Community-Residing Older Adults Research Articles

Risk and protective factors associated with intentional self-harm among older community-residing home care clients in Ontario, Canada.

We aim to concurrently examine risk and protective factors associated with intentional self-harm among community-residing older adults receiving home care services in Ontario, Canada. Administrative health data from the home care sector were linked to hospital administrative data to carry out the analyses. Home care data are collected in Ontario using the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool that identifies strengths, preferences and needs of long-stay home care clients. The sample included Ontario home care clients aged 60 years or older assessed with the RAI-HC between 2007 and 2010 (N = 222,149). Multivariable analyses were performed using SAS. Hospital records of intentional self-harm (ISH) were present in 9.3 cases per 1000 home care clients. Risks of ISH included younger age (60-74 years; OR = 3.14, CI: 2.75-3.59), psychiatric diagnosis (OR = 2.29, CI: 2.06-2.54), alcohol use and dependence (OR = 1.69, CI: 1.34-2.14), psychotropic medication (OR = 1.94, CI: 1.75-2.15) and depressive symptoms (OR = 1.58, CI: 1.40-1.78). Protective effects were found for marital status and positive social relationships, yet these effects were more pronounced for men. Cognitive performance measures showed the odds of ISH 1.86 times higher for older adults with moderate to severe cognitive impairment. This study based on provincial data points to tangible areas for preventative assessment by frontline home care professionals. Of interest were the risk and protective factors that differed by sex. As demand for home care in Canada is expected to increase, these findings may inform home care professionals' appraisal and approach to suicide prevention among community-residing older adults.

Students Explore Supportive Transportation Needs of Older Adults

Students in an undergraduate applied research in aging class learned about qualitative research methods by analyzing previously collected narratives. The interviews were with 32 participants who were national experts in senior transportation in the United States. The purpose of the study was to explore the specialized supportive mobility needs of community-residing older adults. The policy goal of the study was to expand the discussion on levels of assistance needed in senior transportation. The educational goal of the study was to expose undergraduate students to qualitative research methods, having them analyze transcripts and audio recordings. In preparation for the research, students reviewed the current literature in transportation and aging and learned that the ability to get to where you want to go, when you want to go there, is a key factor for aging-in-place in our communities. When that ability is compromised, the informal network of family and friends may not be a sustainable transportation option. Students were divided into three analysis groups by the domains of challenges, strategies, and policies and coded themes and subthemes through an iterative process. An important subtheme that emerged was the connection of community mobility to health care outcomes.

Development of a self-administered dementia checklist (SDC) (1): Examination of factorial validity and internal reliability

The aim of this study was to develop a self-administered dementia checklist (SDC), in order to help community-residing older adults realize their declining functions and encourage them to begin using necessary services, and to examine its factorial validity and internal reliability. A panel of dementia clinical experts developed a questionnaire according to pre-selected items and conducted a self-administered survey with community-residing people aged 65 + (n=2,483). The team developed a scale through an exploratory factor analysis and item response theory (IRT) analysis (Study 1). Using this scale, they conducted a self-administered survey with community-residing people aged 65 + (n=5,199), conducted another exploratory factor analysis, and developed a 10-item scale. A confirmatory factor analysis was subsequently conducted and reliability coefficients were computed. The exploratory factor analysis of the proposed 37 items extracted 5 factors: Factor 1 was named "subjective decline in daily living functioning," and Factor 2 was "subjective cognitive decline" in the early stage of dementia. The team developed a 20-item scale by selecting 10 items from each factor which had high factor loadings and high slope values in the IRT analysis (Study 1). After the exploratory factor analysis of the 20-item scale, they developed a 10-item scale by selecting 5 items from each factor which had strong associations. The confirmatory factor analysis verified the 2-factor model. The Cronbach α coefficients for the subscales of Factors 1 and 2 were 0.935 and 0.834, respectively, and 0.908 for the overall 10-item scale. The authors developed a 10-item SDC with 2 factors and confirmed its factorial validity and internal reliability.

Memory Performance and Affect: Are there Gender Differences in Community-Residing Older Adults?

After age 65, the incidence of episodic memory decline in males is greater than in females. We explored the influence of anxiety and depression on objective and subjective memory performance in a diverse sample of community-residing older adults. The study was a secondary analysis of data on three samples of adults from two states, Ohio and Texas: a community sample (n = 177); a retirement community sample (n = 97); and the SeniorWISE Study (n = 265). The sample of 529 adults was 74% female, the average age was 76.58 years (range = 59–100 years), and educational attainment was 13.12 years (±3.68); 68% were Caucasian, and 17% had depressive symptoms. We found no memory performance differences by gender. Males and females were similarly classified into the four memory performance groups, with almost half of each gender in the poor memory category. Even though males had greater years of education, they used fewer compensatory memory strategies. The observed gender differences in memory were subjective evaluations, specifically metamemory. Age was not a significant predictor of cognition or memory performance, nor did males have greater memory impairment than females.

“Is It Whole Grain?” Program Improves Older Adult Whole Grain Knowledge and Increases the Desire to Eat More Whole Grains

ObjectiveThis pilot study evaluated the “Is It Whole Grain?” program for community-residing older adults (age 60+).Study Design, Setting, Participants, and Intervention“Is it Whole Grain?” is a three week (one hour per class) program that incorporates whole grain (WG) discussion, hands-on activities and taste-testing. Participants completed WG knowledge questionnaires and the Dietary Screening Tool at the beginning of Class 1 (Pre) and Class 3 (Post). Classes took place at one congregate mealsite, two low-income senior apartments, and four retirement communities. Sixty people started; 59 completed (98.3% completion rate). Participants were primarily educated, white females, age 81+ years, who were at “possible” nutritional risk.Outcome, Measures and AnalysisDescriptive statistics assessed general sociodemographic data and intention to eat WGs. McNemar Test measured knowledge change and paired t tests assessed changes in WG intake frequency and nutritional risk from Pre to Post.ResultsThe number of participants who correctly identified WG consumption as beneficial for reducing cancer (Pre=22, Post=45; p=.0005), heart disease (Pre=31, Post=45; p=.001) and diabetes (Pre=28, Post=39; p=.013) risk and who correctly identified the three steps to choosing WGs (Pre =19, Post =33; p=.007) significantly increased. No significant change was noted in WG intake frequency or nutritional risk. At Post, nearly all (n=49, 83.1%) intended to eat more WG foods, with most (n=34, 69.4%) reported a strong intention to do so.Conclusions and ImplicationsThese results suggest that “Is it Whole Grain?” is a useful strategy for educating older adults about WG since it is effective at improving WG knowledge and promoting the desire to consume more WG among older adults.FundingIowa State University Extension and Outreach Excellence in Extension Grant ObjectiveThis pilot study evaluated the “Is It Whole Grain?” program for community-residing older adults (age 60+). This pilot study evaluated the “Is It Whole Grain?” program for community-residing older adults (age 60+). Study Design, Setting, Participants, and Intervention“Is it Whole Grain?” is a three week (one hour per class) program that incorporates whole grain (WG) discussion, hands-on activities and taste-testing. Participants completed WG knowledge questionnaires and the Dietary Screening Tool at the beginning of Class 1 (Pre) and Class 3 (Post). Classes took place at one congregate mealsite, two low-income senior apartments, and four retirement communities. Sixty people started; 59 completed (98.3% completion rate). Participants were primarily educated, white females, age 81+ years, who were at “possible” nutritional risk. “Is it Whole Grain?” is a three week (one hour per class) program that incorporates whole grain (WG) discussion, hands-on activities and taste-testing. Participants completed WG knowledge questionnaires and the Dietary Screening Tool at the beginning of Class 1 (Pre) and Class 3 (Post). Classes took place at one congregate mealsite, two low-income senior apartments, and four retirement communities. Sixty people started; 59 completed (98.3% completion rate). Participants were primarily educated, white females, age 81+ years, who were at “possible” nutritional risk. Outcome, Measures and AnalysisDescriptive statistics assessed general sociodemographic data and intention to eat WGs. McNemar Test measured knowledge change and paired t tests assessed changes in WG intake frequency and nutritional risk from Pre to Post. Descriptive statistics assessed general sociodemographic data and intention to eat WGs. McNemar Test measured knowledge change and paired t tests assessed changes in WG intake frequency and nutritional risk from Pre to Post. ResultsThe number of participants who correctly identified WG consumption as beneficial for reducing cancer (Pre=22, Post=45; p=.0005), heart disease (Pre=31, Post=45; p=.001) and diabetes (Pre=28, Post=39; p=.013) risk and who correctly identified the three steps to choosing WGs (Pre =19, Post =33; p=.007) significantly increased. No significant change was noted in WG intake frequency or nutritional risk. At Post, nearly all (n=49, 83.1%) intended to eat more WG foods, with most (n=34, 69.4%) reported a strong intention to do so. The number of participants who correctly identified WG consumption as beneficial for reducing cancer (Pre=22, Post=45; p=.0005), heart disease (Pre=31, Post=45; p=.001) and diabetes (Pre=28, Post=39; p=.013) risk and who correctly identified the three steps to choosing WGs (Pre =19, Post =33; p=.007) significantly increased. No significant change was noted in WG intake frequency or nutritional risk. At Post, nearly all (n=49, 83.1%) intended to eat more WG foods, with most (n=34, 69.4%) reported a strong intention to do so. Conclusions and ImplicationsThese results suggest that “Is it Whole Grain?” is a useful strategy for educating older adults about WG since it is effective at improving WG knowledge and promoting the desire to consume more WG among older adults. These results suggest that “Is it Whole Grain?” is a useful strategy for educating older adults about WG since it is effective at improving WG knowledge and promoting the desire to consume more WG among older adults.

Caregiver's perceptions of the relationship of pain to behavioral and psychiatric symptoms in older community-residing adults with dementia.

Pain is underrecognized and undermanaged in older adults with dementia. Because dementia patients have a diminished capacity to communicate discomfort, untreated pain may be expressed in the form of behavioral and psychiatric symptoms. The goal of the present study was to examine the relationship between pain and behavioral and psychiatric symptoms of dementia in community-residing older adults from the perspective of the family caregiver. Dyads composed of 272 dementia patients, and their family caregivers were assessed to determine dementia patient's mental status; family caregiver's assessment of care recipient's pain, functional dependence, and number of behavioral symptoms; analgesic use; and demographic information. Hierarchical multiple regression analysis controlling for age, marital status, race, functional disability, and analgesic use showed that pain explained a small but significant percent of variance in the number of behavioral symptoms (3%, P<0.001). Pain had a stronger influence on the number of behavioral and psychiatric symptoms of dementia among those with severe cognitive impairment (F1,69=11.75, P<0.001) compared with those with low to moderate cognitive impairment (F1,199=4.543, P=0.034.). The findings indicate that pain is a risk factor for behavioral symptoms in individuals with dementia and suggest that pain is a more significant predictor of behavior for individuals with severe dementia, compared with those with mild/moderate stage dementia. These results reinforce the importance of proper pain assessment and its management as part of dementia care planning.

Social Activity Decreases Risk of Placement in a Long-Term Care Facility for a Prospective Sample of Community-Dwelling Older Adults

The purpose of this study was to determine the role of modifiable factors in the risk of long-term care (LTC) placement. Using data from a cohort of community-residing older adults (N = 189), a secondary analysis was conducted of the contribution of social activity, sleep disturbances, and depressive symptoms to the risk of LTC placement. Analyses controlled for cognitive and functional impairment, age, and medical conditions. Within 5 years, 20% of participants were placed in a LTC facility. Each unit increase in social activity was associated with a 24% decrease in the risk of placement (odds ratio [OR] = 0.763, p = 0.001, 95% confidence interval [CI] [0.65, 0.89]). Cognitive impairment (OR = 3.05, p = 0.017, 95% CI [1.23, 7.59]), medical conditions (OR = 1.22, p = 0.039, 95% CI [1.01, 1.47]), and age (OR = 1.101, p = 0.030, 95% CI [1.01, 1.20]) were also significant individual predictors of placement. Although many of the strongest risk factors for placement are not modifiable, older adults who engage in more social activity outside the home may be able to delay transition from independent living.

Student Service Learning – Obstacles and Opportunities

Service learning is a key component of the graduate education program at the Fisher Institute for Wellness and Gerontology at Ball State University in Muncie, Indiana. Every time a graduate student is accepted as a Graduate Assistant into the Applied Gerontology Program, the student is trained on their responsibilities which include outreach to community-residing older adults. Outreach includes program planning to ensure delivery of programs both at the Community Center for Vital Aging in downtown Muncie and at various types of senior citizen establishments. Students each month reflect on their experiences through a Monthly Report form. Analysis of Monthly Report forms for the time period May to November, 2012 indicates that the students have learned skills, indicate better understanding of well and disabled older adults, lessened fear of working with and on behalf of older adults, and have a better understanding of what the older adult consumer desires.

Mistreatment and Self-Reported Emotional Symptoms: Results From the National Elder Mistreatment Study

Many community-residing older adults in the United States report past year mistreatment; however, little is known about mental health correlates of abuse. This study investigated whether a recent history of emotional, physical, or sexual abuse is associated with self-reported emotional symptoms (e.g., anxiety, depression) among a representative sample of older adults. Results demonstrated that each abuse type increased likelihood of reporting emotional symptoms; when other known correlates were controlled, only emotional abuse remained a significant predictor. Additional study of mistreatment-related correlates of depression and anxiety is needed, with a focus on the often overlooked category of emotional mistreatment.

Functional Fitness and Physical Activity of Portuguese Community-Residing Older Adults

The purposes of this study were to generate functional-fitness norms for Portuguese older adults, to determine age and sex differences, and to analyze the physical activity-associated variation in functional fitness. The sample was composed of 802 older adults, 401 men and 401 women, age 60-79 yr. Functional fitness was assessed using the Senior Fitness Test. Physical activity level was estimated via the Baecke questionnaire. The P50 values decreased from 60 to 64 to 75 to 79 yr of age. A significant main effect for age group was found in all functional-fitness tests. Men scored significantly better than women in the chair stand, 8-ft up-and-go, and 6-min walk. Women scored significantly better than men in chair sit-and-reach and back scratch. Active participants scored better in functional-fitness tests than their average and nonactive peers. This study showed a decline in functional fitness with age, better performance of men, and increased proficiency in active participants.

Depressive Symptoms and Gait Dysfunction in the Elderly

Assess the association between depressive symptoms (not meeting the criteria for major depression) and gait dysfunction in older adults. Cross-sectional study. Einstein Aging Study, a community-based longitudinal aging study. Six hundred ten nondemented and nondepressed community-residing adults age 70 and older. Depressive symptoms measured using the 15-item Geriatric Depression Scale. To obtain a comprehensive assessment of gait, eight individual quantitative gait parameters were assessed: velocity (cm/s), stride length (cm), cadence (steps/min), swing phase (seconds), stance phase (seconds), double support phase (seconds), stride length variability (SD of stride length), and swing time variability (SD of swing time). Multiple linear regression analysis was applied to study the association of depressive symptoms with gait, adjusting for potential confounders including demographic variables, medical illnesses, and clinical gait abnormalities. Increased level of depressive symptoms was associated with worse velocity, stride, and swing time variability. The relationship of the remaining five gait variables with depressive symptoms was not significant in the fully adjusted models. Higher levels of depressive symptoms are associated with worse performance in specific quantitative gait variables in community-residing older adults.

Effectiveness of Tai Chi as a Community‐Based Falls Prevention Intervention: A Randomized Controlled Trial

To compare the effectiveness of tai chi and low-level exercise in reducing falls in older adults; to determine whether mobility, balance, and lower limb strength improved and whether higher doses of tai chi resulted in greater effect. Randomized controlled trial. Eleven sites throughout New Zealand. Six hundred eighty-four community-residing older adults (mean age 74.5; 73% female) with at least one falls risk factor. Tai chi once a week (TC1) (n = 233); tai chi twice a week (TC2) (n = 220), or a low-level exercise program control group (LLE) (n = 231) for 20 wks. Number of falls was ascertained according to monthly falls calendars. Mobility (Timed-Up-and-Go Test), balance (step test), and lower limb strength (chair stand test) were assessed. The adjusted incident rate ratio (IRR) for falls was not significantly different between the TC1 and LLE groups (IRR = 1.05, 95% confidence interval (CI) = 0.83-1.33, P = .70) or between the TC2 and LLE groups (IRR = 0.88, 95% CI = 0.68-1.16, P = .37). Adjusted multilevel mixed-effects Poisson regression showed a significant reduction in logarithmic mean fall rate of -0.050 (95% CI = -0.064 to -0.037, P < .001) per month for all groups. Multilevel fixed-effects analyses indicated improvements in balance (P < .001 right and left leg) and lower limb strength (P < .001) but not mobility (P = .54) in all groups over time, with no differences between the groups (P = .37 (right leg), P = .66 (left leg), P = .21, and P = .44, respectively). There was no difference in falls rates between the groups, with falls reducing similarly (mean falls rate reduction of 58%) over the 17-month follow-up period. Strength and balance improved similarly in all groups over time.

Sixteen-Month Evaluation of Depressive Symptomatology in Older Adults

We examined the prevalence of depressive symptoms over time in a sample of community-residing older adults at baseline, 2 months, 6 months, and 14 months. The nonprobability sample (N = 222) was 90% female, 87% Caucasian, 15% Hispanic, and 12% African American with an average age of 75 years. If depressive symptoms had been measured at only one time, 19% of the sample would have scored above the cutoff versus 39% scoring above the cutoff when measured at all 4 periods. The findings provide evidence that depressive symptoms in older adults are variable and fluctuate over time. The significance of this research was the longitudinal evaluation of depressive symptoms in community-residing elders.

Memory Performance, Health Literacy, and Instrumental Activities of Daily Living of Community Residing Older Adults

Health literacy is associated with cognitive function across multiple domains in older adults, and these older adults may face special memory and cognitive challenges that can limit their health literacy and, in turn, their ability to live independently. The aim of this study was to evaluate if an association existed among health literacy, memory performance, and performance-based functional ability in community-residing older adults. Forty-five adults participated in this study. Designed to reflect everyday memory, the Rivermead Behavioral Memory Test (RBMT) bridges laboratory-based measures of memory and assessments obtained by self-report and observation. The RBMT classifies individuals into four categories of memory performance: normal, poor, mildly impaired, and severely impaired. The participants were recruited in the two categories of normal (≥22) or impaired (≤16) category on the RBMT. The sample consisted of 14 who were in the impaired category and 31 in the normal group. Their average age was 77.11 years, and their average number of years of education was 15.33 years. Health literacy scores measured with the Rapid Estimate of Adult Literacy in Medicine. Health literacy scores were high (M = 65.09, SD = 2.80). Thirty-four participants or 76% of the sample scored a 66 out of a possible score of 80. Pearson correlations were calculated for the study variables. Health literacy scores with education and cognition (.30), memory performance groups (normal vs. poor; .25), and performance-based instrumental activities (.50) were associated significantly. The development of a broader assortment of health literacy instruments would improve the ability of researchers to both compare studies and build on the knowledge and results of others.

Walking while talking: Investigation of alternate forms

The aim of this study was to develop alternate forms of the walking while talking (WWT) dual task, and to determine whether beginning the WWT in mid-alphabet vs. at the beginning of the alphabet, affects task outcomes. Alternate test forms help reduce practice effects leading to more precise estimates of change over time. We conducted a cross-sectional study in 145 community-residing older adults (mean age, 79.2±6.8y) without dementia or depression. Subjects performed four WWT trials with a different initial letter (a, b, m or n). There were no differences in velocity, correct letters, or errors on WWT trials beginning at shared points in the alphabet (‘a’ compared to ‘b’ and ‘m’ compared to ‘n’). However, trials initiating with letters from the beginning of the alphabet compared to mid-alphabet showed significant differences (with higher number of correct letters and fewer errors for ‘a’ and ‘b’ trials) but not for velocity. Thus, starting WWT in mid-alphabet is different from starting at the beginning of the alphabet. Alternate forms of the WWT with two separate initial letters from a shared point of the alphabet (specifically ‘a’ and ‘b’ or ‘m’ and ‘n’) may be used upon repeated administration to reduce practice effects.

Racial Disparities in Quality of Medication Use in Older Adults: Findings From a Longitudinal Study

Background The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drugs, appropriate treatment of prevalent chronic disease states, or a set of predefined quality indicators of medication use rather than the patient. It is also suggested that racial differences in the quality of medication use may exist in older adults. Objective This study was conducted to determine the prevalence, number, and types of medication-related problems in older adults, examining the impact of race on quality medication use. Methods This was a prospective cohort study involving in-home interviews and medical record reviews of community-residing older adults, stratified by race, conducted 3 times over 1 year. No intervention to address medication-related problems was performed. The quality of medication use was reported as medication-related problems by clinical pharmacists. Results Of the 200 participants (100 blacks, 100 whites), mean age was 78.3 (whites) and 75.5 (blacks), and the majority of patients were female. Although whites used more medications than blacks (mean, 11.6 vs 9.7; P < 0.01), blacks had more medication-related problems per person than whites (mean, 6.3 vs 4.9; P < 0.01). All patients had at least 1 medication-related problem. Common problems at baseline, 6 months, and 12 months for both whites and blacks were undertreatment, suboptimal drug use, suboptimal dosing, nonadherence, and less costly alternative available. Blacks had significantly higher rates of nonadherence than whites (68% vs 42%; P < 0.01). Over the 12-month study, the number of medication-related problems not only persisted but increased (adjusted P = 0.0168). Conclusions Medication-related problems were prevalent in both black and white older adults and persisted over 1 year. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in the quality of medication use in older adults and the impact of race on specific medication-related problems.

The New Frontier of Depression and Aging: Outreach to Community-Residing Older Adults

The New Frontier of Depression and Aging: Outreach to Community-Residing Older Adults

Environmental Correlates of Overweight and Obesity in Community Residing Older Adults

This study examines the role of environmental correlates of overweight and obesity among older adults independent of walking activity and lower body function. In-person interviews were conducted with 789 adults aged 65 and older, residing in four areas in the U.S. Demographic information, general health, lower body function, walking behavior, and awareness of environmental infrastructure features using the modified Neighborhood Environment Walking Survey (NEWS) were obtained. Regression analyses examined the association between Body Mass Index (BMI) and environmental infrastructure features, adjusting for demographics and lower body function. Older adults who perceived their neighborhood as less safe from crime and had reduced access to services were more likely to have higher BMI. Controlling for demographic and functional characteristics, access to services remained significant. This association remained significant for those with lower functional status. This research suggests that neighborhood environment may have an influence on BMI above and beyond walking activity.

Living Arrangement Concordance and its Association with Self-Rated Health Among Institutionalized and Community-Residing Older Adults in China

Although many studies look at the relationship between living arrangement and health among older adults, very little research takes seniors' preferred living arrangements into account. This paper uses data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) to examine what factors are associated with concordance between actual and preferred living arrangements for both institutionalized and community-residing Chinese seniors, and to investigate associations between living arrangement concordance and self-rated health. Our analyses show that economic independence is negatively associated with living arrangement concordance among institutionalized older adults (net of other factors), while being older, female, minority ethnicity, having higher SES, and being unmarried are positively associated with living arrangement concordance among community-residing seniors. For both institutionalized and community-residing older adults, living arrangement concordance increases the likelihood of rating self-rated health as good, with concordance having a greater impact on health for institutionalized elders (odds-ratios of 1.67-1.93) than for community-residing elders (odds-ratios of 1.12).

Personal Meaning Orientations and Psychosocial Adaptation in Older Adults

This study examined how different patterns of sources of meaning in life impact the psychosocial adaptation of older adults. A total of 120 (62 women and 58 men) community-residing older adults completed self-report measures of sources of meaning in life, physical health, life satisfaction, depression, personality, existential regrets, attitudes toward aging, and attitudes toward life. Cluster analysis of sources of meaning revealed four distinct meaning orientations: self-transcendent ( n = 32), collectivistic ( n = 24), individualistic ( n = 34), and self-preoccupied ( n = 30). MANCOVA analysis of the four groups, controlling for age, marital status, education, and financial satisfaction, revealed a strong multivariate main effect for meaning orientation. No statistically significant gender and Gender × Meaning orientation interaction effects were found. Older adults, who derive meaning from self-transcendent sources, are more extraverted, open to experience, agreeable, and conscientious; perceive greater purpose and coherence in life; feel more in control in directing their lives; express a stronger desire to get more out of life; and are less depressed compared with those who derive meaning through pursuing self-serving interests without any real commitment to personal, interpersonal, or societal development. The implications of the findings for positive aging are discussed.