Dementia
and
Sight Loss
SVS 2011
Introduction
Barbara Sharp
• Practice Development Manager,
Alzheimer Scotland
• Research student looking at experience of
...
Dementia and Sight Loss
• A brief overview of dementia as
relevant to professionals in the field of
eye health and visual ...
Dementia
Dementia is a collective term used to
describe a range of losses in brain
function - such as thinking, planning,
...
Dementia
• Many conditions cause the features of
dementia
• These conditions cause damage to
neurones and complex connecti...
Types of dementia
Of the many different conditions that
cause dementia the most common are:
•
•
•
•

Alzheimer’s disease
V...
Changes within the brain

SVS 2011
The kind of
person you
are and
ways of
coping

Personal life
experiences
and
relationships

EXPERIENCE OF
DEMENTIA

Physic...
SVS 2011
The person may experience
difficulties with…
•Communication
•Memory
•Recognising people,
places, objects
•Coping with unfa...
Possible difficulties…

•
•
•
•

Reasoning and judgment
Controlling emotional responses
Coping with everyday activities
Le...
Dementia and sight loss
Age related changes
and common conditions
•Cataracts
•Glaucoma
•Retinal disorders
•Macular degener...
Dementia and sight loss
Good vision required for many
activities associated with lowering
risk to dementia and keeping wel...
Dementia and sight loss
• Implications under researched
• Estimated of 750,000 people in UK with
dementia – 100,000 will a...
Visual difficulties in dementia
•
•
•
•
•
•

Visual acuity
Spatial awareness
Perception of depth
Contrast sensitivity
Colo...
Posterior Cortical Atrophy
Difficulties with:
• Recognising faces or objects in pictures
• Spatial awareness
• Handwriting...
Experiences of dementia and sight
loss
• Increased sense of disorientation
• Worries about safety – sometimes source
of co...
Experiences of dementia and sight
loss
• Exceptional demands on carers
• Little significance attached to sight loss by
dem...
How can I help
communicate?
•
•
•
•
•

Gain attention and give full attention
Be calm and patient
Speak slowly and clearly...
How can I help
communicate?
• Be aware of the tone of your voice
• Focus on emotions and feelings
• Make suggestions if pe...
How can I help
communicate?
• Be aware of your own body language
• Provide clues and visual/verbal prompts to
assist under...
How can I help with vision?
•
•
•
•
•
•

Strong colour contrasts and matt finishes
Avoid strong patterns on flooring
Good ...
What needs to be done?
• Research on availability and up-take of
sight tests
• Awareness, education and training
• Promote...
What needs to be done?
• Flexibility - tailor sight tests to the
individual
• Ensure relative/carer present - consent
• Cl...
Assessing visual function
•Conventional
approaches may be
inadequate –
dependent on
difficulties
experienced
•Some researc...
Working in partnership
Alzheimer Scotland and RNIB
• Learning from each other
• Working nationally and locally together
• ...
www.alzscot.org
SVS 2011
References and
useful sites
alzheimers.org.uk – Coping with sight loss Living with dementia Feb 2011 p 8-9
Guidelines: ‘Ex...
Upcoming SlideShare
Loading in …5
×

Barbara Sharp, Dementia and sight loss

683 views
465 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
683
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • People with dementia who seek or need assistance of eye health professionals – useful for those professional to understand the kind of difficulties that people with dementia experience
    Look specifically at how dementia can affect sight – a feature that until fairly recently has received very little attention
    Consider some of the issues for people with dementia who also experience sight loss
  • Defining dementia is complex because it is not a single condition but a collective term used to describe a range of losses in intellectual functioning (SIGN, 2006) which severely impact on personal, social and occupational life (Kurz and Lautenschlager, 2010).
    Collection of features sometimes referred to as a syndrome – although more correctly syndromes – because there is not one fixed set of features – they vary tremendously as you would expect of conditions that affect the brain – because the brain itself is so complex
  • The common factor in these many brain conditions is that they damage brain cells (neurones) and the complex connections between them (synapses)
    Dementia is without social, economic or ethnic boundaries and exists worldwide (ADI, 2010). It affects older people more commonly but not exclusively, also occurring in people under the age of 65 (Cox and Keady, 1999). Approximately 72,500 people have dementia in Scotland in 2011. Around 2,300 of these people are under the age of 65. these numbers are continuously under review and likely to change - upward
    Dementia brings about progressive disability over a sometimes prolonged trajectory of illness and is the fourth most common cause of death in Scotland after heart disease, strokes and cancer (Alzheimer Scotland). It is without cure and currently presents a major and growing challenge to health and social care planning and service provision in Scotland, with numbers affected expected to rise to 127,000 by 2031 (Alzheimer Scotland 2011).
  • Alzheimer’s disease
    Amyloid plaques and tau tangles are found in the nerve cells. Amyloid is a protein produced when amyloid pre-curser protein is broken down. The amyloid is deposited in large numbers of amyloid plaques on the surface of the nerve calls in the brains of people with the disease.
    Neurofibrillary tangles result when an abnormal form of a protein called tau occurs within the nerve cells which stops the cells from functioning normally.
    Vascular dementia
    A form of dementia associated with problems with the blood supply to the brain. Damage to the brain may occur due to an interruption to its blood supply through a blockage, bleed or clot, causing a stroke. A single stroke may cause the symptoms of dementia or it may result from many smaller strokes over time. Vascular dementia can also occur due to disease of the fine blood vessels of the brain. 10% of cases.
    Dementia with Lewy bodies
    Lewy bodies - tiny, spherical protein deposits develop inside the nerve cells. Their presence in the brain interrupts normal communication between nerve cells by disrupting the action of important chemical messengers.
    Lewy bodies are also found in the brains of people with Parkinson's disease.
    Thought to be the second or third most common cause of dementia, accounting for 15% to 20% of cases of dementia which start after the age of 65. This means that there could be about 11,000 people with Dementia with Lewy bodies in Scotland.
    Patchy mental impairment and disorientation but quite normal memory function.
    First described by Frederich Lewy in 1912 - looked at the brains of people with Parkinson’s disease, where Lewy bodies are mostly found in one tiny area of the brain. In people with Lewy body dementia, these changes are much more widely spread throughout the brain.
    It is not yet clear what the Lewy bodies signify, but it is likely that they are a sign of damage to the nerve cells. They contain various proteins, only some of which have been identified.
    Front-temporal
    The term 'fronto-temporal dementia' covers a range of conditions, including Pick's disease, frontal lobe degeneration, and dementia associated with motor neurone disease. These types affect areas of the brain responsible for our behaviour, emotional responses and language skills. There is atrophy of the fronto-temporal lobes of the brain. There is a family history in about 35 – 50% of all cases. Some of these inherited forms have been linked to specific genes - the most important discovered so far are two genes called tau and progranulin. In a number of families the responsible gene defect has not been identified.
    Fronto-temporal dementia is a significant cause of dementia in those under 65yrs - the second most common cause of dementia (after Alzheimer’s disease) in this age group.
    Other dementias
    There are many other types of dementia (hundreds) although less common than those above.
    These all have different pathologies – sometimes mixed pathologies – and types have sub-types
  • The changes in the brain – and the areas of the brain affected begin to tell us something of the difficulties that people will experience
    Suppose you are in a gallery admiring a painting. Your retinas capture the image of the painting and via nerve impulses, send to the visual area of your brain, which reconstructs the overall image. These impulses are then routed to your hippocampus, which acts as the gatekeeper and decides whether or not to accept the information and pass it on to your long-term memory. If your hippocampus does not let this information in, you will probably forget the image of the painting within a minute. But if your hippocampus does accept this information, it will eventually be returned to the area it came from: the visual cortex. There the image of the painting will be placed in long-term memory, point by point, in the form of thousands of strengthened connections between neurons. 
  • Fascinating though these brain processes are, they are no short of devastating when they go wrong because they disrupt so much of our basic human functioning – and it’s the human element in all this we mustn’t forget.
    We understand dementia today as more complex than the physical changes within the brain (complex enough!) but as an interplay between the pathology and –
    PERSONAL LIFE EXPERIENCES
    THE KIND OF PERSON YOU ARE AND WAYS OF COPING
    RELATIONSHIPS
    ENVIRONMENT
    WISHES HOPES AND DREAMS
    PHYSICAL AND PSYCHOLOGICAL HEALTH – other conditions
    EXPERIENCE OF DEMENTIA
    The kind of person you are
    Each one of us behaves differently when faced with difficulties and concerns. For example, when faced with a disabling feature of dementia – perhaps finding you are no longer able to do something that you were good at before – one type of person may withdraw into themselves, another may become very angry about their situation and yet another may cover up their mistakes (or hurt) with humour.
    Physical health and psychological state
    The majority of people with dementia are older and likely to have other health issues
    It is more likely that older people will have hearing and sight problems
    The co-existence of depression is not uncommon
    Stress and anxiety can make the features of dementia worse or mask the underlying problem
    Many common illnesses, including chest and bladder infections make older people confused. A sudden increase in confusion in people with dementia may indicate an additional health problem
    Changes to the brain and function
    The specific damage to the brain cells caused by dementia will lead to specific areas of difficulty in function – for example, remembering, planning, recognising, communicating
    It is important to appreciate that changes in function can fluctuate – the person may be able to do something one day and not another
    Personal life experiences and ways of coping
    We draw on our past experiences to help us understand situations
    Our responses to situations and difficulties will be influenced by our past life experiences
    We develop different ways of coping with difficulties based on past experiences
    Environment
    An environment can be enabling or disabling for a person with dementia
    Noisy environments where there is a lot happening can be frightening and confusing
    Physical environments where it is easy to get lost because there are no directions or because doors and corridors look the same are especially difficult
    People and their behaviour within an environment are important too, for example - rushing around, talking too quickly, asking lots of questions – can make someone with dementia very anxious and more confused
    IT SEEMS THE CHANGES WITHIN THE BRAIN BEGIN MANY YEARS BEFORE WE EVER EXPERIENCE SYMPTOMS – SOMETIMES A MIS-MATCH BETWEEN LEVEL OF DISABILITY AND PATHOLOGY (NUN STUDY) – OUR GENERAL HEALTH AND PSYCHOLOGICAL WELL-BEING ARE IMPORTANT BOTH BEFORE AND AFTER WE DEVELOP DEMENTIA – INCLUDING SIGHT
  • We are all different – this doesn’t change because you have dementia – it is a uniquely different experience for everyone
  • People with dementia experience different symptoms at different stages of their illness and these are not fixed because of the influencing factors outlined and the wide variety in the nature changes that can take place, their pace and severity. These are just some aspects of difficulty that you might anticipate but should not presume! There can be good days – bad days – able to do something one minute – not the next.
    Communication
    Understanding what is being said - finding the right words - recognising people, places, objects
    Memory – remembering recent experiences can be especially difficult in Alzheimer’s – remembering what has been said or asked of you
    Difficulty concentrating, easily distracted
    Deterioration in reading and writing ability
    May feel very stressed by new experiences – or questions – and this will undermine abilities further. Coping with unfamiliar places and or activities can be very difficult
    Controlling emotional responses
    Orientation and skills
    Keeping track of time can be difficult – internal body clock – circadian rhythms – an issue re appointments
    Difficulty in locating places – mapping out – visual memory - may feel lost – might happen suddenly - finding your way around can become difficult and make you feel very anxious
    Difficulty with sequencing of everyday tasks and erosion of skills in ordinary daily activities
    – e.g. getting dressed, eating a meal or making a cup of tea – anything learned in our lives can be unlearned/lost. This might include social ‘rules’ and inhibitions
    Deterioration in walking and other aspects of co-coordinated movement – may or may not be associated or compounded by visual problems
    Reasoning and judgment skills may be affected
  • All these changes not only affect people in their functional ability but can undermine the very sense of who you are
  • Dementia more common in older people – and the likelihood of developing dementia increases with age so age related changes in vision and/or more common types of visual loss experienced by older people are going to be present in the majority of people with dementia.
    My mum – venous thrombosis in right eye, glaucoma, macular degeneration, cataracts – as well as Alzheimer's disease – confuses the presenting picture and makes on-going support much more challenging. One of our common approaches to supporting people with their memory loss is to provide ‘visual access’ – doesn’t work when you can’t see.
  • People who have long term of life long visual impairment are not immune to developing dementia.
    There may even be some risk factors associated with sight loss and dementia.
    One recent study reported in the American Journal of Epidemiology (Feb 11) indicated that elderly people with visual disorders left untreated were more likely to develop Alzheimer’s disease – poor vision may be a predictor rather than symptom. Visual disorders may interfere with normal mobility and hinder participation - Good vision required for many activities associated with lowering risk to dementia and keeping well when you have dementia
    (Journal of Gerontological Nursing 36 (5) 2010
    Vision plays a critical role in many cognitive tasks that affect functional ability and visual dysfunction may contribute greatly to the disability in people with dementia and may exacerbate the effects of cognitive loss – people with dementia very vulnerable to additional dysfunction resulting from the co-morbid conditions – increasing disorientation and impairing learning.
  • Research by University of Bradford – Schools of Optometry and Health Studies – Ron Bramley CEO of Thomas Pocklington Trust – reviewed procedures for sight tests and eye examinations among those with dementia
    Imagine how the use of some of the aids provided by the low vision unit or the RNIB would be compromised by the kind of memory, communication and learning difficulties outlined – this doesn’t mean that they are not worth trying but it can be unpredictable as to what will be helpful – e.g. my mum – talking clock and photograph album, blips on cooker – great – talking books, can openers, TV controller and hot drinks indicators – no use – made her more anxious
    http://www.pocklington-trust.org.uk 
  • Visual acuity, contrast sensitivity and colour vision can be impaired, as well as spatial awareness and perception of depth.
    Since ability to cope with this sight loss is reduced by dementia, it has a far greater impact on cognitive performance, mobility and daily living activities.
    Despite this, research demonstrates that few people with dementia appear to have access to regular eye tests.
    Alzheimer’s disease and other forms of dementia can significantly change how people interpret what they see, hear, taste, feel and smell.
    Depth perception difficulties make it harder to identify objects set against background of similar colour
    Glare can interfere with visual perception and cause illusions
    In Alzheimer’s – axonal degeneration and deterioration of the retinal ganglion cell. Reduced amount of myelin in the visual cortex. Performance on measures of visual acuity affected by cognitive state.
  • Posterior Cortical Atrophy – damage is to the brain cells focused in back region of the brain responsible for visual processing – most common problem for people with PCA is vision rather than memory
    Symptoms of PCA
    Difficulty recognising faces or objects in pictures
    Decline in spatial awareness – e.g. judging distances and speeds
    Difficulties with handwriting or reading
    Difficulty with mental arithmetic
    Problems dealing with money
    Difficulties with co-ordination
  • Results of research carried out by Thomas Pocklington Trust – 19 case studies – 13 had severe vision impairment
    Published in Working with Older people September 2009 13 (3) pp 29-33
  • Position yourself to be heard/seen - give your full attention
    Be calm and patient
    Speak slowly and clearly
    Cues – text and image – highly individual
  • Cues – text and image – highly individual – images that connect to the person – text large enough to capture attention – aid navigation and orientation
    Strong colour contrasts – utensils and tabletop, floors and walls, toilet against wall and floor doors and adjoining walls
    Use of matt finishes to reduce reflections
    Patterned carpeting or dark borders may increase visual-spatial difficulties
    Some research evidence for use of light as effective therapy for reducing agitation and increasing sleep – even light to eliminate shadows. Use sensor light – especially for route to bathroom at night (mum’s hall used to be lit up like a runway). Natural daylight best
    Occupational therapist – advice re grab rails, bath aids
    Low vision unit – talking watches and clocks, coin holders
  • Promoting the fact that some optometrists make home visits could be vital
    Clear communication of the findings, not just to the person tested but to their family and/or professional carers.
    Recommendations prompted by the study outline seven steps towards improving policy and practice:
    Conduct a systematic study of the availability and uptake of sight tests among people with dementia.
    Set up a website for people with dementia and their carers with information on how dementia affects eye health, and the importance of eye examinations.
    Develop education and training for optometrists and care home staff.
    Compile a list of optometrists experienced in providing eye care for people with dementia.
    Reduce loneliness and isolation
    Next slide
    Develop a template for recording the results of eye examinations in people with dementia – something which can be endorsed by professional bodies and made available to care homes.
    Measure the effectiveness of eye care, such as sight tests and cataract removals, on the quality of life of people with dementia.
    Research clinical testing methods so that guidelines can be strengthened. Measuring contrast sensitivity, for example, in someone with dementia could be vital as an inability to judge contrasts can make daily tasks impossible.
    Ron Bramley said: “The steps set out in this study show ways to meet the eye health needs of people with dementia that are both thorough and tailored to the individual. These steps could revolutionise the eye care of people with both dementia and sight loss.”
    Research has shown that mental health professionals have failed to recognise sight loss and sensory loss as factors in the confusion and disruptive behaviour associated with dementia n November 2008 Thomas Pocklington Trust released a report, “The experiences and needs of people with dementia and serious visual impairment: a qualitative study,” by researchers at King’s College London.The research showed that sight loss compounded the effects of dementia and that the combined effects of the two conditions could be severe.The study revealed that specialists dealing with dementia did not recognise the importance of sight loss.Both mental health and sensory-loss professionals identified shortcomings that prevented those with dementia and sight loss from getting the care they need.
    Mental health professionals acknowedged that staff in dementia services might lack the time and expertise to respond to sight loss
    Sight loss professionals had tried but failed to find training to help them deal with dementia. They said there was a false expectation that sight loss could be dealt with in isolation
    Dementia care staff said they met multiple needs but few felt that visual impairment would have a significant effect on how they worked with clients
    Sensory rehabilitation professionals said the co-existence of sight loss and dementia was common and growing, yet they have no guidelines for working with people with dementia. They criticised GPs, ophthalmologists, and mental health professionals for failing to share information about dementia, which could put clients at risk.
    There was little evidence of communication between mental health and sensory impairment teams. Assessments were undertaken independently and information was rarely shared.
  • Tailor tests to the individual – e.g. if poor attention span – adapt exam with emphasis on objective techniques that will not prolong exam
    Have someone accompany the person with dementia when examinations taking place – keep record of who and contact details – person with dementia should consent re other person receiving results and recommendations.
    Clear communication to other people involved _ professional and family carers – and adapt any feedback/findings to needs of the person with dementia – e.g. write down if memory poor – Disability Discrimination Act - must provide info in accessible format
    Measure the effectiveness of eye care, such as sight tests and cataract removals, on the quality of life of people with dementia
    Develop a template for recording the results of eye examinations in people with dementia – something which can be endorsed by professional bodies and made available to care homes.
    Research clinical testing methods so that guidelines can be strengthened. Measuring contrast sensitivity, for example, in someone with dementia could be vital as an inability to judge contrasts can make daily tasks impossible.
  • Research using Teller Acuity Cards – developed for infants – also used where no verbal communication including people with dementia (Marx, Werner, Cohen-Mansfield and Hartman 1990) when unable to perform visual tasks –
    Found to be a useful method of assessing visual acuity in older people with dementia
    Morse, Teresi, Rosenthal, Holmes and Yatzkan (2004)
    Journal of Visual Impairment and Blindness Sept 2004 pp 560 - 566
  • Barbara Sharp, Dementia and sight loss

    1. 1. Dementia and Sight Loss SVS 2011
    2. 2. Introduction Barbara Sharp • Practice Development Manager, Alzheimer Scotland • Research student looking at experience of stress in people with dementia • Relative of someone who experienced dementia and sight loss SVS 2011
    3. 3. Dementia and Sight Loss • A brief overview of dementia as relevant to professionals in the field of eye health and visual loss • Dementia and its impact on sight • Consider some of the issues for people who experience both dementia and sight loss SVS 2011
    4. 4. Dementia Dementia is a collective term used to describe a range of losses in brain function - such as thinking, planning, calculating, remembering, reasoning, language – losses which severely impact on personal, social and occupational life SVS 2011
    5. 5. Dementia • Many conditions cause the features of dementia • These conditions cause damage to neurones and complex connections between them • Impact is highly individual – mostly progressive SVS 2011
    6. 6. Types of dementia Of the many different conditions that cause dementia the most common are: • • • • Alzheimer’s disease Vascular dementia Dementia with Lewy bodies Fronto-temporal dementia SVS 2011
    7. 7. Changes within the brain SVS 2011
    8. 8. The kind of person you are and ways of coping Personal life experiences and relationships EXPERIENCE OF DEMENTIA Physical Psychological Health SVS 2011 Environment Changes to brain and function
    9. 9. SVS 2011
    10. 10. The person may experience difficulties with… •Communication •Memory •Recognising people, places, objects •Coping with unfamiliar places, people or activities •Sense of time SVS 2011
    11. 11. Possible difficulties… • • • • Reasoning and judgment Controlling emotional responses Coping with everyday activities Learning, concentration, planning and motivation SVS 2011
    12. 12. Dementia and sight loss Age related changes and common conditions •Cataracts •Glaucoma •Retinal disorders •Macular degeneration SVS 2011
    13. 13. Dementia and sight loss Good vision required for many activities associated with lowering risk to dementia and keeping well when you have dementia SVS 2011
    14. 14. Dementia and sight loss • Implications under researched • Estimated of 750,000 people in UK with dementia – 100,000 will also have sight loss • Ability to cope symptoms of dementia reduced by sight loss and ability to adapt to sight loss undermined by dementia http://www.pocklington-trust.org.uk SVS 2011
    15. 15. Visual difficulties in dementia • • • • • • Visual acuity Spatial awareness Perception of depth Contrast sensitivity Colour vision Misinterpretations SVS 2011
    16. 16. Posterior Cortical Atrophy Difficulties with: • Recognising faces or objects in pictures • Spatial awareness • Handwriting or reading • Mental arithmetic • Dealing with money • Co-ordination SVS 2011
    17. 17. Experiences of dementia and sight loss • Increased sense of disorientation • Worries about safety – sometimes source of conflict • Threat to identity heightened by multiple losses SVS 2011
    18. 18. Experiences of dementia and sight loss • Exceptional demands on carers • Little significance attached to sight loss by dementia care staff • Visual hallucinations common and disruptive • Isolation SVS 2011
    19. 19. How can I help communicate? • • • • • Gain attention and give full attention Be calm and patient Speak slowly and clearly Introduce yourself verbally Cues – text and image – highly individual SVS 2011
    20. 20. How can I help communicate? • Be aware of the tone of your voice • Focus on emotions and feelings • Make suggestions if person struggling to find words • Be aware of facial expressions, body posture or mannerisms – what are they telling you? SVS 2011
    21. 21. How can I help communicate? • Be aware of your own body language • Provide clues and visual/verbal prompts to assist understanding and promote confidence • Try providing information in a variety of formats and with range of approaches SVS 2011
    22. 22. How can I help with vision? • • • • • • Strong colour contrasts and matt finishes Avoid strong patterns on flooring Good lighting and keep it even Avoid clutter Colour code clothes Advice re aids and adaptations SVS 2011
    23. 23. What needs to be done? • Research on availability and up-take of sight tests • Awareness, education and training • Promote home visits by optometrists • Develop expertise • Reduce loneliness and isolation • Manage threats to independence SVS 2011
    24. 24. What needs to be done? • Flexibility - tailor sight tests to the individual • Ensure relative/carer present - consent • Clear communication of results • Research clinical testing methods • Measure impact on quality of life of eye care, sight tests and cataract removal SVS 2011
    25. 25. Assessing visual function •Conventional approaches may be inadequate – dependent on difficulties experienced •Some research on use of Teller Acuity Cards SVS 2011
    26. 26. Working in partnership Alzheimer Scotland and RNIB • Learning from each other • Working nationally and locally together • Developing information, training programmes and materials on dementia and sight loss SVS 2011
    27. 27. www.alzscot.org SVS 2011
    28. 28. References and useful sites alzheimers.org.uk – Coping with sight loss Living with dementia Feb 2011 p 8-9 Guidelines: ‘Examining the patient with dementia or other acquired cognitive impairment’, The College of Optometrists. Nov 10 Section C4 pp1-4 www.college-optometrists.org Lawrence and Murray (2009) Understanding the experiences and needs of people with dementia and sight loss Working with Older people September 13 (3) pp 29-33 Morse, Teresi, Rosenthal, Holmes and Yatzkan (2004) Research Report: Visual Acuity Assessment in Persons with Dementia Journal of Visual Impairment and Blindness Sept pp 560 – 566 http://www.pocklington-trust.org.uk - Research discussion paper, Improving vision and eye health care to people with dementia Thomas Pocklington Trust Dec 2010 Number 8 SVS 2011

    ×