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Abstract
Cognitive and behavioral interventions for persons with dementia include a large range of tools used to enhance cognitive, behavioral, and affective functioning as well as self-maintenance. Such interventions should follow a detailed analysis of the problems, goals, and abilities of these persons. The interventions are described under the following categories: cognitive, behavioral, self-affirming, sensory, social contact, structured activities, environmental, medical/nursing care, and staff/caregiver training and management. Although these interventions have shown promise in prior research, the field of investigation is still in the early stages, and larger controlled intervention studies are needed. Furthermore, research is needed to clarify the process of intervention and which intervention ingredients are crucial for success. These studies would lead the way to effectiveness and cost analyses.
Outline
- Introduction
- Purpose of Interventions
- Theoretical Frameworks
- Types of Interventions
- Efficacy, Effectiveness, and Utility
1. Introduction
The scope of cognitive and behavioral interventions for persons with dementia can be conceptualized from a narrow or a wide perspective. The narrow perspective includes only interventions traditionally referred to as cognitive behavioral, including reinforcement techniques and cognitive restructuring. A wider perspective includes a range of techniques based on different theoretical frameworks and disciplines, many of which are used either to prevent or to substitute for use of psychoactive medication. This research paper uses the latter approach, with the goal of clarifying the wide range of techniques available to clinicians in enhancing the quality of life of persons with dementia.
The various intervention techniques that are used with persons with dementia can be organized along several dimensions: the function of the intervention, the theoretical framework serving as a basis for the intervention, the type of activity undertaken during the intervention, and the population subgroups for whom a technique is appropriate. Interventions should be ranked by their effectiveness within a subgroup for certain goals with specific outcome criteria. Some of these dimensions are reviewed briefly in what follows.
2. Purpose Of Interventions
Cognitive and behavioral interventions are used for improving functions in many domains, including the following:
Cognitive goals include enhancement of memory as measured by memory tests, enhancement of memory for daily tasks, enhancement of ability to communicate, an increase in task engagement, an increase in orientation to time and place, and a decrease in overall cognitive decline.
Functional goals usually involve an increase in independence or in participation in the performance of activities of daily living (ADL) (e.g., dressing, eating, toileting) and a decrease in risk of falling.
Affective goals include a decrease in negative affect (e.g., depression, anxiety) and an increase in positive affect (e.g., pleasure, contentment).
Behavior change involves a decrease in problem behaviors (agitation) such as aggressive behaviors, repetitive nonaggressive and restless behaviors, and repetitive verbal/vocal behaviors. Such behaviors are frequently indicative of discontent in persons with dementia and may also be disruptive to caregivers.
In terms of self-affirmation, a loss of sense of self and of identity is a common characteristic of dementia. Even when the inner sense of self may remain intact, the socially defined self is often diminished by the decline in social, work, and leisure roles. Therefore, some interventions target enhancement of the sense of selfhood/personhood in dementia.
3. Theoretical Frameworks
Many theoretical frameworks underlie cognitive and behavioral interventions. Some of the basic concepts used in these frameworks are described in what follows.
3.1. Cognitive
Research on cognitive processes differentiates between explicit and implicit memory. Explicit memory requires the ability to produce the memorized material and usually involves conscious knowledge of the material. In contrast, implicit memory affects behavior but does not involve awareness of the memory. Explicit memory is usually lost earlier in the dementia process than is implicit memory. Procedural memory involving everyday activities frequently involves implicit memory. Therefore, some simple procedures can be learned during the early and middle stages of dementia even when there is no awareness of the learning process.
3.2. Behavioral Theory
Behavioral theory asserts that behavior manifestation is affected by its antecedents and consequences. Environmental stimuli can become associated with a behavior and trigger it, whereas consequences such as reinforcement can affect the likelihood of the behavior’s manifestation. To change a behavior, the contingencies between a behavior and its consequences need to be changed, for example, withdrawal of reinforcement or introduction of reinforcement for different behaviors under different circumstances. Alternatively, an intervention can alter the environmental stimulus that triggers the behavior.
3.3. Cognitive and Behavioral Theories of Depressed Affect
Cognitive and behavioral theories of depressed affect include (a) cognitive theory that ascertains that depression is a consequence of negative and distorted cognitions about oneself (based on work by Beck and Ellis), (b) theory that claims that depression involves learned helplessness and a sense of loss of control (based on Seligman’s work), and (c) theory that depression relates to an insufficient level of reinforcements or pleasurable experiences (based on Lewinsohn’s work).
3.4. Unmet Needs Theory
The unmet needs theory asserts that people with dementia manifest inappropriate behavior due to unmet needs. The theory claims that people with dementia have the same needs as do other people. These needs, which are generally summarized under Maslow’s hierarchy of needs, include physiological, safety, love and belonging, esteem, and self-actualization needs, with the latter sometimes being manifested as a need for cognitive stimulation or for meaningful activity. According to this theory, these needs frequently go unrecognized by caregivers, and even when they are recognized, these needs are often not satisfied because caregivers do not understand their significance or do not know how to address them. The unmet needs result in inappropriate behavior in one of several mechanisms. First, the inappropriate behavior may be a call for help due to the unmet need. Second, the inappropriate behavior may be an attempt by the person with dementia to respond to his or her need (e.g., self-stimulation as a response to sensory deprivation). Finally, the inappropriate behavior may be a direct result of the unmet need (e.g., screaming due to pain).
3.5. Humanistic Theory
Humanistic theory maintains that a person’s subjective understanding of his or her experiences is more important than objective reality.
3.6. Stages of Human Development
Erikson described eight stages of human development culminating in the eighth stage (age 65 years or over), described as ‘‘Integrity versus Despair,’’ in which a person looks back at accomplishments and ahead to the unknowns of death and feels either fulfilled or saddened. Feil added a ninth stage to Erikson’s developmental framework that she termed ‘‘resolution versus vegetation.’’ It is viewed as an opportunity to resolve conflict and achieve a sense of integrity before death.
4. Types Of Interventions
This section includes a descriptive list of interventions used with people with dementia. In understanding the interventions on this list, several underlying principles need to be clarified.
4.1. General Issues in Considering Types of Interventions
An intervention should follow a thorough assessment such as a functional analysis that examines the nature of the behavior as well as possible causes, antecedents, and consequences. The assessment should also include information about past stresses, identity, habits, and preferences as well as current medical and psychosocial status. This assessment would guide the understanding of the etiology of presented symptoms as well as realistic goals and options for treatment. Once an intervention is implemented, it should be evaluated. If it does not meet the goals, a different treatment alternative should be taken. Such alternatives might be a different intervention or might involve a different aspect of the intervention (e.g., different timing, differing amounts [dosage], different presentation style, different therapist).
The list of interventions is not exhaustive but provides examples of the currently available interventions. Interventions are in the process of being developed and tested, so the list is an evolving body of knowledge.
Interventions often have multiple purposes, and there are multiple options for interventions in any functional domain (see Table I). For example, cognitive interventions can be used for improving cognition, function, behavior, and/or affect.
The descriptions in what follows provide only a general concept of the various interventions. However, each type of intervention can be considered as a whole range of possible interventions and, therefore, can be delivered in many different ways. It is the specific operational details that may make any treatment effective.
The manner in which an intervention is presented can be crucial for its success.
An important issue in understanding the utility of interventions is discerning the active ingredient of the interventions. Two interventions might seem quite different, yet the potent factor in both may be the opportunity to interact with a supportive person. The understanding of the underlying differences among interventions should be a focus for future research.
TABLE I Nonpharmacologic Interventions: Examples of Type of Intervention by Goal
Matching interventions to the person and the purpose is important. Cognitive and behavioral interventions cannot be applied uniformly to all persons with dementia. Interventions are appropriate for specific goals and need to be matched to individuals based on their cognitive and sensory abilities as well as on their identities, habits, and preferences. In addition to tailoring the type of intervention to the person and their specific needs, the content of the intervention, such as the type of music that is played, needs to be matched to the person’s preferences. This need to individualize treatments makes both research and practice more complex.
4.2. Cognitive Interventions
4.2.1. Memory Training
Positive results have been described for memory training with older persons. However, these are usually conducted with persons with either no memory impairment or mild cognitive impairment. Interventions reported for persons with dementia usually involve more support and less reliance on the person than traditional memory training methods. Interventions such as mnemonics are therefore usually inappropriate for this population. However, positive results have been demonstrated in small studies that involved daily cognitive stimulation by caregivers and with a computerized cognitive remediation system created by Butti and colleagues.
4.2.2. Cognitive Restructuring
Cognitive interventions based on Beck’s and Ellis’s work have been used to treat depressed persons with mild levels of dementia. These interventions involve cognitive restructuring, that is, challenging or changing distorted thought processes and thoughts that cause depressed affect.
4.2.3. Task Simplification/Cognitive Prosthesis
The most common and straightforward cognitive methods involve task breakdown, enhanced instruction, modeling, rehearsal, cueing, and gradual approximations of a task. These principles apply across different domains. The notion of simplifying tasks can also be applied across daily activities such as by providing consistency in caregiver assignment (this helps to orient older persons across different tasks). Similarly, many environmental interventions have been used to simplify orientation such as placing items that are frequently needed in a permanent location, using labels and signs, wearing a large wristwatch, and placing a card with important information in a pocket.
4.2.4. Memory Books
Memory books are booklets with autobiographical, daily schedule, and problem resolution information. When nursing assistants were trained to use the memory books, nursing home residents showed improvement in conversation and affect.
4.2.5. Spaced Retrieval for Procedural Memory
Spaced retrieval is a memory training technique that involves repeated rehearsal, with testing occurring over gradually increasing time intervals. For example, the resident may be trained to check whether his or her glasses are being worn. The resident would first be asked to check immediately after instruction, then after 20 seconds, after 40 seconds, after 1 minute, after 2 minutes, and so on. In this way, people with dementia are able to learn procedures so as to consistently check their calendars. This procedural learning is essential for independent functioning and is based on the use of procedural implicit memory, which is retained until the later stages of dementia.
4.2.6. Reality Orientation
Reality orientation is an intervention in which staff members present orienting information, including information about time, place, and person, to persons with dementia. Such information may be conveyed in special group sessions, which may include discussion of current events or may be ongoing in interactions between (usually formal) caregivers and persons with dementia.
4.2.7. Cognitive Tasks
Cognitive tasks include both group and individual activities that involve use of cognitive and memory skills. Group examples include ‘‘question-asking readings’’ in which a group reads a relatively low-reading level script that is typed in large font and high contrast and that is accompanied by questions typed on cards that allow participants to discuss related topics. Another group memory task is ‘‘memory bingo,’’ in which participants have bingo-type cards with endings of popular sayings. For each card, the group facilitator reads the beginning of the saying, and participants use long-term memory to complete the sentence and use recognition skills to find it on the card in front of them. The sayings can also be used to stimulate discussion. Individual cognitive tasks include activities such as card or object sorting by category.
4.3. Behavioral Interventions
4.3.1. Differential Reinforcement
Differential reinforcement may involve positive reinforcement contingent on nonagitated behavior or ‘‘time out’’ (e.g., moving the person to a quiet area when agitated) or ‘‘restriction’’ (e.g., denying the person goods [e.g., candy], activities, or access to a location or another person when agitated).
4.3.2. Stimulus Control
Stimulus control is based on behavior being emitted under specific antecedent conditions and not others. Stimulus control involves changing the stimuli that tend to trigger a behavior, so that the behavior will be less likely to be triggered, or changing the association between the antecedent stimulus and the behavior by changing contingencies depending on the presence of various antecedent stimuli. Camouflaging exit doors and placing stop signs on them, along with training that the stop sign means stop and walk away, are examples of the use of stimulus control.
4.3.3. Maximizing Control
Helplessness has been shown to relate to depressed affect, whereas control is associated with well-being. Providing residents with opportunities to exercise control can involve having a door that they can open to an outdoor area, having a plant that they can care for, or allowing them to make decisions about meals, clothes, and the like.
4.3.4. Increasing Levels of Pleasant Activities or Noncontingent Reinforcements
Clarifying which activities or experiences are reinforcing to individuals with dementia and providing these activities or experiences is a method that has been used to treat depressed affect in persons with dementia.
4.4. Self-Affirming Interventions
4.4.1. Reminiscence Therapy
Reminiscence therapy encourages persons with dementia to recall their pasts. Sessions may use audiovisual aids such as old family photos and other objects. Reminiscence can enhance patients’ sense of identity and sense of worth and/or general well-being, and may also stimulate memory processes.
4.4.2. Validation Therapy
Validation therapy, developed by Feil, involves communication with a therapist who accepts the disorientation of the person with dementia and validates his or her feelings. The assumption is that the person returns to unfinished conflicts in the past, around which a meaningful conversation can take place addressing the emotions that are important for the elderly person rather than trying to correct the disorientation. Thus, it fits within the perspective of humanistic theory. Validation therapy can take place in one-on-one treatment or in a group.
4.5. Sensory Interventions
4.5.1. Massage/Touch
Massage or therapeutic touch has been used to decrease behavior problems in people with dementia. Touch is sometimes considered a form of communication when verbal communication is no longer available. In many of the research papers reporting on massage therapy, the procedures took approximately 5 minutes and were performed once or twice a day.
4.5.2. Music and White Noise
Music has been used for decreasing behavior problems and for improving cognition or function. Music has been used to relax patients during meals or bathing or as a means of providing sensory stimulation to people who are understimulated. Music interventions take many forms, including listening to a music tape, playing musical games, dancing, moving to music, and singing. Prior to using music therapy, hearing would need to be checked, and an amplifier, headphone, or hearing aid might need to be used. Music is more effective when it is individualized to match the person’s preferences. White noise has also been used to induce relaxation, thereby improving sleep and decreasing restlessness.
4.5.3. Sensory Stimulation
Sensory stimulation involves the presentation of stimuli that affect different sensory modalities, including hearing, touching, seeing, and smelling. Therefore, it can include elements of the massage and music interventions described previously as well as aromatherapy, moving lights, pictures, and the like. The ‘‘Snoezelen’’ sensory stimulation program, which was developed in The Netherlands and includes a variety of relaxing stimuli, is also a type of sensory stimulation.
4.6. Social Contact Interventions
Loneliness is highly correlated with depressed affect, and being alone has been shown to relate to behavioral problems. The best intervention for loneliness is positive interaction with a person who is meaningful to the elderly person. However, this is often not feasible. Therefore, a variety of alternative social interventions have been developed. In addition to the following social contact interventions, most group activities, including cognitive ones, can be used as vehicles to promote social contacts.
4.6.1. One-on-One Interaction
One-on-one interaction is a potent intervention for loneliness and behavior problems. It can be conducted with relatives, paid caregivers, or volunteers.
4.6.2. Pets/Dolls
Pet therapy often involves visits with a dog that last from a half-hour to an hour. However, other pets (e.g., a cat, fish) can be used as well. Even plush stuffed animals have been used successfully, as have robotic pets. Dolls have also been used to simulate companions, since they can be viewed as real babies. Pet therapy not only involves interaction with the pet but also serves as a topic for interaction with other people.
4.6.3. Stimulated Interaction/Family Videos/ Interaction Videos
Simulated presence therapy uses an audiotape to simulate phone interactions. The tape contains a relative’s portion of a telephone conversation and leaves pauses that allow the older person to respond to the relative’s questions. Family videotapes also simulate interaction by having a loved one talking to the person with dementia. These videotapes have been found to produce engagement and decrease agitation in persons with dementia. Interaction videos are those in which the persons on the videos, usually professionals, interact with the persons with dementia, often recalling information from the past or inviting the persons with dementia to sing along, using long-term memory for well-known songs.
4.7. Structured Activities
4.7.1. Indoor Activities
Structured activities are used to improve affect and decrease behavior problems. They can take many forms and include activities that Buettner termed ‘‘simple pleasures,’’ including both group and individual activities. The activities may involve manipulation (e.g., ball throwing), nurturing (e.g., watering a plant), sorting, cooking, sewing, or engaging in sensory intervention as described previously (e.g., music, tactile stimulation with a fabric book). The content of activities may be based on information regarding which activities were or are reinforcing to the individual.
4.7.2. Outdoor Activities
Outdoor walks and physical activities are forms of structured activities that have the potential to improve function and affect and to decrease problem behaviors. Outdoor walks may take place in the company of a caregiver and so may also involve a social component, or they may occur in a secure outdoor area involving an environmental intervention. Outdoor walks are often limited by weather conditions.
4.8. Adapted/Enhanced Environmental Interventions
Environmental interventions can be used for multiple goals such as to decrease or accommodate behavior problems, to enhance functional status, and to increase orientation.
Environments for increasing functional ability have included different levels of environmental adaptation, from decreasing clutter to providing grab bars or handrails. The following are specific types of adaptation or enhancements.
4.8.1. Visibility of Cues Needed for Activities of Daily Living
The importance of visibility has been demonstrated in several research studies. For example, use of toilets increased when toilets were more visible, and eating behavior improved with better light and increased contrast between plates and the table.
4.8.2. Seating in Motion
Rocking chairs and gliding swings have been used for relaxation, improved affect, stimulation, and reduced physical agitation.
4.8.3. Homelike Ambience
Homelike furnishings in the institutional setting and enhanced ambience can affect many aspects of wellbeing for both patients and their caregivers.
4.8.4. Reduced Falls
Decreasing bed height, placing mattresses on the floor, using hip protectors, improving light on the way to the bathroom, and improving call systems all can help to decrease the risk of injury due to falling.
4.8.5. Privacy and Intrusion Deterrence
To prevent trespassing into other people’s rooms or through emergency exit doors, doors and doorknobs can be camouflaged with cloth panels or murals, thereby disguising the doors. In addition, providing alternative doors, which can be controlled by the patient and permit movement into another secured area, can be useful in reducing trespassing.
4.8.6. Clear Labels and Signs
Clearly labeled signs with large font and high contrast can be used to increase orientation. Nursing homes can also use boxes with pictures of residents taken in the past, or other memorabilia that is meaningful to them, to help orient residents in finding their rooms. Clear labels on public toilets are useful in decreasing incontinence.
4.8.7. Wandering Areas
Places that allow people to walk in a safe environment can be created either indoors or outdoors. These usually involve some type of walking loop that allows for walking but does not have an exit door that might allow for egress into an insecure area. In contrast, exit doors that can be opened by residents and allow them control of their own exit to another secure area can be therapeutic.
4.8.8. Peace and Quiet
Reduced stimulation environments, such as quiet rooms with soft colors, an absence of paging systems, and only a few objects, have been reported to be helpful. Reduced stimulation interventions may use neutral colors on pictures and walls and a consistent daily routine, with no televisions, radios, or telephones (except one phone for emergencies).
4.8.9. Nature Environments
Natural environments, including pictures of fish and/or sounds of bird songs or bubbling brooks, have been used to decrease agitation in the shower. Visual, auditory, and olfactory stimuli have been used to make nursing home corridors feel like home or like a natural outdoor environment, thereby improving resident and staff well-being and decreasing trespassing and exit seeking behaviors.
4.9. Medical/Nursing Care Interventions
Although medical and nursing care interventions would not usually be considered cognitive or behavioral treatments, they are included here because it is the behavioral assessment that is used to reveal the underlying etiology of negative affect or behavior problems that allows a medical or nursing intervention to relieve the condition. Therefore, interventions such as light therapy to improve sleep, pain management, reduction of discomfort by improved seating or positioning, and removal of physical restraints all have been associated with improvement in behavior. Similarly, the provision of eyeglasses or hearing aids can be an important intervention for treating sensory deprivation and loneliness as well as the ensuing depressed affect and problem behaviors.
A behavioral approach may also guide nursing interventions directly in helping elderly persons to achieve maximal functional levels. One example is that of cognitive interventions that include cueing and task breakdown. Another example involves toileting management protocols. Two types of toileting protocols have been described. In scheduled or timed voiding toileting, patients are taken to the toilet either at fixed times (usually every 2 hours) or on a schedule that is based on their voiding pattern. Prompted voiding involves asking residents on a regular basis whether they need assistance with toileting. Patients are helped when they indicate such a need. Both types of protocols can be effective in reducing incontinence.
4.10. Staff/Caregiver Training and Management
Staff training programs can take many forms and focus on any of the interventions outlined previously. Many focus on improved understanding of older persons and the impact of the disease and on improving verbal and nonverbal communications with persons suffering from dementia. Given that good communication skills are crucial for proper assessment of a problem area and for delivery of any intervention, training for such communication is the basis of good caregiving. Examples of methods for simplifying and clarifying communication using both verbal and nonverbal communication channels were provided by Beck and Heacock in 1988. Changing caregiver behavior through training is a complex and difficult challenge and often requires ongoing instruction, modeling, monitoring, feedback, and support of the caregiver. Therefore, in institutional settings, staff training is closely tied to management.
4.11. Combination Therapies
Good care involves using combinations of the available interventions and tailoring them to the needs, abilities, and preferences of the older person. In addition, many intervention programs combine elements from various intervention modalities.
5. Efficacy, Effectiveness, And Utility
There are two basic questions concerning interventions. First, are interventions effective? Second, what is the cost of interventions? There is insufficient research to answer either question, although partial answers have been suggested. One study reported the benefits of validation therapy for reducing aggressive behavior, and another reported on the benefits of reality orientation on orientation and affect, in comparison with control groups. However, in a review of reality orientation, validation therapy, and reminiscence therapy, Gagnon concluded that reality orientation and validity therapy do not produce sufficient change to justify their costs. Cohen-Mansfield reviewed 83 studies of nonpharmacological interventions for inappropriate behaviors in dementia and described the majority as reporting a positive, but not always significant, impact. Many of the studies included small samples and other methodological limitations, most often resulting from limited funding for this type of research.
There are few studies that have examined the question of cost. One study by Rovner and colleagues implemented an intervention that included daily group-structured activities, reduction of psychotropic medications, and weekly educational rounds with staff members. They calculated the cost of the 6-month intervention program at $8.94 per patient per day. Another study by Schnelle et al. examined ways in which to improve nursing practices concerning exercise and incontinence care and concluded that current staffing levels are inadequate to provide good care.
Given the early stage of research in this field, there is an urgent need to increase our understanding about the following basic questions. Which interventions are efficacious for which individuals? Which aspects of an intervention are necessary for it to be efficacious? What are the active ingredients, or principles at work, in various interventions? Which personal characteristics (e.g., gender, culture, prior stress) need to be considered when matching an intervention with a person? Process variables (e.g., the person who is delivering the intervention, the timing of the intervention) and their significance need to be elucidated. Only after we have answers to these basic questions can the questions of effectiveness and costs be addressed properly.
References:
- Beck, A. (1997). The past and future of cognitive therapy. Journal of Psychotherapy Practice & Research, 6, 276–284.
- Beck, C., & Heacock, P. (1988). Nursing interventions for patients with Alzheimer’s disease. Nursing Clinics of North America, 23, 95–124.
- Camp, C. J., Foss, J. W., O’Hanlon, A. M., & Stevens, A. B. (1996). Memory interventions for persons with dementia. Applied Cognitive Psychology, 10, 193–210.
- Cohen-Mansfield, J. (2000). Theoretical frameworks for behavioral problems in dementia. Alzheimer’s Care Quarterly, 1(4), 8–21.
- Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, summary, and critique. American Journal of Geriatric Psychiatry, 9, 361–381.
- Day, K., & Calkins, M. P. (2002). Design and dementia. In R. B. Betchel, & A. Churchman (Eds.), Handbook of environmental psychology (pp. 374–393). New York: John Wiley.
- Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.
- Feil, N. (1982). Validation: The Feil method. Cleveland, OH: Feil Productions.
- Gibbons, A. C. (1988). A review of literature for music development/education and music therapy with the elderly. Music Therapy Perspectives, 5, 33–40.
- Lewinson, P. M., & Youngren, M. A. (1976). The symptoms of depression. Comprehensive Therapy, 2(8), 62–69.
- Opie, J., Rosewarne, R., & O’Connor, D. (1999). The efficacy of psychosocial approaches to behaviour disorders in dementia: A systematic literature review. Australian and New Zealand Journal of Psychiatry, 33, 789–799.
- Schnelle, J. (1990). Treatment of urinary incontinence in nursing home patients by prompted voiding. Journal of the American Geriatrics Society, 38, 356–360.
- Seligman, M. E. P. (1974). Depression and learned helplessness. In R. J. Friedman, & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. Washington, DC: Winston–Wiley.
- Seligman, M. E. P. (1975). Helplessness: On depression, development, and death. San Francisco: Freeman.
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