Let's Talk About Sex...in Nursing Homes.

Sexuality is an exciting topic at any age. Thanks in no small part to the daily dose of sexuality we ingest through television and media, the drugs constantly offering to help us have better sex, and the societal mentality that defines people according to who they have sex with, we think about sex a lot. One place, however, you might not spend a great deal of time thinking about sex in is a nursing home. Times they are a-changing.

Seniors today are far more active than they have ever been before. They are living longer, fuller lives. While many of the senses may dull or fail with old age, the sense of touch remains intact. Seniors have desires and seniors are having sex.

A conversation with any worker in an assisted living community will confirm this fact if you have any doubt. When the families are through visiting, the room swaps begin. This has brought about some difficult ethical questions to answer for administrators in facilities and communities. Do they have the legal power to stop consensual sex between adults? At what point is sex no longer consensual with regards to dementia?

There are examples on both sides of the debate. On the more conservative side is an example out of Iowa where to two seniors with dementia were caught having sex on Christmas day. Administrators and nurses were fired and lambasted as public examples of negligence. Charges were filed by the family against the facility for failing to prevent the rape of one resident by another. Eventually, both of the residents in question passed away as did the lawsuit. The administrators never worked in senior care again; the scarlet letter of a new era. In the Bronx, there is a nursing home with an entirely different take on the issue which is making headlines. At this home, the administrator brags that his staff "actively encourages and supports sex and intimacy among its residents. Our position is very strongly that consenting adults who have capacity, this is a civil right of theirs. They do not give up a civil right simply because they are in need of nursing care in a facility. And that our obligation as a nursing facility is to encourage their civil rights, as we would do with respect to voting."

No matter where you fall on this issue, the reality is that seniors are having sex more than probably ever before. With the rapidly increasing numbers of this demographic and the rise of seniors who are struggling with dementia, this is a conversation that needs to be had.

Low Testosterone Shown To Increase Risk For Parkinson's

In a recent study, a drop in the testosterone levels of male mice caused them to manifest symptoms that appear to be very similar to those found in Parkinson's Disease. Male testosterone levels typically peak in the mid-30's and then decline around 1% each year thereafter. The decline can be made more sudden by other factors such as stress or other life events. Low testosterone has also been linked to an increased risk for Alzheimer's. Given that men are already known to be 1.5 times more likely to develop Parkinson's, the link to lower testosterone levels seems to make a lot of sense.

http://www.medicaldaily.com/articles/17863/20130728/mouse-study-shows-link-between-low-testosterone.htm

Woman Marries for the Fourth Time at 80 Yrs Old

A local woman made headlines this week when she married for the fourth time at the age of 80. When a local news station interviewed her recently, they asked her a myriad of questions about life, marriage, happiness, and of course her new husband. 

 The interviewer asked her questions about what it felt like to be marrying again at 80, and then... about her new husband's occupation. "He's a funeral director," she answered.

"Interesting," the newsman thought.

He then asked her if she wouldn't mind telling him a little about her first three husbands and what they did for a living. She paused for a few moments, needing time to reflect on all those years. After a short time, a smile came to her face and she answered proudly, explaining that she had first married a banker when she was in her 20's, then a circus ringmaster when in her 40's, and a preacher when in her 60's, and now - in her 80's - a funeral director.

The interviewer looked at her, quite astonished, and asked why she had married four men with such diverse careers.

She smiled and explained,

"I married one for the money, two for the show, three to get ready, and four to go."

 

- Thanks to HISC franchise owner Karin Lindblom for sending this to me.

Want to Improve Your Memory? Eating smart really can help you keep your brain sharp.

Antioxidants! Omega-3s! Anti-inflammatory diets! Can something you eat really help you remember — again — where you put your cellphone or reading glasses? If you add blueberries to your morning oatmeal or sip a glass of red wine at dinner, will your brain cells stay healthier longer?


http://www.aarp.org/health/brain-health/info-06-2013/worried-about-your-memory.html?intcmp=HPBB1J

The Difficult Choice of Caring At Home

Yesterday, NPR ran a segment entitled “The True Cost of At-Home Caregiving.” The article brilliantly paints a portrait of what our clients and their families face each and every day. For many years, the accepted norm with regards to aging was that seniors would move in with their families when they were unable to live by themselves without assistance. Then the culture shifted. Parents began to place their children into daycare facilities and mother’s day out programs so that they could free themselves to pursue the all-important American dream. In return, when those parents aged, it became customary for their children to place them into nursing homes and facilities. As my father is fond of saying, “We placed our kids in institutions as soon as they were old enough so that we could be free to live our lives. Why are we surprised that, now that we are older and need assistance, they aren’t hesitating to return the favor?” However, the pendulum has swung back the other way. More and more families are making the difficult decision to move an aging parent into their homes and provide care themselves. This is due in no small part to the tremendous rise in the cost of caring for a senior in a facility. At first glance, a multi-generational living arrangement would seem to be a cost saver but, as any family caregiver will freely tell you, the cost is not always easy to see.
One of the things we recognize at Home Instead Senior Care, is the importance of the family caregiver. Many agencies address the needs of the client but largely ignore the person who many times needs our help the most, the family caregiver. It is one of my favorite questions to ask during an initial meeting. “How are you?” It is amazing to witness the reactions people have when they haven’t been asked that question in so long that they no longer know how to answer. Most of the time the family caregiver will deflect the question and continue to speak about the condition of their loved one. I ask again. “How are you?”
Caring for your loved one at home is a beautiful gift. It is also an extremely difficult task particularly where Alzheimer’s Disease or other dementias are present. Home Instead Senior Care can help. We work to give the respite care that families need on a short-term or recurring basis. We want daughters to be free to be daughters again.

Carnivore with a Side of Vegan

As a professing Texan (as if there was any other kind), I soundly reject all aspects of the plant based approach to survival. In my mind, heaven looks like an amazing cookout. Jesus, Moses, Noah, Paul, John and I are all sitting on a deck somewhere in Texas in mid-April. Perfectly marbled, 2 inch thick rib-eye steaks are sizzling their way to a glorious medium-rare and some of Texas' finest craft beer waits to be poured while we talk theology and Aggie football. Paradise.

Yet the growing number of studies being publishing which detail the tremendous health risk of an animal based protein diet have certainly gotten my attention. I read them all online with a skeptic's eye and then quickly delete my browsing history lest someone should suspect me of considering them as a viable alternative to carnivorism.

Recently, I found myself watching an excerpt from a speech given by Neal Barnard MD. In this excerpt, Dr.Barnard speaks of the huge health risk that a diet high in saturated fat poses. He goes as far as to state that minimizing the levels of saturated and trans fat intake substantially lowers the risk for Alzheimer's Disease and Mild Cognitive Impairment. While I do not personally subscribe to some of the more extreme steps that he and many of his colleagues recommend for reasons previously stated, I do believe that our country consumes far too much meat and far too few vegetables. Watch the video below but tell no one you saw it here.

Bundle Up Folks!

Two weeks ago, I spent the entire Sunday in shorts and a t-shirt playing basketball with my oldest three sons. This past Sunday, the clothing ensemble looked more appropriate to a typical January day but the weather was still remarkably warm coming on the heels of a snowy Friday morning which caused the cancellation and delay of  hundreds of schools and businesses across the Triangle. This morning's forecast warns of an extreme cold front moving through our area during the next few days. Tonight's temperatures are expected to dip into the low twenties and tomorrow night will reach into the teens. Daytime temps will offer very little respite from the cold. High temperatures are expected to be in the low 40's with wind chills that should keep most of us inside for the next 7-10 days. Brrrrr!

In light of the approaching winter weather, allow me to ask a question. What are you doing to make sure that the senior in your life survives? Pardon the Draconian language but extreme bouts of cold weather are potentially lethal for seniors.

Part of the normal aging process is a natural thinning of the skin. Gone are the days of being regarded as 'thick-skinned.' This change makes it more difficult for a senior to regulate the temperature of their own body. By itself, thin skin isn't particularly dangerous and is easy problem for which to compensate. The complications arise when you factor in some of the other changes and realities of the normal aging process. A senior nervous system doesn't process information as quickly as it did during younger years. As a result, a senior likely will not realize he is cold until the early effects of hypothermia have already set in. Furthermore, one of the early signs of hypothermia is muscle stiffness particularly in the neck, arms and legs. Have you ever met a senior who complains of being a little stiff? Ironically, the chronic aches and pains that most seniors have grown accustomed to ignoring are the very ones that should alert them of danger within their own bodies.

For a moment, we should consider the possibility that the seniors in our lives might also be taking prescription medications. Seniors account for 25% of all prescription medications taken in this country so it seems only reasonable that we consider this as a possibility. Many of the medications that seniors take can further inhibit the body's natural alarm systems placing seniors at an even greater risk.

Here are a few things you can do if you are a senior to protect yourself:

• If you live alone, arrange for a daily check-in call with a friend, neighbor, relative, etc.
• Wear warm clothing. Instead of tight clothing, wear several loose, warm layers. Wear a hat and scarf to avoid significant heat loss through your head and neck. Stay dry. Moisture from perspiration, rain, or melting snow can seriously reduce or destroy the insulating value of clothing because water conducts body heat over 25 times faster than air.
• Use extra blankets because hypothermia can develop during sleep.
• Eat nutritious foods and exercise moderately; proper diet and physical conditioning help protect you against abnormal heat and cold.
• Get proper rest; fatigue makes you more vulnerable to subnormal heat and cold.
• Drink adequate amounts of liquids, such as water. Limit your alcohol intake because alcohol speeds up body heat loss.

Check out this article from the SC Office on Aging about warning signs and dangers of hypothermia in senior citizens.  http://aging.sc.gov/seniors/HealthAndSafety/Pages/ColdWeatherTips.aspx

The Fine Line Between Binging and Moderation

Researchers at Rutgers University have reported that binge drinking can decrease the development of adult brain cells by as much as 40 percent. Whew! I sure am glad that I don't have a binge drinking problem.

Not so fast. Also included in the study is information about the thin line that tends to separate drinking in moderation from what many consider to be binge drinking.

It has long been accepted as truth that a couple glasses of wine each day are a good way to promote cardiovascular and brain health. However, lead author of the study, Megan Anderson, cautions "Moderate drinking can become binge drinking without the person realizing it. In the short term, there may not be any noticeable motor skills or overall functioning problems. But in the long term, this type of behavior could have an adverse effect on learning and memory."

According to the National Institute of Alcohol Abuse and Alcoholism, men who drink 14 drinks a week and women who drink 7 are considered at-risk drinkers. While many people commonly assume that binge drinking is a strictly collegiate phenomenon, the statistics counter that assumption. According to the institute, 70 percent of binge drinking involved adults age 26 and older. "This research indicates that social or daily drinking may be more harmful to brain health than what is now believed by the general public."

Dementia Observations

I was watching on of my favorite "lazy Sunday afternoon movies' this weekend, A Few Good Men. At one point in the movie, the lawyers are discussing their case when Tom Cruise's character says: "It doesn't matter what you think. It only matters what you can prove!" Sometimes art really does imitate life. But then again, sometimes it doesn't.

There are a number of things that I have learned in my years at Home Instead Senior Care. Some lessons I have learned correlate with specific scientific studies and factoids which validate my amateur assertions. Most of the time, however, my experience has taught me things that medical science may not publish.

This is one of those times.

There is an old adage about Alzheimer's and dementia which states: "Once you've seen one case of Alzheimer's, you've seen one case of Alzheimer's." That is true. And while every person who battles with Alzheimer's has a unique story to tell, there are some fairly consistent themes. Alzheimer's is typically a steady progression. It may be a fast progression. It may be a slow progression. In every case I have seen, it is a steady progression.

Here is a theoretical (and in no way related to a real person that I spoke with recently) example.
A previously competent father falls one morning and is admitted to a hospital for observation. After being discharged, he is sent to a rehab facility where he can receive medical attention for his wounds until they are healed. Within days of admittance into the facility, he begins to show massive signs of confusion and is hardly able to carry on a conversation. The family contacts me and says- 'He won't be able to return home now that his Alzheimer's has progressed.'

This is not the Alzheimer's that I have seen. Whenever there is an immediate drop in cognitive function, there is almost always another cause. There might be a stroke or some other type of event. Most commonly, it is a result of medication changes in my experience. Senior's kidneys work less efficiently and therefore make them more susceptible to the effects of 'pharmacological tinkering.'

So if you see someone who was as 'sharp as a tack' yesterday and 'doesn't know he's in the world' today, chances are that it isn't Alzheimer's.


[Opinions expressed therein are observational in nature and do not constitute a medical diagnosis. Lair Family Ventures LLC dba Home Instead Senior Care are not liable for any damage done if reader adopts what was previously stated as an opinion as a matter of fact. But seriously people, why would you look to a blog to diagnose or treat anyone. I'm flattered. But seriously?]

The Wonderful Wizard of Hos-pice

Last week I found myself visiting with the daughter of an aging parent. After reviewing their situation, I mentioned that it might not be a bad idea to contact a hospice organization. As soon as the word "hospice" escaped my lips, I found myself face to face with a hysterical daughter who sobbed uncontrollably at the imminent passing of her father. That wasn't what I said!

At Home Instead Senior Care, we often partner with hospice organizations. Home Instead is dedicated to the mission of helping people live life on their own terms. So is hospice. Home Instead recognizes that there are certain realities that are naturally associated with the aging process that cannot be avoided. So does hospice.

Many people think about hospice as a place but in actuality it is a philosophy of care. Hospice can help patients and their families begin to deal with whatever is happening to them on their own terms and in their own time frame. If life is a journey, think of hospice as a travel agent. Hospice helps coordinate community resources and helps you to know where to go in order to get the very best of everything. While most of us try to cheat death at every turn, there has only ever been one man who has managed to defeat death. That makes the human mortality rate pretty close to 100%. If you are the child of an aging parent and are approaching the point where care is more important than cure then I would highly suggest getting in touch with a hospice organization. They are truly wonderful people and have been a tremendous comfort to to the clients we have partnered with them to serve.

It's Not A Toomah!

Don't you just hate armchair physicians? Well intentioned people who roam the streets and speak half-truths into the lives of those around them, usually without being asked, drive me crazy. I generally resent unsolicited advice of any nature but on the healthcare front I find myself especially agitated by pseudo-doctors who feel the need to diagnose and offer treatment suggestions whenever I sneeze, cough, or just feel a little off.

Seniors face a number of challenges with regards to the normal aging process. Certain things just start to wear out after about 70-80 years. When I meet with the family of a prospective client, I take care to question where each claimed illness has been diagnosed. Specifically with regards to dementia, I find that many seniors are living life under the impression that they have Alzheimer's or dementia. Out of all the illnesses that befall the elderly, none is more terrifying than this one. A disease which causes you to lose your memories and any sense of who you are is not a diagnosis that should be lightly made. Yet we see countless examples of this at Home Instead Senior Care. We see huge numbers of seniors who live in fear of Alzheimer's disease because they momentarily forgot where they put their house keys and some well intentioned person mentioned dementia as a reason.

If you happen to be one of those people who feels the constant urge to offer possible explanations to anyone who is suffering from anything at any given time, please pull Alzheimer's and dementia out of your little black bag of non-authorized diagnosis doom. While I appreciate your desire to help it is only fair to point out that you lack the medical training with which to squeeze a pimple and therefore have no business diagnosing a disease that has befuddled the brightest minds in the medical community for over a century. It's not a toomah!

Gimme the Candy!

To say that there are an abundance of children in my neighborhood would be an understatement. Our house sits on the corner of two cul-de-sacs which, in total, represent 32 children. Halloween is kind of a big deal. Nevertheless, I am guilty of two Halloween sins. First, I turn my lights off before the candy is really gone. Once the stash of candy has run down to the dregs, I flip the light off and retreat to my lazy boy (aptly named) where I work to avoid the stomach ache which will undoubtedly follow the consumption of that many Sour Patch Kids. Second, I lie to my children. My oldest son has a peanut allergy and we therefore must screen all of our children's loot to ensure that there are no peanut candies hiding in the mix. Over the years, my wife and I have taken increasing liberties with the screening process. My kids are now convinced that there are many candies that could potentially spell disaster for people with a peanut allergy. Such as: Gummy Savers, the aforementioned Sour Patch Kids, Smarties, Rolo's, Swedish Fish, Airheads, Nerds, Sweet Tarts, Now-n-Laters,  and anything with dark chocolate in it. These are a few of my favorite things. Following the onslaught of our neighbor's goodwill, the kids all come back home and dump their goodies onto the living room floor where I scour the contents of their respective pumpkins, removing all "risky" items. Safety is important on Halloween.

I thought this blog was about seniors?

Relax, I'll get there.
One of the parts of the natural aging process is the reduction in the body's ability to taste things. This is due to a number of factors such as a reduction of saliva production as well as a reduction in the actual number of taste buds. Frequently, you will see older people dumping unholy amounts of salt, pepper, vinegar, Tabasco, etc. onto everything they eat. They don't decide to begin bathing their food in hot sauce because they have suddenly gone cajun at the ripe old age of 65. They do this because it is the only way they can taste the foods. The reduction of a senior's ability to taste their food has a couple effects which merit words of caution. First, it is no fun for older adults to eat so they don't. The only thing worse than eating by yourself is eating a meal you physically can't enjoy by yourself. Proper nutrition is important at every stage of life but probably most of all for seniors, some of whom are managing chronic conditions. These conditions can be greatly exacerbated by poor nutrition. At Home Instead Senior Care, our caregivers pay special attention to the nutritional needs of seniors and work to make meals more enjoyable. They do this not only through companionship but also by working to make mealtime more of an event. Eating out of microwaveable cardboard container stinks even with good conversation. Setting a nice table goes a long way toward making meals more palatable even if it is only for the eyes.

Ok. But how does this have anything to do with Halloween and your crimes against children?

Hold on to your hats because I'm about to bring it all home.
Riddle: If you are unable to taste anything except for things that are exceptionally salty or sweet and suddenly find yourself with an abundance of Halloween candy, what will you probably eat?
Answer: All of the leftover Halloween candy.
The days following Halloween are great times to visit the senior in your life and check in on the nutrition front. Look to make sure that there isn't a ton of candy left over which could pose a significant health threat in the absence of other foods. Plan a trip to the grocery store to provide nutritious companions if not alternatives to the belly full of Snicker's Minis that will represent the first thing your senior has been able to taste in weeks.

If the senior in your life is unreceptive to this kind of assistance then I would encourage your children to be more insistent about that second or third treat in the basket. Arm them with kind words like: 'It's for your own good,' and 'Because we care.'

Have fun and be safe tonight, dear readers. Happy Halloween!

How Does Your Garden Grow?

I find some of my greatest life lessons in my garden. Last year, I built two raised bed gardens in my backyard. I had grand dreams of the food we would grow there. Initially, the garden I made was a thing of beauty. Rich black soil, the smell of fresh mulch, bees buzzing busily as they pollinated my crops. Each morning and evening I would water and preen by hand. In short order, my garden began to blossom. Then life happened. I got busy. I got too busy to continue to spend the amount of time that I had initially spent cultivating my garden. As a result, weeds and bugs began to invade. Before long, the fantastic thing I built was no longer.

So much of in-home care is a garden. Initially, we utilize a ton of resources to ensure that we are recruiting and training the very best caregivers available. The background check we run on all our applicants continues to be the most thorough available, the reference checks and drug screening we insist upon have set the standard for in-home care. But that isn't enough. We must continue to water and preen our garden lest the weeds and bugs should invade. This is the new battlefield for in-home care providers.

One of our two core values at Home Instead Senior Care in Chapel Hill is to exceed the expectations of everyone that we encounter. We call it our 4E's. Sadly, the expectations from seniors and their families are fairly low. They have become accustomed to a certain amount of tardiness, a certain amount of apathy, a certain amount of absenteeism when dealing with in-home care. Their experience with the industry has taught them what they can realistically expect. From day one, we fight against this "assumed reality" with our clients and our caregivers. From birthday and anniversary cards, to our P.E.A.Q. program, to our quality assurance visits, to our on-call policy, to our community involvement-Home Instead Senior Care is working to exceed the expectations of everyone that we encounter. As anyone who is happily married can tell you, relationships do not build themselves. Like gardens, relationships require constant effort if they are to grow.

Engaging the Lost Causes

When caring for people who are suffering from Alzheimer's and other forms of dementia, there comes a time when the person suffering loses the ability to communicate. During typical late stage Alzheimer's, a person may be bed or chair-bound, unable to speak, and in some cases completely unresponsive. Sadly, the temptation is to disengage from the person we love at this point. Why bother talking with them when they can't talk back? Why ask them questions to which they can no longer respond? While this approach is understandable to anyone who has dealt with this disease firsthand, it misses a huge opportunity to continue to connect with the people we care about.

During our Alzheimer's and Other Dementia training at Home Instead Senior Care, we deal specifically with late stage clients. We address the fact that just because the people for whom we are caring aren't able to verbally validate our attempts, we shouldn't be discouraged from continuing to interact with them. We should, however, amend the techniques we use in order to give them the maximum benefit of our involvement.

The techniques we use for late stage clients all revolve around the five senses: smell, touch, taste, sight, and hearing. These senses unlock a world of memories for the clients that we serve that we may never truly realize. For all of us, there are certain things which take us to another time and place.

-If I smell Cinnamon Butter Cake, I am transported back to my grandparent's house in Woodward, OK. I can see the large front door they had swinging open as my brother and I bound out of the car after a long drive up from Texas and into their waiting arms.
-The feel of a saxophone in my hands brings back memories of long band bus trips and cold competition mornings.
-The taste of tamales paints a portrait of Christmas in San Antonio that no artist could ever come close to rivaling.
-The sight of pictures of my kids in their toddler years brings smiles to my heart that last all day.
-If I hear the song "Two Princes" by the Spin Doctors, I find myself sitting in the back seat of Jana Davis' car on the way to school. She was a beautiful flute player in the high school band who as a senior agreed to give me a ride as a freshman so that I wouldn't have to ride the bus.

None of these journeys you can go on with me. For our dementia clients in their late stages, you can't go where they are headed either. You may never get the validation of knowing that you have given them the memory tool to take that mental trip. But we do not care for those in our lives in order to attain some personal validation, we care for them in order to provide them with the best possible quality of life. And on that mission, we never give up.

The Foul Ball

This is the story of an unbelievable experience I had while caring for one of our clients. It appears as it was published in Fifteen-501 The Magazine.

"As the owner of a senior care company, I've learned that spending as much time as possible with clients keeps me in touch with what I believe to be the heartbeat of our business. While most still live in their homes with our assistance, many clients reside in facilities. For the latter, we provide a much-needed escape from the monotony that can have a devastating effect on the morale of those who, despite their outward appearance, feel no different than they did 40 years ago.

I had the privilege of taking one such client, Mr.H, to a Durham Bulls baseball game last season. Mr.H, who lives in an assisted living facility in Chapel Hill, has moderate dementia. As with many who suffer from this condition, there are things about his life that are clear as a bell and others that elude him: He can't tell you what he did for a living for 35 years or how he came to be in Chapel Hill, but he can tell you what it was like to storm the beaches at Normandy, how cold the water was, and how he prayed that he would make it to the beach before he was shot down because he didn't want to die drowning.

He can also tell you what it was like to watch Babe Ruth take batting practice during the late 1920's, and how the effortlessly the slugger knocked 10 or 12 balls over the fence. In medical circles, they call these memories "moments of clarity." A s a student of history, I don't mind the repetition of stories, so we spent the first five or six innings of the game talking through some of these moments. He asked me several times whether I had ever caught a foul ball, and mentioned how he couldn't believe that in 83 years of attending baseball games he'd never caught one himself.

As the day wore on, the heat finally got the best of us. After the seventh inning stretch, we decided to call it quits. He asked the foul-ball question again as we were leaving, and I replied that we'd have to wait until next time around. At that exact moment, we heard the crack of the bat and both turned to look. the ball floated in the air toward us in almost slow motion, and after what seemed like an eternity, it landed-- literally--at Mr.H's feet. I bent down, picked it up, and handed it to him. He had caught his first foul ball.

The ride back was quiet to say the least. The entire experience was surreal. He spent most of the time tossing the ball between his hands, smiling, quietly uttering, "Eighty-three years. I can't believe it. Eighty-three years."

When we returned to the facility, he shook my hand, thanked me again and began to walk inside. After four or five steps, he turned around and looked down at the ball, then back at me.

"Maybe you can come sometime and we can have a catch," he said. "Sure," I replied. "It would be my pleasure."

I know Mr.H might not remember that I was the one who took him to the game that day. I know he might not be able to recall what teams were playing. I do know, however, that he'll remember the day that he caught a foul ball. I know that as cloudy as his mind might be, that moment has joined the pantheon of Babe Ruth and Normandy, and I was there to see it. I got to see an 83-year-old become just another boy at the ballpark. I watched a man come alive, if only for a moment.

9/11

We remember all of those who lost their lives on this day 11 years ago.