Psychosis is common in late life and exacts enormous costs to society, affected individuals, and their caregivers. A multitude of etiologies for late-life psychosis exist, the two most prototypical being schizophrenia and psychosis of Alzheimer’s Disease (AD). As such, this review will focus on the non-affective, neuropsychiatric causes of chronic psychosis in the elderly, specifically schizophrenia, delusional disorder, and the psychosis of AD and other dementias. As evidenced in this review, the current research regarding the onset and course of late-life schizophrenia reflects a more favorable prognosis than that painted by the Kraepelinian notion of schizoprenia as “dementia praecox.” Antipsychotics are useful in controlling the symptoms of late-life schizophrenia, but their use among older adults warrants increased vigilance because of older adults’ increased proclivity to side effects. Psychosocial interventions can be effective, usually in conjunction with medication. Meanwhile, psychosis of AD occurs in nearly half of people with AD and is associated with increased hospitalizations, institutionalization, caregiver distress, and mortality. Despite the profound consequences of psychotic symptoms associated with dementias, the extant literature does not afford clinicians clear, consistent guidance on how to provide optimal treatment to specific patients. Second generation antipsychotics are usually the choice treatment for psychosis, but the black box warning regarding their associated 1–2% increased absolute risk in stroke and overall mortality in patients with dementia complicates their use. Using second generation antipsychotics in low doses for brief periods and discontinuing them when possible is the best clinical practice for dementia-related psychosis. Psychosocial interventions for the treatment of psychosis with AD appear promising in empirical research, but more rigorous study is needed.

There is a widening disparity between the proportion of ethnic minority Americans in the population and the number of researchers from these minority groups. One major obstacle in this arena relates to a dearth of mentors for such trainees. The present academic settings are not optimal for development and sustenance of research mentors, especially for mentees from underrepresented minority ethnic groups.

Mentoring skills can and should be evaluated and enhanced. Universities, medical schools, and funding agencies need to join hands and implement national- and local-level programs to help develop and reward mentors of junior scientists from ethnic minority groups.

The study of wisdom has recently become a subject of growing scientific interest, although the concept of wisdom is ancient. This article focuses on conceptualization of wisdom in the Bhagavad Gita, arguably the most influential of all ancient Hindu philosophical/religious texts. Our review, using mixed qualitative/quantitative methodology with the help of Textalyser and NVivo software, found the following components to be associated with the concept of wisdom in the Gita: Knowledge of life, Emotional Regulation, Control over Desires, Decisiveness, Love of God, Duty and Work, Self-Contentedness, Compassion/Sacrifice, Insight/Humility, and Yoga (Integration of personality). A comparison of the conceptualization of wisdom in the Gita with that in modern scientific literature shows several similarities, such as rich knowledge about life, emotional regulation, insight, and a focus on common good (compassion). Apparent differences include an emphasis in the Gita on control over desires and renunciation of materialistic pleasures. Importantly, the Gita suggests that at least certain components of wisdom can be taught and learned. We believe that the concepts of wisdom in the Gita are relevant to modern psychiatry in helping develop psychotherapeutic interventions that could be more individualistic and more holistic than those commonly practiced today, and aimed at improving personal well-being rather than just psychiatric symptoms.

Purpose of review

Although the basic standards of adjudicative competence were specified by the U.S. Supreme Court in 1960, there remain a number of complex conceptual and practical issues in interpreting and applying these standards. In this report we provide a brief overview regarding the general concept of adjudicative competence and its assessment, as well as some highlights of recent empirical studies on this topic.

Findings

Most adjudicative competence assessments are conducted by psychiatrists or psychologists. There are no universal certification requirements, but some states are moving toward required certification of forensic expertise for those conducting such assessments. Recent data indicate inconsistencies in application of the existing standards even among forensic experts, but the recent publication of consensus guidelines may foster improvements in this arena. There are also ongoing efforts to develop and validate structured instruments to aid competency evaluations. Telemedicine-based competency interviews may facilitate evaluation by those with specific expertise for evaluation of complex cases. There is also interest in empirical development of educational methods to enhance adjudicative competence.

Summary

Adjudicative competence may be difficult to measure accurately, but the assessments and tools available are advancing. More research is needed on methods of enhancing decisional capacity among those with impaired competence.

Background

The reasons for the reportedly high use of TV watching among older adults despite its potential negative health consequences are not known.

Purpose

To investigate age differences in time use and affective experience in TV use in a nationally representative sample

Methods

Using an innovative assessment of affective experience in a nationally representative sample, several putative reasons were examined for age-related increases in TV use. A sample of 3982 Americans aged 15–98 years who were assessed using a variant of the Day Reconstruction Method, a survey method for measuring how people experience their lives, was analyzed. To understand age increases in TV use, analyses examined whether older people (1) enjoy TV more, (2) watch TV because it is less stressful than alternatives, or whether (3) TV use related to age differences in demographics, being alone, or life satisfaction. Data were collected in 2006 and analyzed in 2008–2009.

Results

Adults aged >65 years spent threefold more waking time watching TV than young adults. Despite this trend, older people enjoyed TV less, in contrast to stable enjoyment with other leisure activities. Older adults did not seem to experience the same stress buffering effects of watching TV as did young and middle-aged adults. This negative age-associated trend in how TV was experienced was not accounted for by demographic factors or in time spent alone. Greater TV use, but not time spent in other leisure activities, was related to lower life satisfaction.

Conclusions

Older adults watch more TV but enjoy it less than younger people. Awareness of this discrepancy could be useful for those developing interventions to promote reduced sedentary behaviors in older adults.

OBJECTIVES

Lay perceptions of “successful aging” are important for understanding this multifaceted construct and developing ways to assist older adults to age well. The purpose of this qualitative study was to obtain older adults’ individual perspectives on what constitutes successful aging, along with their views regarding activities and interventions to enhance its likelihood.

METHODS

Qualitative interviews were conducted with 22 community-dwelling adults over age 60. Participants were recruited from retirement communities, a low-income senior housing complex, and a continued learning center in San Diego County. Interview transcripts were analyzed using a “Coding Consensus, Co-occurrence, and Comparison” grounded theory framework.

RESULTS

The mean age of participants was 80 years (range: 64 to 96), with 59% being women. Two primary themes were identified as key to successful aging - i.e., self-acceptance/self-contentment (with sub-themes of realistic self-appraisal, a review of one’s life, and focusing on the present) and engagement with life/self-growth (with sub-themes of novel pursuits, giving to others, social interactions, and positive attitude). A balance between these two constructs appeared critical. A need for interventions that address support systems and personally tailored information to make informed decisions and enhance coping strategies were also emphasized.

CONCLUSIONS

Older adults viewed successful aging as a balance between self-acceptance and self-contentedness on one hand and engagement with life and self-growth in later life on the other. This perspective supports the concept of wisdom as a major contributor to successful aging. Interventions to enhance successful aging may include those that promote productive and social engagement along with effective coping strategies.

Objective

Treatments for the cognitive impairments of schizophrenia are urgently needed. We developed and tested a 12-week, group-based, manualized, Compensatory Cognitive Training (CCT) intervention targeting prospective memory, attention, learning/memory, and executive functioning. The intervention focused on compensatory strategies such as calendar use, self-talk, note-taking, and a six-step problem-solving method, and did not require computers.

Method

In a randomized controlled trial, 69 outpatients with DSM-IV primary psychotic disorders were assigned to receive standard pharmacotherapy (SP) alone or CCT + SP for 12 weeks. Assessments of neuropsychological performance and functional capacity (primary outcomes) and psychiatric symptom severity, quality of life, social skills performance, cognitive insight, and self-reported everyday functioning (secondary outcomes) were administered at baseline, post-treatment, and 3-month follow-up. Data were collected between September 2003 and August 2009.

Results

Hierarchical linear modeling analyses demonstrated significant CCT-associated effects on attention at follow-up (p=0.049), verbal memory at post-treatment and follow-up (ps≤0.039), and functional capacity (UCSD Performance-based Skills Assessment) at follow-up (p=0.004). The CCT group also differentially improved in negative symptom severity at post-treatment and follow-up (ps≤0.025) and subjective quality of life at follow-up (p=0.002).

Conclusion

Compensatory Cognitive Training, a low-tech, brief intervention, has the potential to improve not only cognitive performance, but also functional skills, negative symptoms, and self-rated quality of life in people with psychosis.

Longitudinal data suggest heterogeneity in the long-term course of schizophrenia. It is unclear how older adults with schizophrenia perceive changes in their experience of schizophrenia over the lifespan. We interviewed 32 adults aged 50 years and older diagnosed with schizophrenia (mean duration 35 years) about their perceived changes in the symptoms of schizophrenia and functioning over the lifespan. Interview transcripts were analyzed using grounded theory techniques of coding, consensus, co-occurrence, and comparison. The study was conducted by a research partnership involving a multidisciplinary team of academic researchers, community members, and mental health clients engaged in all aspects of study design, interviewing, and analysis and interpretation of data. Results revealed that, in regard to early course of illness, participants experienced confusion about diagnosis, active psychotic symptoms, and withdrawal/losses in social networks. Thereafter, nearly all participants believed that their symptoms had improved, which they attributed to increased skills in self-management of positive symptoms. In contrast to consistency among participants in describing illness course, there was marked heterogeneity in perceptions about functioning. Some participants were in despair about the discrepancy between their current situations and life goals, others were resigned to remain in supported environments, and others working toward functional attainments and optimistic about the future. In conclusion, middle-aged and older adults with schizophrenia believed that their symptoms had improved over their lifespan, yet there was substantial variability among participants in how they perceived their functioning. Functional rehabilitation may need to be tailored to differences in perceptions of capacity for functional improvement.

Objective

The objective of this study was to examine the influence of military veteran status within a data set of older patients with schizophrenia or schizoaffective disorder.

Methods

The data set was examined to determine whether veteran status influenced psychopathology, quality of life, cognitive performance, and everyday functioning among 746 male participants.

Results

There were no significant differences between the groups on measures of premorbid functioning or psychopathology. Veterans in the sample were older, had a higher likelihood of being married (or previously married), had a lower likelihood of living in a board-and-care facility, and had a later age of onset of schizophrenia compared with nonveterans. Though veterans reported worse physical health, they also had better everyday functioning and better performance on some cognitive tasks than nonveterans. Fewer veterans endorsed current use of substances than nonveterans.

Conclusions

There were several differences based on veteran status, including everyday functioning, health-related quality of life, cognitive performance, and current substance use.

Objective

Supported employment is the evidence-based treatment of choice for assisting individuals with severe mental illness to achieve competitive employment, but few supported employment programs specifically target older clients with psychiatric illness. The purpose of this study was to evaluate the efficacy of supported employment for middle-aged or older people with schizophrenia.

Method

Participants included 58 outpatients with schizophrenia or schizoaffective disorder aged 45 or older who were recruited from a community mental health clinic. Participants were randomly assigned to receive Individual Placement and Support (IPS; the manualized version of supported employment) or conventional vocational rehabilitation (CVR) for one year, and completed assessments at baseline, six months, and twelve months.

Results

IPS was superior to CVR on nearly all work outcome measures, including attainment of competitive employment, weeks worked, and wages earned. Fifty-seven percent of IPS participants worked competitively, compared with 29% of CVR participants; 70% of IPS participants obtained any paid work, compared with 36% of CVR participants. Within the IPS group, better baseline functional capacity (as measured by the UCSD Performance Based Skills Assessment) and more recent employment were modestly associated with better work outcomes.

Conclusions

Middle-aged and older adults with schizophrenia are good candidates for supported employment services.

Many neuroimaging studies interpret the commonly reported findings of age-related increases in frontal response and/or increased bilateral activation as suggestive of compensatory neural recruitment. However, it is often unclear whether differences are due to compensation or reflective of other cognitive or physiological processes. This study aimed to determine whether there are compensatory age-related changes in brain systems supporting successful associative encoding while taking into account potentially confounding factors including age-related differences in task performance, atrophy, and resting perfusion. Brain response during encoding of face-name pairs was measured using functional magnetic resonance imaging in 10 older and nine young adults and was correlated with memory performance. During successful encoding, older adults demonstrated increased frontal and decreased occipital activity as well as greater bilateral involvement relative to the young. Findings remained significant after controlling for age-related cortical atrophy and hypoperfusion. Among the older adults, greater response was associated with better memory performance. Cognitive aging may involve recruitment of compensatory mechanisms to improve performance or prevent impairment. Results extend previous findings by suggesting that age-related alterations in activation cannot be attributed to the commonly observed findings of poorer task performance, reduced resting perfusion, or cortical atrophy among older adults.

A review of literature on the neurodevelopmental origins of schizophemia is presented, with particular attention to neurodevelopmental processes in late-onset schizophemia. Definitions of the term “neurodevelopmental” as used in schizophernia literature are first provided. Next, evidence for the developmental origins of the neuropathology in schizophemia is reviewed. This evidence includes studies of the associations between schizophemia and neurodevelopmental brain aberrations, minor physical anomalies, obstetric complications, prenatal viral exposure, childhood neuromotor abnormalities, and pandysmaturation. A brief discussion of the predominant theories about the neurodevelopmental origins of schizophemia is then provided. The concept and nature of “late-onset schizophenia ”is next defined and discussed. Finally, the neurodevelopmental literature is discussed in relation to the phenomenon of late-onset schizophemia. Based on this review, we conclude that there exists a strong likelihood that late-onset schizophrenia involves neurodevelopmental processes.

This study examined differences in the frequency of leisure activity participation and relationships to depressive symptom burden and cognition in Latino and Caucasian women. Cross-sectional data were obtained from a demographically matched subsample of Latino and Caucasian (n = 113 each) post-menopausal women (age ≥60), interviewed in 2004–06 for a multi-ethnic cohort study of successful aging in San Diego County. Frequencies of engagement in 16 leisure activities and associations between objective cognitive performance and depressive symptom burden by ethnicity were identified using bivariate and linear regression, adjusted for physical functioning and demographic covariates. Compared to Caucasian women, Latinas were significantly more likely to be caregivers and used computers less often. Engaging in organized social activity was associated with fewer depressive symptoms in both groups. Listening to the radio was positively correlated with lower depressive symptom burden for Latinas, and better cognitive functioning in Caucasians. Cognitive functioning was better in Latinas who read and did puzzles. Housework was negatively associated with Latinas’ emotional health and Caucasians’ cognitive functioning. Latino and Caucasian women participate in different patterns of leisure activities. Additionally, ethnicity significantly affects the relationship between leisure activities and both emotional and cognitive health.

Unimpaired cognition is an important feature of successful aging. Differences in cognitive performance among healthy older adults may be related to differences in brain structure. We reviewed the literature to examine the relationship between brain structure size and cognitive performance in older adults. Eighty-three percent of studies found at least one positive relationship between these factors; however, findings were variable. Positive relationships emerged most consistently between the hippocampal formation and global cognition and memory and between frontal measures and executive function. Additional longitudinal study is needed to further evaluate structure-cognition relationships in older adulthood and across the adult lifespan.

Aging is not a uniform process. In the general population, there is a paradox of aging: age-associated decline in physical and some cognitive functions stands in contrast to an enhancement of subjective quality of life and psychosocial functioning. This paradox is even more striking in people with schizophrenia. Compared with the overall population, individuals with schizophrenia have accelerated physical aging (with increased and premature medical comorbidity and mortality) but a normal rate of cognitive aging, although with mild cognitive impairment starting from premorbid period and persisting throughout life. Remarkably, psychosocial function improves with age, with diminished psychotic symptoms, reduced psychiatric relapses requiring hospitalization and better self-management. Many older adults with schizophrenia successfully adapt to the illness, with increased use of positive coping techniques, enhanced self-esteem and increased social support. Although complete remission is uncommon, most individuals with schizophrenia experience significant improvement in their quality of well-being. Cohort effect and survivor bias may provide a partial explanation for this phenomenon. However, the improvement also may reflect some brain changes that are beneficial for the course of schizophrenia along with neuroplasticity of aging. The proposed hypothesis has several implications. As significant medical morbidity in schizophrenia takes years to develop, studies of changes in sensitive biomarkers of aging during the course of illness may point to new treatments aimed at normalizing the rate of biological aging in schizophrenia. At the same time, effective psychotherapeutic interventions can affect brain structure and function and produce lasting positive behavioral changes in aging adults with schizophrenia.

Objectives

The purpose of this study was twofold: 1) To investigate the individual- and system-level characteristics associated with high utilization of acute mental health services according to a widely-used theory of service use—Andersen’s Behavioral Model of Health Service Use —in individuals enrolled in a large, public-funded mental health system; and 2) To document service utilization by high use consumers prior to a transformation of the service delivery system.

Methods

We analyzed data from 10,128 individuals receiving care in a large public mental health system from fiscal years 2000–2004. Subjects with information in the database for the index year (fiscal year 2000–2001) and all of the following three years were included in this study. Using logistic regression, we identified predisposing, enabling, and need characteristics associated with being categorized as a single-year high use consumer (HU: >3 acute care episodes in a single year) or multiple-year HU (>3 acute care episodes in more than one year).

Results

Thirteen percent of the sample met the criteria for being a single-year HU and an additional 8% met the definition for multiple-year HU. Although some predisposing factors were significantly associated with an increased likelihood of being classified as a HU (younger age and female gender) relative to non-HUs, the characteristics with the strongest associations with the HU definition, when controlling for all other factors, were enabling and need factors. Homelessness was associated with 115% increase in the odds of ever being classified as a HU compared to those living independently or with family and others. Having insurance was associated with increased odds of being classified as a HU by about 19% relative to non-HUs. Attending four or more outpatient visits was an enabling factor that decreased the chances of being defined as a HU. Need factors, such as having a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder or having a substance use disorder increased the likelihood of being categorized as a HU.

Conclusions

Characteristics with the strongest association with heavy use of a public mental health system were mutable enabling and need factors. Therefore, optimal use of public mental services may be achieved by developing and implementing interventions that address the issues of homelessness, insurance coverage, and substance use. This may be best achieved by the integration of mental health, intensive case management, and supportive housing, as well as other social services.

Cognitive heterogeneity has been a key barrier to clarifying the neuropathologic underpinnings of schizophrenia. We used an idiographic method for cluster analysis of neuropsychological data from 144 middle-aged and older people with schizophrenia to characterize and group the patterns of relative (within-person) profiles of cognitive strength and weakness. Results indicated a 5-cluster solution as most appropriate, with relatively even distribution across the five clusters in terms of the proportion of patients in each cluster. Cognitive subtyping may be useful in imaging and genetic research on schizophrenia, as well as having practical utility in treatment planning and cognitive rehabilitation.

Introduction

Attitudes toward own aging (ATOA) refers to expectations about the personal experience of aging. As of now, there is limited literature that addresses the impact of ATOA on indicators of psychological, physical, and social health. In this study, we examine associations between ATOA and several measures associated with successful aging.

Methods

A detailed cross-sectional survey questionnaire on successful aging was completed by 1,973 older women enrolled in the San Diego site of the Women's Health Initiative study. ATOA was measured using the Philadelphia Geriatric Morale Scale (PGMS)

Results

The final sample consisted of 1151 women. The mean ATOA score was 3.8 indicating generally positive ATOA. Positive ATOA score was significantly associated with younger age, lower income, being married, higher SF-36 Physical Composite scores, higher SF-36 Mental composite scores, lower depression scores, and higher resilience scores. Approximately 40% of variance in ATOA scores was explained by successful aging-related domain scores.

Conclusions

Better physical and emotional functioning, greater resilience and lower depression are associated with more positive ATOA. Associations with sociodemographic traits are complex. Modifying ATOA may have potential to impact a broad range of health and successful aging related outcomes.

The enormous advances in genetics and genomics of the past decade have the potential to revolutionize health care, including mental health care, and bring about a system predominantly characterized by the practice of genomic and personalized medicine. We briefly review the history of genetics and genomics and present heritability estimates for major chronic diseases of aging and neuropsychiatric disorders. We then assess the extent to which the results of genetic and genomic studies are currently being leveraged clinically for disease treatment and prevention and identify priority research areas in which further work is needed. Pharmacogenomics has emerged as one area of genomics that already has had notable impacts on disease treatment and the practice of medicine. Little evidence, however, for the clinical validity and utility of predictive testing based on genomic information is available, and thus has, to some extent, hindered broader-scale preventive efforts for common, complex diseases. Furthermore, although other disease areas have had greater success in identifying genetic factors responsible for various conditions, progress in identifying the genetic basis of neuropsychiatric diseases has lagged behind. We review social, economic, and policy issues relevant to genomic medicine, and find that a new model of health care based on proactive and preventive health planning and individualized treatment will require major advances in health care policy and administration. Specifically, incentives for relevant stakeholders are critical, as are realignment of incentives and education initiatives for physicians, and updates to pertinent legislation. Moreover, the translational behavioral and public health research necessary for fully integrating genomics into health care is lacking, and further work in these areas is needed. In short, while the pace of advances in genetic and genomic science and technology has been rapid, more work is needed to fully realize the potential for impacting disease treatment and prevention generally, and mental health specifically.

Unregulated production of reactive oxygen species (ROS) is a marker of cellular and organismal aging linked to cognitive decline in humans and rodents. The sources of elevated ROS contributing to cognitive decline are unknown. Because NADPH oxidase (Nox) inhibition may prevent memory decline with age, we hypothesized that Nox and not mitochondrial sources of synaptic ROS production are linked to individual variance in cognitive performance in aged mice. Young (8 mo) and aged (26 mo) mice were tested in the novel object recognition task (NORT). Mitochondrial and Nox ROS production was assayed in isolated synaptosomes using spin-trapping electron paramagnetic resonance (EPR) spectroscopy. Aged mice exhibited variance in NORT performance, with some performing similar to young mice while others exhibited poorer short-term memory. EPR studies indicated that Nox rather than mitochondria was the major ROS source at the synapse, and Nox- but not mitochondrial-induced ROS levels correlated with NORT performance in aged mice. Our findings support the hypothesis that variance in Nox-specific synaptic ROS production may predict short-term memory deficits with age.

Introduction

The role of spirituality in the context of mental health and successful aging is not well understood. In a sample of community-dwelling older women enrolled at the San Diego site of the Women's Health Initiative study, we examined the association between spirituality and a range of variables associated with successful cognitive and emotional aging, including optimism, resilience, depression, and health-related quality of life (HRQoL).

Methods

A detailed cross-sectional survey questionnaire on successful aging was completed by 1,973 older women. It included multiple self-reported measures of positive psychological functioning (e.g., resilience, optimism,), as well as depression and HRQoL. Spirituality was measured using a 5-item self report scale constructed using two items from the Brief Multidimensional Measure of Religiosity/Spirituality and three items from Hoge's Intrinsic Religious Motivation Scale

Results

Overall, 40% women reported regular attendance in organized religious practice, and 53% reported engaging in private spiritual practices. Several variables were significantly related to spirituality in bivariate associations; however, using model testing, spirituality was significantly associated only with higher resilience, lower income, lower education, and lower likelihood of being in a marital or committed relationship.

Conclusions

Our findings point to a role for spirituality in promoting resilience to stressors, possibly to a greater degree in persons with lower income and education level. Future longitudinal studies are needed to confirm these associations.

Background

Despite substantial research on overall decision-making capacity (DMC) levels in schizophrenia, factors causing individuals to make errors during decision-making regarding research participation or treatment are relatively unknown.

Methods

We examined the responses of 84 middle-aged and older patients with schizophrenia or schizoaffective disorder on a structured DMC measure—the MacArthur Competence Assessment Tool for Clinical Research—to determine the frequency and apparent cause of patients’ errors.

Results

Most errors were due to difficulty recalling the disclosed information (seen in 65.5% of patients), particularly the study’s procedures, potential risks/discomforts, and purpose. Errors attributable to concrete thinking, thought disorder or other psychotic symptoms, or perceived coercion were rarer.

Conclusions

Informed consent procedures might be improved for this population by providing information in a way that facilitates learning and memory, such as iterative disclosure of the information, corrective feedback, and emphasis of key points (e.g., the study’s purpose, procedures, and potential risks).

Background

The Global Assessment of Functioning (GAF) scale is widely used in psychiatry, yet it has certain drawbacks.

Objective

The authors seek to generate further discussion and research around developing an improved successor to the GAF.

Method

The authors used the Apgar scale as a template for constructing a possible successor to the GAF. Consulting with 16 colleagues, they selected 5 domains that were felt to be central to functioning in psychiatric patients. Psychiatrists in diverse clinical settings then completed both a GAF and a Psychiatric Apgar scale on 40 patients.

Results

The two scales were found to agree significantly. Use of the Psychiatric Apgar, however, provides clearer guidance about assessing functioning.

Conclusion

The GAF was a brilliant addition to psychiatric practice. As we develop the next Diagnostic and Statistical Manual, it is pertinent to ask whether the GAF approach could be optimized even further by applying the lessons of Virginia Apgar.