Geriatric Issues Flashcards
Clinical Problems of Aging
- In younger adults individual diseases tend to have a ____ distinct pathophysiology with ____-_____ risk factors
- Diseases in older persons may have a _____ distinc pathophysiology and are often the result of _____ ______ mechanism
- Causes and clinical manifestations are less _____ and can ____ widely between individuals
- Care of older patients demands an understanding of the effects of _____ on human physiology and a broader perspective that incorporates geriatric ______
- more distinct patho with well-defined risk factors
- less distinct patho, failed homeostatic mechanisms
- less specific, vary
- aging, syndromes
Clinical Problems of Aging
- _____ aging emerged as a worldwide phenomenon for the first time in history within the past century.
- Governments and societies-as well as families and communities now face new s____ and ec____ challenges that affect health care
- While the number of children has remained relatively stable, explosive ____ has occurred among older populations (especially among the oldest)
- The number of persons aged 80-89 yrs more than _____ btwn 1960-2010
- _______ has added ave of 30 yrs to lifespan
- Population
- social and economic
- growth
- tripled
- Vaccinations
Population Aging and Health
- Many chronic diseases increase in prevalence with age and it is not unusual for older persons to have _____ chronic diseases
Major issues with aging include:
- Increasing _____ (difficulty with (1) )
- C______ impairment
- Increased use of healtcare r_____/increased health ex______
- Expenditures increase with ___, degree of _____, and are highest in the last ____ of life
- multiple
- disability (Activities of daily living)
- Cognitive
- resources, expenditures
- age, degree of disability, last year of life
Basic Activities of Daily Living
Basic Activities of Daily Living =
- Personal hy_____
- Dre____ and undressing
- E_____
- ______ from bed to chair and back
- ______ controlling urinary and fecal discharge
- Using the t_____
- ______ around (as opposed to being bedridden)
Self-Care tasks
- hygiene
- Dressing
- Eating
- Transferring
- Voluntarily
- toilet
- Moving
Instrumental Activities of Daily Living
Not Necessary for Fundamental Functioning, but Perman an individual to?
- Doing light ____work
- Preparing m_____
- Taking m______
- _____ for groceries or clothes
- Using the t_____
- Managing mo___
- Using te_____
Live independently (autonomously)
- housework
- meals
- medications
- shopping
- telephone
- money
- technology
Erikson’s integrity vs. despair: sense of self vs. depression
Systemic Effects of Aging
- Systemic consequences of aging are widespread but can be clustered into four main domains or processes
- Body _____
- Balance between (1) and (1)
- (1) like the endocrine and nervous system that maintain ______
- Neuro_______
- Body Composition
- Energy availability and energy demands
- Signaling networks endocrine and nervous system that maintain homeostasis
- Neurodegeneration
Systemic Effects of Aging (Notes)
- Changes in Body Composition
- Decline in? Increase in?
- How your body balance energy and for any chronic conditions
- _____ more quickly
- Body systems falter
- Ex waking up for school, as an older person cannot?
- Neurodegeneration such as
- brain _____
- Decline in lean body mass (muscle and visceral tissue of organs), Increase in body fat percentage
- Fatigue more quickly
- Cannot jump out of bed as quickly bc baroreceptor reflex starts to fail
- Brain atrophy
A unifying model of aging, frailty, and the geriatric syndromes
Domains of the aging phenotype ->
(1) Disease susceptibility, reduced functional reserve, reduced healing capacity, unstable health, failure to thrive ->
Geriatric Syndromes
- An_____/malnutrition
- G____ disorders/falls
- Dis_____
- D_____ susceptibility/Comorbidity
- Urinary ______
- Decubitus _____
- S______ disorders
- Del_____
- C_______ impairment
Frailty (low resistance to stress, very weak, essentially one stressor away from rapid decline)
- Anorexia
- Gait
- Disability
- Disease
- incontinence
- ulcers
- sleep disorders
- Delirium
- Cognitive
Being older does not automatically make someon frail: when it develops means that they are in the last stage of their lives -> vulnerable to 1 or more of these geriatric syndromes -> then can very quickly lead to end of life
Examples of Assessment of the Four Domains of the Aging Phenotype
Body Composition Assessment
- Self report X
- Physical Examination =
- Lab values =
- Imaging =
- Other = H___static weighing
- Self Report X
- Muscle strength testing (isometric and isokinetic), Anthropometrics (weight, height, BMI, waist circumference, arm and leg circumference, skin fold)
- Biomarkers (24h creatinuria or 3 methyl-histidine)
- CT, MRI, DEXA
- Hydrostatic weighing
Energetics Assessment
- Self Report =
- Physical Examination =
- Lab Values X
- Imaging =
- Other =
- Self reported questionnaires investigating physical activity, sense of fatigue/exhaution , exercise tolerance
- Performance based tests of physical function
- X
- Magnetic resonance spectroscopy
- RMR, treadmill testing of O2 consumption during walking, objective measures of physical activity (accelerometers, double labeled water)
Homeostatic Regulation Assessment
- Self report X
- Physical examination X
- Lab values =
- Imaging X
- Other =
- X
- X
- nutritional biomarkers (eg vitamins, antioxidants)/ baseline lvl of biomarkers and hormone lvls/ inflammatory markers (ESR, CRP, IL6, TNF a)
- X
- Stress response, response to provocative tests, such as oral glucose tolerance test, dexamethasone test, and others
Neurodegeneration Assessment
- Self Report X
- Physical Examination =
- Lab values X
- Imaging =
- Other =
- X
- Objective assessment of gait, balance, reaction time, coordination standard neurologic exam, including assessment of global cognition
- X
- MRI, fMRI, PET, and other dnamic imaging techniques
- Evoked potentials electroneurography and electromyography
Body Composition
- Profound changes in body composition may be the most _____ effect of aging
- While body weight tends to increase through childhood, puberty, and adulthood until late middle age, it tends to decline in men ages __-__ and women somewhat _____
- Lean body mass (muscle and visceral organs), decreses steadily after age ___, while fat mass tends to increase in middle age and then _____ in late life, reflecting trajectory of weight gain
- _____ circumference continues to increase across the life span, a pattern suggesting their _____ fat, which is responsible for most of the _______ consequences of obesity, continue to accumulate
- ______ strength declines with aging, this decrease not only affects the ______ status but also is a strong independent predictor of ______
- evident
- 65-70, later
- 30, fat increases then decreases later in life
- Waist, visceral, pathologic
- Muscle strength declines, functional status, mortality
- Fast twitch muscle is that rapid muscle contraction vs. slow twitch muscle is what allows us to go on a long run example*
- Low impact strength training very helpful in older age to low decline in weak muscle mass and bones, and anything that requires body awareness and balance like yoga, tai chai -> decreases falls*
Men Vs. Women Body Composition
_____ Trajectory
- (1) declines in both
- (1) increases than decreases after a certain age
- (1) increases then decreases
- (1) increases until the end
Same
- Lean body mass
- weight
- fat
- waist circumference
Body Composition cont.
Progressive de______ and architectural modification occur in bone, resulting in ->
Progressive loss of ____ strength increasing risk of ______
Rate of bone loss greater in which gender?
All changes in body composition with aging are influenced not only by aging and illness but also by lifestyle factors such as (2)
demineralization
bone, fracture (when an older person falls, more likely to fracture, then if they have to be immobilized in order to heal -> more bone weakness)
Women > Men - tend to lose bone mass at younger age and more quickly reach threshold of low bone strength that increases rik of fracture
Physical acitivity and diet
Balance Btwn Energy Availability and Demand
- A person’s “fitness” (defines as the maximal possible _____ production over an extended period of ____) ____ with age
- Energy production and consumption (measured indirectly by _____ consumption) declines progressively with age and the rate is accelerated in persons who are s_____ and affected by chronic _____
- Energetic eff_____ declines with age
- Resting (or basal) metabolic rate (RMR) declines with age and is only partially explained by the decline in metabolically active ____ body mass
- Aging individuals with (1) expend more energy in the _____ state (dt activation of compensatory mechanisms) which leads to higher RMR, contributes to ____ loss observed with illness, and is an independent risk factor for mortality
- maximal possible energy production over an extended period of time
- oxygen, sedentary, chronic illness
- efficiency
- lean body mass
- chronic illness -> resting state, weight loss
Chronic illness ie) heart disease, DM, respiratory disease such as COPD -> higher resting metabolic rate
Balance Btwn Energy Availability and Energy Demand
- Moreover, it is not well understood why but old age, chronic illness, and physical impairment all increase the energetic cost of motor activities - ie despite available energy levels being lower, chronically ill older people require more energy both at rest and during all physical activities
- For this reason, sick older inviduals often consume all their available energy performing the most basic (1) leaving them fatigued and mostly _______
consume most energy doing
basic ADLS - fatigued and mostly sedentary
Neurodegeneration
- Brain _____ occurs with aging after the age of __ years. Atrophy proceeds at _______ rates in different _____ of the brain.
- Age associated brain atrophy may contribute to age-related declines in c_____ and m____ function
- In mild cognitive impairment, atrophy has been found mostly in the (2) parts of the brain - function of both (2)
- Atrophy, 60 yrs, varying rates in different parts of the brain
- cognitive and motor function
- Prefrontal cortex: mini executive, regulates attention, organize tasks, manage life
- Hippocampus: short term memory and learning
Neurodegeneration
Other changes in the brain of older ppl compared ot younger ppl include:
- less c_______ btwn brain regions
- less l________ of cortical activity during tasks requiring executive function
- can see these changes (atrophy) WITHOUT any cognitive impairment -> so its all about how the person and their brain _____ to normal changes of aging*
- So keeping mentally active will see less of a decline in cognitive function such as?
Brain pathology typically been associated with specific disease (such as (2) considered the pathologic hallmarks of Alzheimer’s disease) have been found in the _____ of many older individuals who had _____ cognition, as assessed by extensive testing in year before death
- less coordination
- less localization
- adapts*
- playing bridge, knitting “use it or lost it”
Amyloid plaques, neurofibrillary tangles found in autopsies of ppl with normal cognition
Neurodegeneration
The spinal cord also experiences changes after the age 60 yrs, including reduced # of _____ neurons and damage to ______
As motor units become _____, they decline in _____ at a rate of ~1% per year, starting after the _____ decade
These larger motor units contributes to reductions in ____-motor and manual dex_____
**Taken together the age-related changes in the brain and spinal cord are thought to be ________ - an attempt taken by the nervous system to re-organize and compensate for aging - for this reason signficant declines in function are not always present in older individuals***
- motor neurons, damage to myelin
- larger, decline in number, third
- reductions in fine motor and dexterity (handwriting gets messier)
- Compensatory changes -by increased branching complexity and service ot larger motor units
Alterations in Signaling Networks that Maintain Homeostasis
- Signaling networks that maintain homeostasis include hormonal signaling via the ______ system, electrical via _______ system, and signaling that involves cy_____ release and im_____ function
- Age related changes develop in ______ and affect one another through many feed-foward and _______ loops
- Some ______ interactions are well understood, while others are not
- endocrine, nervous, cytokine and immune
- parallel, feedback
- systemic
Alterations in Signaling Networks that Maintain Homeostasis
Examples of known interactions:
- age related changes in (1) changes in the hormonal and cytokine/adipokine regulation of e_____ balance
- higher ____ mass leads to ______ resistance, and altered leptin/adiponectin can promote _________
- these first two are from changes in body composition effecting endocrine and nervous system
- increased in______, lower te_____, and less IGF-1 (associated w aging) contributes to the decline in _____ mass and strength
- Age related neurodegeneration can affect hy_____ and au_____ functioning which in turn can affect nearly all _____ maintenance systems
- body composition, energy
- fat mass -> insulin resistance, neurodegeneration
- inflammation, lower testosterone, decline in muscle mass and strength
- hypothalamus, autonomic, homeostatic
Clinical Problems of Aging: Frailty
The phenotype (or outward manifestation) of the aging process is characterized by
- Increased susceptibility to d______
- High risk of ______ coexisting diseases
- Impaired response to ____ (including limited ability to h_____ or recover after an acute disease)
- Emergence of “geriatric _____” (with stereotyped clinical manifestations but multifactorial causes),
- altered ______ to treatment
- high risk of dis_____
- and loss of personal _____ with all its psychological and social consequences
- disease
- multiple
- stress, heal
- “geriatric syndromes”
- response
- dsiability
- autonomy
Frailty
- The aging phenotype may make the detection and treatment of specific overlaying pathological conditions difficult, why?
- An extreme presentation of the aging phenotype (obvious problems in multiple main systems affected by aging, they tend toward extreme degrees of susceptibility and loss of resilience) - is a global term referred as (1)
- Frailty, in turn, can lead or worsen common “_____ ______”
- older person with UTI or PNA, may only have sx of AMS
- FRAILTY
- “geriatric syndromes”
Frailty
Frailty has been described as a physiologic syndrome characterized by decreased (2)** that results from cumulative decline across multiple ______ systems, and that causes vulnerability to _____ outcomes and a high risk of ______
Decreased reserve and Diminished resistance to stressors, physiologic, adverse outcomes, death
Frailty Index
(5) Signs
These 5 signs of Frailty are included in the “Frailty Index” which has been shown to be a reliable predtor of (2)
- Weight loss
- Fatigue
- Impaired grip strength
- Diminished physical activity
- Slow gait
- survival in community dwelling
- survival, length of stay and discharge location in acute care settings
Frailty vs. Chronic Disease and Stress
It’s important to understand the potential interactions between frailty and pre-existing or newly emerging specific pathological conditions
- Chronic disease vs. Frailty =
- Frailty vs. Acute stress =
- Pre-existing chronic diseases (DM, HF) may trigger the onset of frailty in an aging person, worsen the condition, QOL, and lead to mortality
- Presence of frailty in an older person can mean that injury, disease, or impairment may trigger a rapid decline in health precipitating signficant disabilty or death (falls and fractures bone = increased risk of mortality within 6m of injury)
4 Clinical Consequences of Frailty
- Ineffective or incomplete ________ response to _____
- Multiple coexisting ______ (multi-comorbidity) and ________
- Physical _______
- Geriatric ________
- homeostatic response to stress
- multiple diseases and polypharmacy
- disability
- geriatric syndromes
Geriatric Syndromes
- In_______
- De_______
- F_____
- Pressure ______
- S______ disorders
- Problems with e_____ or f______
- P____
- Depressed _______
De_____ and physical d_____ are also sometimes considered to be geriatric syndromes
- Incontinence
- Delirium
- Falls
- Pressure ulcers
- Sleep disorders
- Problems w eating or feeding
- Pain
- Depressed mood
Dementia, physical disability
Low Resistance to Stress
At an early stage and in the absence of stress, mildly frail older individuals may appear to be _______
However, they have reduced ability to c____ with challenges, such as acute diseases, traumas, or surgical procedures
For example, acute illness involving a hospital stay is associated with undern______, and ina_______, causing residual m_____ mass to fail to meet the minimal requirement for ______ - leading to ______ that may be unrecoverable
Older individuals have a reduced ability to tolerate in______ dt diminished (1) responses - infections are more likely to become severe or sy______ and resolve more ______
Treatment plans may need to be modified to enhance tolerance, hospitalization and ___-rest should be avoided, infections should be p______, anticipated, and ass______ treated.
- normal
- cannot cope with challenges
- undernutrition, inactivity, muscle mass too little to walk -> disability
- infections, dt diminished inflammatory/immune response, systemic, resolve more slowly
- avoid bed-rest, prevent infections and assertively treat
Comorbidity and Polypharmacy
Drug treatment planning is made more complex bc of comorbid diseases may affect the _________ of drugs leading to fluctuation in th_______ levels and increased risk of?
Patients with many diseases are usually prescribed multiple drugs, especially when they are cared for multiple ______ who do not _________
The risk of adverse drug r______, drug-drug ______, and poor c______ increases dramatically with the NUMBER of drugs prescribed and with the severity of frailty
- pharmacokinetics, therapeutic levels, risk of under or overdosing
- specialists who do not communicate
- adverse reactions, drug interactions, poor compliance
Rules to Minimize Effects of Polypharmacy
- Always ask patients to _____ in all medications, including prescription drugs, OTC products, vitamin supplements, and herbal preparations (the “_____ ____ test”)
- Screen for ________ drugs; those without a clear indication should be ________
- S______ the regimen in terms of number of agents and sch______, try to avoid frequent ch_____, and use single _____ dose regimens whenever possible
- Avoid drugs that are expensive or not covered by _______ whenever possible
- ______ the number of drugs to those that are absolutely ______, and always check for possible in______
- Make sure that the pt or an available caregiver understands the administered regimen, and provide legible wr_____ ins______
- Schedule periodic medication ________
- bring “brown bag test”
- unnecessary, discontinued
- Simplify, schedule, avoid changes, singe daily dose
- Avoid not covered by insurance
- Minimize to absolutely essential drugs, check for interactions
- written instructions
- medication reviews
Disability
______, regardless of the criteria used for its defintion, is a robust and powerful risk factor for disability
Disability occurs late in the frailty process, after ______ and compensation are _______
THe multifactorial nature of disability in frail older persons reduces the capacity for ________ and interferes with functional recovery
Interventions aimed at preventing and reducing disability in older persons should have a _____ focus on both the precipitating cause and the systems needed for compensation
- For example, fall prevention in older adults should also include _____ and _____ training which will both be needed for recovery from a fall if it occurs
Frailty - powerful risk factor for disability
reserve, exhausted
dual focus
- balance and strength
Delirium
Delirium is an _____ disorder of disturbed _______ that ______ with time.
It affects 15-55% of _______ older patients
Can be transient and r_______ and a normal consequence of surgery, chronic disease, or inf______ in older ppl
Delirium ay be associated with a substantially increased risk for _______ and is an independent risk factor for morbidity, prolonged hospitalization, and ______. These associations are particulary strong in the ______ of old.
Strongest predisposing factors for delirium are ______, any other condiiton associated with chonic or transient n_______ dysfunction (neuro diseeases, alcohol consumption, psychoactive drugs), and sensory (v_____ and h_____) deprivation
acute disorder of disturbed attention that fluctuates with time
hospitalized
reversible, infection
dementia, death, oldest
dementia, neuro dysfunction, visual and hearing deprivation
Delirium Clinical Presentation
Is heterogenous, but frequent features include
- A rapid decline in the level of _______, with difficulty focusing, shifting, or sustaining ______
- Cognitive changes (rumbling incoherent ______, ______ gaps, dis______, hall______) not explained by dementia and
- A medical ______ suggestive of a pre-existing ______ impairment, fr_____, and co_____
- consciousness, attention
- incoherent speech, memory gaps, disorientation, hallucinations
- history of pre-existing cognitive impairment, frailty, comorbidity
Assessment and Management of Delirium
in Hospitalized Older Patients
Decide on hospital admission, what is the current metnal status, prevent from becoming delirious
- RO dementia, depression, mania, psychosis
- Then address the delirium the best we can
Falls and Balance Disorders
Unstable gait and falls are serious concerns in the older adult bc they lead not only ot injury but also to restricted _____, increased (1) utilization, and even death
Poor muscle strenght, neural damage in the _____ ganglia and cer______, dia_____, and peripheral ______ are all recognized risk factors of falls
Interventions depend on the factors identified but often include ______ adjustment, _____ therapy, and _____ modificiations
restricted activity, increased health care utilization
neural damage to basal ganglia, cerebellum, diabetes, peripheral neuropathy
medication adjustment, physical therapy, home modifications (throw rugs)
Falls and Balance Disorders
Patients with a positive history of multiple falls as well as well persons who have sustained one or more injurious falls should undergo an evaluation of g_____ and b______ as well as a targeted___ and ____ detect sensory, nervous system, brain, CV, and MSK conditions
Supplementation with (1) may help reduce falls, esp in older persons with low levels
gait and balance, history and physical
Vitamin D at 800IU daily
Persistant Pain
Pain from _____ sources is the most common symptom reported by older adults
Persistent pain results in restricted act_____, dep______, s_____ disorders, and social _______ and increased risk of adverse events due to medication
The mot common causes of persistent pain are _________ problems, but n_______ pain and i______ pain occur frequently, multiple concurrent causes are often found
For persistent pain, (1) are appropriate and should be combined with ________ approaches such as splints, physical exercise, heat, and other modalities
______ of the patient and mutually agreed upon _____ setting are important since pain is not usually fully eliminated but rather controlled to a ______ level that maximizes ______ while minimizing adverse effects
multiple
activity, depression, sleep, social isolation
musculoskeletal, neuropathic, ischemic
regular analgesic schedule + nonpharmacologic
Education of patient, set goals, tolerable level, maximize function
Urinary Incontinence
=
Effects which gender more? Approx ___% will experience some form of urinary incontinence over a lifetime
Risk factors: _____ age, ____ race, child____, and medical co_____
Involuntary leakage of urine that is highly prevalent in older persons and has a profound negative impact on QOL
Females* 50% of american women
Increasing age, white race, childbirth, comorbidity
What type of Incontinence?
Failure of the sphincteric mechanism to remain closed when there is a sudden increase in intraabdoinal pressure, such as a cough or sneeze. In women it is often dt insuffient strength of pelvic floor muscles, while in men is almost exclusively secondary to prostate surgery
Stress Incontinence
What type of Incontinence?
The loss of urine accompanied by a sudden sensation of need to urinate and inability to control it and it is due to detrusor (bladder) muscle overactivity (lack of inhibition) caused by loss of neurological control or local irritation
Urge Incontinence
What type of Incontinence?
Characterized by urinary dribbling, either constantly or some period after urination. The condition is due to imparied detrusor (bladder) contractility (due usually to denervation, for example, in diabetes) or bladder outlet obtruction (prostate hypertrophy in men and cystocele in women)
Overflow Incontinence
finished urinating but urine still coming out
Urinary Incontinence
Urinary incontinence is connected to the disrupted aging systems that contribute to frailty, body composition changes (_____ of the bladder and pelvic floor muscle), and ____degeneration (both central and peripheral nervous systems)
_____ is a strong risk factor for urinary incontinence. Indeed, older women are more likely to have _____ (urge + stress) incontinence than any pure form
Like other geriatric syndromes, urinary incontinence derives from a predisposing condition (aging) superimposed on stressful precipitating factor (like a _____ or vaginal/uterine pr____)
The first line of treatment is bladder _____ associated with pelvic muscle exercise (1)
A long list of ______ can precipitate incontinence including? Whenever possible, these medications should be discontinued
atrphy, neurodegeneration
Frailty, mixed
UTI, prolapse
training, kegels
medications (diuretics, antidepressants, sedative hypnotics, adrenergic agonists or blocker, anticholinergic, and CCBs)
Under nutrition and Anorexia
Normal aging is associated with a _____ in food intake
To some extent, food intake is reduced bc _____ demand declines as a result of the combination of a lower level of physical activity, a decline in lean body mass, and slowed rates of protein turnover
Other contributors to decreased food intake include loss of ____ sensation, reduced st_____ compliance, higher circulating levels of ch______, and in men, low testosterone levels associated with increased ______
When food intake decreases to level below the reduced energy demand, the result is energy ___nutrition
Undernutrition in older ppl is asctd with multiple adverse health consequences, including impaired mu_____ function, decrease b____ mass, im_____ dysfunction, an____, reduced cognitive function, poor wound ______, delayed ______ from surgery, increases risk of falls, disability, and death
Despite these serious potential consequences, undernutrtion often remains unrecognized until it is well advanced bc weight loss tends to be ______ by both pts and clinicians
decline
energy
taste, stomach, cholecystikinin, leptin
malnutrition
muscle, bone, immune, anemia, healing, recovery
ignored
Undernutrition and Anorexia
Muscle w______ is a frequent feature of weight loss and malnutrition that is often associated with loss of subcutaneous fat
The main causes of weight loss are anorexia, c______, sarcopenia, malabsorption, hypermetabolism, and de______, almost always in various combinations
Other important causes include a recent move to a (1) setting, acute _____ (often with inflammation), hospitalization with (1) for as little as 1-2 days, dep_____, drugs that cause anorexia and nausea (dig, antibiotics), sw_____ problems, oral infections, dental problems, GI pathology, thyroid and other hormonal problems, poverty, isolation, reduced access to food
wasting
cachexia, dehydration
long term care seeting, acute illness, bed rest, depression, swallowing
Undernutrition and Anorexia
Patients or caregivers should be taught to ______ weight regularly at home, the patient should be weighed at each clinical encounter, and a record of serial weights should be maintained in the medical record
When an older person has malnutrition, the diet should be li_____ and dietary _____ lifted as much as possible
Nutritional ______ should be given between eals to avoid interference with food intake at mealtime. Limited evidence supports the use of any pharm intervention to treat weight loss
Is weight loss good in old age?
record
liberalized, dietary restrictions lifted
supplements between meals
Little evidence that intentional weight loss in overweight prolongs life, weight loss after 70 should probably be limited to persons w extreme obesity should always be medically supervised
(WE WANT THEM A BIT CHUBBY)
