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Psychiatric Morbidity Among Elderly People Living in Old Age Homes and in the Community: A Comparative Study
Anil Kumar Mysore agara!" Senior Resident, Department of Psychiatry, #oseph Mathe$" Final year MBBS, %aveesh &evinahalli an!ego$da" Associate Professor and Head, Department of Psychiatry, Sumanth Malli'ar!una Ma!gi" Assistant Professor, Department of Community Medicine, Purushothama SM" Assistant Professor, Department of Physiology, Mysore Medical College and %esearch (nstitute" Mysore) *+,,,-" Karnata'a" (ndia. Address /or Correspondence: 0r. Anil Kumar Mysore agara!" Senior Resident, Dept of Psychiatry, Mysore Medical College & Research nstitute, Mysore! "#$$$%, &arnata'a, ndia( E)mail: nagara)a'm*+,gmail(com Citation: -agara) A&M, Mathe. /, -an)ego.da RB, Ma)gi SM, Purushothama SM( Psychiatric Mor0idity Among 1lderly People 2i3ing in 4ld Age Homes and in the Community5 A Comparati3e Study( Online J Health Allied Scs. *$%%6%$7+85" 1%L: http599...(o)has(org9issue+$9*$%%!+!"(htm Open Access Archives: http599cogprints(org93ie.9su0)ects94/HAS(html and http599openmed(nic(in93ie.9su0)ects9o)has(html
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Abstract: &ac'ground: Disorders such as depression, an:iety, cogniti3e and psychotic disorders ha3e a high pre3alence among elderly( ;here is some preliminary e3idence that life in old age homes is percei3ed 0y inmates as more supporti3e, though the issue is not .ell studied( Aim: ;his pro)ect is direc! ted to.ards studying and comparing the psychiatric mor0idity and <uality of life of elderly people residing in t.o uni<ue set! tings5 community and old age homes( Method: t is a cross!sec! tional study .here the elderly su0)ects, "$ each in 0oth the groups, .ere selected 0y simple random sampling techni<ue and assessed on Mini Mental Status 1:amination 7MMS18, n! formant =uestionnaire on Cogniti3e Decline in 1lderly 7 =! C4D18, Brief Psychiatric Rating Scale 7BPRS8 and =uality of life 3isual analogue scale( %esult: 4n comparison using suit! a0le statistical analysis, there .as no significant difference in the total scores on MMS1, =C4D1 and <uality of life scale across the groups( Depression .as present in **> of people in the community and ?@> of old age home inmates( Psychosis .as present in *@> of people in the community and *$> of old age home inmates( Conclusion: ;he psychiatric mor0idity is high in elderly irrespecti3e of the setting in .hich they li3e( Key 2ords: 1lderly people6 4ld age homes6 Psychiatric mor! 0idity6 Cogniti3e distur0ances6 =uality of life( (ntroduction: Age is an important determinant of mental illness( ;he o3erall pre3alence of mental and 0eha3ioural disorders tends to in! crease .ith age due to the normal ageing of the 0rain, deterior! ating physical health and cere0ral pathology(7%8 2ac' of family support and restricted personal autonomy are other important contri0uting factors( Psychiatric mor0idity among elderly people is fre<uent, se3ere and di3erse( Disorders such as de! pression, an:iety, cogniti3e and psychotic disorders ha3e a high pre3alence in this segment of the population(7*8 Studies sho. that up to *$> 0eing cared for in the community and a0out ?#> 0eing cared for at the primary le3el are suffering from de! pression(7?8 ;he ndian aged population is currently the second largest in the .orld and is pro)ected to rise from #$ million, according to

the -ational Census of *$$%, to almost ?*+ million 0y the year *$"$, .ith serious social, economic and pu0lic health con! se<uences(7?8 Alo0al trends in the incidence and pre3alence of geropsychiatric disorders are reflected in ndia too( Du0e, in %B#$, reported the pre3alence of mental illnesses in the elderly to 0e *(*?>, -andi and co!.or'ers in %B#", as ??(?>, Ramachandran and co!authors in %B#B, as ?"> and ;i.ari SC in *$$$, found it to 0e much higher in the geriatric group 7+?(?*>, compared to +(@@> in the non!geriatric group8(7+!#8 Sood and his team reported that the most common psychiatric mor0idities in the ndian set up .ere Depression, Ad)ustment Disorders, An:iety Disorders, Dementia and Delirium 7Cognit! i3e Disorders8, Psychoses, Bipolar Disorders and Su0stance!re! lated psychiatric illnesses(7C8 Further, multiple factors are 'no.n to affect mental health in old age( Female se:, lo. edu! cation or illiteracy, 0eing .ido.9.ido.er9di3orcee, medical co!mor0idities, poor socio!economic status and disa0ility are all .ell esta0lished as playing significant role in psychiatric ill! nesses among elderly(7C,%"!*%8 As the ma)ority of elderly in n! dia are illiterate, their li3ing conditions depend upon their co! residence .ith children and9or their a0ility to .or' and earn an income 0eyond the officially designated age of retirement(7B8 n this scenario, due to the increased physical and economic de! pendence, more and more elders are compelled to stay in old age homes( ;here is some preliminary e3idence that life in old age homes is percei3ed 0y inmates as more supporti3e( ;hose in old age homes are psychologically 0etter and e:perience less cogniti3e impairment(7**,*?8 Ho.e3er, this issue is not .ell studied and hence definiti3e e3idence is lac'ing( ;his pro)ect is directed to.ards studying and comparing the psychiatric mor0idity and <uality of life of elders residing in t.o uni<ue settings6 elders li3ing in the community .ho still retained their family ties and those residing in homes for the aged, .hose families or caregi3ers, for some reason, had en! rolled them at the facility( Materials and Methods ;he study sample .as selected from t.o of the largest old age homes 7one pri3ate and the other philanthropic8 and three dif!

ferent localities representati3e of the community .here elderly people li3ed along .ith their family mem0ers( All the fi3e loca! tions are in ur0an Mysore t is a cross!sectional study .here the psychiatric mor0idity and <uality of life of elderly population in the t.o said li3ing setups .ere compared( ;he study .as conducted in t.o months, from %"th /ul *$%$ to %"th Sep *$%$( Su0)ects .ere selected 0y simple random sampling techni<ue( n old age homes, the su0)ect on e3ery alternate 0ed of the dormitory .as inter3ie.ed( Dhen the candidate on a particular 0ed did not meet the criteria to 0e in! cluded in the study, the candidate on the ne:t alternate 0ed .as assessed( n case of community sample, e3ery third house in the gi3en locality .as loo'ed into for an elderly su0)ect( f the can! didate in a particular house .as not found to 0e suita0le for this study, the ne:t third house .as selected( 1lderly people .ere defined as those aged @$ years or a0o3e(7%$8 All persons aged @$ years or a0o3e, .ho ga3e consent to participate and those .ith an informant .ere selected to participate in the study( ;he su0)ects ha3ing medical co!mor0idities .ere also included in the study pro3ided it is not!se3ere enough to pre3ent him9her from participating in the study( Persons aged less than @$ years, terminally ill patients, uncooperati3e persons, those .ithout in! formants and those .ho did not gi3e consent to ta'e part in the study .ere e:cluded( ;he total sample siFe .as %$$, of .hom "$ resided in the com! munity 7denoted as A%8 and "$ stayed in Homes for the Aged 7referred to as A*8( 1ach group included *" males and *" fe! males( Clearance .as o0tained from the nstitution 1thics Com! mittee for carrying out this study( 1lderly people .ere inter! 3ie.ed either at their respecti3e residences or in the Homes for the Aged( ;he Authorities in charge of the Homes for the Aged .here the study .as to 0e conducted .ere contacted prior and permission o0tained( n the community, a door!to!door sur3ey .as underta'en( nformed consent .as ta'en from all parti! cipants .ho 3olunteered for the study( After o0taining consent, each person .as inter3ie.ed on the socio!demographic data sheet( ;hen all those included in the study .ere su0)ected to e3aluation 0y administering the four study <uestionnaires G Mini Mental Status 1:amination 7MMS18 7%%8, nformant =uestionnaire on Cogniti3e Decline in 1lderly 7 =C4D18 7%*8, Brief Psychiatric Rating Scale 7BPRS8 7%?8 and a <uality of life 3isual analog scale called Delighted ;erri0le Scale 7D;S8 7%+8 de3eloped 0y Heinrichs and colleagues( ;he a0o3e mentioned instruments .ere used in this study to compare Cogniti3e defi! cits 7MMS1 and =C4D18, Psychiatric mor0idity 7BPRS8 and the satisfaction an elderly su0)ect reports in his life 7=uality of 2ife8( ;hose recording a score of + or more on the item of de! pressed mood .ere inter3ie.ed 0y CD %$( All assessments of one su0)ect .ere finished in a single session( ;he data .as then analyFed( Statistical Analysis5 ;he Statistical Pac'age for Social Sciences 7SPSS %#($8 soft.are for Dindo.s .as employed for the stat! istical analysis( Descripti3e statistics .as applied to calculate means( Cross ;a0s .ere used for comparisons of age, educa! tion, marital status, medical co!mor0idity( BPRS scores 0et.een the t.o groups and associations .ere tested for signi! ficance using Chi!s<uare tests( ; tests .ere used to compare the scores of MMS1 and =C4D1 and Pearson correlations .ere used to e:amine associations 0et.een these 3aria0les( Differ! ences in MMS1 scores 0y education le3el and in cogniti3e function 0y years of stay in old age homes .ere determined us! ing one!.ay A-4EA and ;u'eyHs HSD post!hoc test( Mann Dhitney I test .as used to compare the =uality of 2ife 3ari! a0les 0et.een the t.o groups( A correlation .as plotted 0et.een the MMS1 scores standardised for education and the =C4D1( Statistical significance .as set at pJ$($" for all com! parisons(

%esults: A comparison of 3aria0les on the socio!demographic sheet and on the different tools of assessment .as done( ;he items on so! cio!demographic sheet that .ere compared are age, years of education, marital status, and medical co!mor0idity( Most indi! 3iduals 7nK*B8 0elonged to the #$!#+ year category( ;he a3er! age age of the indi3iduals li3ing in the community and in old age homes .as #*(B@L#(@? and #*(#$L#(@* years respecti3ely( n 0oth the groups, ma)ority 0elonged to the group of @!%% years of education( ;he age distri0ution, years of education and medical co!mor0idities across the t.o groups .ere e3enly matched( ;he comor0idities .e loo'ed into .ere the presence of some common chronic conditions li'e hypertension, dia0etes mellitus, 0ronchial asthama90ronchitis, cere0ro3ascular dis! orders and others( For analysis, .e further categoriFed it as the presence of nil, one, t.o, three or more co!mor0idities( More people in the community .ere currently married and staying .ith the partner 7nK?$8 compared to old age homes 7nK%C8( ;his differed significantly( ;he details are sho.n in ;a0le % and Figure %( 3able -: Comparison o/ Socio)demographic variables across the t$o groups Socio)demographic variables Chi s4uare p Age *(C@* $(#* 1ducation +(@%+ $(*$ Marital Status %$(#%+ $($%M Medical co!mor0idities %($@@ $(#C

5igure -: Comparison o/ Marital Status in the t$o 6roups ;he data on MMS1 and =C4D1 .as normally distri0uted( ;he paired t test .as used to compare the scores of groups on these <uestionnaires( ;here .as no significant difference in the indi3idual items as .ell as the total scores on 0oth the <uestion! naires( ;a0le * represents this comparison( ;here .as no cog! niti3e impairment recorded on MMS1 in ?+> of people in 0oth groups( Rest of them in 0oth settings .ere classified as ha3ing mild or se3ere impairment 0ased on their total score ie %C!*? and $!%# respecti3ely( ;he groups .ere e3enly matched .ith respect to cogniti3e functioning( ;his is represented in ;a0le ?( ;he scores on MMS1 3aried .ith education, higher the educa!

tion, 0etter the score( ;his is depicted in Figure *( ;he groups .ere also e3enly matched for their cogniti3e a0ilities on =! C4D1, .hich is an o0)ecti3e assessment( ;a0le + gi3es a com! parison of this( 3able 7: Comparison o/ MMSE and (8CO0E scores in the t$o 6roups 6roup Clinical 67 6- Nn K "$O t p 9ariables Nn K "$O Mean Mean L SD L SD ;otal **(#C L +(#@ *?(@+ L +(B* !$(CCC ,.:++ MMS1 A3erage =! ?(?* L $(*C ?(+$ L $(?? !%(*#+ ,.7,; C4D1 A%5 Community 6 A*5Home for the Aged 3able :: Cognitive (mpairment based on MMSE score in the t$o 6roups Cognitive 6roups (mpair) Chi ment 3otal P 667 S4uare based on MMSE -one ?+ ?+ @C Mild %$ %* ** ,.*<7 ,.+=< Se3ere @ + %$ 3otal *, *, -,, A%5 Community 6 A*5Home for the Aged 3able =: Cognitive (mpairment based on (8CO0E score in the t$o 6roups Cognitive 6roups (mpair) Chi ment 3otal P 667 S4uare based on (8CO0E -ot Signi! ?* *# "B ficant -.,:: ,.:,> Signific! %C *? +% ant 3otal *, *, -,, A%5 Community 6 A*5Home for the Aged

5igure 7: 9ariation o/ MMSE Scores $ith education across the groups n BPRS, those .ho scored P+ on indi3idual items .ere con! sidered for comparison( 4ut of the %C items of BPRS, three items differed significantly across the groups, .hen compared 0y Chi!s<uare test( Motor retardation .as the most common symptom in 0oth groups 7nK *% for A% and nK?? for A*8 and it differed significantly 7pK$($%8 fa3ouring those in the com! munity( 4ther items that .ere differing significantly .ere gran! diosity 7nK C for A% and nK* for A*8 7pK$($+@8 and emotional .ithdra.al 7nK%% for A% and nK+ for A*8 7pK$($"8, 0oth fa! 3ouring those staying in old age homes( ;he se3erity of grandi! osity .as moderate 7score +8 in all cases and it did not re<uire hospitaliFation( Depressi3e mood, somatic concern, an:iety and 0lunted affect .ere the other symptoms recorded fre<uently in 0oth the groups( Ho.e3er, none of the other %" items of BPRS re3eal any significant statistical difference across the t.o groups( ;hose .ho scored at least + on items of depression .ere further e3aluated on CD %$( ;.enty t.o percent of those in community .ere found to ha3e mild to moderate depression as compared to ?@> of old age home inmates( 4n comparison, it .as not statistically significant 7pK$($@?8( Further, *@> of elderly in community setting had psychosis as compared to *$> in old age homes, as assessed 0y the items for psychosis 7conceptual disorganiFation, grandiosity, hostility, suspicious! ness, hallucinatory 0eha3ior, unusual thought content, e:cite! ment8 on BPRS( 4n comparison, there .as no statistical signi! ficance 7pK$(*+8( ;he <uality of life .as assessed on the 3isual analogue scale GDelighted ;erri0le Scale, 0y Mann Dhitney I ;est( ;he mean ran's .ere "%(@B for A% and +B(?% for A*( 4n comparison, they .ere e3enly matched 7pK$(@#@8( ;hus on comparing the total scores on MMS1, a3erage scores on =C4D1 and mean ran's of Delighted ;erri0le Scale, there .as no significant difference( n BPRS, the three items namely emotional .ithdra.al, grandiosity and motor retardation 3aried significantly 0ut rest of items did not differ( ;hough 0oth groups re3ealed cogniti3e impairment, clinical depression and psychosis, there .as no significant difference 0et.een them( 0iscussion: ;his is a cross!sectional study, in .hich .e compared the psy! chiatric mor0idity of elderly people in t.o setups5 community and old age home( t is an esta0lished fact that among elderly, older the age, lo. education le3els and past history of psychiat! ric illness are all the predictors of cogniti3e disorders( 7%"!%C8 Further female se:, medical co!mor0idity, poor social!econom! ic status, .ido.ed state, disa0ility are some of the strong pre! dictors of geriatric depression(7C,%",%B!*%8 Ho.e3er there is no su0stantial e3idence as to staying in community .ith oneHs o.n people has a positi3e impact on oneHs psychological status than staying in old age homes( 4n the contrary, the a3aila0le scant literature fa3ours residents of old age home(7**, *?8 ;hus the study .as carried out on a hypothesis 0ased on a3aila0le literat! ure( Age is the 3ital 3aria0le in geriatric mental disorders( ;he t.o groups .ere e3enly matched .ith respect to the age( n our study, marital status differed significantly across the t.o groups( More num0er of elderly .ere currently married and staying .ith their partners in the community setting( Marital status is an important fa3oura0le factor associated .ith geriatric depression( Many studies ha3e re3ealed that depression in eld! erly is associated .ith .ido.ed state or staying alone(7%",%B8 n our study, old age home inmates 7?C>8 suffered depression more commonly than those in their o.n homes 7**>8( 4ne of the factors associated .ith this could 0e that most of them stayed alone( Medical co!mor0idities also did not differ signi! ficantly in our study( Further, our study corro0orated the earlier studies that inferred higher the education, 0etter the cogniti3e function(7#,%",%#,%B8

;o e3aluate the cogniti3e function, 0oth o0)ecti3e 7 =C4D18 and su0)ecti3e 7MMS18 assessment tools .ere used( MMS1 identified mild cogniti3e impairment in *$> of elderly li3ing in community as compared to *+> in old age home inmates( Se3ere impairment .as seen in %*> and C> respecti3ely( ;he =C4D1 determined ?@> of community d.elling elderly to ha3e significant cogniti3e impairment( t .as +@> in case of the old age home inmates( ;he cogniti3e impairment on 0oth these instruments .as not statistically significant across the groups( Recent studies suggest that o3er half of the residents of old age homes ha3e some degree of dementia(7*+,*"8 De did not determine dementia in those .ith cogniti3e decline, using diagnostic manuals( De ha3e come across many studies that ha3e used MMS1 alone for assessment of cogniti3e impair! ment(7*@!*C8 n a prospecti3e study, o3er eight years, it .as identified using MMS1 that "?> of the elderly suffered minor cogniti3e decline and %@> ma)or cogniti3e decline(7*@8 ;hough ours is a cross!sectional study, the rate of cogniti3e impairment detected is compara0le to other studies( ;.enty nine percent of the total sample had depression( ;.enty t.o percent of those in community .ere found to ha3e mild to moderate depression as compared to ?@> of old age home inmates( 4n comparison, it .as not statistically signific! ant( Many studies ha3e found depression to 0e a common psy! chiatric mor0idity in elderly(7@,C,*B!?%8 Dorld.ide, a num0er of studies ha3e estimated the pre3alence of depression in non! demented elderly to 0e +$>(7?*,??8 Some community 0ased studies ha3e re3ealed that the point pre3alence of depressi3e disorders among the geriatric population in ndia 3aries from %?> to *">(7%B,?+8 Ho.e3er cogniti3e impairment often co! e:ists .ith depression in elderly patients( ;hus due to high pre! 3alence of dementia and the difficulties in assessing mood in people .ith se3ere dementia, it is difficult to predict the e:act pre3alence of depression(7?"8 Further, *?> of the sample popu! lation .as found to ha3e psychosis( Dhen classified under groups, *@> of those in community and *$> of those in old age homes had psychosis( ;his difference across the groups .as not statistically significant( According to the e:isting liter! ature, the o3erall pre3alence of psychosis in the elderly li3ing in community is a0out ">( t ranges from %$ to @?> in nursing home populations(7?@,?#8 n our study the presence of psychos! is in community is *@> .hich is higher than that reported in other studies( Ho.e3er this is 0ased on scores on BPRS and no diagnostic manual .as used( Also for a community 0ased study, the sample siFe could ha3e 0een larger( De did not com! pare males and females for psychiatric mor0idity as our primary o0)ecti3e .as to compare the influence of t.o different settings for cogniti3e impairment and psychological .ell 0eing( Also, .e did not administer any diagnostic schedule to assess and diagnose other possi0le psychiatric disorders( Ho.e3er, for treatment purposes, a psychiatrist consultation .as suggested to the authorities of old age homes and to the family mem0ers of elderly li3ing in the community( 4urs is a cross!sectional community 0ased study .here su0! )ects .ere recruited 0y simple random techni<ue( ;he total sample siFe .as %$$, di3ided as "$ each from community and old age homes( ;he authors did not come across studies done in similar settings .ith similar methodology( Ho.e3er a rele3ant study that compared psychiatric mor0idity of elderly in old age home and those 3isiting a hospital is also a cross!sectional study .ith a sample siFe of B*( People in old age home had a significantly 0etter perception of social support and felt 0etter than those li3ing .ith their childrenHs family(7*?8 Another re! cent study underta'en to in3estigate the dependency and health status of a cohort of older people admitted to long term nursing and residential care compared the cogniti3e impairment of eld! erly in the t.o settings( t is a retrospecti3e cohort study .ith a sample siFe of *$"( n this study, again people in residential homes, despite ha3ing more disa0ility .ere found to ha3e less! er cogniti3e impairment(7**8 ;hough the longitudinal studies

are ideal for assessing the cogniti3e impairment in elderly, attri! tion is high due to 3arious reasons including death( All in all, our results are compara0le to these studies to the e:tent that staying in old age homes is at least as good as staying in their o.n homes( Conclusion: ;he psychiatric mor0idity is high in elderly irrespecti3e of the setting in .hich they li3e( 1ducation and li3ing .ith spouse are the factors associated .ith 0etter psychological health( t could not 0e esta0lished from our study that li3ing in old age home is associated .ith significantly 0etter psychological .ell 0eing and cogniti3e a0ilities than li3ing in community .ith oneHs o.n family mem0ers( Ac'no$ledgements: ;he authors sincerely and graciously e:press their gratitude to ndian Council of Medical Research, -e. Delhi, ndia, for funding this pro)ect under short term studentship Reg -o *$%$! $%*?+( %e/erences: %( ngle A&, -ath A( Aeriatric Health in ndia5 Concerns and Solutions( Indian Journal of Community Medicine. *$$C6??7+85*%+!*%C( *( Dening ;, Bains /( Mental health ser3ices for residents of care homes( Age and Ageing. *$$+6??5%G*( ?( Dorld Health 4rganiFation( Burden of mental and 0eha3i! oural disorders( ;he Dorld Health Report *$$%6 Mental Health5 ne. understanding, ne. hope( Aene3a, S.itFer! land, *$$%( pp ?!+, %BG+", Bo: ?(#( +( Du0e &C( A Study of pre3alence and 0iosocial 3ariation in mental illness in a rural and ur0an community in Ittar Pradesh, ndia( Acta Psychiatr Scand. %B#$6+C5%C( "( -andi D-, A)mani S, Aanguli A, Baner)ee A, Boral AC, Ahosh A, San'ar S( Psychiatric disorders in a 3illage community in Dest Bengal( Indian J Psychiatry( %B#"6%#5C#( @( Ramchandran, Menon SM, Ramamurthy B( Psychiatric disorders in su0)ects o3er fifty( Indian J Psychiatry. %B#B6**5%B?!%BC( #( ;i.ari SC( Aeriatric psychiatric mor0idity in rural north! ern ndia5 mplications for the future( Int Psychogeriatr. *$$$6%*5 ?"!+C( C( Sood A, Singh P, Aargi PD( Psychiatric mor0idity in non! psychiatric geriatric inpatients( Indian J Psychiatry. *$$@6+C5"@!@%( B( rudaya Ra)an S( Population Ageing and Health in ndia( Centre for 1n<uiry into Health and Allied ;hemes 7C1! HA;8, *$$@, Sur3ey -o( *C$+ & *C$"( PP %!**( %$( CMR( Mental Health and Ageing( ICMR Bulletin. %BB%6*%5+B!"+( %%( Folstein MF, Folstein S1, McHugh PR( Mini!Mental State5 A practical method for grading the state of patients for the clinician( J Psychiatric Res. %B#"6%*5%CB!%BC( %*( /orm AF( ;he nformant =uestionnaire on Cogniti3e De! cline in the 1lderly 7 =C4D185 A re3ie.( International Psychogeriatrics. *$$+6%@7?85%!%B( %?( 43erall /1, Aorham DR( Brief Psychiatric Rating Scale( Psychol Rep. %B@*6%$5#BB!C%*( %+( Heinrichs DD, Hanlon ;1, Carpenter D; /r( =uality of 2ife Scale5 an nstrument for rating the SchiFophrenia De! ficit Syndrome( Schi ophrenia Bull. %BC+6%$7?85??C!?BC( %"( -andi PS, Baner)ee A, Mu'her)ee SP, et al( A study of psychiatric mor0idity of elderly population of a rural community in Dest Bengal( Indian J Psychiatry. %BB#6?B5%**!%*B( %@( Buntin:, &ester A, Bergers /, &nottnerus /A( s Depres! sion in 1lderly People follo.ed 0y DementiaQ A Retro! specti3e Cohort Study 0ased in Aeneral Practice( Age and Ageing, %BB@6*"5*?%!*??(

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