Docstoc

Pre Test

Document Sample
Pre Test Powered By Docstoc
					                                   Seasons Seminars, Inc.
                                       911 20th Street
                                    Plano, Texas 75074
                                        972-422-1513
                                     972-881-9333 Fax
                                  www.seasons-seminars.com

Thank you for choosing a Seasons Seminars, Inc. Self Study Course.

The Course you have chosen, Managing Difficult Behaviors in Those with Dementia, has been
approved for 2 hours of continuing education by NAB/NCERS (Domain-Resident Care
Management) and NCAAP. It is also approved for Nurses, Texas Social Workers and
Occupational Therapists.

Learning objectives:
   1. List the four categories of causes of difficult behaviors in those with dementia
   2. Describe the steps of the Problem Solving Approach
   3. Discuss the five techniques for preventing or minimizing behavior problems

Complete as follows:
1. Complete the Pre-Test.
2. Read the course content and complete the Post-Test found at the end of the booklet. Submit
   the Pre-Test, Post-Test and Evaluation by fax (972-881-9333) or mail. A passing grade of
   70% must be made to receive a Certificate of Completion.
3. Complete the information at the bottom and submit payment of $49.95 for the course with
   credit card, check or money order. Payment must be received before a Certificate of
   Completion will be mailed.
4. Certificates of Completion are mailed within 14 days. A $25 fee will be charged to have
   Certificates of Completion processed more quickly.
5. Contact Seasons Seminars, Inc. if you have any questions at 972-422-1513 or
   seasons@season-seminars.com.

Name (Please print)________________________________________________________
Street Address____________________________________________________________
City_____________________________State_____________Zip___________________
License Number(s) with state________________________________________________
Phone number_________________________e-mail address_______________________
 Check enclosed               Prepaid
 VISA         MasterCard            American Express             Discover
Card Number_____________________________________________________________
Expiration date_________________Name on Card_______________________________
Signature________________________________________________________________
           Managing Difficult Behaviors in Those with Dementia

                                       Pre-Test

True or False:
_____ 1. Alzheimer's disease is a mental illness.

_____ 2. All people with Alzheimer's disease will have problem behaviors at some time.

_____ 3. All behavior has meaning.

_____ 4. All behavior problems in those with AD can be prevented.

_____ 5. Staff does not need any special training to care for those with dementia.

_____ 6. The environment can cause behavior problems.

_____ 7. Reality orientation should be used for those in the middle stage of AD.

_____ 8. Use of reminiscence can help to prevent problem behaviors.

_____ 9. Alzheimer’s disease is the greatest cause of communication problems in the
             elderly.

_____ 10. Wandering by a dementia resident usually has a purpose.

_____ 11. Sundowning is a syndrome that causes behavior problems to become worse in
            late afternoon.

_____ 12. Some residents with dementia suffer from depression.

_____ 13. Inappropriate sexual behavior may be a result of low self-esteem.

_____ 14. Behavior problems occur because of damage to the frontal lobe of the brain.

_____ 15. At times medication will need to be used for behavior management.




Name ____________________________                   Date_________________
    Managing Difficult Behaviors in Those with Dementia
Alzheimer’s disease is a progressive neurological disease that is caused by cell
deterioration in the brain. Symptoms of Alzheimer’s disease are impaired short-term
memory, disorientation and decline in occupational activities and activities of daily living
severe enough to interfere with daily life.

Difficult behaviors are a common symptom of many residents who suffer from
Alzheimer's disease and other dementias. It is the inability to manage these behaviors
that leads many family members to admit their loved one to the nursing home. It is also
one of the most frustrating tasks for staff. Good intervention of difficult behaviors adds
to the quality of life of the resident as well as decreases the stress of staff.

                                   What is Behavior?
Behavior is defined as the action or reaction of persons or things in response to a
stimulus. For example, pulling your hand away from a hot stove is a behavior,
responding to the stimulus of heat.

There are key points about behaviors:
 All behavior has meaning; it doesn't just happen.
       Sometimes the reason for the behavior is easily identified. Other times it is not.
       It becomes necessary for the staff to become detectives to determine the cause of
       the behavior. A problem solving approach will be discussed later to help address
       this. There are times when the meaning of the behavior will not be identified. In
       other situations a behavior may have more than one meaning. Wandering may be
       due to boredom, looking for a bathroom or working off frustration or stress.

    Behavior is a means of communicating needs and desires.
        Alzheimer’s is the leading cause of communication problems in the elderly, so
        they resort to other methods to communicate needs and desires. Often these
        methods are interpreted as behavior problems. For example, a person who asks
        the same question repeatedly may be expressing the need for reassurance or
        security. A person who continually heads out the front door may be expressing
        his desire to "go home" to something familiar. Again, the staff should become a
        detective to determine what need or desire the resident is trying to meet with the
        behavior.

    At times, the expression of needs becomes an activity.
         Sometimes what staff perceives as a difficult behavior, is actually an activity for
         the resident. The resident who likes to straighten papers at the nurses' station may
         be doing that because she is bored and needs activity in her life. If she was a
         secretary or a school teacher in the past this would be a normal activity for her.
   Behavior can express the resident's abilities or demonstrate disabilities or challenges
    to the resident.
        A resident who unbuttons her blouse repeatedly may do so because it something
        that she can do successfully, and she is not given any other opportunity to
        participate in a successful activity. A resident who eats his meals with his fingers
        may do so because he no longer can handle a fork or spoon. A resident who yells
        at another resident may do so because she wants that resident to do something and
        that resident does not understand, and the frustration level builds as she tries to
        make that resident understand.

                             Disease Related Behaviors

Difficult behaviors, also known as disease related behaviors, can be expected at some
point in all those who suffer from an Alzheimer’s type dementia. While there is some
predictability to these behaviors, as with all symptoms of dementia, they vary from
individual to individual. Some residents may never exhibit some of the expected
behaviors, but may have extreme problems with others. Some residents may have more
mild behavior symptoms. The following suggests at what stage certain behaviors may be
seen by caregivers.

In the early stage of Alzheimer’s and related dementias, behavior difficulties include
those often mistaken for stubbornness: uncertainty and hesitancy, mood and personality
changes and difficulty following directions. Because these symptoms often appear before
diagnosis, they often are misunderstood by family members and caregivers. These
behaviors are considered difficult because of this misunderstanding. Caregivers think
that not following directions correctly or hesitating to do tasks that they used to do easily
are just the person being stubborn or ornery. Exhibiting a personality that has less tact or
more withdrawn are often perceived as the person being difficult. It is important for
caregivers to understand that these are behaviors that occur because of brain damage, and
that they have no control over them.

In the middle stage, as impairment increases, the following behaviors may occur:
disorientation leading to repetitive questions, suspiciousness, agitation, delusions and
paranoia, wandering, pacing and rummaging. These symptoms are difficult because they
interfere with activities of daily living and are frustrating for caregivers who do not
understand them or how to approach the resident who is experiencing them. They often
lead to combativeness. These behaviors may also have an effect on other residents.

In the late stage, the most common behavior difficulty is combativeness because of the
increased confusion and memory loss and great difficulty in communicating while having
a increased need for more assistance with care.

Many residents with Alzheimer’s and other dementias may also suffer from sundowning
at any stage. Sundowning is a phenomenon that causes behavior problems to become
greater in the late afternoon. It is believed to be due to fatigue, dehydration and that is
“time to go home”.
Another disease related behavior that may be observed by caregivers is that of
inappropriate sexual behavior. The part of the brain that controls impulses and knowing
right from wrong is the most affected part of the brain. As a result the person with
Alzheimer’s is acting on a basic human need without the ability to know what behavior is
appropriate.

              Determining Interventions for Difficult Behaviors
Not all behaviors will need to be addressed. There are three questions to ask to determine
if any action should be taken:

1. Does the behavior significantly violate the rights of others?
2. Does the behavior pose a significant threat to anyone's safety or health?
3. Does the behavior make it significantly more difficult to meet governmental
   regulations (will it cause a deficiency)?

If the answer is "no" to all three of the above questions, then no intervention is necessary.
While these questions are accepted as guidelines, they can be misleading. For example,
if a resident asks repeated questions of the staff, on the surface that behavior does not
seem to meet any of the three criteria above. However, a resident who asks repeated
questions may actually be indicating a need for more attention or boredom. In this
situation a deficiency may be written because the resident is not having all of her needs
met unless there is documentation that indicates all of the interventions that have been
tried to minimize the repetition. Another good guide to determine if action should be
taken is to ask the question "Would I do something if this were my mother (or other loved
one)?"

If it is determined that action should be taken to prevent or minimize a behavior then the
Problem Solving Approach should be applied. To begin this approach the following
questions should be asked:
 What is happening? (define the behavior)
 When is the behavior happening? (e.g. after the daughter visits, late afternoon)
 Who is involved? (e.g. a certain staff person, another resident)
 Where is the behavior exhibited? (e.g. shower room, dining room)
 Why does the behavior usually occur? (e.g. another resident instigates it, the resident
     believes that he needs to go to work)
 What emotion is expressed? (e.g. anger, fear)
 Finally, what changes can be made to prevent the behavior?

Another part of the Problem Solving Approach is the trending of behaviors, especially if
it looks like there is no trigger (the answers to the above questions). Trending includes a
flow sheet that allows for documentation of the answers to the first six questions above
each time the behavior occurs. After a period of time it may become apparent that only
when a resident is near another resident does he lash out, etc.
It is important that all staff is trained to report any behavior to the charge nurse. It is not
unusual for staff to think that the first time they see a behavior that it is not important to
report it. What they do not know is that maybe others have seen the behavior, also, and
therefore it is now something that needs to be addressed. The other extreme to that is that
they believe that everyone all ready knows about the behavior because the nurse aides
have talked among themselves, but it has not been reported to the charge nurse, social
worker or administrator.

When staff are documenting behaviors it is necessary to be specific and descriptive.
Stating that a resident is agitated does not tell someone who reads that what the behavior
truly is. Agitation can be expressed by repeated verbalizations, stripping clothes, lashing
out at others, etc. Each of these specific behaviors would need a different intervention. It
is important in trending behaviors for everyone to clearly understand exactly what the
behavior is. Documentation descriptions should be such that any one who reads it will
clearly know what the behavior is.

                            Causes of Problem Behaviors

Causes of behaviors typically fall into four categories: health, environment, people and
task-related. Health causes result from physical and emotional health problems
including:
 Brain damage
 Effects of medication
 Impaired hearing or vision
 Acute illness
 Chronic illness
 Dehydration
 Constipation
 Fatigue
 Physical discomfort
 Depression
 Loss of control
 Lack of security
 Unused build up of energy

Environmental causes include:
 Too large or small an environment
 Too much clutter
 Excessive stimulation
 No orientation information or cues
 Unstructured environment
 Unfamiliar environment
People related causes:
 Behavior of caregiver
 Behavior of other residents
 Behavior of family or other visitors

Task-related causes
 Task is too complicated
 Too many steps or directions given
 Task is not modified for changing impairments
 Task is unfamiliar
 Impaired communication/unable to understand task

                   Coping Strategies for Problem Behaviors
Having the right skills for intervening when a difficult behavior occurs can prevent the
behavior from becoming more difficult or out of control. Prevention of the behavior
should be a goal as well. There are techniques known as Coping Strategies that can be
used to prevent or diffuse a problem behavior.

The first Coping Strategy is Reality Orientation. Reality Orientation was considered the
best approach in the 1980’s for communicating with Alzheimer residents. It is now an
approach that should be used only for those in the early stages of the disease who are able
to tolerate hearing the truth. Reality Orientation is often thought of as telling residents
that “Today is Wednesday, January 12, 2000. You are at Happy Hollows Nursing Home
in Lovely, Texas.” For those in the middle to late stages, this may make them unhappy if
they do not realize that they are living in a nursing home. They will also probably not
remember this information. Other inappropriate uses of Reality Orientation are telling
someone who is looking for their mother that she is dead or that she has already eaten
lunch.

For those in the early stages of the disease Reality Orientation may be useful in helping
residents to stay oriented. Reality Orientation should be used in a non-threatening
manner, however. For example, for someone who is commenting that their daughter
never visits, even though she visited this morning, a staff person may take the following
approach: “I thought I saw your daughter here this morning. Weren’t you talking about
your grandson, Jack?” This may trigger the memory of the morning visit. If the resident
appears not to remember, the staff person can then respond “Oh, I must have been
mistaken.” This approach to Reality Orientation gives cues to prompt a memory without
putting the resident on the spot and embarrassing him when he does not remember.

While all residents should have access to current date and time, it is especially important
for those in the early stages. Calendars and clocks should be easily visible in the
residents’ room or common areas that they see every day. Part of the MDS assessment is
the resident’s orientation to time, date and place. If the residents have no access to that
information then they are likely to not know it when assessed by staff; thus, their
cognitive status is assessed inaccurately.
A second approach for behavior intervention is Validation Therapy. Validation Therapy
is a technique developed by Naomi Feil when she realized that Reality Orientation did
not work for those who are moderately to severely confused. The basis for Validation
Therapy is to recognize the emotional state of the resident. Instead of telling a resident
that her mother is dead, the response could be “It sounds like you miss your mother.”
This opens the door for the resident to talk about her mother and the relationship they
had. The staff person may have to further prompt to initiate this conversation by saying
“Tell me about your mother.” This approach is successful because as the resident starts
to talk about her mother she will forget about wanting to find her, or it may give the staff
person a clue as to what need the resident is trying to meet by finding her mother.
“Mother” may be the person will have food for the resident who is hungry, or provide
comfort for the person who is in pain or feeling lost. The resident may have taken care of
her mother before she died, and is now worried about who’s taking care of her. By
discovering the reason that the resident is missing her mother the staff person can now fill
that need, physical or emotional.

The Validation Therapy approach is also beneficial for those residents whose language
skills are minimal. By listening to and responding to the emotion, rather than the words,
the staff person will be able to help calm the resident. As humans, we experience many
emotions and many times we want someone to recognize them, whether it be anger and
frustration or happiness and joy. For those negative emotions we aren’t usually looking
for someone to “fix” the problem, but just to listen. (Don’t you have someone that you go
to to vent when having a bad day?) Residents with Alzheimer’s disease continue to have
that need to vent as well. They also want to share happy times with others, just as you
do. The Validation Approach response in these situations should be “It sure sounds like
you’re mad/frustrated/ angry/happy. Tell me about it.” At this point the words are not
important, it is the active listening that is.

The third approach is Reminiscing Therapy, talking about the past. Remembering and
sharing stories about the past has positive benefits. Reminiscing usually is done about
the “good ol’ days.” Talking about these events recalls the times when things were good
and the resident was feeling good about himself. Thus, reminiscing will improve self-
esteem and contentedness. Reminiscing is also a positive distraction. Having an
audience to brag to about past successes distracts the resident from the negative behavior
that he was engaging in. Reminiscing is also a form of successful communication. It
allows the resident to feel important, feel like part of the community and have attention
focused on him. He also has control and is having a successful experience. Negative
behaviors often result from a lack of control in their life and frustration at not being able
to do the things that they want to do.

Reminiscing can be a part of all activities of the resident’s day. When nursing staff are
performing activities of daily living they can engage the resident in conversation about
past occupations, family or community involvement. Activity staff can build reminiscing
into all activities, and housekeeping staff can ask the resident to reminisce while cleaning
the room.
A fourth approach for behavior management is the use of Therapeutic Fibs. Therapeutic
Fibs are a recognized technique for quickly relieving the resident’s fear, anxiety or worry.
They are a means of stepping into the disoriented resident’s reality. Your staff is probably
all ready using them without realizing that they had a name. An example of a
Therapeutic Fib is telling a resident that her husband is at work and will be home at the
end of the day when she asks where her deceased husband is.

Therapeutic Fibs can only be used for those residents who are moderately to severely
confused and who have very poor short term memory. Part of their effectiveness is that
the resident does not remember what was said to them shortly after it was said, but the
calm remains. For these residents Reality Orientation will only frustrate and/or anger the
resident and thus the staff. While Validation Therapy and Reminiscing therapy can be
used in these situations, and should ideally be tried first, Therapeutic Fibs are better when
a quicker technique is needed. Sometimes staff may not have the time to listen to the
resident at that particular moment or it is the hundredth time that morning that the
resident is asking the same question. Or it may be that all the resident wants to know is
that whatever they are afraid of, anxious about or worried about will be all right.

Sometimes none of the above approaches for behavior management will work. The fifth
approach then is Distraction. Distraction is diverting a resident to another activity or
positive behavior. Unfortunately, there will be times when nothing works and the staff
may need to just monitor the resident for safety.


                   General Guidelines for Difficult Behaviors
In addition to the Coping Strategies discussed there are some general guidelines for
managing difficult behaviors. They are:
1. Build a positive, trusting relationship with the resident. The friendlier, more familiar
    a resident is with a staff person, the more cooperative he or she is likely to be with
    care and behavior interventions. The better the staff knows the resident, their
    personal information that can be used in conversation, the less problems there will be
    with difficult behaviors.
2. Use effective verbal and nonverbal communication techniques. Alzheimer's disease is
    the greatest cause of communication problems in the elderly. In addition to the basic
    communication techniques used with all persons, it is important to remember to use a
    more simple language and allow time for a response. Nonverbal language becomes
    especially important for those with dementia who can no longer interpret language.
3. Encourage independence in the resident. A sense of control and competence are basic
    needs for all humans, and for those suffering from a disease that takes away so much
    control and competence, it becomes essential that staff help the resident to increase
    independence.
4. Avoid arguing, yes/no battles, rational or logical explanations, and debates.
    Residents with dementia have their own reality because of memory loss and other
    brain damage. They do not have the ability to be reoriented. Stepping into their
    reality is the only way to prevent, minimize or diffuse a problem behavior.
5. When behavior requires intervention, act quickly with positive techniques and
   activities. Acting quickly will help to keep a behavior from escalating to a point
   where intervention is difficult.

Effective behavior management is a goal of all those who work with residents who have
dementia. Unfortunately, as with other aspects of dementia care, sometimes no matter
how much experience or how much training staff has, behavior interventions will not
always work. Learn to accept mistakes and to learn from them.

                                  Use of Medication

When behavior interventions do not work, it may be necessary to use medications. This
should be a last resort, and medications should only be used to improve the quality of life
of the resident. There are many new medications available now. They fall into four
categories: anti-anxiety, anti-depressants, anti-psychotics and mood stabilizers.
If the primary physician is not familiar or comfortable with these medications, then a
referral to a psychiatrist should be made. Note, that while psychologists are not able to
prescribe, they are often familiar with the most current medications and can make
recommendations to the primary physician.

Anti-anxiety medications that have been effective are Buspar, Ativan, Xanax, Klonopin,
Restoril and others. It is important to be aware of the side effects of these medications,
especially Ativan, which can make residents unsteady, and Xanax, which is addicting.

Anti-psychotic medications that are effective in minimizing behavior problems include
Risperdal, Zyprexa, Seroquel, Haldol and others. The first three listed are fairly new with
few side effects. While Haldol can be sedating in the elderly, small doses have worked
well for some without any adverse reactions.

Anti-depressants should be considered for those with Alzheimer’s and other dementias.
Depression is common, especially in those in the early stages, but easily goes
undiagnosed since the symptoms of depression can mimic those of dementia. Symptoms
of both disease include withdrawal, self-neglect, sleeping problems and other personality
and behavioral changes. Common anti-depressants used are Paxil, Zoloft, Elavil, Desyrel
and Prozac, as well as others.

Recently, psychiatrists and neurologists have started to use the mood stabilizer Depakote
for those with behavior problems that do not respond to the medications discussed above.

When medications are used for management of difficult behaviors the key is “Start low,
and go slow”. Older persons usually do not need the normal adult dosage for drugs to
work. It also takes approximately two to three weeks to see the full effect of a new
medications. It also takes that long to see the reaction to decreasing or stopping a
medication.
                                      SUMMARY

Difficult, or disease related, behaviors are a part of Alzheimer’s disease and related
dementias because of brain damage. These behaviors are a leading cause for family
caregivers to admit their loved one to a nursing home.

All behavior has meaning, and it becomes the staff’s role to determine what the cause of
the behavior is so that an appropriate intervention can be used. Good interventions are
needed to improve quality of life for the resident and to decrease the stress of the staff.

Certain behaviors can be expected at different times in the disease, but not all those
suffering from dementia will exhibit the same behaviors at the same time or in the same
way. And not all residents will exhibit all the possible behaviors.

Staff should look at behaviors to determine if they are really a problem or just something
out of the norm that can be accepted. If it is determined that a behavior is one that needs
intervention then the staff should implement a problem solving approach. This approach
will help to determine the intervention that will work best to prevent or minimize the
problem.

There are five Coping Strategies that can be used for intervention: Reality Orientation,
Validation Therapy, Reminiscing Therapy, Therapeutic Fibs and Distraction. Each of
these techniques has a specific purpose and time for use.

In addition to the Coping Strategies, there are general guidelines for managing difficult
behaviors that will help to prevent or minimize difficult behaviors. These guidelines
emphasize good communication techniques and promoting independence in the residents.

As with all aspects of dementia care, there will be times that it seems like nothing works.
Staff should learn to accept mistakes and learn from them.

When behavior interventions do not work then medication may be the answer.
Physicians should look at prescribing an anti-anxiety, anti-depressant, anti-psychotic or
mood stabilizer. The goal of these medications is to improve quality of life.
           Managing Difficult Behaviors in Those with Dementia

                                       Post-Test
Circle the right letter:
1. Alzheimer’s is a:
        a. Mental illness
        b. Neurological disease
        c. Normal part of aging
        d. None of the above

2. The most common reason a person with Alzheimer’s disease is admitted to a nursing
   home is:
      a. Incontinence
      b. Wandering
      c. Behavior problems
      d. Communication problems

3. Good interventions of behavior problems:
      a. Add to the quality of life of residents
      b. Decreases the stress of staff
      c. Requires training of all staff
      d. All of the above

4. Behavior is a means of communicating:
      a. The need for activity
      b. Needs and desires
      c. None of the above
      d. A and B

5. The resident who likes to straighten papers at the nurses station may be expressing a
   need:
      a. For activity
      b. For attention
      c. To be a part of the staff
      d. To drive staff crazy

6. Behavior can:
      a. Express the resident’s abilities
      b. Demonstrate the resident’s disabilities
      c. Demonstrate the resident’s challenges
      d. All of the above
7. Behavior difficulties in the early stage often occur because caregivers perceive the
   resident as:
       a. Being cognitively intact
       b. Not listening
       c. Being stubborn
       d. None of the above

8. Many of the behaviors in the middle stage often lead to:
     a. Combativeness
     b. Disorientation
     c. Poor communication
     d. All of the above

9. To determine what action should be taken to minimize a behavior, do the following:
      a. Talk to a family member
      b. Refer to the social worker
      c. Use the Problem Solving Approach
      d. Ask the doctor for help

10. Trending of behaviors help to identify:
       a. What staff are doing wrong
       b. The trigger
       c. What medication works
       d. All of the above

11. Documentation of behaviors should be:
       a. Done daily
       b. General in description
       c. Done only to meet state regulations
       d. Specific and descriptive

12. Causes of behaviors fall into these four categories:
       a. Emotional, environmental, people and physical
       b. Brain damage, staff, residents and environmental
       c. Health, environmental, people and task-related
       d. Health, staff, residents and task-related

13. To relieve resident’s fear, anxiety or worry, staff should use:
       a. Reminiscence
       b. Validation therapy
       c. Therapeutic fibs
       d. Reality orientation
14. The coping strategies that all staff can use to minimize behavior problems is:
       a. Reminiscence
       b. Validation therapy
       c. Therapeutic fibs
       d. Reality orientation

15. Managing difficult behaviors requires:
      a. A lot of time
      b. Good communication techniques
      c. Medication
      d. All of the above




Name _________________________________________ Date ___________________
                          Seasons Seminars, Inc.

                        Participant Program Evaluation


Program title: Managing Difficult Behaviors in Those with Dementia

Date Home Study Completed _________________________________

Learning objectives:
   1. List the four categories of causes of difficult behaviors in those with dementia
   2. Describe the steps of the Problem Solving Approach
   3. Discuss the five techniques for preventing or minimizing behavior problems

Scale: 5=Excellent, as good as I’ve ever completed.
       4=Good, meets high standards, would recommend to others
       3=Satisfactory, acceptable but not outstanding
       2=Poor, having at least one serious deficiency. Would not recommend.
       1=Terrible, as bad as I’ve ever completed.


Rate the following aspects of the program:

_____ Learning objectives and content material

_____ Appropriateness of topic and content

_____ Usefulness of the knowledge/skills acquired

_____ Course writer’s knowledge of topic

_____ Presentation of written coursework

_____ Overall rating


Time spent completing this course: ____________________________

Comments (please comment on any ratings of 1 or 2):

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:12
posted:7/10/2011
language:English
pages:15