Tips for Assisting an Elder with Dental Care

If you are looking after a loved one, helping to maintain their dental health can be a difficult subject to broach. Tooth loss and dental disease, along with decreased finger dexterity and general mobility which makes it difficult to properly clean teeth, can all take a toll on an elderly person’s dignity.

Whether you are a family caregiver or a professional carer, you may encounter a bit of resistance initially. However, ensuring oral health is an essential part of caring for an elder’s overall health. Poor oral health has been linked to higher incidence of lung infections and can aggravate existing conditions like diabetes and heart conditions.

Here are a few practical guidelines to help ensure the oral care and support you provide is both effective and kind.

1. Look out for any existing oral conditions

Mouth or tooth pain can leave anyone feeling poorly. In addition, a host of medications can dry out the mouth, adding to the overall discomfort. On the other hand, a healthy mouth means tastier food, better appetite and usually also improved communication.

As you provide support with tooth brushing and dental hygiene, keep an eye on any changes in gum and tooth health. Any bumps, swellings or lesions that do not heal in two weeks, or bleeding and loose teeth are cause for a trip to the dentist or at least a call to your dentists’ practice to seek advice. Regularly ask your loved one if their teeth are sensitive and note any difficulty they may experience when chewing or swallowing.

2. How to help with teeth brushing

Though the level of support you may need to provide when brushing teeth will vary, it is important to make the experience as pleasant and comfortable as possible.

Your loved one might be able to brush their teeth at the sink. In that case, ensure you have a chair positioned in front of the sink and a towel and cup handy. Brushing teeth can easily be done simply sitting up in bed too and rinsing into a cup.

Brush: Using a soft bristled brush, use small round motions to clean each tooth. Also gently clean the tongue. Consider an electric toothbrush as they can be a good option for providing thorough care.

Floss: Floss each tooth, implant and dental bridge. Normal dental floss should work fine but you could also try spongy floss or floss picks to see which works best.

Rinse: Use an antibacterial mouthwash to finish. If the elder you are caring for is unable to rinse with mouthwash, just ask them to spit out any toothpaste into a cup. Don’t worry about remaining residue. If it’s fluoride toothpaste this will actually benefit the teeth.

Dentures: Dentures should be removed at night and cleaned thoroughly daily.

3. Cleanliness after meals and throughout the day

Having frequent sips of water during the day is a great way of keeping the mouth feeling fresh and moist. After meals ensure all food is wiped away and ask your loved one to rinse into a cup to remove any remaining food from their mouth. You could also offer xylitol gum for chewing in between meals.

4. Don’t forget about the dentist

Most dentist recommend that seniors pay their dentist a visit every six months for a checkup and thorough clean. This is a good time to raise any general dental health questions you may have, but don’t wait for the bi-annual visit to address any serious dental health issues.

5. A few notes on diet

Often foods that are easy to prepare, eat and chew are also high in sugars and refined carbohydrates. These can not only increase the chance of cavities but will also aggravate other conditions like having a dry mouth. Thankfully there are quite a lot of teeth-friendly and generally more healthy foods options out there.

It’s a good idea to familiarise yourself with elder nutrition guidelines and where relevant to work with the care facility.

About the Author

Emma Harris lives in Cuffley, Hertfordshire, where she writes for her local dentist, Cuffley Village Dental Practice who have extensive experience providing dental care to elderly patients.

Using Home Health Care to Facilitate Independent Living

When faced with the choice between living in an elderly care facility or aging as independently as possible at home, home health care is almost always the more desirable choice. Still, it’s not always easy to build a feasible support system for aging seniors who wish to retain as much independence and dignity as possible by continuing to live in their own homes.

Understanding the unique needs of an individual patient and the level of care required to help them stay in their own homes doesn’t have to be complicated. With the right assistance in place and a plan of action, it’s very possible to help your loved ones retain some semblance of an independent, healthy lifestyle well into their golden years.

Realistic Evaluation of Need

To create a plan for an extended aging-in-place arrangement, it’s imperative to objectively take stock of your loved one’s needs and requirements. Some seniors will require little more than a few hours a day of supervision, which includes assistance with housekeeping and management of medication or physical therapy. Others may require more intensive services and direct medical care, transportation to and from appointments with physicians or daily living task assistance like bathing and dressing, which will typically require several hours or even round-the-clock care. Whether your loved one falls at one end of the spectrum or the other, or somewhere in between, enabling them to maintain as normal a routine as possible will require you to have a clear understanding of their needs and the necessary level of care.

Benefits of Home Health Care

Data from current research indicates that seniors who are encouraged to maintain a high level of independence through home health care also show higher levels of mobility, bladder control and emotional well-being. These patients are also less likely to require urgent, unplanned care as a result of injuries, falls or accidental medication mismanagement. Transitioning to a residential care facility may often leave your loved one with less independence and less freedom, which has been linked to higher levels of depression and anxiety. In the vast majority of situations, aging in place with home assistance is the most effective and comfortable solution for all involved parties.

Facilitating a successful home health care plan will allow your aging loved one to retain more control over their daily activities, while helping to prevent injuries, medication mishaps and even problems like malnutrition. Living at home, even with a chronic illness, a disability or an age-related reduction in mobility, is often the best possible option for both the physical and emotional health of a senior citizen. Home health care also helps to stave off feelings of loneliness and social isolation, which are relatively common among seniors.

Creating a Feasible Alternative to Facility Living

Families committed to helping their aging loved ones to live out their remaining years in dignity and the best possible health may know how important aging in place is to their family member’s emotional and physical health, but not how to execute a feasible plan for facilitating such an arrangement.

After assessing your loved one’s level of need, it’s time to determine the best way of building a support system to meet those needs. Family care can be a far less expensive alternative in some situations, but isn’t always feasible. Unless someone is able to dedicate some time each day to the management of medication and nutrition, along with basic daily needs, it may become necessary to work with a professional care provider. For some families, an ideal arrangement may consist of primarily family-driven care, with supplemental assistance from a professional caregiver or home health care provider. Because every situation is unique, your plan for enabling your loved one to age in place must also be customized to fit the existing level of need. Maintaining an open line of communication with your loved one’s primary care physicians and other medical care providers is one of the best ways to determine the most effective course of action, especially when aging in place is the preferred option.

About the Author

Selwyn St. Louis is the Director and CEO of Better Living Senior Services, located in Tampa Bay, Florida. Since 2009, Selwyn has been on a mission to help those in need with home health care options for the elderly.

Making the Transition: Hospital to Home Health Care

For aging adults and their families, a lengthy hospital stay can be a frightening and confusing time. At the end of this particular long road lies another; the transition from extended hospital care to home health care. Making this transition can be a challenging experience, but it’s also one which can be handled deftly with the proper preparation and reasonable expectations.

When home health care is the preferred solution for an aging patient, having a transitional plan in place before hospital discharge is essential. Medicare data indicates up to one in five patients will be readmitted to a hospital within thirty days of discharge, and almost half of those cases can be directly attributed to lack of access to community services or social interaction. Keeping your loved one healthy and comfortable at home will require that they’re able to remember and attend all follow-up appointments with a primary care physician, maintain the appropriate medication schedule and have access to a reasonable level of in-home assistance.

Planning Ahead

For the greatest chances of a successful transition to home health care after a hospital stay, it’s wise to begin making plans for this transition as soon as possible. Depending upon existing medical conditions and the advice of an attending physician, you may need to make arrangements for the procurement of specific equipment and supplies. Hospital beds, oxygen supplies, assistive showering and toileting devices and even disposable items like adult diapers and gloves are commonly suggested. Adjustments to make room for these tools should be handled as early as possible, to ensure a smooth transition from hospital care to home. Having all the necessary supplies in place on the day of discharge can alleviate much of the stress of the transition, making it more manageable for everyone involved.

More often than not, an aging patient will be prescribed new medication in order to more readily address the condition being treated during a hospital stay. Medication management becomes another important aspect of the transition to home health care from hospital care. It can be confusing for a senior recovering from an illness or procedure to integrate new treatment into their medication schedule. It’s crucial for a home health care professional or knowledgeable family caregiver to understand the intricacies of medication management, especially if new medications are contraindicated with older ones or there are overlapping prescriptions.

Understanding Care Requirements

After being discharged from a hospital stay, regardless of the length, most seniors will require at least some assistance at home. Working with attending physicians and primary care physicians to determine the required level of home assistance is advised. Some patients may require as little as a few hours of maintenance and medication  management each day, while others require 24-hour assistance with necessary activities like toileting and routine hygiene. Recent studies suggest more than half of patients over the age of eight-five will require some level of assistance with basic daily activities after leaving the hospital, though the duration of this assistance will vary from one individual to another.

In order to create an environment which will facilitate successful transition, it is crucial for family members to have a realistic understanding of home health care requirements. Because there may also be as much as a full day’s gap between discharge from the hospital and the beginning of covered home health services, it’s also important to have a plan in place for the day of release.

With the right level of preparation and a clear line of communication between patients, family members and medical care providers, it’s entirely possible to facilitate a smooth and successful transition from a hospital stay to home health care. Properly executed home health plans can also reduce the likelihood of repeat hospitalizations, improve quality of life and help your loved one enjoy their golden years to the fullest.

About the Author

Selwyn St. Louis is the Director and CEO of Better Living Senior Services, located in Tampa Bay, Florida. Since 2009, Selwyn has been on a mission to help those in need with home health care options for the elderly.

My Experience with Elder Care and Assisted Living

elder careEighty-four percent of Americans over the age of 50 expect an immediate family member to move into a senior living community within the next 10 years, while 24 percent over the age of 65 expect the same for themselves, according to a new national survey of American attitudes on assisted living released today by the Coalition to Protect Choice in Senior Living (CPCSL). The poll found just more than half (51 percent) expect their parents to live in a senior living community within 10 years, with 15 percent expecting the same for their spouse and 10 percent for a sibling.

My Story

I’d like to briefly share the story of the event that started me on this path. I imagine it’s similar to your own in that it begins with an unexpected phone call.

My wife and I had just returned from celebrating our engagement in Greece, and we were sharing stories over bowling with some good friends.

I was the product of a second marriage, and my mom and I had become quite close since my father’s passing while I was in high school. We spoke often, so I wasn’t surprised when my cell phone rang and the caller ID showed it was her.
I was surprised when I answered and it was the paramedics.

Apparently, my mother called 411 asking for my name and phone number as she could not remember it. The operator called 911, and in a matter of minutes, they had arrived, kicked down the door and called me.

My mother had a stroke. I was only 33, and totally unprepared for the depth of emotions, or the complexity of the decisions I was about to face.

That a 73-year old woman had a stroke is not unusual. My mom’s case was unique because of the series of complications that nearly killed her. In the eighteen months following her stroke, she endured major back surgery to remove a staph infection from her spine, a perforated intestine that required stomach surgery, several MRSA infections1 requiring IV antibiotics and a broken hip. She spent several weeks in the surgical intensive care unit recovering from her back surgery. Many of these nights, I feared the worst. But my mom is a fighter.

The medical system these days isn’t designed for long-term recovery. Hospital personnel are highly trained at treating acute problems and dealing with specific injuries and conditions. In fact, we have some of the most skilled doctors in the world.

But when you’re older and recovering from a serious illness, your options are usually to go home, or go to a skilled nursing facility – where staff can provide physical or occupational therapy, administer IVs and perform other functions requiring a registered nurse.

During this time, she spent nearly six months moving back and forth between the hospital and skilled nursing. In January of 2006, I moved Mom from San Diego to Orange County. She graduated from skilled nursing and was on her way to assisted living.

Trust, Hope and Hard Work

When Mom arrived in assisted living, she could not stand or walk and required a 24-hour caregiver. She could not eat or drink on her own and was in a deep state of depression.

While I found much advice on medical conditions and treatment, I found virtually nothing on understanding assisted living. Sure, there were some Websites that taught you the basics, like “make sure a nurse is on duty” or “make sure the kitchen is clean.” But this is my mom and I wanted far better for her. I wasn’t putting her away; I was playing a key role in her recovery.

Because of the lessons I learned – and a lot of hard work on the part of my mother – she is doing very well. In fact, we’ve become very close friends. She walks with a walker; her memories are clear and vibrant. She has a circle of friends and a packed calendar.

She even made it to my wedding. And she looked beautiful. I cried. They say your wedding toast is one of the most important speaking opportunities you’ll ever have. And I consider myself to be a good public speaker, routinely speaking at tradeshows and other events. But when I looked into the crowd and saw my mother smiling, I fell apart.

The joy I felt at seeing her on that special day was overwhelming. So was my commitment to her continued well being. It was my clear intention that she be given every opportunity in her assisted living situation to thrive, to grow, and to be fulfilled.

Recall the statistics at the beginning of the chapter. While I was shocked these numbers were so high, I completely agree. I did some homework. In an informal study of about 40 people, I sensed an almost inevitability about needing assisted living. I also found that financial issues and quality of care topped the list of concerns for both Baby Boomers and their children.

I followed up my informal study with a formal study of nearly 200 families. The Assisted Living Family Attitude and Preparedness Report showed that 75% of respondents believed a friend or family member would soon require assisted living. The report is free to anyone who wants to read it and can be accessed at the link above.

My goal is to share with you some of what I learned through my journey. My hope is that these lessons can make it easier for you and your mom, dad, relative or loved one. I assume you’re reading this blog because you or a loved is considering assisted living. Since you likely haven’t gone through it before, the decisions can be overwhelming. I’ve written this blog to help you make more informed decisions, and to be calm in what is likely to be an emotional storm. I sincerely hope I can help you avoid some of the pitfalls of learning the assisted living ropes.

While a move to assisted living may initially be seen as negative, I know first- hand that with some careful and thoughtful planning, you can make it a huge positive for all concerned. Over the last several years, my relationship with my mother has strengthened. She has become one of my best friends and an integral part of my life.

I hope you enjoy reading this blog and that I’m able to somehow make your journey a bit easier.

Photo Credit: andrewmalone.

Five Tips for Finding a Quality Home Care Provider

You and your family have decided that it is time to bring in outside help to assist with the care of a loved one in need. Because you want them to be able to remain safe, comfortable and independent in their own home for as long as possible, you have chosen to hire an in-home caregiver or home healthcare agency. The next step is choosing the best care provider for you and your loved one. But how do you know who the best is?

Here are five tips for finding a quality home care provider:

  1. Get recommendations. Talk to trusted professionals and community members. Your parent’s doctor, financial advisor, attorney, other medical providers, friends or family members may have familiarity and experience with local companies that do a good job. A list of providers is also available from your local Area Agency on Aging or hospital social work department. However, it is rare for these resources to make specific recommendations.
  2. Know your liability. Understand the possible liabilities and ramifications involved when hiring a caregiver privately. Consider issues such as taxes, insurance, liability and worker’s compensation, backup coverage, background checks/oversight and training.  If hiring through a nurse registry or employment agency, the family may end up being the official employer, responsible for pay, taxes and other obligations. On the other end of the spectrum, fully licensed private duty home health agencies offer more comprehensive services and protections as employers of the caregivers.  To learn more about state agency requirements and protections, contact your state licensing agency for healthcare organizations, or visit the National Private Duty Association at www.privatedutyhomecare.org.
  3. Consider innovation. Research how current their monitoring and communications technology is. How easy is it to monitor the care your loved one is receiving? Do they use technology like telephone clock in systems and scheduling software for quality assurance?  How quickly are they aware if a caregiver has not shown up to provide care?  What methods do they use to communicate with you?  Do they offer you conveniences such as online monitoring and paying bills online or via credit card?  Do they keep up to date with aging in place technology and can they provide you recommendations that may bolster care?
  1. Get to know who you’re hiring. When talking with an agency, get a feel for their process. Will they allow you and your loved one to interview potential caregivers? How do they handle replacing a caregiver that is not a good fit? What steps do they take to ensure coverage and accountability? How do they supervise, train and support staff? Do they strive for continuity or will your loved one have different staff each time?  How many caregivers will cover the shifts your loved one requires?  It is important to discuss your loved one’s specific diagnosis and needs, finding out the agency’s experience with similar situations and any special training and guidance they provide, for example training on working with clients with Alzheimer’s disease.  While regulations standardize licensed home care agencies to a degree, these are the things that will set one agency apart from another.
  2. Research involvement. Seek out providers who have a history in the community and the industry. Check if providers are involved with local and national associations such as the Alzheimer’s Association, the Area Agency on Aging and the National Private Duty Association. Their involvement demonstrates passion and dedication for their field. Management staff that has a history in the community and the profession demonstrates a commitment, stability and a positive reputation that they would want to protect.

Photo credit: familymwr

About the authors: Alex Chamberlain is executive director at EasyLiving, Inc. (http://www.easylivingfl.com), a fully licensed, private duty home health care company serving individuals and families in Pinellas and Pasco counties in Florida.

Shannon Martin, M.S.W., CMC, serves as Director of Communications for EasyLiving, Inc. and Aging Wisely, LLC (http://www.agingwisely.com). Shannon has worked for Aging Wisely, a professional geriatric care management and consultation firm, for over 8 years.

Finally, a Vision for Care Referrals That Will Improve Outcomes

Picture this: you’re one of millions of Americans who needs care at home either because of aging, dementia, recovery from surgery or other disabilities.  You’ve got a family—and often an unpaid caregiver who helps with your care.  They’re part of an elaborate team of caregivers, physicians, therapists and non-medical assistance.  I’ve lived this first-hand as I’ve cared for my mother, and I’ve spoken to literally hundreds of families in the same situation.

Insurance companies and other employee benefit programs often deliver these care recommendations.  They do the best they can considering maintaining these programs—and the underlying data—is not their primary business.  Unfortunately, they struggle to extend these programs across the whole company so that each member-facing group can leverage the same data to provide the best care referrals to their members. I’ve just assumed it was one of those “not-yet-solvable” situations, as healthcare technology is always a bit slower than other industries.  So we did the best we could and used what was not an ideal support system.

The Future of Care Referral Programs

I think I finally found a vision for the future.

I ran into a white paper from SNAPforSeniors that really caught my eye.  If SNAP can deliver on this vision—and if insurance companies, call centers and other providers have the vision and foresight to adopt it—it will dramatically change the outcomes of care coordination as part of the age in place movement.  More important, it will give families like mine the peace of mind that we are getting referred to the best matched providers for our care.

I know this vision may not concern some of you, but I highly recommend you check it out.  These types of ideas are the ones that are going to make the biggest impact. If you think your family would benefit from your insurer adopting programs like this, you should let them know.

Here’s the link to the paper – http://bit.ly/aPPsWU.

How to Choose a Caregiver

The title of caregiver is not as obvious as it may seem.  Caregivers can aid in eldercare on many different levels and depending on your needs their roles can provide key benefits.

Benefits of caregivers

Your eyes and ears: Whether you live close by or far away, a caregiver can observe and update you on areas of nutrition, hygiene, activity level, services and other daily issues.

A concierge: Scheduling and staying current with weekly and monthly activities such as doctor’s visits, shopping, hair appointments, and therapy requires phone calls and follow up.  Allow the caregiver to take some of this off or your mind and your to-do list.

An influencer: Communication and opinions by close family members are sometimes not seen as being objective or carry as much weight as a professional caregiver.  Therefore it may be easier on everyone if the caregiver steps in at times to advise the patient rather than a family member.

Finding a caregiver

Before you choose a caregiver, you should determine the range of services you want so that you are making a decision that covers your predetermined needs.  Consider the following:

Make a list of daily activities: By reviewing the activities of a typical day of the patient you will be able to determine the specific duties required.  It helps to create a timeline of activities so that you plan for meals, naps and regular appointments.

Assess the degree of specialty: If the patient suffers from any degree of dementia or physical disability make sure you look for a caregiver with appropriate knowledge and experience.

Determine the need for meal preparation: Not only should you make a choice for a caregiver on their ability to prepare meals if necessary, but also their understanding and ability to create diet-specific meal choices.

Once you have your specific needs list refined, go to the following resources to be connected to the appropriate pool of caregivers to begin your interview process.

Additional resources:

www.caregiverlist.com

www.caregiver.com

10 Caregiver Questions

To make the most of your time during the interviewing process, conduct preliminary interviews on the phone rather than starting with in-person appointments.  Describe the job in detail along with the required hours needed and wages available.  If you feel the applicant may be a good match based on their experience and ability to provide references, then schedule the in-person interview.  It is a good idea to have another family member or friend participate in the interview to provide an objective perspective.  Finding that great match may be easier with a second opinion.

In preparation for the interview, create a list of questions pertinent to the job description.  Ask questions relevant to the caregiver’s experience and expertise surrounding the daily activities list you previously created.

  1. Where have you worked before?
  2. What were your duties?
  3. What type of patient medical limitations have you worked with in the past?
  4. What is your experience cooking for other people (including dietary restrictions)?
  5. Is there anything in the job description that you are uncomfortable doing?
  6. Have you had to deal with a patient emergency in the past?
  7. Can you keep track of and administer medications?
  8. Would you be able to transfer someone from a wheelchair into a car or into a bed?
  9. How do you feel about caring for a disabled person? Or a person with memory problems?
  10. Can I contact at least two work-related and one personal reference?

If you need a template for a caregiver interview, download this form as a guide:

http://www.agis.com/Document/38/professional-caregiver-interview-form.aspx

Once you narrow down your field of applicants, make sure you observe the applicant’s interactions with your family member on a casual basis before making a decision.  If your family member is able, he or she should be included in the interview process and in making the final decision.

Consider the person most qualified for the job and with whom you feel most comfortable. Always check the references of at least two final applicants. Good applicants may have more than one opportunity at a time, so don’t wait too long before proceeding with an offer.

Your Senior Health Care Bill: $260,000!

I have always been a big fan of Howard Gleckman, author of Caring for Our Parents.  In fact, he was the very first person I interviewed for my Leaders in Elder Care series.  If you aren’t familiar with Howard’s blog, you’re really missing out on a complete play-by-play of how the health care debate is impacting the cost of senior care.

This morning, he shared some startling statistics about paying for elder care that I have quoted below.  In this article, Howard has links to some fascinating studies about the out-of-pocket costs for seniors, and it is shocking.  It is mind-boggling to me how financing elder care will be solved as we move forward. He wrote:

A typical couple would have to save nearly $200,000 to pay for their out-of-pocket medical costs from the time they are 65 until they die, according to an important new study by the Center for Retirement Research at Boston College. Add in nursing home costs, and they are likely to need $260,000.

But that’s only part of the story. About 5 percent of 65-year-old couples will face catastrophic medical and long-term care costs exceeding $570,000, according to researchers Anthony Webb and Natalia Zhivan.They estimate those expenses would have exhausted the total financial assets of 85 percent of all retirees even at the peak of the stock market in 2007.

As someone who has first-hand experience with out-of-pocket expenses and my Mother’s care, I was still so stunned by these numbers, that I could not write a conclusion to this article.  What do you say?

Obviously, I encourage you to check out Howard’s writing.  In the meantime, what are your thoughts about these big numbers?

Photo: bubble dumpster

Assisted Living Saved My Mom in Oregon

A couple weeks ago I had the pleasure of traveling to Oregon to speak at three assisted living communities across the state.  I posted some pictures of the event on the Inside Elder Care Facebook page at http://www.facebook.com/eldercare.  Brookdale brought me up from California to visit three communities—all from distinct areas within Oregon.  They were:

  • Albany – small towns set in an agricultural area just southeast of Portland
  • McMinnville – right in the center of Oregon wine country
  • Gresham – at the base of Mount Hood (yes, I was cold)

At each community, I gave a talk entitled Assisted Living Saved My Mom—a presentation communities ask me to give that provides an insider’s view about how to determine which assisted living community is best for your family.  Assisted Living Saved My Mom shares many techniques that uncover information you would never get from just speaking to an admissions director.  Brookdale provided a copy of my book to each who attended—something appreciated by the attendees.  Based on the large amount of feedback I received from attending families and people in the industry, the message really hit home and benefited many people.

Despite the obvious differences in the locations of each of these communities, I found a few things in common:

  • Warm and friendly: nearly every person I met—from the staff to the residents—were very welcoming and warm.
  • Pride: there is a strong sense of pride in the residents that carried over to their feeling that it was their responsibility to make new residents comfortable.
  • Camaraderie: I got the feeling that the residents genuinely enjoyed each other’s company. You could tell because they all knew each other’s little quirks and habits—something they found amusing.

One thing that came up repeatedly was the concern over “How do I pay for this stuff?” Many people were surprised there were other payment options beside just selling their house and paying cash.

When I wrote the By Families, For Families Guide to Assisted Living, I interviewed nearly 200 families to ask them about the concerns related to assisted living and elder care.  The issue of paying for elder care came up as a primary concern from almost three-quarters of those families.

The financial issues are the elephant in the room.  Most people don’t know how to solve them or even where to start, because there is no holistic guide for families on how to navigate these issues.  I am a month or two away from releasing my second book that gets into these answers—the feedback from those that have seen it has been really positive.  Stay tuned.