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KMK > Human Development > Flashcards

Human Development Flashcards

1
Q

At what age can you start using VEP?

A

1 month

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2
Q

Infants reach VA of 20/20 w/ VEP at what age?

A

6 months

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3
Q

VEP

A

provide info about the integrity of the pathway of the visual system
- does NOT provide info about the ability to perceive a visual stimuli

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4
Q

Subjective methods show VA 20/20 by what age? (ex. snellen, forced-choice method)

A

3-4yo

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5
Q

Most common subjective method used for infants?

A

forced choice preferential looking (FCPL)

  • infants prefer to look at a patterned stimulus rather than a solid background
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6
Q

Teller acuity

A

based on FCPL and widely used in pediatric clinics for infants up to 12 months

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7
Q

Examples of FCPL

A

broken wheel, teller acuity cards, cardiff

  • used for infants up to 18 months of age
  • Teller acuity cards are used up to 12 months of age
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8
Q

What’s the threshold of teller acuity cards?

A

75%

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9
Q

approximate spatial visual acuity using FCPL methods for:

1 month of age
1 yo
3-4 yo

A

1 month = 20/600 - 20/1200
1 year = 20/50-20/60
3-4 years = 20/20

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10
Q

OKN drum

A
  • elicit optokinetic nystagmus
  • slow eye mvmt will follow the direction of rotation the drum followed by a fast saccade in the OPPOSITE direction
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11
Q

Children will have asymmetric OKN until what age? Why?

A

3-5 yo due to incomplete development of the cortex

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12
Q

Normal vs abnormal OKN response

A

TONS = NORMAL
Temporal to Nasal

The other way is abnormal (Nasal to temporal)

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13
Q

positive vs negative OKN response

A

(+) = pt can see stripes
(-) = pt cannot see stripes or not paying attention

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14
Q

Vernier acuity (aka hyperacuity)

A

ability to detect misalignment of 2 lines
- develops slowly and worse than spatial acuity until 4 months of age

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15
Q

Vernier acuity reaches adult levels at what age?

A

6-8 years

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16
Q

Recognition acuity develops at what age?

A

the ability to detect optotypes
2-3 yo

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17
Q

Examples of recognition acuity

A

Allen pictures
American Optical pictures
HOTV chart
Lea symbols
Landolt C chart
Tumbling E chart

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18
Q

Snellen chart may be used at the beginning of what age?

A

2 yo or older may respond to the snellen chart

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19
Q

Why is VA poor until the age of 3-5 yo?

A
  • Foveal cones are short and wider in infants compared to PR in adults ( reaches adult levels at 4yo)
  • myelination of the visual pathway is incomplete (completed at 2 years old)
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20
Q

Lenght and density of cone reaches adult level at what age?

A

4 years old

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21
Q

Infants will not have a bright foveal reflex until what age?

A

15 months

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22
Q

Myelineation is complete at what age?

A

2 years

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23
Q

The visual cortex reaches adult level at what age?

A

6 months

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24
Q

Avg refractive error for a full term newborn?

A

+2.00D

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25
Q

Avg axial length for a full term newborn?

A

16mm (90D), compared to an adult axial length of 24mm (60D)

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26
Q

Emmetropization

A
  • processes that occurs in the eye after birth, eye losing 30D to reach refractive state of emmetropia
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27
Q

Greatest degree of emmetropization occurs at what age?

A

within the first 2 years of life in response to retinal blur and location of blur relative to the retina

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28
Q

What’s the mean refractive error for..

10 weeks of age
1 year of age

A

10 weeks of age = +4.00D
1 year of age = +0.50D to +1.00D

myopia increase in prevalence during school years

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29
Q

When does emmetropization NOT occur?

A

extreme refractive erros >+5.00D/-4.50D

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30
Q

Premature infants (<37 weeks) or ROP usually have what kind of refractive error?

A

high myopia, high astig or anisometropia at birth but often have normal emmetropization with similar levels of hyperopia and astig by 12 months of age compared to full term infant

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31
Q

Astigmatism in newnobrn

A

astigmatism is present in 50% of newborn infant, with an avg 2.00D ATR

by 2 years, astig decr to 0.50D or less

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32
Q

Accommodation reaches adult levels at what age?

A

3-4 months

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33
Q

Vergence occurs at what age?

Divergence
Convergence
Vergence reaches adult levels at what age?

A

Divergence = 1 month
Convergence = 2 months
Reaches adult levels = 6 months

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34
Q

Accommodation and vergence becomes linked at what age?

A

2 months

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35
Q

Fixation, saccades, pursuits reaches adult levels at what age?

A

6 months

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36
Q

Stereopsis reaches adult levels at what age?

A

6 months

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37
Q

Immaturity of which part of the brain is thought to be the initial limiting factor to sensory and stereopsis before 3 months of age?

A

immaturity of the visual cortex

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38
Q

Stereoacuity reaches adult levels of 1 min of arc at what age?

A

24 months

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39
Q

Testing for sensory fusion and stereopsis in infants is very important to rule out developmental anomalies (strab, anisometropia) that may result in amblyopia

A
  • Frisby test plates (FCPL method for children 13 months or older)
  • Lang stereo test (6 months - 4 years)
  • Random dot E (3 years or older)
  • Randot (4 y or older)
  • W4D (sensory fusion)
  • Keystone visual skills card (sensory fusion for children 4 y or older)
  • Vectograms (3 y or older)
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40
Q

Contrast sensitivity reaches adult levels at what age?

A

7-9 years

initial limitations due to immature retinal PR

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41
Q

Critical flicker frequency reaches adult levels by what age?

A

3 months

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42
Q

Newborn primarily sees what color?

A

red until 3yo

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43
Q

Ability to discriminate color occurs at what age?

A

3 months

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44
Q

scotopic sensitivity curve in infants reaches adult levels at what age?

A

4-7 months

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45
Q

Human development review

A
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46
Q

ocular dominance histogram

A

visually displays the number of cells that are driven by the left eye only, right eye only, or both eyes along with the degree of neural input from the right vs left eye for binocular cortical cells
- reflection of one hemisphere of the brain

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47
Q

ocular dominance histogram:
What does column 1 represent?

A

cortical cells driven by the contralateral eye

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48
Q

ocular dominance histogram:
What does column 7 represent?

A

cells driven by the ipsilateral eye

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49
Q

ocular dominance histogram:
What does column 2-6 represent?

A

binocular cortical cells that receive some degree of input from both eyes

50
Q

ocular dominance histogram:
Which column represents cortical cells that receive equal input from the right and left eye?

A

column 4

51
Q

What would the ocular dominance histogram look like if the OD was occluded since birth? (Right hemisphere)

A
52
Q

When does the critical period occur?

A

7-9 yo, first 2 years of life are most sensitive in terms of visual development

53
Q

What would the ocular dominance histogram look like if the pt has an alternating strabismus? (Right hemisphere)

A

column 1 and 7 will have the most cortical cells
- no binocular cells represented
- overtime almost ALL cortical cells become monocularly driven by one eye or the other and the pt will have abnormal binocular vision with reduced stereopsis

54
Q

Amblyopia

A

Dissimilar retinal images or monocular deprivation that occurs during the critical period results in reduced cortical connection in one eye compared to the other and causes a decr in vision

55
Q

3 types of amblyopia

A
  • occlusion
  • refractive (anisometropic, isometropic, meridional)
  • strabismic
56
Q

Occlusion amblyopia/Deprivation amblyopia

A
  • occurs when one eye is deprived of vision during the critical period preventing development of connection
  • visual cortex becomes completely driven by the fellow eye without the occlusion
  • Congenital cataract, ptosis, or corneal opacities may lead to occlusion amblyopia
57
Q

Refractive amblyopia

A
  • occurs when there is an asymmetric or large uncorrected RE in the 2 eyes, resulting in blurred img and decr natural input to cortical cells from one or both eyes
  • there are 3 types anisometropic, isometropic, meridional
58
Q

Anisometropic

A
  • occurs when there is a large asymmetric RE between the eyes.
    This asymmetry leads to a clear retinal img in one eye and blurred retinal img in the other eye.
    the eye with blurred retinal img will develop less cortical connections, leading to amblyopia
59
Q

Risk of development and severity of amblyopia is much greater in pts with what kind of refractive error

A

anisometropic hyperopia

60
Q

Isometropic amblyopia

A

occurs when there is a large symmetrical RE in each eye. b/c the RE is so large neither eye will receive a clear retinal img, resulting in reduced neural input to the visual cortex in each eye and decreased vision

61
Q

Meridional amblyopia

A

occurs with large uncorrected amt of astig during the critical period
- certain cells in the visual cortex respond more to a certain line orientation compared to others
- uncorrected astig leads to a near line and a far line on either side of the retina. The line closest to the retina will be clearer than the other line image = decr cortical connection and sensitivity to stimuli with the same orientation as the line img furtherest from the retina

62
Q

Strabismic amblyopia

A

occurs when there is a constant, unilat deviation of one eye compared to the other
- in order to prevent diplopia and confusion caused by the ocular deviation = supression/amblyopia

63
Q

T/F alternating suppression will not reuslt in amblyopia

A

T, but they will have poor stereopsis

64
Q

Infant reflexes

A

Survival reflexes
- Sucking reflex
- Rooting reflex

Non-survival reflexes
- Palmar grasp
- Babinski reflex
- Plantar grasp
- Placing
- Stepping
- Fencing

65
Q

Sucking reflex

A

important for feeding
- involuntary until 2 months of age

66
Q

Root reflex

A

stroke a newborn’s cheek and it turns its head in the same direction and opens its mouth

67
Q

Palmar grasp

A

grasp your finger as you apply a light touch to its palm

68
Q

Babinski reflex

A

stroke an infants foot will cause its toses to fan outward and towards the infants body

69
Q

Plantar grasp

A

toes will curl downward if plantar surface of the foot is touched

70
Q

Placing

A

As baby is held next to a surface it will lift its foot as if its stepping onto that surface

71
Q

Stepping

A

When baby is held up so that its feet are touching a surface, the baby should mimic walking

72
Q

Fencing

A

When you turn a baby’s head to one side, arm and leg on that side should extend

flexion should occur of the arm and leg on the contralateral side

73
Q

Reflexes gradually become voluntary at what age?

A

3 months (as the cortex matures and neural pathways become myelinated)

74
Q

Infants who continue to demonstrate primitive reflexes should be tested for what?

A

developmental delays

75
Q

Which one do children learn first? motor or fine motor control?

A

Motor (larger muscles develop before smaller muscles)

76
Q

Name important milestones for fine/motor development for the following ages: (Arnold Giselle)

5 months
7 months
9-10 months
12 months
15 months
15 months - 2 years
2 years
3 years
5 years
6 years

A

5 months: raise head from lying position and able to roll over from the back of their stomachs

7 months: creep (drag on stomach), pincer grasp (holding objects btw thumb and forefinger)

9-10 months: crawl and cruise (few steps if holding on to furniture)

12 months: Walk w/ someone holding hand, refine pincer grasp

15 months: Walk by themselves, throw objects, turn pages of book, hold spoon, build tower w/ 2 blocks

15 months - 2 years: wlak backwards, climb up and stairs w/assistance, jump, scribble on paper

2 years: walk up/down stairs w/o assistance, run faster, open doors, kick ball, build tower with 7 blocks

3 years: manipulate buttons and scissors, walk up the stairs like an adult, build a tower with 10 blocks, draw a circle

5 years: Children can copy a circle (3 years), cross (3.5), square (4), triangle (5)

6 years: child’s motor skills begin to vary (sports vs playing an instrument)

77
Q

At what age can a child copy the following shapes?

Circle
Cross
Square
Triangle

A

Circle 3
Cross 3.5
Square 4
Triangle 5

78
Q

Quick review of gross and fine motor development:

7 months
1 year
2 year
2-3 yo
5 yo

A

7 months - sit by themselves
1 year - walk
2 year - jump
2-3 yo - stack blocks, draw circle
5 yo - draw triangle

79
Q

4 stages of cognition (Jean Piagets)

Sensorimotor stage (birth - 2 years)
Birth (1 month)
Primary circular reaction (1-4 months)
Secondary circular reaction (4-10 months)
Coordination of schemes (10 months - 1 year)
Tertiary circular reactions (12-18 months)
Beginnings of symbolic thought (18 months - 2 years)

A

Sensorimotor stage (birth - 2 years): childs cognitive understanding is shaped by its immediate experience within the first 2 years

Birth (1 month): newborns’ actions are limited to primitive reflexes. The newborn does not learn any behavior and does not see itself as different from other objects in its immediate environment

Primary circular reaction (1-4 months): newborn exhibits behavior that causes something to happen by chance, the baby then continues to repeat the behavior (ex. baby waves hands and its thumb makes contact w/ mouth, will continue to repeat behavior)

Secondary circular reaction (4-10 months) newborn shows behavior that has an effect external objects. The newborn then continues to repeat behavior in order to understand the consequences of that behavior (ex. throwing a cup repeatedly on the floor)

Coordination of schemes (10 months - 1 year) newborn can anticipate consequences from certain behaviors and learn to mimic actions displayed by people around them. The infants display a certain behavior to accomplish something (goal-oriented behavior)

Tertiary circular reactions (12-18 months): The infant develops an understanding of cause and effect relationships. They also actively explore new objects and experiment with new behaviors.

Beginnings of symbolic thought (18 months - 2 years ) The child can create memories and can also solve problems cognitively (rather than physically). The child is also able to mimic action that has been seen in the past (delayed imitation)

80
Q

What happens at the end of sensorimotor stage?

A

object permanency - child understands that a toy still exists even if that toy is no longer in the room

81
Q

Pre-operational stage (2-7 years)

A
  • stage begins after child understands object permanency
  • rapid development of new language
  • displays egocentrism
  • sense of time and space
  • learns concept of conservation (quantity does not change if shape changes
  • centration (focusing on only one aspect of an object)
  • once child suprass milestone of of centration, they are able to understand conservation
82
Q

Concrete Operations Stage (7-12yo)

A
  • mature understanding of conservation and reversibility
  • understand multiple aspects of an object that they have personal experience with, although they still do not have the full capability to think in abstractions
  • the child becomes less egocentric in though and starts to understand things from a different perspective
83
Q

Formal Operations Stage (12 yrs and older)

A
  • capable of abstract reasoning
  • more logical in their thought process
  • understand convos and reversibility in real and imagined situations
84
Q

Emotional development

3 month
4-5 months
10 months
2 years
5 years
6-12 months

A

3 month = smile

4-5 months = smile at faces they recognize, sense of self

10 months = moderate emotions

2 years = 2’ emotions ( beyond fear, anger, suprise, and joy), feel shame, show defiance and more independence

5 years = capable of controller their impulses and understanding of appropriate behavior, comply to parents wishes, traditional gender roles, independent activities

6-12 months = sense of competence and success, peer interaction is important at this stage, judge, cooperation/fairness/reciprocity, developing loyal friendship

85
Q

Language development

4 months
6 months
7 months
1 year
2 year
3 year
5 year
7 year

A

4 months = pay attention to sounds having meaning to them (mothers voice), will try to vocalize (babble, cry) if bothered or hungry

6 months = learn to coo

7 months = recognize emotion behind speech pattern, babble for long periods using different pitches, infants may try to mimic vocalization of adults

1 year = recognize words for common activities, consistently uses few single words correctly, begin to recognize names

2 year = vocab of 50 words, combine 2-3 words into short but meaningful sentences, respond when spoken to

3 year = vocab of 900 words and form larger and more complex sentences

5 year = vocab of 1500, children start to narrate long stories

7 year = able to have long convos and a solid understanding of spoken directions in a variety of situations

86
Q

The greatest risk for developmental delay

A

born premature (less than 35 weeks)
low birth weight (less than 5.5lbs)

87
Q

Developmental Tests

A

Denver II developmental screening test
Bartelle developmental inventory screening test

88
Q

Denver II developmental screening test

A
  • birth to age 6
  • 125 items divided into 4 sections =
    Social/personal = socialization inside and outside home (smile, wave bye-bye, play ball with examiner)

fine motor function = eye-hand coordination and manipulation of small objects and problem-solving ( put block in cup, build a tower of cubes)

gross motor function = sitting, walking, jumping (among other large muscle mvmts)

language = item assesses the ability to recognize, understand, produce, and utilize language

89
Q

Bartelle developmental inventory screening test

A

test for children age 6 months to 8 years
- direct observation of child abilities as well as reports from parents
- test consists of 96 items in areas of personal-social development, adaptation, gross and fine motor development, communication (receptive and expressive)

90
Q

Child development, quick review chart

A
91
Q

Visual information processing (VIP)

A

ability to discriminate, recognize, and interpret visual stimuli

  • impairments = learning-related visual disorders that can be misdx as developmental disabilities
92
Q

What are the 4 categories of VIP?

A
  1. Visual-spatial skills
  2. Visual analysis skills
  3. Visual attention and processing skills
  4. Visual motor integration
93
Q

Visual-spatial skills

A

awareness of one’s self in space related to other objects and the position of objects in space relative to each other
- the vestibular system works closely w/ the visual system to integrate info from objects in space to head mvmts

Bilateral integration = awareness and ability to use both sides of the body independently or together
Laterality = understanding own left and right
Directionality = ability to distinguish btw left and right of an object in space (distinguish if ball is on left or right side)

94
Q

S/S of lack of visual-spatial skills

A

lack of coordination, balance, not knowing left and right, reversing letters when writing

95
Q

Testing for visual-spatial skills:

Bilateral integration tests
Laterality
Directionality

A

Bilateral integration tests = standing test (body control), chalkboard circles test, standing angels in the snow

Laterality = Piaget’s right-left awareness

Directionality = Jordan’s left-right reversal test, reversals frequency test, Piaget’s right-left awareness test

96
Q

Visual analysis skill

A

gathering and evaluating visual info from the environment

What am I seeing?
Where is it located?
Why is it important?

describes the ability to use visual memory to identify objects in the environment when certain characteristics are missing or when distracting objects are present
- important for letter and number recognition, math, concentration, and completing tasks efficiently

97
Q

Categories of visual-analysis skill categories

A

Visual discrimination
Visual closure
Visual form constancy
Visual figure-ground
Visual spatial relations
Visual memory

98
Q

S/S of visual analysis

A

Difficulty learning the alphabet and recognizing words, difficulty writing, poor number recognition, difficulty with math, poor reading comprehension, short attention span

99
Q

Visual discrimination

A

ability to identify features of an object that differentiate it from different objects (pt picks the choice that best matches the given image)

100
Q

Visual closure

A

ability to identify an object when portions of it are missing

101
Q

Visual form constancy

A

identify a shape even when size, color, orientation of an object changes

102
Q

Visual figure-ground

A

ability to identify an object in the presence of a background

103
Q

Visual memory

A

ability to recall visual objects that were previously preesnt

104
Q

s/s of visual analysis skill

A

difficulty learning the alphabet or recognizing words, difficulty writing, poor number recognition, difficulty with math, poor reading comprehension and short attention span

105
Q

Tests for visual analysis skill

A

TVPS (Test of visual perceptual skill)
MFVP (Motor free vision perception test)
DTVP (Visual attention and processing skill)

106
Q

Visual attention and processing skill

A

ability to attend to a single object for sustained periods and the ability to shift attention between multiple objects

107
Q

Tests for visual attention and processing skill

A

Symobla digit modalities
Children color trails test

108
Q

Visual-motor integration skills

A

ability to use visual processing information to direct fine motor mvmts (hand skills such as writing or typing)
- Visual-motor integration involves visual analysis (perceiving characteristics of an object)

109
Q

s/s of visual motor integration skills

A

difficult copying from board during school, poor spacing of letters/words, significantly rotating the paper when writing, poor spelling when writing, and difficulty organizing mathematical columns of numbers

110
Q

Tests for visual motor integration skills

A

Developmental test of visual motor integration (Beery-VMI)
World sentence copying test
Test of visual motor skills - revised test

111
Q

Piaget’s right-left awareness test

A

Visual-spatial test
ability to distinguish right and left on one’s self (laterality) , and out in space (directionality).

A: show me your left/right hand
B: show me my right and left hand
C: Where is the coin in regard to the pencil
D: Watch on one hand, watch on the other - where is the following items located?
E: pencil, key, coin

112
Q

At what age should a child have laterality and directionality mastered?

A

11 yo

113
Q

Jordan left-right reversal test (Jordan-3)

A

Visual-spatial test
determines how well a child (5-18yo) can identify reverse images, letters, numbers, and sequence of letters.
- There are 5 subtest

1-A: 5 pictures presented, which picture in the row is reversed?
1-B: rows that contain individual letters (first upper case, then lower case) and numbers shown; which given letters/numbers are reversed?
2-A: 20 rows with words and identify which words are reversed
2-B: 20 sentences, which sentence. contains words that are reversed
2-C: 2 columns that each contain 16 letter sequences, which sequence in the 2nd column are out of order compared to the letter sequences given in the first column

2 scores were received: accuracy and error, childs behavior is also observed

114
Q

Test of visual perceptual skills (TVPS-3)

A

Visual-analysis
- given to ages 4-0 to 18-11 (year/month)
- assess visual perceptual abilities without integrating motor abilities
- items are presented in multiple-choice format
- each subset starts with 2, non-scored ex followed by 16 test items in increasing difficulty
—————
Visual discrimination: shown design and match

Visual memory: shown design and match via memory

Spatial relationships: shown series of design and must choose design different from the rest

Form constancy: shown design and match same design (larger, smaller, rotated)

Sequential memory : shown design sequence for 5 seconds on one page then match design via memory

Visual figure-ground: find certain design among many designs w/ complex background

  • STOP test if child has 4 consecutive wrong answers
  • Raw score is based on number of correct responses and then converted to scaled scores using TVPS manual
  • Note abnormal behavior
115
Q

Motor-Free Visual Perception Test (MVPT-4)

A
  • test for visual analysis
  • assess visual perceptual skills in children and adults ages 4 through > 80 yo
  • pt will respond verbally or point to the correct answer
  • 5 subsections

Spatial relationships
Visual discrimination
Figure-ground
Visual closure
Visual memory

*Similar to TVPS

116
Q

Developmental Test of visual percception (DTVP-3)

A

asessement of visual perception and visual-motor abilities
- administered to ages 4-12
- 5 subtest

Eye-hand coordination: draw precise straight or curved lines
Copying: shown figure and asked to draw it
Figure-ground: child is shown figure and asked to find as many ex of that same figure hidden in multiple places within complex and confusing backgrounds
Visual-closure: shown a figure and must choose an incomplete matching figure
Form constancy: shown figure and ask to identify the same figure among a series of choices (different sizes, rotated or hidden within a bg)

  • STOP test if pt misses 3 consecutive items
  • DTVP-3 provides 3 scores: motor-reduced visual perception, visual motor integration, central visual perception
117
Q

Developmental test of visual motor integration (Beery-VMI)

A
  • determines how well a pt can integrate visual and motor abilities (eye-hand coordination)
  • short form = 21 items and administered to children ages 2-7 yo
  • Full form = 30 items, given to all ages 2-100 yo

Ex. tasks
- imitation drawings: copy geometric shape
- spontaneous scribbling
- imitiation scribbling

STOP test if pt earns 0 pts on 3 consecutive items

118
Q

World Sentence Copy Test

A
  • determines the ability to quickly and accurately copy a sentence from top to bottom of the page
  • child is instructed to write neatly and quickly, requires child to copy 110 letters
  • test is timed
  • to determine the copy rate, take 6600/(time it took the pt to copy the letters (in seconds)
  • norms provided for males and females and combined genders for different grade school levels
  • the observations should be recorded

Posture
Number of fixations
Spacing (figure-ground)
Vocalization/sub-vocalization
Speed
Concentration, attention, fatigue
Formation
Frustration level

119
Q

Test of visual motor skills (TVMS-3)

A
  • assess visual motor skills, specifically eye-hand coordination through copying
  • administered to pts 3 to >90 yo
  • asked to copy 39 designs (easiest to hardest)
  • STOP test once pt scores 0 on 4 tests
  • Pt given 2 scores for each design: acurracy, error
  • types of errors described below

Closure
Incorrect angles
Line quality
Line length
Line connections
Modification of part or size
Addition or deletions
Rotation or reversal
Overlap

120
Q

What causes hearing loss in elderly pts?

A
  • 50% of pts over the age of 85 have hearing loss
  • deterioration of hair cells in the organ of Corti
  • excess deposits of bone cells, resulting in fusion of the oval window and stapes
  • increased impaction of ear wax in the external canal due to loss of sebaceous glands
  • decr/loss of conduction of sounds due to sclerosis and increased translucency of the tympanic membrane
121
Q

What causes decr coordination in the elderly?

A
  • decr muscle mass and neural control leading to loss of coordination and balance
  • elderly will have reduction in bone mass, resulting in kyphosis (back hump), red vertebral height, and increased risk for bone fractures
122
Q

Mini-mental status exam (MMSE)

A

screening test for cognitive deficits and evaluates five areas:

  • orientation
  • attention and recall
  • calculations
  • language
  • figure construction

risk of dementia doubles 5 years after the age of 60

KMK (18 decks)

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