Rush Manual 6. Managing Health and Understanding Behavi...

Rush Manual 6. Managing Health and Understanding Behaviors

UNDERSTANDING BEHAVIOR AS A FORM OF COMMUNICATION

With any person the way we act and behave is really a form of
communication. It tells those around us what we are thinking
and what we are feeling. Along with what people say, their
behavior and actions are an important indicator of their
thoughts and moods.

People with Alzheimer's disease begin to have more trouble
expressing themselves verbally. They are not always able to tell
us what they are feeling and thinking. For this reason, the
behaviors they exhibit really become an important way for them
to communicate with those around them. Looking closely at
their behaviors becomes our chance to better understand what
the person might be feeling.

This might take a change in attitude on the part of the caregiver.
Years ago it was thought that the behaviors exhibited by the
person with Alzheimer's disease were an unfortunate and
inevitable part of the disease process. It was thought that the
best course of action was to try and stop the behavior without
really looking at what might be causing the person to act in such
a way.

We now undestand that to best meet the needs of the person
with Alzheimer's disease it is more important to look at all
behaviors, both positive and negative, and ask what might the
person be feeling to respond in such a way. If the behavior they
are exhibiting seems positive we want to encourage that to
continue. If the behavior they are exhibiting is negative and
unpleasant for the person we want to learn why that might be
happening and think of ways to reduce it from happening again.

When looking at the behaviors that someone is exhibiting a
person takes on the role of an investigator. One must ask such
questions as what might the person be feeling and why would
they be feeling that way? Are there any factors that might be
influencing the person? Some of these factors include emotional
and physical well-being, environmental factors, and the
approaches of others.

___
Behaviors are a a form of
communication. They tell
the caregiver what the
person with Alzheimer's
might be thinking and
feeling.
___


Emotional Well-Being

Our emotional well-being greatly influences how we act. When
we are feeling down, overwhelmed or scared we will show it
through our behavior. People with Alzheimer's disease often feel
this way. Their self-esteem is often lowered because of the confu-
sion and uncertainty they are experiencing. They can also
become stressed easily if there is a change in routine. If more
people are over to visit or if they are going out to a new location
they can become more agitated or anxious. At times they might
become scared or frightened.


Physical Well-being

Another factor that can influence how we act is our physical
well-being. People with Alzheimer's disease are not always able
to tell others when they are feeling uncomfortable or in pain. As
family members we have to be very observant for any of the
following physical problems:
* negative reaction to medication
* pain
* impaired sleep
* infections
* dehydration and malnutrition
* constipation
* poor vision and hearing


Environmental Factors

Sometimes the environment can be confusing or overwhelming
for anyone. This can especially be true for a person who is
confused. Finding their way from one room to the other can be
stressful and difficult. This is true even in a home where they
have lived many years. Noise around them might be more then
they can tolerate, such as TV, radio, and other's talking or laugh-
ing. You might need to look around your home and see if there is
anything that could be adding to the stress of the person.


Approaches from Others

The final area of stress that can influence the person's behavior
is the approach of others around them. If unrealistic expectations
or demands are placed on the person it will probably add to their
levels of anxiety. At times it can be difficult to remember that
the person might not be able to do all the tasks that they had
done before. It is not always easy to accept the fluctuation with
this disease, where one day their abilities can greatly differ from
another day. As caregivers we must keep in mind that this
disease can make even simple activities difficult for the person to
perform.

Also, sometimes a person's verbal response can add to the anxi-
ety of the person with Alzheimer's disease. People with dementia
are not always able to understand words said to them but they
are very good at picking up on the mood of the person. If their
caregiver shows that they are angry, frustrated or annoyed the
person with AD often becomes aware of this. The most success-
ful caregivers find ways to keep these emotions from the person.
This is not always easy since these are often common emotions
for a caregiver. It takes practice to see what response is the most
helpful for the person with AD. As caregivers we can not be too
hard on ourselves when we make mistakes.

By looking at what might be causing a person to be acting in
such a way we will be able to have a better understanding of
what the person with AD might be feeling. When we have a
better understanding of what they might be feeling we get better
at meeting their needs. For any caregiver the goal is to help the
person with Alzheimer's disease to feel safe and comfortable.



COMMON MEDICATIONS

During the course of Alzheimer's disease, the person with demen-
tia may need medication for two possible reasons: to treat
problems that occur as the disease progresses or to treat other
medical conditions not related to dementia. Remember that
medication is anything taken by mouth, inhaled, put on the
skin, or taken rectally, which is prescribed by a health care
professional or bought over the counter. Vitamins, alcohol or
dietary supplements should be considered medications.


Medication Administration

To ensure that medication works effectively, ask your health care
professional about the purpose of the medicine, the possible side
effects and how long it takes for the medication to begin work-
ing. Be aware that all medications can cause side effects;
therefore, report any new symptoms that occur when the person
with dementia takes a new medicine. Be sure to report the names
of the medications that the person is taking, including all over-
the-counter medicines. If the person with dementia is unable to
take pills, many medications come in another form, such as
capsule or liquid. Some pills can be crushed and sprinkled on
food such as applesauce or yogurt. However, others should not be
crushed since their protective coatings allow the drug to be
absorbed in the intestine rather than the stomach. Do not stop
medications on your own and do not give any medicine
prescribed for you to someone else.

People in the early stage of dementia can often participate
in the administration of their own medication with the aid of
reminders such as daily phone calls or pill boxes. However, as
confusion and forgetfulness increase, you will need to assume
more responsibility for supervising medication administration.
Administering medication is easier if you give simple
instructions. Store all medications in a safe place using a locked
container if necessary. Pill containers with compartments for
days of the week can be purchased at most pharmacies. The pill
box can help you remember when to give a medication.


Treating behavior changes with medications

___
Avoid scenes or
arguments when you
give medications. If medi-
cation is refused, don't
argue but rather try again
in a short time -- the
person may forget they
refused it before.

Try not to skip doses of
medicine and do not give
double doses of medicine
to try to catch up.
___


As the disease progresses, the person with dementia may develop
agitation, restlessness and sleeplessness. Before treating these
behaviors with medication, try to determine if the behaviors are
triggered by underlying factors such as a need to go to the toilet,
pain, alcohol use, medication, caffeine (found in cola, coffee, tea
and chocolate) or cigarettes. Some behaviors may be due to
physical discomfort, an upsetting environment or changes in the
usual routine. It is usually better to try managing behaviors first
without medications and if unsuccessful, a trial of medication
should then be considered.

The person with dementia may experience anxiety, restless-
ness and depression. The following section describes some of the
classes of medications that may be prescribed. The general
purposes, types, and possible side effects are noted. Be sure to
report any changes you notice in the person with dementia if any
of the drugs are prescribed. Do not assume that the side effects
listed are normal or inevitable. It often takes several weeks for
the medication to produce the desired effect. To evaluate how
the medicine is working, communicate often with your health
care provider.

___
It is usually better to try
managing problem behav-
iors first without drugs and
if various techniques are
not successful, a trial of
medication should then
be considered.
___


- Anti-Anxiety/benzodiazepines

Purposes: This class of drugs is mainly used to alleviate anxiety,
restless and mild agitation. These drugs can also be used at night
as sleep aids when anxiety is at the root of the sleep disorder.

Types: The most commonly used anti-anxiety agents are: Ativan
(lorazepam), Xanax (alprazolam) and Valium (diazepam).

Possible side effects: Drowsiness, dizziness, unsteadiness, and
lethargy. These drugs can increase confusion, and the risk for
falls. These medications can cause a paradoxical reaction, that is,
instead of producing a calming effect, the person may become
more agitated. This is a rare reaction, although it is necessary to
be aware of this possibility.

- Anti-Psychotics

Purposes: Anti-Psychotics may be effective in reducing
paranoia, hallucinations, delusions, agitation, and aggressive
behavior.

Types: Atypical anti-psychotics include Risperdal (risperidone),
Zyprexa (olanzapine), Seroquel (quetiapine), Geodon (ziprasi-
done) and Abilify (aripiprazole). Older anti-psychotics such as
Haldol are used less frequently because of their side-effects and
should only be used with extreme caution and close monitoring.

Possible side effects: The side effects of anti-pyschotics include
drowsiness, dry mouth, dizziness, constipation, increased confu-
sion, muscle stiffness, and a shuffling gait.

- Antidepressants

Purposes: Symptoms of depression are quite common and may
respond to treatment at any stage of dementia.

Types: There are several types of drugs used in the treatment of
depression. One class of anti-depressant frequently prescribed for
persons with dementia are known as SSRIs (serotonin reuptake
inhibitors). These include: Prozac (fluoxetine), Zoloft
(sertraline), Paxil (paroxetine), and Lexapro (escitalopram).
Most antidepressants usually require up to four weeks before any
positive effects can be detected.

Possible side effects: Common side effects of SSRIs include
nausea, diarrhea, abdominal cramps, anorexia, tremor, insomnia
and dry mouth.

- Hypnotics

Purposes: Insomnia or sleep disturbances can occur in dementia.
Many people with dementia experience insomnia at some point
in their illness. Some can have a problem falling asleep but then
will be able to have several hours of sustained sleep. Others will
fall asleep but awaken after a few hours and be unable to fall
asleep again. Still others will fall asleep and wake up several
times throughout the night. Depending upon the kind of insom-
nia, different medications can be used. Good sleep habits should
also be maintained and excessive napping during the day should
be discouraged. Keeping an active routine is the most important
way to prevent sleep disorders. Traditional sleeping medications
are intended for short term use and should not be used for ongo-
ing management of a sleep disturbance.

Types: Some of the drugs available for sleep disorders are
Ambien (zolpidem tartrate), Noctec (chloral hydrate) and
Restoril (temazepam). Since sleeping pills may adversely affect
cognition, it may be preferable to use an anti-psychotic medica-
tion such as Seroquel or an anti-anxiety drug such as Ativan for
sleep disorders.

Possible side effects: Common side-effects include lightheaded-
ness, dizziness, poor balance, and increased confusion.


- Anticonvulsants

Purposes: Persons with severe aggressive behaviors that do not
respond to anti-psychotics may benefit from drugs which are
normally used to control seizures.

Types: The most commonly used anticonvulsants for this purp-
pose are Depakote (valproic acid) and Trileptal (Oxcarbazepine).

Possible side effects: Side effects include skin rash, tremor,
involuntary movements, muscle stiffness, gait problems,
dizziness, drowsiness, double vision, and slurred speech. In addi-
tion, Depakote may cause bone marrow depression and blood
levels must be monitored.

Of note, it is often challenging to find the right drug and
dose that will be effective in treating behavior changes.
Medications prescribed for behavior changes should be re-evalu-
ated periodically since they may not be needed through all stages
of the illness.


FACTS ABOUT BASIC MEDICAL PROBLEMS

Caring for the person with Alzheimer's at home requires basic
medical knowledge and good common sense. As the disease
progresses, some other medical problems might arise. These
complications may lead to behavioral problems, which can be
alleviated if the underlying problem is addressed first.

___
As Alzheimer's disease
progresses, the person
may have difficulty with
walking and other motor
abilities.
___


Flu and pneumonia

Adults need to be immunized and protected from serious diseases
such as influenza, pneumonia, diphtheria and tetanus. Influenza,
or flu, is a highly contagious disease, and complications of the flu
such as pneumonia, weight loss, and dehydration are more likely
to occur among older persons with dementia. The flu vaccine is
advised for all adults aged 65 years and older. A yearly shot is
advised every fall since different strains of the flu virus are active
each season. Side effects of flu shots are mild for most people, but
the benefits far exceed the risks since the flu can magnify symp-
toms of dementia for weeks. Equally important is a pneumonia
vaccine to protect against the bacteria that causes diseases such
as meningitis, bacteremia, and bacterial pneumonia. Everyone 50
years of age and older should get a pneumonia shot. Again, side
effects of the shot are minimal and pale in comparison to the
risks of getting pneumonia. This vaccine is considered effective
for about five years. The flu and pneumonia shots can be given
at the same time without increasing side effects. Medicare pays
for the cost of both shots.


Fever

Afever may indicate an infectious disease, dehydration, heat
exhaustion or constipation. The person may not be able to
inform you that she is not feeling well or has a fever. If you
suspect a fever, it is best to use an oral, battery-operated
thermometer. A mercury-filled, glass thermometer can easily
break in the person's mouth and cause injury. Report any fever of
more than 100 degrees to your health care provider immediately.


Falls

As Alzheimer's disease progresses, the person may have difficulty
with walking and other motor abilities. Perception, balance and
coordination may be affected. The person in the late stage of the
disease may begin to walk slower, shuffle, lean to one side or
become hesitant in climbing stairs. Arm and leg rigidity may
develop along with tremors. The person may become unsteady
on their feet and be at risk for falls. Some people become appre-
hensive if the floor surface they are walking on changes from tile
to carpeting. They may "freeze" in place and have difficulty
moving again. They may also have trouble changing positions
from standing to sitting or vice versa. Some people have trouble
getting into cars or crossing a threshold from one room to
another. They may not be able to make judgments about the
space or objects around them and may bump into furniture or
people in their path. Others may seem oblivious to clear dangers
in their way. For example, they might walk into the street with-
out noticing passing traffic.

It is important not to restrain the person because you fear
they may fall. Staying mobile is important for exercise. But you
will want to keep your home free of obstacles. For example,
throw rugs should be eliminated or tacked down.

Consider installing railings in a long hall, which may aid in
walking. Grab bars placed at strategic spots in the bathroom near
the toilet will help with balance. Chairs with arms help in sitting
down and getting up again. Make sure the person wears sturdy
walking shoes, preferably without shoelaces.


Choking

People with late-stage dementia are prone to choking and swal-
lowing problems. This results from a complex set of problems
involving the gag reflex and swallowing. Some people have diffi-
culty eating certain kinds of food, such as lettuce, meat and fish.
If this is the case, solid foods should be softened or pureed into a
consistency that is easily consumed.

The person with dementia may resort to "pouching," in
which food is partially chewed and tucked in the cheeks. They
may forget they are eating and may choke on the food in their
mouth. Make sure to closely monitor the person's eating. You
may need to remind them to swallow and chew. You may even
need to remove the food from their mouth so they won't choke.
Don't interfere with a person who is choking unless they can no
longer talk, cough or breathe; then you must offer help immedi-
ately.

The Heimlich maneuver forces out the food caught in the
throat. Whether the person is seated or standing, stand behind
them and overlap your two hands in the middle of their belly
right below the ribs. Pull hard and quickly up toward you. If the
person is lying down, turn them face up, put your hands in the
middle of the belly, and push down and toward their head. This
should cause the lodged piece of food to fly out of the mouth.
Ask a nurse or other health care professional to demonstrate the
Heimlich maneuver.


Constipation

The person with dementia may become constipated due to
changes in eating patterns, medications, decreased activity, and
decreased fluid intake. Although it is normal not to have daily
bowel movements, any significant change in the usual bowel
pattern may mean the person is constipated. Untreated constipa-
tion can result in hard feces impacted in the bowels. Removal of
this blockage may require medical attention. Encourage the
person to drink at least six glasses of fluid a day. This can include
water, decaffeinated coffee, tea, soup, Jello, ice cream or hot
cereals. Also, encourage walking and stand-up/sit-down
exercises. Such activities help stimulate the bowels to move on a
regular basis. Provide foods that include roughage, such as
whole-grain breads and cereals, raw fruits and vegetables, stewed
prunes, fruit juices and bran. If necessary, give Metamucil or
some other fiber supplement. If the problem persists, consult
your health care provider.


Diarrhea

Diarrhea can have many causes, including an infection,
impaction in the bowels, overeating, eating the wrong foods or
side effects of medications. To manage the diarrhea, make sure
the person drinks at least eight glasses of clear fluids a day, such
as broth, ginger ale, or tea. A bowl of Jello may also count as a
glass of fluid. Solid foods should be avoided. When the diarrhea
begins to subside, the person may try a diet of dry toast, bananas
and rice. Remember to not scold the person if they have an acci-
dent. A sign that reads "TOILET" or a picture of a toilet on the
bathroom door will help the person find the bathroom and
perhaps prevent accidents from happening. Over-the-counter
medications such as Imodium or Kaopectate may help relieve the
diarrhea, but if it continues for more than 48 hours, notify your
health care provider.


Dental problems
___
Careful attention to dental
hygiene needs to be an
integral part of daily care.
___

The person with dementia cannot always tell you if they are feel-
ing dental pain. For example, with a toothache, they may
respond to the pain by becoming either agitated or subdued. An
annual exam by the dentist is important to detect any problems
such as tooth decay, infection, or ill-fitting dentures. Careful
attention to dental hygiene needs to be an integral part of daily
care. Dental hygiene should include a thorough brushing of
teeth. In the early stage of Alzheimer's, this may be part of one's
daily routine. However, as the disease progresses, the person may
need reminders and assistance.


Myoclonus

Myoclonus is a brief spasm or muscular contraction in the arms,
legs or the entire body. These movements appear similar to
seizures but are relatively mild in nature. Consciousness is not
lost, but the person must be watched to prevent them from strik-
ing a limb or their head on an object. Medications that are used
to treat seizures often are not useful for myoclonus. Notify your
physician about this problem.


Skin problems

The skin is the body's first line of defense against disease. If the
skin becomes broken due to cuts, abrasions or pressure sores,
infection can result. The person with dementia cannot always
communicate effectively about a skin problem. Therefore, you
should give particular attention to skin care.

Bedridden people in particular are at risk for breakdown of
the skin or pressure sores. To avoid these skin problems, pay
special attention to the bony areas of the body such as the heels,
hips, shoulders, spine, elbows, knees and ankles. Wash the skin
with mild soap and water and apply moisturizing creams every
day, gently massaging the cream into the skin. The person who is
bed-bound should be turned at least every two hours during the
day and bony areas of the body should be massaged during each
turn. Use an alternating pressure mattress, egg crate mattress or
wheelchair pad for additional precaution against pressure sores.
These items are available through a medical supply store.


Foot care
___
Another important consid-
eration is foot care. The
person's feet need to be
examined for open cuts,
pressure sores, corns
and callouses.
___

Another important consideration is foot care. Feet need to be
examined for open cuts, pressure sores, corns and calluses.
Toenails should be cut on a regular basis. Daily foot care, which
consists of soaking feet in warm water and washing with mild
soap, may help prevent foot problems. Application of skin cream
may also be useful. A podiatrist should be consulted about persis-
tent foot problems.


Dehydration

Dehydration refers to excessive loss of water from the body. It
can be due to vomiting, diarrhea, diabetes, certain medications
or decreased fluid intake. Symptoms of dehydration include a
rapid pulse rate, dry mouth, dizziness or hallucinations. To
prevent dehydration, remind the person to drink at least six
glasses of liquid daily. This amount should be increased during
hot weather, especially if the person is outside for any prolonged
period of time or if the home lacks air conditioning. Be sure to
report instances of vomiting and diarrhea since dehydration can
easily result from these problems.


Other problems

Of course, people with Alzheimer's disease are not immune to
other chronic medical problems such as hypertension, arthritis,
diabetes, glaucoma or cancer. Common acute problems such as
urinary tract infections and pneumonia are often accompanied
by increased confusion and/or behavior changes. Any sudden
change in a person's congitive or functional abilities warrants an
evaluation to rule out a medical problem. Make sure the person
gets an examination by a health care provider at least annually,
or anytime there is a sudden change.


EASING A TRIP TO THE EMERGENCY ROOM

Atrip to the emergency room is stressful for most people, but for
the person with dementia it can be especially challenging.
People with dementia do best in an environment that is calm
and predictable, and an emergency room is anything but that.
The loud noises, strangers and frenetic activity typical of most
emergency rooms can all increase anxiety in the person with
dementia.

What can a caregiver do to make the experience less threat-
ening while meeting urgent medical needs? Here are six
suggestions to help maintain control and ease stress in an emer-
gency situation:

1. Prepare a list of all the information you will need in advance
and keep it handy. Include the person's name, nickname,
address, insurance information (including policy numbers
and pre-authorization phone numbers) and physicians' names
and phone numbers. Also bring copies of advance directives,
such as durable powers of attorney, to ease decision-making.
A current list of medications and dosages is also helpful.

2. Call a friend or family member to meet you in the emergency
room. While you are completing forms and answering ques-
tions, someone else can focus on your family member and
help him or her feel safe.

3. Be prepared to explain the medical symptoms and events
several times. You may even want to take notes so you can
quickly repeat the information to different staff members. If
you can provide a record of the past few days, it may help
with the diagnosis and treatment of the condition. For
instance, if your family member has been running an
elevated fever or has been vomiting, it is helpful to have an
accurate account of these symptoms.

4. Inform staff about the person's dementia, especially in rela-
tion to his or her communication needs. Provide tips on how
best to ask questions and make the person feel safe. Tell the
staff to make eye contact and talk slowly and calmly.
Remember to keep the tips simple and to the point.
Emergency room staff persons often have little or no training
in Alzheimer's disease, so you may be their first and only
teacher.

5. The next challenge is to wait. After the initial flurry of activ-
ity, you may spend hours waiting for test results, further
examinations, doctor consultations and a final decision on
whether or not to admit the person to the hospital. Having a
snack can be an excellent way to pass the time and keep up
strength during the waiting period. It can also be used to
distract the person with dementia and reduce his or her anxi-
ety.

6. Finally, if the person can return home, make sure you have
complete instructions for follow-up care. You should review
these written instructions and ask questions. If
hospitalization is recommended, first find out if there is any
way to avoid a hospital stay through outpatient or home care.
If a hospital admission cannot be avoided, make sure staff
will be available to check on the person frequently.



COPING WITH A HOSPITALIZATION
___
Quite clearly a hospitaliza-
tion presents many risks
to the person with demen-
tia and may cause
disruption within the rest
of the family.
___


Although a person with Alzheimer's disease may be physically
healthy to a remarkable degree for many years, there may be
occasions when an acute illness requires admission to a hospital.
These may be extraordinarily stressful times for someone with
dementia as well as family caregivers. The acute illness itself may
result in a temporary worsening of memory, thinking, judgment,
language and behavior. The abrupt change from a familiar place
to a busy and unfamiliar environment with dozens of strange
people and a disrupted schedule can also provoke further decline.
All of the confusion may result in agitation, which can interfere
with diagnostic and treatment measures. Consequently, medica-
tions may be prescribed to control behavior, which can further
impair thinking and behavior. Quite clearly a hospitalization
presents many risks to the person with dementia and may cause
disruption within the rest of the family. It may take weeks for all
concerned to recover from such a traumatic experience.

There are steps, however, to ease the transition to a hospi-
tal. First, every effort should be made to avoid hospitalization by
trying to diagnose and treat an acute illness on an outpatient
basis. If conditions do not permit this possibility, notify the
doctor and nursing staff about the specific needs of the person
with dementia. For example, inform them about the predictable
confusion brought on by the sudden change in environment and
the need to maintain as much of a routine as possible. Give
details about medication use, food preferences, and personal
grooming habits. Identify yourself as the primary caregiver and
tell staff that you must be consulted about diagnostic tests and
treatment measures. In addition, be sure to provide staff with a
copy of the person's completed power of attorney for health care
form to underscore your rightful role as the designated decision-
maker.

Due to the acute illness, different surroundings and any
newly prescribed medications, the person with dementia is
bound to be more disoriented than usual. Abilities such as
eating, toileting, talking and walking may be diminished. It
usually helps to have a familiar person available as much as
possible for the sake of comfort and consistent care.

Accompanying the person to tests and providing help with meals
and personal care may prevent or reduce stress and relieve staff
from the need to be constantly vigilant. Also, family members
can usually get permission to spend the night at the hospital if
the person with dementia has a problem with sleeping.

No individual can or should take on total responsibility for
such a high level of care when the person is hospitalized. This is
the time to involve other family members and friends who are
sympathetic to the needs of the person with dementia. Someone
who can devote time, patience and understanding may be far
more valuable than hospital staff who may be busy attending to
so many others at the same time. Hiring a sitter from an agency
may be called for in the absence of such helpers. Hospital stays
should be kept to a minimum to return the person back to their
home as soon as reasonably possible. Procedures or treatments
that are not absolutely necessary and delay discharge should be
discouraged. Planning for the return to one's place of residence
should begin soon after admission. A social worker or nurse
should be available to consult with you and the doctor about the
most appropriate course of action and link you up with needed
services.

A hospitalization may indeed restore the physical health of
the person with dementia but a moderate worsening of cognitive
status can usually be expected, too, in the course of recovering
from an acute illness. In most cases, it will take several weeks for
the person's overall condition to return to their previous level.
Caregivers should serve as advocates and helpers during the
hospital stay without interfering with the professional expertise
of the staff. At the same time, caregivers need to make sure that
steps are taken to care for themselves during this critical time.

___
Caregivers should serve
as advocates and helpers
during the hospital stay
without interfering with the
professional expertise of
the staff. At the same
time, caregivers need to
make sure that steps are
taken to care for
themselves during this
critical time.
___