The SCANS content team headed by Jean Bandos along with the development team announced today that the SCANS Version 1.3 - May release is now available.  SCANS Version 1.3 is a major content release to the SCANS Knowledge Base.

In order to make more real-world tools for eldercare available more quickly, Jean and the team have devised a "rolling release".  For 3 months beginning in May another group of resources, processes, and tools will be made available to geriatric care managers at My Health Care Manager and our affiliates.

The May release contains 57 new and/or revised resources, processes and tools.  Some sample items include: 
 

• Behaviors and Alzheimer's Disease
• Grief Education
• Activities of Daily Living Education
• Depression and Alzheimer's disease
• Early Stages and Impact on Health
• Memory & Cognition Questions
• Memory Care Unit Checklist
• Memory Care Unit Education
• Mild Cognitive Impairment
• Sobriety Programs Resource
• Handyman Resource
• Private Handyman Contractor Checklist
• Smoke & Carbon Monoxide Detectors
• Daily  Money Management Education
• Financial Planning Education
• Trust Education
• Verifying Funeral Arrangements
• Veterans Benefit Information
• Elder Law Resource & Checklist
• Medication Management Procedure
• Medication Reconciliation
• Polypharmacy
• How to Find a Pain Specialist
• Pain Education
• Pain Resources
• Pain Visual Analog Scale
• Arthritis
• Heart Failure
• Hypertension Education
• Family History - Cancer Education
• Family History - Dementia
• Family History - Diabetes Education
• Family History - Heart Education
• Seat Belt Education
• Cataracts Education
• Glaucoma Education
• Hearing Aid Education
• Sensory Changes
• Assistive Devices
• Hospice Education
• Spiritual Connections

Stay tuned; the June release will include resources on incontinence, cognition, supporting services, and more processes.

Be sure to visit Jean's blog, click here.

There are many drug-free (non-pharmacological) options that have been proven to help relieve certain types of pain, which could be from arthritis, chronic pain, or another chronic disease. These techniques can help complement the pain management medications prescribed by your doctor.
1. Apply heat or cold to the affected area
2. Ask your geriatrician or health care provider about specific exercises to help with pain
3. Find something that distracts you such as music or a hobby
4. Practice relaxation or deep breathing techniques
5. Massage or vibration can help relax you and may relieve the pain
6. Applying pressure to the area that is in pain
7. Find support groups or someone to talk with
8. Modify your environment so that it is more comfortable for you
9. Plan activities earlier in the day when pain is sometimes not as bad
10. Learn how to manage pain- learn what triggers it, what makes it worse, and what makes it better
11. Consider keeping a journal of when pain occurs and what helps relieve it
 
If you are not sure of how to use these techniques ask your health care provider and/or discuss with your Health Care Manager.  If you're a caregiver, you can discuss these options with your aging loved one and have them work with their health care provider to integrate the techniques into daily life.

The holidays are a time to get together as family and friends.  A lot of adult children may not live near their aging parents or have not seen them for several months, so the holidays are a time when families do get together but it may also be a time of discovery...that mom or dad needs assistance in their daily life.  If you are visiting or spending time with your aging parents, keep your eyes open to the indicators that they may need some assistance with staying independent.

Here are some things to be aware of when visiting your aging parents:

1.  Mail and bills are piling up or mom/dad is having a hard time with money management and bill paying, when this has not been a problem in the past.
2.  Minimal groceries in the refrigerator and cabinets, or food is left in the microwave or rotting in the refrigerator.
3.  Mom/dad is wearing the same clothes over and over, clothes are soiled or not getting properly cleaned.
4.  Grooming habits have declined, not bathing/showering, hair and/or facial hair is unkept, teeth/dentures not being properly cleaned.
5.  Prescriptions are not being filled - look for empty bottles around the house or for medications that have expired.  Are medications being taken properly?  Have mom/dad show you the medication management system in use.  Where do they store their medications?  Do they use a pillbox?  Who fills the pillbox?  Is it filled correctly?
6.  Are they keeping up with preventative practices (e.g. attending routine health exams, receiving routine/recommended vaccinations)?
7.  Difficulty walking or getting around the house, gait disturbance/difficulty with balance, trouble getting up from a chair, difficulty with stairs.
8.  Forgetfulness or confusion regarding recent conversations, familiar faces, simple tasks or daily activities.
9.  Check the house for hazards (e.g. rugs that can easily be tripped on, inability to take care of the lawn or shovel snow/ice off walkways).  Install grab bars in the bathroom if needed, and smoke alarms and carbon monoxide monitors.
10.  Be alert for scammers.  Scammers often prey on vulnerable older adults.  Are people calling or coming over to mom/dad's and you do not know who they are?  Are they giving money or writing checks to people or organizations that you do not know?

If you discover that your aging parent or loved one is in need of additional service, contact your local Area Agency on Aging for resources or a professional geriatric care manager for assistance.

Happy Holidays!

It's that time of year where seniors have the opportunity to change their Medicare Prescription Drug Plan.  Open enrollment begins November 15 and ends December 31.  Seniors are encouraged to enroll or switch programs as early as possible to avoid any problems with prescription drug coverage starting in January.
Medicare Prescription Drug Coverage (or often referred to as Medicare Part D) covers prescription drugs and may help lower a person's prescription drug costs and helps protect against future higher costs.
So how does a senior know which is the best prescription drug plan for them?  A plan that has low premiums for the most coverage is ideal.  There are several ways a person can evaluate their current plan or search for alternative plans.  One way is on the internet at www.medicare.gov.  This website allows individuals the opportunity do a personalized search, which allows the person to enter in their personal information and their prescriptions; or by doing a general plan search, which allows people to search and review plans.  Navigating this website can sometimes be tedious and overwhelming, especially if multiple plans show up as alternatives...how do you choose?  The positive is that the website will list the plans in graph format in the order of most coverage to least coverage, just watch for premium costs.  Another way to evaluate your current plan or search for an alternative plan is to have your local pharmacist run your prescriptions in the Medicare system for you.  Another suggestion is to consult a professional care manager or medical social worker for guidance.  I do not suggest calling Medicare directly....I don't think I've ever talked to a human being on that phone line and callers are usually on hold for long periods of time.

For the last several months, we have been discussing safety concerns for the older adult.  We all know that medication management and fall risk prevention are instrumental to healthy aging, but a holistic picture is what is most important to assist in aging in place and maintaining good “health”.  As the boomers age, we will see more and more written on wellness, well-being, and just overall aging tips. 

But what is key to a healthy life style?

According to American Geriatrics Society it is

1. Not smoking
2. Drinking alcohol in moderation
3. Exercising
4. Getting adequate rest
5. Eating a diet high in fruits and vegetables
6. Coping with stress and
7. Having a positive outlook.  

These are important, but I feel that whether you are elderly or young, you need to understand your overall health issues, have social connections, be at peace with where you are in life, have a purpose, live in a safe environment that supports your needs, and keep your brain functioning. 

Good Morning America does a segment that highlights individuals celebrating their 100th or older Birthday.  Today a man was 107! I am always amazed at the life history of those over 100...  The majority have remained both physically and intellectually active and have remained connected with society.  Amazing, they never reference how many fruits and vegetables they have eaten!!   So stay connected… and do your brainteaser and always learn something new each day. 

In most practices, doctors are busy, the front offices are short staffed and the nurses are swamped.  Is it any wonder that calls don’t get returned promptly or orders don’t get faxed in a timely manner?  While there is an easy explanation for these delays, it can be frustrating to a family that is anxiously awaiting test results or a prescription change for their parent. 

I hear it all the time from everyone I know. “I can’t get through to a nurse…I left a message on voicemail and haven’t heard back from anyone…I am tired of pressing 1 for this and 3 for that and never getting any real information or a live person.”

These experiences are especially troublesome when you are worried about your parent and want information as soon as possible.  It can also be difficult to find times to talk privately during the work day, except for a lunch hour or during a short break, so waiting for a call can be very hard to manage.

So what do you do? 

• Make sure the medical provider knows to call your cell phone.  There is nothing more frustrating than to wait for a call and find out when you arrive home at 6:00 PM that the Dr. left a message on your home voice mail at 10:00 AM.
• Make a list of your questions and have it available when you receive the call from the Dr’s office.  Getting back in touch with the same person quickly may be difficult, so try to minimize the need to call back with additional questions.
• Be respectful of office protocols and policies, but be persistent.  If you don’t receive a return call in a reasonable period of time – call back and try to reach a “live” person.  Restate your concerns and/or questions and tell them you are willing to stay on the line while they find someone to help you.
• Send a fax addressed to the appropriate party.  It might get routed more quickly than a phone message.  Also, it lets the Dr’s office know that you are really serious about your need for information.
• Always remain polite and respectful. Becoming angry or obnoxious certainly won’t help your case and could brand you forever as “difficult.” 

These suggestions are based on my own personal experience and I hope you find them helpful.  They are meant to help facilitate communication between a physician’s office and a senior’s family when a voicemail culture seems to be impeding communication.

My colleague Jennifer brought another in home communication device/service to my attention recently.  It's called Celery. 

You may remember a previous blog (click here) on the Presto Printer; a great way to communicate with parents living independently at home of in a retirement community. 
Celery is a service which combines FAX and Email capability.  It allows a caregiver or remote family member to send an email to a FAX machine in their loved one's home.  This can include a text message and even pictures.  The FAX is hooked up to a standard phone line so you don't have to obtain Internet service or have a computer.  The exciting part is that the receiver can hand write a reply and FAX it back to a special Email service that will match it to a preset list of authorized email accounts and send the message on as an image.  This makes the communication two-way.  For more on Celery see their web site http://www.mycelery.com/. 

This could be used to reduce social isolation, provide reminders about heath care, improve medication management, and just keep in touch with distant and busy family members.

In several of my past blogs, I discussed safety concerns and the older adult.  One the main concern is medication safety. Not just the management of medications but how many are actually taken.

It is often reported in the news about a medical error made and the impact it has on individual lives.  Those articles are frequently about hospitals errors.  But have you ever thought about the older adult and how they manage at home...?  The impact our current health system has on managing medications...?  How chronic illnesses such as congestive heart failure, diabetes, and arthritis impact the older adult and his/her caregivers...?  Different providers – prescribing different medication – generic versus brand names.  multiple medications with multiple doses all affect the medication management and the safety of the older adult.

Let’s look at the key safety issue: polypharmacy (multiple medications).  
A caregiver may ask what defines polypharmacy or how many pills or too many?  The answer would have to be that different entities in the current health care system define Polypharmacy differently.  I have seen it defined as low as two or more medications, but in general it deals with using more than three to five medications or herbal supplements for longer than 90 days in a given year.  In my career I have witnessed shoe boxes filled with medications that have numbered over 20 different medications- especially when dealing with multiple chronic diseases, over the counter medications, herbs, and vitamins.

Where should the caregiver and/or older adult start in trying to deal with their medications?
First, realize that the main problem with polypharmacy is that it increases the clients’ risk for drug interactions.  Drug interactions occur when one medication or herbal supplement reacts negatively with another medication when they are taken together. It is important to report any side effects to your physician.
 
The following are some steps you can take to prevent drug interactions:

• Provide a complete list of your medications and herbal supplements to your physician and/or pharmacist
• Discuss how each medication/herbal supplement works inside the body.
• Verify with your physician that you are receiving the recommended dose of each medication/herbal supplement.
• Verify with your physician that you are receiving the recommended form of each medication/herbal supplement you are taking (pill, liquid, tea, extract).
• Determine how many times a day your medications/herbal supplements should be taken.
• Discuss any side effects that might be experienced.
• Discuss the common prescription medication interactions.
• Discuss the common herbal supplement interactions.

If you can not complete a list of medications, take them all into your physician or pharmacist and have a list made for you. 

The National Institute on Aging is a great resource for learning more about medication managements, herbs, vitamins and safety concerns - learn more by clicking here.

I'm going to cheat just a little bit and pre-announce to my blog readers that SCANS Version 1.0 is about to go into production release. 

This is the Knowledge Repository Edition of SCANS.  It provides Health Care Managers at My Health Care Manager and our Affiliates with a comprehensive knowledge base of best practices in geriatric care. 

It contains information on all of the most common problem areas encountered when caring for aging parents.  More importantly it provides concrete geriatric care solutions, step by step actions, and powerful, practical tools for implementation.    Some examples of the issues addressed by SCANS include:

• Behavioral Issues
• Caregiver Support
• Cognitive Issues
• Family Communications
• Continence Problems
• Emotional Concerns
• Environmental Issues
• Information Management
• Intellectual Engagement
• Medication Management
• Nutritional Needs
• Pain Management
• Prevention/Wellness
• Provider Coordination
• Service Coordination
• Social Support
• Spiritual Well-being
• and many more

Our Director or Research, Jean Bandos, puts it this way:

"My Health Care Manager is in the process of developing an advanced technology Knowledge Management and Decision Support System that will change the way geriatric care management is delivered. This system is directly concerned with the caregiving challenges of the senior and their family ...  (this) Knowledge  management and Decision Support System will assist the Health Care Managers in delivering complete, comprehensive, and predictable services."

Our Research and Development team is particularly proud of delivering this first version to commercial use in less the 4 months of receiving a major grant from the Indiana 21st Century Research and Technology Fund of the Indiana Economic Development Corporation.

More advances are in the works...

Laurie recently posted a comment about her mom having problems mixing up her medications.  This is a very common problem.  The average person over age 65 is taking 8 prescription medications.  Someone who is battling chronic diseases may be taking many more. 

The number of medications is confusing in the best of circumstances, but clearly other challenges like declining vision, cognitive issues, or problems with manual dexterity make medication management a daunting task. 

Some of the posts in my blog can help.  See Technology in Day-to-Day Medication Management and Create Your Medication List Now.  You can also click here for our full blog list on Medication Management where you will find lots of additional advice and insight.

You can also ask question directly of a Health Care Manager by joining our Caregiving community.  Click here for that link.

Got a headache, back pain, high cholestrol levels, etc?...then pop a pill.  That is often the "magic" solution in today's health care system.  According to the American Heart Association, 32 million Americans take 3 or more medications daily.  Seniors often take double or triple that amount and sometimes more.  The problem is, is that with all medications come potential side effects and then to treat those side effects people are often prescribe another medication and so on.  Another problem is that seniors often have multiple physicians who often are not aware of what the other physicians' treatment plans are and what medications they are prescribing.  According to Medco Health Solutions, a pharmacy benefits manager, "the risk for drug errors is 7 times greater in seniors than in people under age 65."  CNN.com released an excellent article this week titled "Is Grandma drugged up?"  This article tells a story of a 66 year old woman who was experiencing confusion and slurring of her words.  Her family took her to the emergency room where the possibility of a stroke was ruled out; she was admitted to the hospital and was diagnosed with Alzheimer's Disease.  Her children believed that the diagnosis was incorrect, as she has been functioning independently.  They took their mother to a geriatrician at the University of Oklahoma for a second opinion, where they were told that she most likely did not have Alzheimer's Disease but was overmedicated.  Dr. Jerry Gurwitz's philosophy is "that any new symptom in an older person should be considered a drug side effect until proven otherwise."  Not only do medications have side effects but they also interact with other medications causing contraindications, enhancing side effects, etc.  It is important to always keep a current list of medications, including prescriptions, over-the-counter medications, herbal medications and supplements.  All medications, not just prescriptions, can interact with each other, as well as, food/beverages and other substances i.e. tobacco.
There are several ways caregivers can assist in medication management.  If you feel that your parent is being overmedicated, talk with your primary care physician or geriatrician, and pharmacist.  There are also several online tools you can use to check your medications for interactions.  Here are two online tools:  PDRhealth.com and drugdigest.org.  Educating yourself on what medications cause potential problems for seniors is a good way to become an advocate for your parent.  As well as knowing the suggested lists of medications to avoid if a senior has a specific diagnosis.  My Health Care Manager also reviews seniors' health history and medications and can consolidate that information into one locale to assist families in managing their parent's health care.

I've had a few questions lately about technical help in dealing with memory loss.  There are some good tools to assist seniors and caregivers with things like medication management, appointments, self monitoring reminders, falling concerns, and even mobility. 

Saying this, I should quickly add that these are all fairly new and nothing has yet emerged standard practice.  This may be due to the reality that memory loss and related conditions of dementia are typically progressive diseases.  Meaning, a technology that works this month likely will not work in six months.  For example, one caregiver we were working with purchased an electronic pill dispenser.  Each time a medication was to be taken an ever more persistent alarm would sound to remind their loved one to take their medicine.  Some of these devices can even use a phone connection to dial a central database and report the activity of the unit.  This worked well for time, but one day their parent decided that this device was annoying, unplugged it, and put it under the bed.  Any attempts to reset the unit resulted in some similar behavior.  A new approach had to be found.

So for caregivers caring for parents with dementia, simply be prepared to monitor and make adjustments with any solution you might consider.  Technology can be a temporary suppport tool.  The news is better if your parent is not dealing with significant cognitive problems.  In this case, technology can be a real and lasting support tool.

In past blogs I've talked about the 17 dimensions My Health Care Manager uses to build the Personal Health Record.

We've spent a lot of time on some of the most used data like the medication list, provider list, and other "current state" information.  By "current state" I'm referring to information which is primarily valuable for it's current data values.  For example, when you are caring for aging parents it may be of some very slight interest which doctors your parents went to 3 years ago, but the current doctors are far more important.  The same would be true in medication management.  It's the current prescriptions and treatment plans that are most relevant.

However, 10 of the 17 dimensions deal with "longitudinal data".  That is, data that should be measured over time.  If you are primary caregiver it is very easy to miss major changes because they happen incrementally. 

It's just like watching children grow up.  Parents, who see their kids every day, know they're growing, but its the Aunt from across the country who's stunned by how much they've grown each Thanksgiving.  Parents can get a sense of this themselves by looking at pictures.  So it is with eldercare.  The people closest to the situation need to take an actual "snapshot" of the key data items and periodically look at those for problem areas.

My Health Care Manager does this through the use of a formal assessment.  At least annually and at every major health event key areas like Activities of Daily Living, Socialization, and Cognitive Skills should be assessed, scored, and tracked. 

Let's return to the question of the impact of technology.  In particular, to the impact on a key issue facing seniors and caregivers, medication management.  We've touched on the fundamentals - preparing and communicating the medication list with simple computer tools.  What we haven't spent much time on is the day to day management of medications.

Technology can help.  For example, one of the tools My Health Care Manager makes available to seniors and their families is a weekly medication schedule.  This schedule provides a map of the all medications with the day and time and dosages they are to be taken over the course of the week.  This schedule can also provide a variety of additional information such as sliding insulin scales or even life style guidance for exercise or other activities.  In many cases our clients will actually record daily health monitoring results on the form (like blood sugars, blood pressures, and so on).  This is a great way to help aging parents and their care givers stay on top of the weekly regimen.  

There are some limits.  We have found that people dealing with Dementia (Alzheimer's disease or other forms) need the assistance of a caregiver to use a tool like this.  Often they will also need reminders through the course of the day to prompt taking their medications.  Technology can help here, as well.  There are a number of medication reminder systems emerging in the market.

 

Don't procrastinate any longer.  Create your medication list or, if you are a caregiver, create one for your aging parents.  If you want help and advice get a geriatric care manager. 

This first job is easy to start.  Even if you are going to enlist help from a geriatric care manager or other in home services, having this list will only speed up their ability to help you or your loved one.  The medication list is the first step in any program of medication management.

Click on this link for a FREE quick spread sheet from one of my previous posts - Medication List Spreadsheet.

Make copies of the list and let your doctors know, it's critical.

There are several innovations available to help seniors organize and remember to take their medicines.  Although not necessary for many older adults managing multiple medications, some can benefit by having their medicines pre-sorted and dispensed in pouches that are organized by time of day and day of week.  We’re moving to a system like this as Mother’s filling a 28 compartment pill tray with 14 prescribed medicines and OTC pills each week becomes even more challenging with her aging.  This pre-loaded dispensing solution has been used in nursing homes and some hospitals for several years, but some companies are now offering the program to individuals in their residences.  But before making any change of this type, be sure to check the Medicare Part D prescription medicine plan to be sure the vendor is recognized in the insurance company’s plan. 

Other higher-tech aids are in development that include pill trays that automatically open at the right time and track results (although it is impossible to remotely know if the pills were actually taken).  We’ll be seeing more use of technology in assisting with eldercare- something I imagine caregivers will welcome wholeheartedly.  Many developments are underway by inventors and large health technology companies, and I’ll use a future blog to describe some of the more promising ones.

Even though Mother was safe and secure in Independent Living (IL) in a Continuing Care Retirement Community (CCRC), we quickly realized that managing her prescription and over-the-counter (OTC) medicines was a challenge of its own.  With 10 prescription medicines and 4 OTCs, the variables of continuing supply with many expirations and prescription renewals combined with generic vs. brand names, dosages and time-of-day preferences were an overwhelming task for her … and her caregivers!  Fortunately, we devised a Weekly Schedule and medicine reconciliation program that allowed her to manage her own meds (with our assistance) that has now become a My Health Care Manager computer-based decision aid.  However, loading her pill tray every week and managing the time for her diabetes blood sugar tests and consumption of the pills became (and remains) an ongoing challenge.  Until becoming exposed to the issues of polypharmacy and older adults, I didn’t understand that normally-prescribed medicines and dosages affect many seniors differently – sometimes even causing symptoms such as confusion and loss of balance.  Even multiple medication regimes that were tolerated in the past can at any moment cause problems or unwanted symptoms.

When trying to get my hands around the multiple medications challenge, it became clear that no single health care provider had information on everything that was being taken by Mother.  Each knew what he or she had prescribed, but the rest of their knowledge was based on answers given to the common question, “What medicines are your taking?” at office visits.  Often confused over generic vs. brand names, dosages, and omitting OTC products, older adults often can’t be counted on to correctly answer this important question.  In developing My Health Care Manager’s suite of decision aids, we added a letter that the senior can choose to send to all of their health care providers (or only to the ones they designate). The letter lists the providers, their prescribed medicines, and any other OTC products being taken by the senior.  Several doctors have remarked that this simple summary of information is not available from any single source in our health care system.  You might try this important task on your own if you are immersed in eldercare.  We’ll have more on managing medicines in my next blog.

We recently had some experience with the "set it and forget it" approach to the medication list.  It's too easy to make a medication list during a flurry of activity to get organized and then consider it done... for good.  Of course medications, dosages, and frequencies change over time and the list needs to be kept current.

For anyone dealing with multiple medications, keeping it current isn't enough.  It also needs to be communicated.  When you first build a medication list for yourself, your parents, or other loved one you should send it to every provider involved.  Yes EVERY provider and caregiver.  If you expect the health care community to make the best choices, they need to know all the medications in play.

At My Health Care Manager our best practice is to write a cover letter to all the health care providers and attach the full medication list.  For members under our Medication Management Program we extend this same notification every time there is a change to the prescription list.  This lets the provider know who else is involved in the care and what medications may be impacting their treatment recommendations.

As a caregiver or active senior, you can certainly do this yourself without the help of geriatric care manager.  Remembering to communicate is the key.  Don't forget to tell the other caregivers involved.  This is critical to making certain the proper amounts are taken and that potentially serious mistakes are avoided.

Today is the last day of National "Talk About Prescriptions" month - so hopefully you have spoken with your aging loved one- especially if they are taking multiple medications. However, I would also like to encourage everyone to talk about another kind of prescription- not for a medication, but for glasses or contacts.  Our vision deteriorates as we age and this can affect our mobility.  Home safety is incredibly important for preventing falls- and one key to preventing falls is recognizing a change in vision.

A recent study proves that worse vision or 'visual field deficit' is associated with falls- especially peripheral vision deficits.  The study also provides information about the occurrence of falls among older adults and the association of falls with a greater likelihood of hospitalization, nursing home admission, and death.  The bottom line: making sure your loved one has regular exams by a health care professional- including vision exams- is a smart move!  You may also speak with your geriatrician or health care professional for more information on preventing falls.  To read the study abstract issued by the  Institutes of Ophthamology at Johns Hopkins School of Medicine and the University College in London, please click here.

October is the national “Talk About Prescriptions” month, sponsored by the National Council on Patient Information and Education (NCPIE). It’s the perfect time to talk to your loved one about the medication they are taking.  Studies have revealed that 40% of seniors cannot read a prescription label, and 76% of seniors cannot understand the medication information given to them.  Caregivers can help!  Considering that our loved ones often take multiple medications as they age (increasing the chance of interactions) and may have medications prescribed to them by multiple physicians, polypharmacy issues must be addressed.  Communication is key- not only within the family, but also (and especially) with your loved one’s geriatrician and other health care providers.  So take a few minutes this month to talk your parents, grandparents, and other loved ones about their prescriptions.  Encourage them to talk to their doctors, and make sure that all of their physicians have a current list of their prescriptions and medications.  For more information, please visit the NCPIE website here or their sister website MUST (Medication Use Safety Training) for Seniors here.