Elderly people who choose the wrong shoes have a lower quality of life

As people get older, they experience changes in their foot morphology. If they do not change their shoe size along with these transformations, older people—most of whom choose the wrong shoes—suffer, among other things, anxiety, apathy, loss of balance and falls, according to a study by the University of A Coruña.

02 mar 2017--In 2015, a research team led by the University of A Coruña conducted a study of people with a mean age of 80 years. They analysed whether the changes to foot morphology that occur in elderly individuals, and their tolerance for pain, led to subjects wearing the wrong shoes. They concluded that the majority (83 percent) did not choose the correct size, and that they often should have been wearing a different size for each foot.
As Daniel López López, a scientist at the University of A Coruña who led this study, tells SINC: "In this stage of life, there are changes in foot morphology involving increased width and length, as well as changes in pain tolerance linked to age, and the loss of muscle mass and fatty tissue in the feet."
The study has for the first time analysed the consequences of this poor shoe choice on the health of elderly individuals. "Because of people's lifestyles at this age, they often use shoes that are harmful to their feet. This, combined with the appearance of chronic diseases such as obesity, vascular diseases, diabetes or rheumatoid arthritis, causes a worrying increase in foot problems in elderly people of between 71 percent and 87 percent. This means having to seek medical and podiatric attention more frequently, as it affects their functional capacity and quality of life," the scientist explains. The study is published in the Revista da Associação Médica Brasileira, the Brazilian Medical Association's journal.

Decreased independence and well-being

The participants in this research project were volunteers from the Podiatry University Clinic at the University of A Coruña with a mean age of 75 years.
Their results demonstrate that elderly people who use the wrong shoes have a lower quality of life in all areas related to pain, foot function, footwear, food health, general health, physical activity, social capacity and vitality.
The most common disorders are foot bone deformities, bunions, toenail malformations, plantar keratosis and flat feet. "This often leads to chronic pain, infections, limited mobility when walking, anxiety, apathy, social disturbances, changes to pressure distribution in feet related to loss of balance and falls, which as a result negatively impact upon health, independence and well-being," López informs us.
These individuals should use proper footwear, including wide-fit shoes with velcro or straps, rubber soles to prevent slipping and falling and those that reduce the impact on joints when walking.
"Additionally, regular visits and monitoring on the part of a podiatrist helps to prevent, control and reduce the appearance of foot diseases and deformities, increase autonomy and, in summary, improve people's quality of life," López concludes.

More information: Daniel López-López et al. Impact of shoe size in a sample of elderly individuals, Revista da Associação Médica Brasileira (2016). DOI: 10.1590/1806-9282.62.08.789


Provided by Plataforma SINC

Some older adults live well, despite advancing years and the burdens of chronic diseases

You might believe that older adults who deal with extensive chronic illnesses or serious diseases would be more likely to be frail and to have a poorer quality of life than healthier older adults. That may be true for some elders—but not for all. Researchers writing in the Journal of the American Geriatrics Society suggest that an undefined coping mechanism of some sort may play a role in how well older adults are able to live despite having burdensome illnesses.

25 jun 2016--The researchers examined three groups of participants enrolled in the Cardiovascular Health Study, a large research project that examined adults 65-years-old and older from four cities around the country.
Researchers assigned people to one of three groups, based on the extent of their disease and their level of vigor or frailty:
1. The expected agers (3,528 people) had higher disease but also higher frailty levels. They spent 47 percent of the remainder of their lives able and healthy.
2. The adapters (882 people) had higher disease levels as well as relatively high vigor (being active and mobile) levels. They spent 55 percent of the reminder of their lives able and healthy.
3. The prematurely frail (885 people) had lower disease levels but higher frailty levels. They spent 37 percent of their remaining lives able and healthy.
The researchers said "adapter" older adults who were more vigorous than expected, based on their disease burden, lived longer lives when compared to those who were more frail than expected based on their disease burden. These "adapters" could have unique characteristics, perhaps some undefined coping mechanism, that should be studied further, suggested the researchers.

More information: Jason L. Sanders et al, Effects of Disease Burden and Functional Adaptation on Morbidity and Mortality on Older Adults, Journal of the American Geriatrics Society (2016). DOI: 10.1111/jgs.14163


Provided by American Geriatrics Society

Oldest old at risk from social isolation

Using new data from the UK's largest ever social survey, Understanding Society, the Personal Finance Research Centre (PRFC) at the University of Bristol and the International Longevity Centre-UK (ILC-UK) have produced preliminary findings about the 'oldest old' (aged over 85) and their levels of participation, wellbeing and health.

28july 2013--This new analysis, funded by the ESRC's Secondary Data Analysis Initiative, is part of a major project exploring the financial dimensions of wellbeing and wider quality of life measures in older age.

The new research reveals: 

• Around a third of over 85s said they were at least partly dissatisfied with their health, while over three-quarters (78 per cent) of the oldest old felt that their health limited even moderate activities, and about a half felt that pain had interfered with their activities over the past few weeks.
• While over eight in ten of the oldest old (81 per cent) felt they could rely on family 'a lot', more than one in ten (13 per cent) reported not having any friends.
• A worrying 26 per cent of people aged 85 and over reported being at least somewhat dissatisfied with their life overall. On the flip-side, three-quarters of the oldest old were at least somewhat satisfied with their lives.

David Hayes, Research Associate at the PFRC said: "This research is extremely important as we know relatively little about the experiences of those aged over 85 yet this group represents the fastest growing sector of the UK population. With around one in four over 85s at least somewhat dissatisfied with their lives, (much higher than in the general population), policymakers need to devote more time to the issues facing this group."

David Sinclair, Assistant Director, Policy and Communications at ILC-UK added: "This research paints a negative picture of life for far too many people aged over 85. The research backs up ILC-UK's analysis of the English Longitudinal Study of Ageing last year which found that almost four in ten of those aged 85 or older faced some kind of social exclusion. Similarly, our research on centenarians published in December 2011 found that quality of life among the oldest old decreases with age and that the oldest old (aged 85 and over) are, as a group, at greater risk of poverty than younger older people (aged 65-85).

"Bereavement and loneliness is a feature of later life for many. Whilst our new research highlights that over eight in ten of the oldest old could rely on family 'a lot', more than one in ten reported not having any friends. Tackling loneliness and isolation in old age has to become a societal priority."

PRFC and ILC-UK plan to extend analysis of Understanding Society to look at the financial wellbeing of the oldest old.

Provided by University of Bristol

Women live longer, but have a lower quality of life

the Institute of Gender Medicine at the MedUni Vienna has presented an alarming result obtained from gender-specific research. According to recent studies, women's quality of life is significantly worse than that of men in terms of health.

16 mar 2013--In Austria and Europe, women live on average around six years longer than men. This is a very positive result for women, one might think, especially in terms of their health. This popular assumption, however, is incorrect. According to Alexandra Kautzy-Willer, Head of the Gender Medicine Unit at the MedUni Vienna, a closer look at the data indicates that women suffer more frequently than men from chronic diseases and functional restrictions and have a poorer quality of life in terms of their health.

Karin Gutierrez-Lobos, MedUni Vienna's Vice Rector for Teaching, Gender and Diversity and Austria's first Professor of Gender Medicine at the MedUni Vienna, adds: "These recent results confirm just how important gender medicine is. They clearly illustrate that women's equality of treatment status is a vital influencing factor on health. If their social status, quality of treatment index or career opportunities improve, for example, so too does their health-related quality of life."

Sex hormones, role models and social behaviour make the difference

According to Kautzky-Willer, the more marked among women phases of life that are greatly influenced by changes in sex hormones, but also by their role models, are also of tremendous importance.

From puberty, women are more affected than men by painful syndromes such as irritable bowel, fibromyalgia and migraine, but also by autoimmune diseases such as lupus, multiple sclerosis, thyroid glandabnormalities or asthma. Menstrual cycle anomalies, infertility or complications of pregnancy can provide vital indicators of an increased risk of illness later in life. After gestational diabetes, for example, women have a seven times greater risk of developing diabetes and are at significantly increased risk of vascular problems. Lifestyle changes such as smoking, taking the contraceptive pill, stress and lack of exercise lead to an increase in mortality from heart attacks, especially in young women. From the menopause onwards, women are more troubled by fat metabolism problems, high blood pressure, cardiovascular disease and osteoporosis. Elderly women are ultimately significantly more severely affected by Alzheimer's dementia, incontinence and immobility. And if all this wasn't enough, women are also two times more likely to suffer depression than men.

"There are a variety of reasons behind these clear differences. They include, for example, the many differences in biology and sex hormones, but most importantly the different effects of environmental influences, differences in lifestyle, gender roles and differences in social behaviour," says Kautzky-Willer. Even the causes and effects of stress differ between men and women.

Recent study researches gender-specific differences in coping with autoimmune diseases

An interdisciplinary study currently underway at the University Department of Internal Medicine III at the MedUni Vienna and the Gender Medicine Unit is investigating a series of autoimmune diseases from gender-specific perspectives. Preliminary results are already available for Crohn's disease, a common disease of the bowel. Says Kautzky-Willer: "If social support, job satisfaction and self-efficacy improve, the positive effect on the course of the illness is the same for both men and women. For women, however, the activity of the disease but most importantly esteem and good resilience are important." These results may in future lead to new, gender-sensitive approaches to the treatment of autoimmune diseases.

Provided by Medical University of Vienna

Emotion-health connection not limited to wealthy nations

09 mar 2013—Positive emotions are known to play a role in physical well-being, and stress is strongly linked to poor health, but is this strictly a "First World" phenomenon? In developing nations, is the fulfillment of basic needs more critical to health than how one feels? A UC Irvine researcher has found that emotions do affect health around the world and may, in fact, be more important to wellness in low-income countries.

The study, which appears online in Psychological Science, is the first to examine the emotion-health connection in a representative sample of 150,000 people in 142 countries. Previous research on the topic has been limited to industrialized nations.

"We wondered whether the fact that emotions make a difference in our health is simply because we have the luxury of letting them," said Sarah Pressman, assistant professor of psychology & social behavior and the study's lead author. "We wanted to assess the impact of emotions on health in places where people face famine, homelessness and serious safety concerns that might be more critical correlates of wellness."

Against expectations, researchers found that the link between positive emotions (enjoyment, love, happiness) and health is stronger in countries with a weaker gross domestic product. In fact, the association increased as GDP decreased, according to Pressman.

People in Malawi, which has a per capita GDP of $900, show a more robust connection between positive emotions and health than residents of the U.S., which has a per capita GDP of $49,800.

"A hostile American with hypertension can take blood pressure-lowering medication. A Malawian cannot," Pressman said. "Medical interventions might lower the impact of emotions on health."

Using data from the Gallup World Poll, researchers noted whether participants had reported experiencing enjoyment, love, happiness, worry, sadness, stress, boredom, depression or anger during the previous day. They also measured physical health and the degree to which subjects' basic needs were met. Security was assessed by asking if participants felt safe walking alone at night or whether they had been robbed, assaulted or mugged.

"We hope that by showing that this phenomenon is prevalent and stronger than some factors considered critical to wellness, more attention will be drawn to the importance of studying both positive and negative emotions," Pressman said.

She co-authored the study with Shane Lopez of the Gallup Organization and Matthew Gallagher of Boston University.

Provided by University of California, Irvine

Organisations must increase flexibility to keep elderly population connected and engaged

19 sept 2012—Staying mobile and socially connected is crucial to the quality of life of older people, but awareness of the issues they face is low, say Massey University researchers.

Dr Juliana Mansvelt, from the School of People, Environment and Planning, says that it is important that organisations don't dismiss older people as inactive just because they require physical assistance to leave their homes.

"It would be a shame for organisations to view these people as unwilling or unable to engage with them, simply because they find it difficult to get out of the house. The truth is that the older people we have interviewed desire meaningful social connections," she says.

"In the face of adversity, many of them are actively and creatively mobilising people and resources in order to remain active and connected to their communities. They want to interact with a range of people and organisations."

In a new paper titled "The Problems and Possibilities of Mobility for Home-Based Elders in New Zealand," Dr Mansvelt and her co-author Professor Ted Zorn argue that organisations need to be more flexible in their systems and customer service behaviour or they will isolate and disempower their older customers.

Professor Zorn, who heads Massey University's College of Business, says there are good business reasons to do so. "This is one of the fastest growing demographics – and that's why the banks and supermarkets we have been working with are really eager to engage with us."

The paper is part of a three-year research project led by Professor Zorn for the Ministry of Business, Innovation and Employment. The research programme aims to improve the engagement of older people with organisations and their communities to create more positive ageing experiences.

Dr Mansvelt found that it wasn't just an older person's physical ability that determined their level of mobility. The built environments they had to negotiate and ageist attitudes were also important factors, and negative experiences could affect a person's subsequent desire to engage with an organisation.

"I found that for those with significant physical mobility and hearing and/or eyesight impairments, everyday practices that more able-bodied people might take for granted could be difficult," she says. "For example, going into a shopping centre becomes a series of encounters involving everything from transport and parking, to finding one's way around and purchasing, with each practice posing a different set of challenges."

Massey researchers are currently working with a number of organisations to improve their interactions with older people. In many cases, simple, practical changes like training staff to be respectful and flexible, not over-filling shopping bags, supplying shallow-tray supermarket trolleys, and providing practical seating and rest areas, can make large differences to the satisfaction levels of older customers.

"What comes through most strongly in our research is the need to raise the awareness of organisations," Professor Zorn says. "These changes are often not rocket science. Most organisations can immediately identify things to do differently and they are very positive about how useful it's been for them to go through the exercise."

In her study of home-based elders, Dr Mansvelt got insight into the lives of older New Zealanders. Many had multiple impairments and very few used computers or had internet access. Social isolation was a problem for some, with a number expressing a desire to leave their homes but a reluctance to ask for assistance for other than essential trips like doctor's appointments.

"They talked about the adaptations they'd made and the things they were able to do with pride, and many demonstrated considerable resilience in the face of significant challenges," Dr Mansvelt says. "However I noted a number of people who were struggling financially, and others who didn't want to burden their families or friends, and I think there are additional challenges for those who live in rural areas. Social isolation and services to rural communities is a real issue that needs more research."

Both academics stress the need for voluntary, government, and commercial organisations to consider the impact of societal and organisational changes on older people. Many changes – like new technologies or larger stores – can improve the experiences of customers, but it is important to make accommodations for those who have limited access to, or challenges in negotiating, these technologies or spaces, says Professor Zorn.

"For older people to feel connected and feel like they matter, they need flexibility," Dr Mansvelt says. "We need to recognise they may be mobile in different ways and enable the normality of doing things differently."

Provided by Massey University

Aging, overweight people stay happy, says new study

Growing older and being overweight are not necessarily associated with a decrease in mental well-being, according to a cross-cultural study looking at quality of life and health status in the US and the UK.

9 march 2012--The study, led by Warwick Medical School at the University of Warwick, analysed lifestyle and health patterns in more than 10,000 people in both countries and their links to participants' mental and physical quality of life and health status.

Quality of life was evaluated using a measure which takes in eight different factors including perception of general health, pain, social functioning and mental health.

The researchers found that people reported better mental quality of life as they age, despite a decrease in physical quality of life.

This is in line with previous research, for example by Professor Andrew Oswald, also at the University of Warwick, which suggests that happiness levels follow a U-shape curve with their lowest point in the mid-40s after which they rise as people move into older age.

Supportive results were found in this cross-cultural comparison study in the UK and US – two countries which have different welfare and health-care systems, factors which could impact on people's quality of life.

The researchers also found that being overweight or obese did not have a significant impact on mental well-being levels, with people with a BMI of more than 30 showing similar mental quality of life levels to those considered to be a healthy weight.

For women in the US, low levels of physical exercise did not appear to impact on their mental well-being. This was not the case for men, where limited physical exercise had a significant adverse impact on their mental quality of life.

Dr Saverio Stranges, who led the study at Warwick Medical School at the University of Warwick, along with Dr Kandala Ngianga-Bakwin, said: "It's obvious that people's physical quality of life deteriorates as they age, but what is interesting is that their mental well-being doesn't also deteriorate – in fact it increases."

"We suggest that this could be due to better coping abilities, an interpretation supported by previous research showing older people tend to have internal mechanisms to deal better with hardship or negative circumstances than those who are younger.

"It could also be due to a lowering of expectations from life, with older people less likely to put pressure on themselves in the personal and professional spheres.

"With regard to our findings on excess body weight and its lack of significant impact on mental-wellbeing - this has been reported in previous research, i.e. the so-called "jolly fat" hypothesis, although not consistently."

The study also looked at the effect of sleep on quality of life, and found there was an optimum window of sleep duration.

Those who sleep between six and eight hours per day tended to have both better physical and mental health scores than those who slept on average less than six hours or more than eight hours.

Owing to its cross-cultural nature, the study was also able to identify differences between the quality of life of US and UK respondents.

In the US, respondents' social background was more likely to affect their quality of life, with those in higher socio-economic groups reporting better mental and physical quality of life.

The researchers suggested this could be due to the presence of universal healthcare in the UK, which has a levelling effect on well-being.

Also, levels of reported physical quality of life tended to be higher in the UK population while mental quality of life was higher in the US group - but researchers suggested this could be due to the slightly younger average age of the UK group and other intrinsic differences in the groups surveyed..

The study, Cross-cultural Comparison of Correlates of Quality of Life and Health Status:

The Whitehall II Study (UK) and the Western New York Health Study (US), was published in the European Journal of Epidemiology.

More information: DOI:10.1007/s10654-012-9664-z

Rebranding exercise: 'Quality of life' a better motivator than 'Live longer'

A new University of Michigan study finds that the most convincing exercise message emphasizes immediate benefits that enhance daily quality of life.

30 oct 2011--Health care, business and public health have presumed that promoting health and longevity benefits from exercise will motivate people to exercise. The new findings, however, indicate that these individuals exercised less than those who aimed to enhance the quality of their daily lives.

"The study showed that what an individual espouses as important does not necessarily translate into behavior," said Michelle Segar, research investigator for the U-M Institute for Research on Women and Gender. "While people say they value health and healthy aging, those distant benefits don't make exercise compelling enough to fit into their busy lives."

These findings challenge the current convention of promoting exercise for better health, longevity, or as medicine.

"Promoting exercise for health is logical, but people's daily decisions are more often connected to emotion than logic," Segar said. "A more effective 'hook' is to rebrand exercise to emphasize the immediate benefits that enrich daily living, such as stress reduction and increased vitality."

Individuals may also appreciate the subsequent benefits that make exercise more personally meaningful, such as being a patient parent, enjoying life, being creative and having focus at work, she says.

"By shifting our model from medicine to marketing, we can improve how we 'sell' exercise to the public by using principles like branding," Segar said.

For example, messages about immediate rewards from exercise that make life more enjoyable, such as "move more, get energy," may better motivate busy individuals than promotions focused on achieving distant and abstract benefits, such as "move more, get healthy."

Segar studied responses from 226 women between the ages of 40 to 60 who worked full time. They completed three surveys during a one-year period. Respondents were asked about their exercise goals and participation, how much they valued their goals, body mass index (BMI) and social support. This study supports other research showing that the reasons why individuals initiate exercise influence their motivation and behavioral sustainability.

Segar recommends four steps to rebrand exercise and to improve engagement and participation:

• Assess the specific exercise benefits your organization has been promoting.

• Evaluate the effectiveness of these motives to engage and motivate ongoing participation.

• Ask your target population what values and experiences they most care about achieving in their daily life that exercise benefits would impact, such as reduced stress and improved mood.

• Develop new messaging that addresses these valued end points.

Caroline Richardson, an associate professor of family medicine at U-M and research scientist at the VA Ann Arbor Healthcare System, and Jacquelynne Eccles, a professor of psychology and education, co-authored the study.

More information: The findings appear in the latest issue of The International Journal of Behavioral Nutrition and Physical Activity.

Provided by University of Michigan

Quality of life survey highlights need for holistic approach in elderly residential care

14 may 2009--Choice, privacy and a sense of identity are just some of the things that older people living in residential care need to maintain a good quality of life, according to research in the May issue of the Journal of Advanced Nursing.

Researchers from the National University of Ireland (NUI), Galway, spoke to 101 older people living in 12 long-stay care homes, including small and large facilities, well-established and recently built homes and those provided by the public, private and voluntary sectors.

They found that four key themes had an impact on the subjects' quality of life: the ethos of care provided by the home, the residents' sense of self and identity, how connected they felt and the activities and therapies they got involved in.

"It was clear from our research that practitioners and policy makers need to take all these factors into account if they are to provide older people with the sort of residential care that enhances their quality of life" says lead author Dr Adeline Cooney, from the School of Nursing and Midwifery at the University.

"We also found that residents tended to be happier if they had been involved in the decision to move into residential care, as they were more likely to make the best of it, getting involved in activities and making friends. People who were not involved in the decision tended to withdraw into themselves and were more likely to be lonely, unhappy and keen to return home."

Two-thirds of the residents who took part in the study were male. All were 65 or over and the majority of residents (45 per cent) fell into the 75-84 age group and had been in residential care for two to four years (37 per cent).

Key findings included:

• Participants said choice was important when it came to their daily routine. "I can go to bed anytime I like" one said positively, while another complained that "you're woken at six and breakfast isn't until ten past eight."
• People valued the opportunity to make their surroundings more familiar. "This is my own furniture" said one, while another complained she was unable to have her computer with her because "there is no space".
• Privacy was also important and even people who had their own rooms said staff tended to barge in without knocking. Others felt it even more acutely. "There's nowhere to get away on your own" said a resident in a shared room.
• Residents liked it when they felt valued by staff and their expertise or skills were drawn on. Some facilities formally involved residents in collective decision making, but not all. One resident spoke about how she loved gardening and had joined the committee to set one up at her residential home.
• Feeling connected to family, the community and the outside world was also important. "If I couldn't keep in contact with the outside world where would I be?" said one participant, while another said of fellow residents "it's not like your family, but you make them your family."
• Residents who were not provided with regular and varied activities often felt frustrated and disengaged. One resident said it was "just the same thing, the same day in and day out…it's boring".
• Residents valued the chance to get out and keep in touch. This could be a simple shopping trip, a visit to family or an event such as a day trip or barbecue. But lack of independence and mobility often restricted how often they were able to go out.
• Previous life experiences also shaped how well people settled in. For example, one resident didn't want to make friends because the other residents were from a "poorer class" and regarded her as too "swanky" for them.
• Health status also had an important effect on quality of life and some residents said their health had deteriorated since they moved in. Important therapies were not always available. "The physiotherapy I was getting just stopped" said one participant.
• Other factors that affected quality of life included the physical condition and homeliness of the facility, the friendliness of the staff, the openness of the visiting policy and strong links with the local community.

"This study highlights the importance of providing a holistic, person-centred approach that goes beyond satisfying the technical and procedural aspects of care" concludes Dr Cooney.

"Care staff should regard the quality of life of residents as an integral part of their role and residents and their families should have significant input into how services are structured and delivered.

"Although this study was carried out in Ireland, the basic principles of how the quality of life of older people in residential care can be enhanced are universal."

###

The study, which was funded by the National Council for Ageing and Older People, was led by Professor Kathy Murphy from the School of Nursing and Midwifery and Professor Eamon O'Shea from the Irish Centre for Social Gerontology, both at NUI Galway.

Notes to editors

Resident perspectives of the determinants of quality of life in residential care in Ireland. Cooney et al. Journal of Advanced Nursing. 65.5, 1029-1038. (May 2009).

What Makes the Golden Years Great?

The keys to a high-quality life after age 60 are health, money, and having a meaningful life, a Canadian study shows.
That doesn't mean you have to be in stellar shape, have oodles of money in the bank, or master the meaning of life to be happy in your golden years. But it may be food for thought in shaping your life, no matter how many candles are on your birthday cake this year.
The study, published recently in Research in Nursing & Health, comes from researchers including Gail Low, PhD, of the faculty of nursing at Canada's University of Alberta.
They interviewed more than 400 adults aged 60 and older living in British Columbia, Canada.
Most participants were 60-80 years old, had a college education, were currently or previously married, lived in their own home, and said they didn't need help with their daily activities.
Quality of Life Quiz
Participants rated their own health and quality of life. They also answered questions including:
To what extent do you find your life to be meaningful?
Do you have enough money to meet your needs?
How satisfied are you with your ability to perform your activities of daily living?
How satisfied are you with your opportunities for physical contact and closeness?
How satisfied are you with the level of intimacy in your life?
How healthy is your physical environment?
How satisfied are you with the conditions of your living space?
Based on the interviews, the researchers concluded that health, finances, and meaning directly affected participants' quality of life.
Emotional support and purpose in life also mattered. Those factors helped people find meaning in their lives.
It's not clear if the findings apply to other groups of people in their 60s or older. But the findings echo the researchers' results from a previous, smaller study.
SOURCES: Low, G. Research in Nursing & Health, April 2007; vol 30: pp 141-150. News release, University of Alberta.