Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness: A Systematic Review and Meta-Analysis.

Importance: Several factors may place people with mental health disorders, including substance use disorders, at increased risk of experiencing homelessness and experiencing homelessness may also increase the risk of developing mental health disorders. Meta-analyses examining the prevalence of mental health disorders among people experiencing homelessness globally are lacking. Objective: To determine the current and lifetime prevalence of mental health disorders among people experiencing homelessness and identify associated factors. Data Sources: A systematic search of electronic databases (PubMed, MEDLINE, PsycInfo, Embase, Cochrane, CINAHL, and AMED) was conducted from inception to May 1, 2021. Study Selection: Studies investigating the prevalence of mental health disorders among people experiencing homelessness aged 18 years and older were included. Data Extraction and Synthesis: Data extraction was completed using standardized forms in Covidence. All extracted data were reviewed for accuracy by consensus between 2 independent reviewers. Random-effects meta-analysis was used to estimate the prevalence (with 95% CIs) of mental health disorders in people experiencing homelessness. Subgroup analyses were performed by sex, study year, age group, region, risk of bias, and measurement method. Meta-regression was conducted to examine the association between mental health disorders and age, risk of bias, and study year. Main Outcomes and Measures: Current and lifetime prevalence of mental health disorders among people experiencing homelessness. Results: A total of 7729 citations were retrieved, with 291 undergoing full-text review and 85 included in the final review (N = 48 414 participants, 11 154 [23%] female and 37 260 [77%] male). The current prevalence of mental health disorders among people experiencing homelessness was 67% (95% CI, 55-77), and the lifetime prevalence was 77% (95% CI, 61-88). Male individuals exhibited a significantly higher lifetime prevalence of mental health disorders (86%; 95% CI, 74-92) compared to female individuals (69%; 95% CI, 48-84). The prevalence of several specific disorders were estimated, including any substance use disorder (44%), antisocial personality disorder (26%), major depression (19%), schizophrenia (7%), and bipolar disorder (8%). Conclusions and Relevance: The findings demonstrate that most people experiencing homelessness have mental health disorders, with higher prevalences than those observed in general community samples. Specific interventions are needed to support the mental health needs of this population, including close coordination of mental health, social, and housing services and policies to support people experiencing homelessness with mental disorders.

Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review.

OBJECTIVE: To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs. DESIGN: Systematic review. SETTING AND PARTICIPANTS: Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management. METHODS: We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4. RESULTS: Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations. CONCLUSIONS AND IMPLICATIONS: There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.

Timely Yet Long Overdue: Canadian Standards for Long-Term Care Homes.

The impact of the COVID-19 pandemic highlighted systemic problems in Canadian long-term care (LTC). While high mortality rates in LTC received significant attention, the pandemic also took an enormous toll on mental health of LTC residents, where mental health conditions, including cognitive disorders, are already much higher than in other community settings. The pandemic resulted in a renewed interest in improving quality of care in LTC and led to the recent development of several National Standards of Canada. The newly available Standards set ambitious targets, but many of the standards are practical and essential to moving beyond a focus on safety and physical needs in LTC and towards one that supports residents as whole persons. While the standards support good mental health indirectly, there is a need to recognize mental health in these settings as a fundamental human right and essential to quality of life, and for this to be reflected in ongoing and future standards development. Ensuring existing and forthcoming National Standards are meaningfully implemented, in whole or in part, will require extensive efforts at multiple levels. The guidance provided by Canadian Standards will shape this transformative process, necessitating aligned federal and provincial investments and policies, and stakeholder engagement to bring about the envisioned high-quality care.

Efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults: a systematic review.

BACKGROUND: Older adults experience symptoms of depression, leading to suffering and increased morbidity and mortality. Although we have effective depression therapies, physical distancing and other public health measures have severely limited access to in-person interventions. OBJECTIVE: To describe the efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults. DESIGN: Systematic review. SETTING: We searched MEDLINE, EMBASE, Cochrane Libraries, PsycINFO, and gray literature from inception to July 5, 2021. PARTICIPANTS AND INTERVENTIONS: We included randomized trials (RCTs) comparing the efficacy of virtual interventions to any other virtual intervention or usual care in community-dwelling adults ≥60 years old experiencing symptoms of depression or depression as an outcome. MEASUREMENTS: The primary outcome was change in symptoms of depression measured by any depression scale. RESULTS: We screened 12,290 abstracts and 830 full text papers. We included 15 RCTs (3100 participants). Five RCTs examined persons with depression symptoms at baseline and ten examined depression as an outcome only. Included studies demonstrated feasibility of interventions such as internet or telephone cognitive behavioral therapy with some papers showing statistically significant improvement in depressive symptoms. CONCLUSIONS: There is a paucity of studies examining virtual interventions in older adults with depression. Given difficulty in accessing in-person therapies in a pandemic and poor access for people living in rural and remote regions, there is an urgent need to explore efficacy, effectiveness, and implementation of virtual therapies.

Association Between Long-Term Care Facility Staffing Levels and Antipsychotic Use in US Long-Term Care Facilities.

OBJECTIVES: Inappropriate use of antipsychotics is an indicator of quality of care in long-term care (LTC) facilities. There is evidence to suggest that staffing levels in LTC may be associated with the rates of inappropriate antipsychotic use. This study sought to examine the association between staffing and antipsychotic prescribing in LTC facilities. DESIGN: Cross-sectional study investigated the association between reported staffing levels and the frequency of inappropriate antipsychotic prescribing at US LTC facilities between 2016 and 2018. SETTING AND PARTICIPANTS: Data from the Nursing Home Compare and LTCFocus datasets were linked, which contain information from the Minimum Data Set database on facility characteristics and staffing measures from the Payroll-Based Journal system. A final sample set of 10,436 facilities was used. METHODS: Descriptive statistics were calculated for all variables of interest. An unadjusted linear correlation analysis and linear regression were performed. Potential confounders were investigated by comparison across low-vs high-staffing facilities where adjusted for in regression analyses. RESULTS: The mean staff level for the facilities was identified as 3.69 (SD = 0.67) staffing hours per patient per day, and the mean antipsychotic use rate across all facilities was 15.24% (SD = 8.62%). There was a 0.75% decrease in inappropriate antipsychotic prescribing per unit increase in overall staff-to-patient ratio. When looking at staffing types, a 3.09% decrease in inappropriate antipsychotic prescribing was observed per unit increase in licensed staff hours. More specifically, we saw a 2.25% decrease per unit increase in RN staffing hours, a 1.83% decrease per unit increase in LPN staffing hours, and nursing aide staffing hours were not associated with antipsychotic use. CONCLUSIONS AND IMPLICATIONS: These findings provide support for policy-based interventions to decrease antipsychotic use in LTC facilities by improving staffing skill mix and staffing levels. The results may also inform nursing staff education and training on antipsychotic prescribing practices.

Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis.

INTRODUCTION: Polypharmacy is commonly associated with adverse health outcomes. There are currently no meta-analyses of the prevalence of polypharmacy or factors associated with polypharmacy. We aimed to estimate the pooled prevalence of polypharmacy and factors associated with polypharmacy in a systematic review and meta-analysis. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched for studies with no restrictions on date. We included observational studies that reported on the prevalence of polypharmacy among individuals over age 19. Two reviewers extracted study characteristics including polypharmacy definitions, study design, setting, geography, and participant demographics. The risk of bias was assessed using the Newcastle-Ottawa Scales. The main outcome was the prevalence of polypharmacy and factors associated with polypharmacy prevalence. The pooled prevalence estimates of polypharmacy with 95% confidence intervals were determined using random effects meta-analysis. Subgroup analyses were undertaken to evaluate factors associated with polypharmacy such as polypharmacy definitions, study setting, study design and geography. Meta-regression was conducted to assess the associations between polypharmacy prevalence and study year. RESULTS: 106 full-text articles were identified. The pooled estimated prevalence of polypharmacy in the 54 studies reporting on polypharmacy in all medication classes was 37% (95% CI: 31-43%). Differences in polypharmacy prevalence were reported for studies using different numerical thresholds, study setting, and publication year. Sex, study geography, study design and geographical location were not associated with differences in polypharmacy prevalence. DISCUSSION: Our review highlights that polypharmacy is common particularly among older adults and those in inpatient settings. Clinicians should be aware of populations who have an increased likelihood of experiencing polypharmacy and efforts should be made to review the appropriateness of prescribed medications and occurrence of adverse effects potentially associated with polypharmacy. CONCLUSIONS AND IMPLICATIONS: Clinicians should be aware of the common occurrence of polypharmacy and undertake efforts to minimize inappropriate polypharmacy whenever possible.

Staff perceptions of the consequences of COVID-19 on quality of dementia care for residents in Ontario long-term care homes.

OBJECTIVES: The first wave of the COVID-19 pandemic necessitated extensive infection control measures in long-term care (LTC) and had a significant impact on staffing and services. Anecdotal reports indicate that this negatively affected LTC residents' quality of care and wellbeing, but there is scarce evidence on the effects of COVID-19 on quality of dementia care in LTC. METHODS: From December 2020 to March 2021, we conducted a cross-sectional online survey among staff who worked in LTC homes in Ontario, Canada. Survey questions examined staffs' perceptions of the impact of COVID-19 on dementia quality of care during the initial wave of the COVID-19 pandemic (beginning 1 March 2020). RESULTS: There were a total of 227 survey respondents; more than half reported both worsened overall quality of care (51.3%) and worsening of a majority of specific quality of care measures (55.5%). Measures of cognitive functioning, mobility and behavioural symptoms were most frequently described as worsened. Medical and allied/support staff had the highest odds of reporting overall worsened quality of care, while specialized behavioural care staff and those with more experience in LTC were less likely to. LTC home factors including rural location and smaller size, staffing challenges, higher number of outbreaks and less COVID-19 preparedness were associated with increased odds of perceived worsening of quality of dementia care outcomes. CONCLUSIONS: These findings suggest that COVID-19 pandemic restrictions and related effects such as inadequate staffing may have contributed to poor quality of care and outcomes for those with dementia in LTC.

Potential Unintended Consequences of Antipsychotic Reduction in Ontario Nursing Homes.

OBJECTIVE: Antipsychotic reduction in nursing homes has been a focus of research and policy attention for several decades; however, there is evidence that these initiatives may have had unintended consequences, such as medication substitution and changes in diagnosis coding. Our objectives were to describe temporal changes in the use of antipsychotics, potential substitution medications, and diagnoses and symptoms used to establish the appropriateness of antipsychotic prescribing. DESIGN: Repeated cross-sectional study design. SETTING AND PARTICIPANTS: Individuals, 66 to 105 years of age, living in nursing homes in Ontario, Canada between April 1, 2010 and December 31, 2019. METHODS: Linked health administrative and clinical data were used to estimate the quarterly prevalence of dispensed antipsychotics, antidepressants, anticonvulsants, and benzodiazepines, as well as diagnoses and symptoms (eg, schizophrenia and delusions) applied to establish the appropriateness of antipsychotic use. Generalized linear models with generalized estimating equations, binomial distribution, and identity link function estimated the absolute changes over time among the population overall, by dementia diagnosis, and by severity of aggressive behaviors and cognitive impairment. RESULTS: Among over 70,000 nursing home residents each quarter, we observed general declines in antipsychotic (-0.70% per year [95% confidence limit (CL) -0.74%, -0.66%]) and benzodiazepine use (-1.17% per year [95% CL -1.20%, -1.14%]), and increases in antidepressant (0.89% per year [95% CL 0.84%, 0.94%]) and anticonvulsant use (1.06% per year [95% CL 1.03%, 1.09%]). Although initially stable, the coding of delusions increased from 3.5% to 10.2% (1.18% per year [95% CL 1.12%, 1.24%]) between 2014 and 2019, whereas schizophrenia remained stable. Increases in antidepressant use and recorded delusions were more pronounced among residents with dementia and aggressive behaviors. CONCLUSIONS AND IMPLICATIONS: Medication substitution and changes in diagnosis/symptom coding may be potential unintended consequences of initiatives to reduce inappropriate antipsychotic use. How this corresponds to resident-level prescribing and clinical outcomes warrants further investigation.

CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia.

INTRODUCTION: Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type. METHODS: The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers? RESULTS: Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized. CONCLUSION: CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.

Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit.

BACKGROUND: People working in long-term care homes (LTCH) face difficult decisions balancing the risk of infection spread with the hardship imposed on residents by infection control and prevention (ICP) measures. The Dementia Isolation Toolkit (DIT) was developed to address the gap in ethical guidance on how to safely and effectively isolate people living with dementia while supporting their personhood. In this observational study, we report the results of a survey of LTCH staff on barriers and facilitators regarding isolating residents, and the impact of the DIT on staff moral distress. METHODS: We completed an online cross-sectional survey. Participants (n = 207) were staff working on-site in LTCH in Ontario, Canada since March 1, 2020, with direct or indirect experience with the isolation of residents. LTCH staff were recruited through provincial LTCH organizations, social media, and the DIT website. Survey results were summarized, and three groups compared, those: (1) unfamiliar with, (2) familiar with, and (3) users of the DIT. RESULTS: 61% of respondents identified distress of LTCH staff about the harmful effects of isolation on residents as a major barrier to effective isolation. Facilitators for isolation included delivery of 1:1 activity in the resident's room (81%) and designating essential caregivers to provide support (67%). Almost all respondents (84%) reported an increase in moral distress. DIT users were less likely to report an impact of moral distress on job satisfaction (odds ratio (OR) 0.41, 95% CI 0.19-0.87) with 48% of users reporting the DIT was helpful in reducing their level of moral distress. CONCLUSIONS: Isolation as an ICP measure in LTCH environments creates moral distress among staff which is a barrier to its effectiveness. ICP guidance to LTCH would be strengthened by the inclusion of a dementia-specific ethical framework that addresses how to minimize the harms of isolation on both residents and staff.

Position Statement for Mental Health Care in Long-Term Care During COVID-19.

COVID-19 has disproportionately impacted older adults in long-term care (LTC) facilities in Canada. There are opportunities to learn from this crisis and to improve systems of care in order to ensure that older adults in LTC enjoy their right to the highest attainable standard of health. Measures are needed to ensure the mental health of older adults in LTC during COVID-19. The Canadian Academy of Geriatric Psychiatry (CAGP) and Canadian Coalition for Seniors' Mental Health (CCSMH) have developed the following position statements to address the mental health needs of older adults in LTC facilities, their family members, and LTC staff. We outlined eight key considerations related to mental health care in LTC during COVID-19 to optimize the mental health of this vulnerable population during the pandemic.

Development and dissemination of an ethical guidance and person-centred isolation care planning tool to support the care of people with dementia during the COVID-19 pandemic.

BACKGROUND: Long-term care (LTC) residents have been disproportionately impacted by the COVID-19 pandemic, both from the virus itself and the restrictions in effect for infection prevention and control. Many barriers exist in LTC to prevent the effective isolation of suspect or confirmed COVID-19 cases. Furthermore, these measures have a severe impact on the well-being of LTC residents. Our aim was to develop a guide for long-term care to address the ethical challenges associated with isolating dementia patients during the pandemic. The Dementia Isolation Toolkit (DIT) was developed by members of the research team in partnership with LTC stakeholders to address: 1) the practical challenges of isolating or quarantining people with dementia in a compassionate, safe, and effective manner; and 2) the need for ethical guidance to support decision-making regarding isolation and infection control in LTC, to prevent indecision and moral distress. To develop the DIT the team reviewed and synthesized the literature on pandemic ethics in a plain-language document, which was then reviewed by our partners and stakeholders. The final ethical guidance tool includes a discussion of the ethics around infection control measures in a pandemic, an ethical decision-making tool, and a person-centred isolation care planning tool. The ethical guidance tool has been downloaded more than 6500 times since it was published (bit.ly/dementiatoolkit), and has been disseminated internationally. The worksheets are being used during outbreaks to support care and decision-making, as well as proactively, to prepare for outbreaks by developing isolation care plans. There is a need for support for ethical decision-making in the context of a pandemic, particularly in settings such as LTC. Future studies will evaluate the implementation of the tool and its impact in addressing moral distress in health care providers in long-term care.

Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial.

BACKGROUND: Inappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use. OBJECTIVES: The objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC. DESIGN: A prospective, stepped-wedge study design was used to evaluate the effect of the intervention. SETTINGS AND PARTICIPANTS: Interdisciplinary staff at 10 Canadian LTC facilities. METHODS: The intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator. RESULTS: The weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was -4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms. CONCLUSIONS AND IMPLICATIONS: This multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.

Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population-Based Study.

OBJECTIVES: Although mental health disorders are common among older adults in long-term care (LTC), little is known about access to psychiatric services in LTC. We described the need for psychiatric services in LTC settings and identified variables associated with receipt of psychiatric services. DESIGN: Population-based retrospective cohort study. SETTING AND PARTICIPANTS: All adults aged 66 years and older who resided in LTC homes in Ontario, Canada, between 2015 and 2016. Individuals were included in the study at the time of LTC admission or first annual reassessment. MEASURES: We determined the percentage of LTC residents who received any psychiatric service within 90 days. We then compared the characteristics of individuals who did and did not receive any psychiatric service to determine variables associated with receipt of psychiatric services. Multivariate logistic regression was used to determine independent variables associated with receipt of psychiatric services. RESULTS: A total of 67,165 unique participants were included in the study sample, 27,650 (41.2%) of whom had identified psychiatric need. Overall, 3175 (4.7%) individuals received any psychiatric service within 90 days following cohort entry. After adjustment for potential confounders, receipt of psychiatric services was positively associated with younger age, male gender, history of major mental disorders, previous receipt of psychiatric services, indicators of psychiatric need, residence in larger LTC homes, and health region of residence. CONCLUSIONS/IMPLICATIONS: Receiving psychiatric services in Ontario LTC homes is limited when compared to the high need for services. Several factors other than patient need symptoms are associated with receipt of services, which suggests inequities in access to care. Improving the distribution of psychiatric services may help address these inequities, and additional psychiatric resources are also likely required to meet these needs. Our results directly apply to a Canadian context and have implications for other comparable countries, including the United States.

Meta-Analysis of the Prevalence of Major Depressive Disorder Among Older Adults With Dementia.

OBJECTIVE: Little is known about the overall prevalence of major depressive disorder (MDD) in persons with dementia (ie, "depression in dementia": DpD). The aim of this systematic review and meta-analysis was to determine the prevalence and factors associated with DpD among older adults (age range 58.7-87.8 years). The protocol was registered in the PROSPERO registry (2015:CRD42015020681). DATA SOURCES: We searched the following electronic databases: MEDLINE (1946-February 2017), Embase (1980-2017 week 5), and PsycINFO (1967-February 2017) using medical subject headings and free-text search terms for studies in the English language. STUDY SELECTION: We screened 9,421 studies, and 55 met the inclusion criteria (ie, used validated criteria for both MDD and dementia). DATA EXTRACTION: Two independent reviewers extracted data from included studies. Meta-analysis was used to determine the pooled estimates and 95% confidence intervals for the prevalence of DpD. Prevalence across dementia subtypes, study setting, diagnostic criteria, and dementia severity was compared in subgroup analyses. RESULTS: The prevalence of MDD in all-cause dementia was 15.9% (95% CI, 12.6%-20.1%). The prevalence of MDD was higher among individuals with vascular dementia (24.7%) compared to Alzheimer's disease (14.8%). Studies using the provisional diagnostic criteria for DpD reported a higher prevalence (35.6%) compared to studies using either the DSM-III-R (13.2%) or DSM-IV (17.3%) criteria. CONCLUSIONS: Depression is common among individuals with dementia, and the type of dementia and diagnostic criteria affect prevalence estimates of DpD. Further studies are required to understand factors that lead to the development of DpD and strategies to prevent and treat DpD.