfectly, â€Å"Friendship is the only cement that will ever hold the world. B. These days, our members of society view liberty as the privilege of not having any outside form of control to limit them. 1 . Landfills are free to go about as they please and act on their impulses. A. Len counterbalancing their behavior against our society, these individuals find a considerable amount of social permissiveness to commit whatever wrongdoing they wish to rationalize as legitimate. . With society mis leading the youth, they are at a disadvantage of understanding the true meaning liberty.Transition: To truly understand good, we must study the concept of virtue. The great philosopher, Aristotle says, â€Å"the true student of politics, too, is thought to have studied virtue above all things, for he wishes to make his fellow citizens good and obedient to the laws† (Aristotle: Ethics). II. As a result, all our choices and decisions should be made with this end result in mind. The way to go about this rule is through making virtue the sole intention in performing our actions. A.Our society has failed to educate our youth that if our decisions are based on self- interest or emotions such as attitudes such as envy, ill will, or hatred, we are indeed lacking liberty. B. This is because if we do not have the ability to practice self-control by choosing to do what's good, we are blinded to the degree that we ourselves are lacking in liberty. Transition: [Review the last point and p review the next. Be sure to use complete sentences. ] Ill. Modern parents work long hours and spend less time with their kids, giving them less room to teach them right from wrong, values, and etc,.A. The parents are more focused on making more and more money in the modern economy. B. The curriculum of education does not place a sufficient amount of importance on artistic activities. C. The system does not spend enough time teaching our children to acquire an ear for a taste in music and poetry. Conclusion: [About 5% of speaking time. ] l. Summary of Main Points: A. The culture of modern society promotes interests aside from going to work and coming back, to simply consume and consume to fill an internally felt psychological emptiness. B.The issue is multifaceted: how to socialize our children to love one another satisfactorily (which encompasses education); how to correctly assess whether an individual is worth pursuing (which is wisdom and sagacity); and lastly how to choose confi dants who will continue to appreciate and care for us even after we have proven to be of no source of personal benefit or entertainment. C. The teaching of love explains that we are not to love the gifts of this world (self- care, companionship, family) for the sake of itself.

Wikis Assignment Example | Topics and Well Written Essays - 250 words

Wikis - Assignment Example can observe how the business offers its services and products by reading other people’s comments, therefore, getting attracted to the business if it has good ratings. This would bring new customers to the business. Thirdly, potential customers seek to work with companies that they can trust. A business that has a wiki creates an atmosphere of trust by showing that it accepts criticism if a service is rendered poorly. Therefore, many businesses that develop wikis are thought to deliver quality services, therefore, attracting new customers (Wagner and Majchrzak 17). The wiki can be critical to the employees as it would offer a platform where they can communicate with the customers, thus making them understand what the business is all about. It also ensures that the employees are treated well in the business to ensure that their comments are in the company’s favor. Partners can view the company’s progress through the wiki by reading the comments and assessing them to see if quality services and products are offered (Wagner and Majchrzak 21). Wikis bear ethical and security concerns in that any individual can add content, which may be offensive or not be relevant to the topics. Secondly, people assume that the wikis can be edited or written in favor of a particular issue, thus reducing credibility. Thirdly, wikis can be tampered with using malware applications or viruses (Cummings 6). The company can address these issues by ensuring that the users are registered before gaining access to the wiki. This helps to detected changes and identifies users’ presence. Antivirus programs can be used to detect malware programs that could be harmful to the computers (Wagner and Majchrzak 37). Cummings, Robert E.. Wiki Writing Collaborative Learning in the College Classroom. Ann Arbor: Digital Culture Books, an imprint of the University of Michigan Press and the University of Michigan Library, 2008.

Unit 4 SEMINAR Research Paper Example | Topics and Well Written Essays - 250 words

Unit 4 SEMINAR - Research Paper Example at these values are adhered to, I will inform my clients on the limits of confidentiality that would involve linking them to the expected moral guidelines (Corey, Corey & Callanan, 2010). This agreement will be of use in determining a professional relationship with the clients as other parties will respond ethically when required. Privileged communication helps put limits to the information that a therapist may disclose (Corey, Corey & Callanan, 2010). I will ensure this ethical aspect is adhered to by strictly directing that no personal information is disclosed whether in legal proceedings or otherwise. Only after the client authorizes is when I will authorize specific information disseminated (Corey, Corey & Callanan, 2010). More so, at the beginning of the contract, I will clearly explain the boundaries to cross in terms of communication and the effects of breaking the guidelines set. Informing the clients in time helps minimize unprofessionalism in the relationship (Corey, Corey & Callanan,

Violent Video Games Essay Example | Topics and Well Written Essays - 1000 words

Violent Video Games - Essay Example However, the diversity of these video games is threatening. Many of these games are violent in nature. Examples of violent video games are: Killer Instinct, Mortal Kombat and Sega's Primal Rage. All these games deal with fighting and killing the opponent in the most terrible and cruel way possible. Many of the more recent violent video games are modifications and are influenced by the above mentioned games. According to Dill, "Provenzo (1991) studied the most popular video games and noted that 40 out of 47 were violent in nature." Several other studies are mentioned by Dill, all of which support the idea that most of the video games are violent in nature. This research seeks to discover the degree of influence of the violent video games to selected college students. Inevitably and naturally, the players are affected by the games they play. This study will try to find out the causal relationship between violent video game and aggression. This will try to prove the hypothesis that the exposure of the students to video game violence increase aggressive behavior and other aggression related phenomena. Specifically, the study will answer the question: Does playing violent video game increase aggressiveness This research will use 40 respondents, 20 males and 20 females. ... The researcher will determine the video game to be played. Immediately after playing the video games, their cardiovascular measures (blood pressure and heart rate) will be taken then immediately they will be asked to answer the questionnaire. The IV (independent variable) will be the video games and the DV (dependent variable) will be the cardiovascular measures and the questionnaire. They must not take alcohol, caffeine, cigarettes and any drugs that may affect their behavior prior to the experiment. The following is a list of the video games that will be played by the respondents. The violent games are: Dark Forces (The player assumes the role of a special ops guy in the Rebellion aiming to steal the Death star plans and to get out alive. Weapons like a blaster rifle and laser pistol are used to kill enemy guards and storm troopers.); Marathon 2 (The shooter is a space marine trapped in a base that is taken over by aliens. His goal is to retake the base and not die, shooting at anything that moves.); Speed Demon (The player drives a heavily armed vehicle in a race with other armed vehicles. One gets points by destroying other vehicles.); Street Fighter (This is similar in many ways to Mortal Kombat. The player chooses a character and then engages in a series of fights with other characters.); and Wolfenstein 3D (The player assumes the role of B.J. Blascowitz, an American soldier caught and taken prisoner trying to infiltrate a top-secret Nazi lab. There are several deadly weapon s and he shots at all things that move). The nonviolent games are: 3D Ultra Pinball (This is simply an electronic version of a pinball game, complete with flippers, buzzers, bells, and various visual and auditory effects); Glider Pro (Players of this game control the forward and

Gun control (Self defence low) Essay Example | Topics and Well Written Essays - 750 words

Gun control (Self defence low) - Essay Example The argument over the right to own a gun and be armed within the home is centralized against a statistically failed premise that to be armed is to be protected. The Second Amendment of the Constitution of the United States is written to say â€Å"A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed† (Harpre 80). The language of this Amendment is convoluted and is not clear on the actual intent of this addition to the Constitution. The problem with the way it is stated is that it can be interpreted to read that the people are entitled to a free militia that may arm themselves, or that the people are entitled to be armed. Regardless to the way the amendment is read, the historical relevancy of the Amendment must be taken into account before deciding if it is contemporarily necessary to allow anyone who can pass through a Historically, the Amendment arose from an issue that the colonies were having with the English monarchy attempting to disarm the citizens. In the period of time surrounding 1768 - 1775, the British government had occupied the colonies with troops loyal to the monarchy. One of the many attempts to assert control over the colonists was to declare in certain areas that personal firearms would not be allowed (Halbrook 21). The collection of personal firearms by the military was undertaken on occasion, denying the colonists the freedom of owning their own guns. In the world of 1768, the necessity of a gun was quite different than it might be in the current culture. As well, the colonists were arming themselves in anticipation of a revolution and the occupying government was aware of this threat. The tension between the monarchy’s needs and the needs of the colonists incited the framers of the Constitution to give this right back to the people. Owning a

The structure of the suggested Central Bank for GCC Assignment

The structure of the suggested Central Bank for GCC - Assignment Example Additionally, the Gulf States generate wealth from their vast oil and gas resources that allows their economies to operate above unprecedented development. The empirical research in this study provides information that supports creation of a well-developed financial system. One of the issues captured in this report tends to answer the question on the better options that are required for economic growth within different regions. The GCC region supports bank-oriented financial system that is contrary to market-oriented financial systems supported by the United States and United Kingdom. According to Demirguc-Kunt and Ross (1999), the structure of financial system and overall level of development is crucial for establishment of suggested Central Bank for GCC. However, financial development majorly depends on legal and political institutions. Based on Structure-Conduct-Performance (SCP) model, the study explores implication of structure and conduct on overall performance of suggested GCC financial institution. According to theory of Industrial Organization, structure refers to the extent of concentration of market shares within the market while conduct refers to general behavior of firms measured by efficiency and profitability (Demirguc-Kunt and Ross, 1999). The banking sector is considered one of the major conduit for economic activities within GCC region. Growth of GCC countries is dependent on critical valuation of the structure, conduct as well as performance of banking industry. Monetary union presents an important cornerstone of an economic union based on chosen political power. The structure of the GCC central bank should be based on sound technical basis and at the same time considered a strategic goal (Strum and Siegfried, 2005). A realistic step towards such a goal involves formation of monetary union that ultimately realigns different political systems. In the European case, monetary union was

Sustainable Design Essay Example | Topics and Well Written Essays - 4000 words

Sustainable Design - Essay Example The balancing of these aspects in the new product development design is the outlook of 'Sustainable product development and design'. "To create sustainable products and services that increase stakeholders' 'quality of life', whilst at the same time achieving major reductions in resource and energy use, will require a significant emphasis on stimulating new ideas through higher levels of creativity and innovation"- e generation Business Learning Centre. Thus it becomes evident that creating new designs may need increased creativity as well as the fullest involvement form the varied strata of people, if new solutions and designs are to be generated which will substantiate the Sustainable Product Design Development. In general 'sustainable development' is to be seen as a basic human concept dealing with the kind of environment the people would like to live in. Sustainable development is a strong image but a provocative one. The best place to get good suggestions on the sustained development is the 'customers'. Many companies have forgotten to talk to customers but have focused inwardly on the technological and improvements required for, primarily eco-design using less energy and less components etc. In many cases such suggestions may not be the right solution but nevertheless, it can be demonstrated that new ideas can reach marketplace if the conditions are right." Quite understandably, the majority of people do not understand the academic concept of sustainable development. Indeed, research for the Department of Environment in the UK, indicated that sustainable development was seen as a government construct to keep people out of environmental issues" Martin Charter and Anne Chick (1997). Keepi ng this context in view, this paper attempts to cover an overview of creation of new sustainable product designs to manufacture products, services and product service systems in so far they address economical, social and environmental issues. This paper also aims to have a re-look in to the past, study the present and suggest possible future solutions to the impact of product design on these issues. 2.0 SUSTAINABLE PRODUCT DESIGN-ECONOMICAL ISSUES As we described at the outset, good design and good business go hand-in-hand. The best challenge in business that a firm may face is to arrive at an exact product design even at the first instance so that the rushing to be first to the market will not result in design flaws and the resultant poor performance of the product. This may totally negate any advantage resulting to the firm because of its efficient and quicker 'time to market'. "An effective design process: Matches product or service characteristics with customer requirements Ensures that customer requirements are met in the simplest and less costly manner Reduces the time required to design a new product or service and Minimize the revisions necessary to make a design workable." - (Roberta S. Russell & Bernard W. Taylor III 2003) All the above objectives flow only in one direction; that is to maximize the benefit of the value design. All forces in an organization work in cognition to align themselves with the common aim of achieving market share, sales volume, brand reputation, customer loyalty, profit margin and channel growth and so on. A careful analysis of these

Management Accounting Essay Example | Topics and Well Written Essays - 1500 words - 9

Management Accounting - Essay Example Coordination involves the systematic combination of various processes to achieve optimal results of pre-planned outcomes. It involves three main processes, which are performing situational analysis, competitor analysis and self-evaluation. Both micro-environmental and macro—environmental aspects must be considered. Concurrent with the above process, clear and specific objectives must be set. Vision statement, overall objectives both short-term and long—term are crafted (Abdel-Kader and Luther, 2006)). With regard to situational analysis, the above processes give rise to a strategic plan. The plan provides details of how coordination is to be achieved. Coordination involves managing dependencies among activities. Chandler suggests that to understand the business coordination concept, a simple intuition must come into mind that, if there is no interdependence, there is nothing to coordinate. It is comprehensible that players carrying out interdependent actions may have inconsistent interests and that might be called opinionated processes. These are ways of managing them in order to ensure best results are realized. According to Chandler, coordination occurs in many kinds of systems, biological, human, computational among others. The question on how community run enslavements among their actions are middle to parts of organization theory, sociology, management science, social psychology, linguistics, law and anthropology. Coordinating these dependencies gives rise to direct and indi rect costs (Lisa, 2006) Indirect Costs are the ones that have been sustained for universal or joint objectives and cannot be enthusiastically recognized with the exact final cost objective. They can also be defined as costs that cannot be directly quantified and may need further analysis to quantify them. They are incurred for various or interlinked activities and are not easily categorized into specific

Audio Surveillance Essay Example for Free

Audio Surveillance Essay Audio Surveillance is implemented with the use of a tape recorder. This method is only effective when one is sure of the origin of the attack and may be used to gather information about a particular activity taking place or how it took place. Telephone conversations may also be recorded to provide security. Models that may be used could include High Tech voice recorders, Tube mike, radio mikes and so on. The modern ESS (Electronic Switching System) is also available to tap into people’s phone lines without having to visit the location physically. Phone Tapping and Encryption Phone tapping is normally used for the protection of national security and prevention of serious crimes. When a phone is tapped, it is possible to listen to conversations from both sides of the telephone. Voice and Word Pattern Recognition In this method of surveillance, an organization uses a central computer to monitor conversations that contain voice patterns and key words that an agency is interested in. This technology involves digital sampling of speech, acoustic signal processing and special analysis. Transmitter Location Transmitter location is used anytime a telephone or mobile phone is involved in an investigation and is used to detect the location of the user. This can be achieved by triangulation and some other innovative methods. E-mail at Workplace Personal messages sent via an organization’s e-mails are not private. Reading employee’s emails may help to alert organizations about possible terrorist activities or sabotage that may be going on within the organization. Electronic Databases Databases containing information about residents within a particular area, biometrics. directories, voter registration records and many other databases present within an organization can help to provide relevant information on terrorism. The Internet Many organizations, individuals and so on, have access to the internet and are able to share information via this global network. Websites that offer social networking features should be continuously checked for possible terrorist correspondence. Challenges of Surveillance Technology Privacy is one of the major issues being faced by operators of businesses and organizations across the world. Surveillance Technologies pose a threat to them because people are unsure of how far vendors are willing to go to sell their products without risking confidential data. This constitutes a threat to commercial businesses (Bogonikolos). Privacy is a big issue and a significant constraint in the deployment of surveillance systems because most people see it as a right that they possess. Privacy has a lot of dimensions and some of the dimensions include: Privacy of the person, personal behaviour, personal communications, data and so on (Bogonikolos). The future of Surveillance Technology In recent times, almost all information is exchanged through electronic means, i. e. via telephone, email and so for this reason, wiretapping capabilities are being incorporated into surveillance systems (Bogonikolos). A continuous education strategy may help to achieve an online data and privacy protection strategy. Global e-commerce has changed the way trade is being conducted all over the world. This had led to the increased complexity of Surveillance Technologies. Enhanced wiretapping capabilities are being incorporated into surveillance technologies and so electronic commerce is getting more and more attention. New technologies for analyzing large amounts of data such as credit card information, online transactions can also help to identify unusual purchasing patterns and relationships (Bogonikolos). Conclusion To operate successfully online and protect countries from attack, we need to assure people that their data is safe and protected from misuse such as unauthorized access, alteration, total loss, and misappropriation (Bogonikolos). After all has been said and done, it can be argued that technology has both negative and positive sides to it. When used for the benefit of society, technology can be seen as a positive contribution to society but when it is used by miscreants to cause havoc to innocent people and unsuspecting organizations, it becomes a disadvantage. The fact remains that it is difficult, if not impossible to stop the misuse of technology but one thing that can help us all is to continually keep ahead of the terrorists by conducting research on state-of the art technologies and inventing new media and surveillance technologies that can help to combat the evils of terrorism. Works Cited Bogonikolos, Nikos. Development of Surveillance Technology and Risk of Abuse of Economic Information. Interim Study. 1999.

Dementia Of Alzheimers Type Health And Social Care Essay

Dementia Of Alzheimers Type Health And Social Care Essay Ageing brings with it changes in number of domains, including attitudes, health, self-image, relationships, status, generational changes, sexual functioning and an awareness of time and mortality. These general themes all appears regularly in clinical work with older people as they come to terms with the realities of retirement or illness. (Wattis and Curran, 2006) The National policy on older persons confers the status of senior citizen to a person who has attained the age of 60 years (Ministry of Social Justice website). An estimated 77 million people or 7.7 percent of the population are senior citizens (Help Age India website) Many of our aged senior citizens live with their families. Hence any physiological and psychiatric changes affect these family members. (Handbook of Psychiatric Social Work,2007) Understanding Dementia The word dementia is an umbrella term which describes a serious deterioration in mental functions, such as memory, language, orientation and judgement. Numerous definition of dementia has been suggested. Roth proposed that it is an acquired global impairment of intellect, memory and personality. A more comprehensive definition has been suggested by McLean, namely, an acquired decline in a range of cognitive abilities (memory,learning, orientation and attention) and intellectual skills (abstraction, judgement, Comprehension, language and calculation), accompanied by alterations in personality and behaviour which impair daily functioning, social skills and emotional control. There is no clouding of consciousness, and other psychiatric disorders are excluded. Dementia usually has an insidious onset, with most people developing symptoms gradually over a period of years. The progression of these diseases is largely unpredictable for each individual. How and what symptoms develop depend on what parts of the brain are affected by which illness, and the unique characteristics of each individual. Dementia has a life changing physical, emotional and mental impacted on the affected person and their primary caregiver and family. Dementia is a neuropsychiatric condition in elderly, disabling illness of late life, which is a hidden problem in India, demanding immediate attention from professionals (Shaji Iype, 2006). Different type of dementia: Some types of dementia are irreversible and progressive. This is not true for all types of dementia, especially if detected early. Types of dementia include: Dementia of the Alzheimers Type Approximately 50 percent of all cases of dementia are caused by Alzheimers disease. Vascular Dementia Vascular dementia is cause by small strokes that stop blood flow to parts of the brain. Dementia Due to Other General Medical Conditions Medical conditions that can cause dementia include HIV, head trauma, Parkinsons disease, Huntingtons disease, Picks disease, Creutzfeldt-Jakob disease, metabolic disorders, and hypoglycemia. Substance-Induced Persisting Dementia The use of a substance such as alcohol or the sudden withdrawal from a substance can cause dementia. This is diagnosed only if the symptoms last beyond normal withdrawal time for the substance. Dementia Not Otherwise Specified This is the category for dementia that doesnt fit in an above category. Dementia differs from delirium, which is characterized by a state of sudden confusion. Dementia is not part of the normal aging process nor is it mental retardation or psychosis. There are medications and therapies that can help manage the symptoms of the disease, making life easier for the patient and his/her family. Dementia of Alzheimers Type (DAT): Alzheimers disease is the most common form of dementia. Alzheimers Disease is named after the German Psychiatrist, Alois Alzheimer, who in 1906 first described the changes caused by the condition. The diagnostic criteria for DAT as mentioned in DSM-IV-TR: A. The development of multiple cognitive deficits manifested by both   (1) memory impairment (impaired ability to learn new information or to recall previously learned information)   (2) one (or more) of the following cognitive disturbances:  Ã‚      (a) aphasia (language disturbance)      (b) apraxia (impaired ability to carry out motor activities despite intact motor function)      (c) agnosia (failure to recognize or identify objects despite intact sensory function)      (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.   C. The course is characterized by gradual onset and continuing cognitive decline.   D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:   (1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinsons disease, Huntingtons disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)   (2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)   (3) substance-induced conditions   E. The deficits do not occur exclusively during the course of a delirium.   F. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Episode, Schizophrenia).   Code based on presence or absence of a clinically significant behavioral disturbance: 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance. 294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance. (e.g., wandering, agitation) Specify subtype: With Early Onset: if onset is at age 65 years or below   With Late Onset: if onset is after age 65 years   ICD-10 diagnostic criteria for dementia: The primary requirement for the diagnosis is evidence of a decline in both and thinking which is sufficient to impair personal activities of daily living. The impairment of memory typically affects the registration, storage and retrieval of new information, but previously learned and familiar information may also be lost, particularly in later stage. Dementia is more than impaired memory. There is also impairment of thinking and of reasoning capacity, and a reduction in the flow of ideas. The processing of information is impaired, in that the individual finds it increasingly difficult to attend to more than one stimulus at a time. (e.g. taking part in a conversation with several people), and to shift the focus of attention from one topic to another. If dementia is the sole diagnosis, evidence of clear consciousness is required. However, a double diagnosis of delirium superimposed on dementia is common. The above symptoms and impairments should have been evident for at least six month s for a confident clinical diagnosis of dementia to be made. Alzheimers disease (F00) In ICD-10, Alzeheimers disease (AD) is divided into Dementia in AD with early onset (F00.0) and Dementia in AD with late onset (F00.1). These categories include the definition of dementia discussed above. For Dementia in AD with late onset, onset is after the age 65years. AD has an insidious onset with a gradual decline in the mental stage, Memory difficulties, especially with regard to new memories, are usually the first symptoms to be noticed. Memory problems may be attributed to old age or absent-mindedness. The onset is so gradual that even a close relative living with the patient the early stages, previous personality may strongly influence the presentation. Patients with a tendency to be suspicious of others or to deny their own limitations may upset carers by accusing them of stealing misplaced items. Others may react to these early changes by becoming extremely dependent on relatives, especially if family patterns of behaviour encourage this. Mood disturbance is not a diagnos tic feature of AD. It may also be common in more advanced AD. Here it may not be reported by the patient, but may be inferred from behavioural changes and response to treatment with antidepressants. The patient usually lacks insight, and as the disease progress their behaviour may become more erratic. Disorientation with regard to time, place and person will also increase, usually in that order. The combination of disorientation in time and place and topographical disorientation may cause the patient to wander, resulting in considerable distress for the family, risk to the patient and the involvement of neighbours, other individuals and the police, who may have to bring the patient home. Patients may get up in the early hours believing that it is time to go to work or get the children ready for school. Hallucinations (usually visual) are fairly common, but are not usually evident except through the description of careers (e.g he spends a lot of time picking up imaginary food from th r floor). As the disease progress, the patient will become unable t recognise their relatives, who often finds this distressing. The patient may then become distressed, as they may believe that their spouse or son or daughter in a intruder. In addition, the patient may fail to recognise him or herself , and this can also cause considerable distress. Carers often find that removing mirrors solves the problem. Other difficulties with moderate to severe impairment include apraxia, which presents with difficulties in dressing and washing and other tasks involving visuo-spatial skills. Dysphasia (inability to express oneself in words or to understand words) can lead to severe frustration when combined with all of the other impairments and confusion. Incontinence (both urinary and faecal) usually develops late in the disease and for many carers is the final straw. Eventually the point is reached when the patient is unable to or anything from him- or herself including the following: dressi ng, personal hygiene, domestic tasks, toileting and feeding. There are characteristic changes in the brain: a marked reduction in the population of neurons, particularly in the hippocampus, substantia innominata, locus ceruleus and temporopareital frontal lobe cortex; appearance of neurofibrillary tangles made of paired helical filaments; neuritic (argentophil) plaques, which consist largely of amyloid and show a definite progression in their development (although plaques without amyloid are known to exist); and granulovacular bodies. Neurochemical changes have also been found, including marked reduction in the enzyme choline acetyltransfearse, in acetylcholinse itself, and in other neurotransmitters and neuromodulators. Causes of AD AD is a primary degenerative cerebral disease of unknown etiology, with characteristics neuropathological and neurochemical features. The precise aetiology of AD is poorly understood. However, it is important because such an understanding may have implications for both prevention and treatment. The relationship between cause and effect may be difficult to establish, particularly with regard to neurotransmitter deficits and the characteristics of neuropathological changes that are seen in AD. On the basis of epidemiological research, the most important risk factors for AD are old age and a family history of dementia and Downs syndrome. Alzheimers and the Brain Alzheimers disease leads to nerve cell death and tissue loss throughout the brain. As the disease progresses, brain tissue shrinks and the ventricles (chambers within the brain that contain cerebrospinal fluid) become larger. The damage disrupts communication between brain cells, crippling memory, speech, and comprehension. Alzheimers Medications There is no cure for Alzheimers disease, and no known way to slow the nerve damage within the brain. But there are a variety of medications that appear to help maintain mental function and slow the disease progression. If these treatments are given during the early stages of Alzheimers, your loved one may be able to remain independent and carry out daily tasks for a longer period of time. Prevalence of Dementia: Global Impact: Worldwide, there is a new case of dementia every seven seconds. As of 2008, there are an estimated 30 million people with dementia worldwide. By 2050, it is projected that this figure will have increased to over 100 million. Much of the increase will be in developing countries. Already more than 60% of people with dementia live in developing countries, but by 2040 this will rise to 71%. The fastest growth in the elderly population is taking place in China, India, and their south Asian and western Pacific neighbours. (Ferri et al, 2005) Stages of Dementia/AD Knowing a persons disease stage helps health professionals to determine the treatment approach and aids communication between health providers and caregivers. Sometimes the stage is simply referred to as early stage, middle stage or late-stage dementia, but often a more exact stage is assigned, based on a persons symptoms. Geriatric population is more affected by dementia of Alzheimers Type (DAT) or Alzheimers Disease (AD) 60-65 % and other related disease. Therefore, when choosing a suitable intervention model for dementia one has to keep in mind stages in dementia, context and circumstance, as care needs vary with stage to best help both the elderly people and their families. The below table demonstrates the changes in persons with Alzheimers disease and related disorders that usually occur during the progression of the illnesses. As patients move through stages, family issues are also changing. The type of clinical intervention that is most appropriate and effective for a particular family should be determined by the types of problems and issues the family needs to address. Early/Mild Stage: mild memory loss and deterioration of skills 1-5 years Changes occurring in patient Effect on family members Clinical Intervention Forgets familiar names Unable to name familiar objects Unable to retain what is read Unable to perform simple calculations Decreased knowledge of current and recent events Becomes careless in grooming habits Becomes anxious and frustrated in demanding situations Denies memory problems and inability to perform tasks Withdraws from challenging situations Gets lost in familiar surroundings Denial used as defense mechanism in coping with pain of relatives diagnosis False hope of improvement Fear of future Fear that they will also get dementia Concern about the effect on their life Conflict over care planning decisions Family assessment to include: genogram, influence of pre-existing family patterns, cultural items, quality of relationships, family conflict, support system, and socioeconomic level. Educate about disease process Validation of feelings (e.g anger) Refer to caregiver support group Evaluate environment of dementia victim Refer for information on legal and financial issues Explore care options Middle/Moderate Stage: Pronounced and severe decline of skills 5-15 years Unable to recall addresses, phone numbers, names of family members Disorientation to time or place Has difficulty choosing the proper clothing to wear Decreased ability to travel, handle finances, make decisions Flattening of affect (facial expression) Sleeping pattern affected Behaviour changes- may become delusional, obsessive, easily agitated, depressed Role changes Social Isolation Anger, resentment over caregiving responsibilities Embarrassed by patients behaviour Guilt over relinquishing caregiving responsibilities Conflict over care planning decisions Overwhelmed by caregiving responsibilities Marital problems Depression Help to prioritize caregiving tasks Assist family with feelings associated with caregiving and/or institutional placement Encourage family members to continue contact with the person in an institutional setting, participating in their care plan Problem-solve to alleviate conflict by resolving issues Encourage participation in a caregiver support group Be supportive to family members who are providing care Increase family support network Use crisis intervention strategies when necessary Educate about behaviour management Individual, marital or family therapy Late/Severe stage: Complete loss of functioning and basic skills 3-5 years Unaware of recent events and experiences Unaware of surroundings, the year, the season Verbal abilities are lost Incontinence of bowel and bladder Loses basic psychomotor skills Requires assistance in feeding, difficulty in swallowing Unable to acknowledge recognition of family members, friends Weight loss Grief over the loss of the person they once knew Conflict over care planning decisions Guilt over this desire for the disease to progress to death Support the familys decisions on terminal care. Problem-solve to alleviate conflict by resolving issues Address the long term grief of caregivers and help them to prepare for their future without the patient Provide case management services as needed, continually assessing the patients needs and the familys coping ability Give the family permission to let go Encourage funeral arrangements Effects of AD As people with dementia need sustained care, it becomes important to provide services for patients with dementia also provide support and guidance to their caregivers. The burden of looking after patients with AD is immense, and carers and families become physically and emotionally exhausted and socially more taxing. At this time families need support from the multidisciplinary team. For the better quality of life of both AD patients and caregivers, there is need for research and intervention models specific to individuals (familys) culture. Most of the time the caregivers are family members, they are encouraged to learn about the principles of long term care in general and dementia care in particular. In India, caregivers have their own strategies for care giving suitable to the family member of dementia. What is lacking is the knowledge of AD, therefore educating them is important, which will change their perception and attitude toward the family member (support with research). In rural areas, lifestyle, physical activity (farming) and environment difference could have contributed to the lower percentage of dementia. This is in particular reference to research done in Ballabgarh (New Delhi, India), there exist no case of dementia in this area, as studied in comparison with/to Pennsylvania community of elderly people, USA. Developing countries are also reaching the statistics of developed countries of increased life expectancy and stress related lifestyle, therefore, increasing risk of Dementia/AD. Some of the Intervention programs for caregivers are mentioned in the next session. This includes different models of intervention based on theory and research. Details of family intervention programs for caregivers of AD includes Educating about dementia, providing support-family counseling, group home support ,skill training. number of sessions, time period, and objective, content, success rate/effectiveness of the session/model. Family Intervention/treatment Caregivers of AD Role of caregivers Challenges faced by caregivers Intervention programs Caregiver: In our society more and more responsibility is placed on the family to provide care. The family caregiver is that significant person in the family, who looks after the basic needs of the patient throughout the day. The care for the caregiver is of immense importance as this population suffers more psychological effect than the patient. With the onset of a disability, the family is forced to take on new roles and greater responsibility. This causes high levels of stress in an already stressful situation. Caregivers are sometimes forced to give up their own needs in order to care for a family member. The caring for someone and constantly giving up ones own personal interests can affect the caregiver both physically and emotionally which, in turn affects the patient. The caregivers need to be aware of their own feelings, judgements, and different ways of reacting to the patients behaviour. They must also take care of their own physical and emotional health in order to provide care to their loved one. Ethnicity and culture issues also play a greater role in care giving. In society today, we have many different types of families. Some cultures tend to have extended and blended families, which can offer more support to the caregiver. Some cultures also view care-giving as an expected family function that can put added pressure and stress on the family. It is important for treatment team to understand the patients needs, but it is also important that they understand the families (caregivers) needs. Stress and caregiver burden: The negative phenomena associated with caring for victims of illness and injury is defined as caregiver burden. Caregiver burden may be further categorised into objective burden and subjective burden. Objective burden included changes in the patients personality and behaviour which are seen by the caregiver as well as financial strain, changes in the daily routine, changes in living conditions, and changes in social activities. Subjective burden is defined as the caregivers negative reaction in response to the presence of objective burden. A study conducted by Mitrani et al (2006) on the role of Family Functioning in the Stress Process of Dementia Caregivers: A Structural Family Framework. It was conducted on One hundred eighty-one family caregivers from the Miami site of the Resources for Enhancing Alzheimers Caregiver Health (REACH) project participated in this study. They assessed socio demographics, burden, depression, anxiety, and perceived health for each caregiver. The results of the study indicated that family functioning significantly contributed to distress in the overall sample and partially mediated the relationship between objective burden and distress. The implication of the study is that Family structural functioning is one contributor to the caregiver stress process. This suggests that interventions targeting structural family problems may reduce caregiver distress. The disease follows a predictable irreversible progression that lasts from between three to twenty years. NonPharmacologic Management of Dementia: The first line of treatment for an older person with dementia, especially one who has recently been diagnosed, is pharmacological, that is medication with cholinesterase inhibitors. Family systems Model: The family systems model is based on the premise that members of family groups influence and are influenced by all other members. Each family is a unique system, with its own set of rules that specify power structure, roles, communication techniques, and problem solving (Bowen, 1971; Haley, 1971; Minuchin, 1974; Kerr, 1981). Family treatment from a systems framework begins with an assessment of family organization and functions. An understanding of the familys structure and dynamics is necessary for making decisions regarding change strategies. From a family systems perspectives, the changes in health and functional status that are associated with dementia affect all members of the family unit. Although a primary caregiver usually assumes the daily care of the dementia patient, all family members experience some changes in roles, relationships, and goals. In some cases, the burden on the family can become excessive, jeopardizing the familys physical, emotional, and social stability (Niederehe Fruge, 1984) Interventions based on the family systems model can be focused on cognitive, emotional, and/or behavioural levels of functioning in families (Wright Bell, 1981). These interventions are directed toward change within the structure of the family, altering the postions of family members and resulting in individual changes as well. The following types of interventions have been found to be effective with families of dementia patients and can be used alone or simultaneously. Cognitive interventions: Directed at the cognitive level of family functioning, these interventions provide new information or a new perspective on a problem. They can include educating the family about the dementing illness and discussing the potential effects of the disease on family members. The next step is to suggest ways in which the family can respond to these effects and to provide information about community resources. It may be extremely painful for the family of a dementing patient to make the decision to place her in a nursing home. The clinician can provide an objective viewpoint, alleviating some of the familys guilt in making the final decision. Emotional interventions: These interventions validate a familys emotional responses and often affect feelings that may be blocking their efforts at problem solving. Validation of family members emotions, such as sadness, anger, and guilt, can help them understand the connection between the dementing illness and their stress. In the validation process, it is important to emphasize that the whole family is affected by the illness. Behavioural interventions: Aimed at the behavioural level of functioning, these interventions can assist family members in modifying behaviours that cause problems in their interactions. This type of intervention attempts to change such behaviour by teaching new adaptive skills. Families area also encouraged not to make sudden and major adjustments in their daily routines following a diagnosis of dementia. Family members do not all react in the same way to this illness; whereas some tend to exist in a state of denial throughout the initial stages and fail to recognize the real needs of the patient, others overcompensate and encourage dependence by the patient. To avoid a continuous state of family disruption, it may be necessary to assign specific behavioural tasks to family members. At the same time, it is important to emphasize that family members should try to continue their regular activities and maintain their accustomed role responsibilities for as long as possible. Before intervening in a family system that is dealing with a dementing illness, clinicians need to understand the familys perception of the illness. The clinicanss objectives is to help the family to adjust t it, not necessary to accept it. Tracy was a 30 year old teacher who sought help for her recent anxiety attacks. During the initial interview with the social worker, she focused on her mother, who was caring for Tracys grandfather, an Alzheimers patient. Tracy and her mother had always had a good relationship, but Tracy had now become focused on how her mother was coping with her grandfathers illness and was making recommendations on how she could get some respite from her caregiving responsibilities. Her mother refused to consider Tracys recommendations. Problem: Originally sympathematic to her mothers caregiving situation, Tracy was now frustrated and angry because she thought her mother was neglecting herself and other family members while caring for grandfather. Tracy reacted to her grandfathers illness by focusing intensely on her mothers cargiving responsibilities and taking on her mothers problem as her own. This focus on her mother allowed her to avoid dealing directly with her feelings about her grandfathers progressive illness and eventual death. Tracys mother reacted to her fathers illness by overcompensating and enmeshing herself in the role of caregiver. Although she often complained that caring for her father was exhausting and left her with little time and energy for herself or other famly members, she refused to consider assistance from her family or community services. Treatment approach: Advise Tracy to stop giving recommendations to her mother, but to continue to be supportive. Encourage Tracy to discuss her feelings about her grandfathers illness and any perceived expectation that she would assume the same caregiving responsibility for her mother in the future. Open communication between Tracy and her mother (and other family members, if possible) to share contents about the patients illness. Suggest meeting with Tracys mother. Encourage her to set time aside for herself and her family, providing support and information on resources and care options. Giver her permission to acknowledge the negative as well as positive feelings of caregiving. Goals: Open lines of communication between Tracy, her mother, and other family members. Acknowledge Tracys and her mothers feelings associated with the patients illness. Remove Tracys self-imposed responsibility for solving her mothers caregiving problems. Family Mediation Family Mediation is a family- oriented, problem-solving, task completion model that was originally used as an intervention in child custody and divorce situations, child-parent conflicts, and family disputes (Parsons Cox, 1989). A model that empowers mediation is an effective strategy for many of the caregiving problems that occur during the course of a dementing illness. The mediator role is based on conflict theory. Three dimensions of conflict have been identified with these caregiving families: a. Family members perceptions of illness and strategies for care. b. Their attitudes and behaviour toward the patient; and c. Their attitudes and behaviour toward the primary caregivers (Miles Huberman, 1984, Semple, 1992). Conflict often results from interaction between systems such as individuals, families, organizations, and communities, and may grow out of differences in values and power that make it difficult for the parties involved to define ways to agree or disagree. The role of the mediator is to move the conflict from the emotional and values level to a more objective level that provides the opportunity for negotiation. Families involved in the care of a person with dementia are faced with many options for difficult decisions, such as relocation, assignment of caregiving responsibilities, home health care, assisted living arrangements, and nursing home placements. Participants in the decision-making process may include dementia patients spouse, children, friends, neighbours and professional care-givers. Decisions involving several participants are usually not unanimous, with conflict resulting throughout the process from feelings of guilt, grief connected with the progression of the deme