The Treatment Of Alzheimer's Disease

Two critical crossroads reached in the approach to treatment for Alzheimer's disease were (1) the recognition of Alzheimer's disease as a disorder distinct from the normal aging process; and (2) the realization that, in developing therapeutic and social interventions for a major illness or disability, the concept of care can be as important as that of cure. Moreover, in addition to the symptoms of Alzheimer's disease mentioned earlier, other symptoms and aggravating factors may compound the problem. Patient, environmental, and family stresses can converge to exaggerate patient dysfunction and family burden during the clinical course of Alzheimer's disease. Identifying these stresses and making appropriate changes can provide the foundation for more effective treatment and fewer everyday problems.

In the Alzheimer's disease patient, depression or delusions can aggravate dysfunction. These problems, which emerge during the course of the disorder in some individuals with Alzheimer's disease, compound memory impairment; they make the affected individual do worse than would be expected from the dementia alone--causing clinical conditions referred to as "excess disability" states. Depression by itself can mimic dementia--a condition that is sometimes termed pseudodementia. When combined with dementia, depression exacts yet greater incapacity and suffering in the Alzheimer's disease patient. Depression in Alzheimer's disease can be treated. Indeed this highlights one of the truly extraordinary phenomena that can be observed in Alzheimer's disease: By alleviating an excess disability state, actual clinical improvement can result--even though the underlying disease process is advancing. In other words, at a given point in time, the patient's symptoms can be reduced, suffering lowered, capacity to cope buttressed, with family burden eased as a further result. These are traditional goals of treatment for all illnesses.

Researchers in the NIMH Intramural program have developed and are testing a Dementia Mood Assessment Scale, designed to rate mood in Alzheimer's patients. This scale tracks the mood states of the patients over the course of their illness and thus may be helpful in testing various antidepressant treatments.

The patient's immediate environment can also interfere with coping, adding to the level of impairment. Modifying the surroundings can reduce stresses imposed by environmental factors. There is the matter of safety, as in the need to protect the person from wandering toward a stairway and subsequently falling. There is the matter of lowering the individual's frustration level, such as by placing different cues in the immediate environment to combat memory loss and to reduce resulting stress and disorganization. There is the matter of finding the most protective but least restrictive setting for care which at some point may involve a move away from home to a nursing home or other care facility well equipped to deal with those who have Alzheimer's disease.

Stress on the family can take a toll on patient and caregiver alike. Caregivers are usually family members--either spouses or children--and are preponderantly wives and daughters. As time passes and the burden mounts, it not only places the mental health of family caregivers at risk, it also diminishes their ability to provide care to the Alzheimer's disease patient. Hence, assistance to the family as a whole must be considered.

As the disease progresses, families experience increasing anxiety and pain at seeing unsettling changes in a loved one, and they commonly feel guilt over not being able to do enough. The prevalence of reactive depression among family members in this situation is disturbingly high--caregivers are chronically stressed and are much more likely to suffer from depression than the average person. If caregivers have been forced to retire from positions outside the home, they feel progressively more isolated and no longer productive members of society.

An NIMH-funded study shows that caregivers not only have increased rates of infectious illness and depression, but often have suppressed immune systems. Another study of caregivers found depressed mood in 54 percent of caregivers and anger in 67 percent. Researchers hypothesize that the caregivers who hold in their anger may be at greater risk of cardiovascular disease.

The likelihood, intensity, and duration of depression among caregivers can all be lowered through available interventions. For example, to the extent that family members can offer emotional support to each other and perhaps seek professional consultation, they will be better prepared to help their loved one manage the illness and to recognize the limits of what they themselves can reasonably do.

George and Mary Ellen's neighbors had become increasingly concerned as it was obvious something was very wrong. When they noticed that the newspaper had not been taken in one morning, two neighbors came over. When no one answered the door, they tried it, found it unlocked, and entered. George was lying on the floor near the telephone, and Mary Ellen was sitting at the piano trying to pick out a tune. The neighbors called an ambulance for George and then placed a long-distance call to one of his daughters. George, in the hospital suffering from a heart attack, for the first time shared with his children the events of the past months and realized that he must make plans for the future. One of his daughters stayed with him and Mary Ellen for 2 months after he left the hospital. She arranged for someone to come in once a week to clean the house. She also contacted Meals-on-Wheels to ensure nourishing meals for her parents. Through her parents' church, she enrolled Mary Ellen in a 5-day-a-week daycare program for the elderly. Each morning Mary Ellen was picked up by the daycare van and was brought back late in the afternoon. George, relieved of constant anxiety, recovered rapidly and began to catch up on his writing projects. Though he missed the social life they had once enjoyed with their friends, there were times when he and Mary Ellen still felt a close relationship. George now accepted the fact that someday Mary Ellen might have to enter a nursing home, but with the support of his family, friends, church, and community he would be able to deal with whatever came.

Since the components of the problem vary, so too should the focus, nature, and sources of interventions. Interventions should focus on the patient's symptoms, the affected individual's everyday environment, and the family support system. Specific interventions can involve support from the family, the help of a homemaker or other aide in the home, employment of behavioral therapies, and the use of medication. The sources for interventions can range from family support groups such as those available through the Alzheimer's Association (AA), to professional consultations for the patient and family with a mental health specialist, to a variety of community programs such as day or respite care. Information on what assistance is available in a given community can be gained by contacting the local Office on Aging, a Community Mental Health Center or local Medical Society, or a local chapter of the AA. In addition, every State has an agency on aging that provides information on services and programs. The State Agencies on Aging, along with other sources of help, are listed at the back of this brochure.

Though Alzheimer's disease cannot at present be cured, reversed, or stopped in its progression, much can be done to help both the patient and the family live through the course of the illness with greater dignity and less discomfort. Toward this goal, appropriate clinical interventions and community services should be vigorously sought.


Hope For The Future Through Research

While Alzheimer's disease remains a mystery, with its cause and cure not yet found, there is considerable excitement and hope about new findings that are unfolding in numerous research settings. The connecting pieces to the puzzle called Alzheimer's disease continue to be found. At the same time, there are more and more partners involved in the effort, with growing national and international interest. Government, industry, academia, and the volunteer sector are all becoming more and more active; Federal, State, community, corporate, and foundation support for new studies and better services are all on the rise.

The U.S. Department of Health and Human Services established a Departmental Task Force on Alzheimer's Disease, which first met in April 1983. This Task Force, later legislatively mandated as the Council on Alzheimer's Disease, is composed of representatives from the following agencies that have programs related to Alzheimer's disease: the National Institute of Mental Health, the National Institute on Aging, the National Institute of Neurological Disorders and Stroke, the National Institute of Allergy and Infectious Diseases, the National Institute for Nursing Research, the Administration on Aging, the Agency for Health Care Policy and Research, the Health Care Financing Administration, the Health Resources and Services Administration, the National Center for Health Statistics, and the Department of Veterans Affairs. The Council, which also includes both the Surgeon General and the Assistant Secretary for Planning and Evaluation as members, is chaired by the Assistant Secretary for Health. The Council's recommendations are sent in an annual report to Congress.

In addition, a non-Federal Advisory Panel on Alzheimer's Disease was established by congressional action. The Panel, which works closely with the Council, consists of 15 national authorities on Alzheimer's disease selected for their depth and breadth of expertise in this area. The Panel has issued four reports, for 1988-89, 1990, 1991, and 1992. The titles are in the reference list. The activities of both the Council and the Panel reflect the scope of concern and interest that is being focused by the Federal Government on Alzheimer's disease.


Glossary

Acetylcholine - a neurotransmitter found in reduced levels in the brains of Alzheimer's victims.


Alzheimer's Disease Associated Protein (ADAP) - a protein that seems to appear only in the tissue of people with Alzheimer's. It has been found in both the brain and spinal fluid.


Amyloid precursor protein (APP) - a normal, essential substance made by brain cells that contain BETA AMYLOID. In Alzheimer's, APP is cut and releases beta amyloid. Beta amyloid then forms clumps called SENILE PLAQUE.


Apolipoprotein E (ApoE) - a protein that ferries cholesterol through the bloodstream. The ApoE gene has three variants (or alleles), E2, E3, and E4. Each person inherits an allele from each parent. Ninety percent of the population inherit one copy of ApoE3, and 60 percent inherit two copies.

Cortisol - the major natural GLUCOCORTICOID (GC) in humans. It is the primary stress hormone.


Dementia - significant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning.


Hippocampus - an area buried deep in the forebrain that helps regulate emotion and memory.


Multi-Infarct Dementia - dementia brought on by a series of strokes.


Nerve Growth Factor - a substance that occurs naturally in the body and enhances the growth and survival of cholinergic nerves.


Neurotoxic - poisonous to nerves or nerve tissue.


Nucleus basalis of Meynert - A small group of cholinergic nerve cells in the forebrain and connected to areas of the cerebral cortex.


Pseudodementia - a severe form of depression resulting from a progressive brain disorder in which cognitive changes mimic those of dementia.



References

Advisory Panel on Alzheimer's Disease. Report of the Advisory Panel on Alzheimer's Disease. DHHS Pub. No. (ADM) 89-1644, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1989. (Available from the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, GPO S/N 017-024-01387-1, $2.25.)

Advisory Panel on Alzheimer's Disease. Second Report of the Advisory Panel on Alzheimer's Disease, 1990. DHHS Pub. No. (ADM) 91-1791, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. (Available from the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, GPO S/N 017-024-01442-7, $3.00.)

Advisory Panel on Alzheimer's Disease.Third Report of the Advisory Panel on Alzheimer's Disease, 1991. DHHS Pub. No. (ADM) 92-1917, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992. (Available from the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, GPO S/N 017-024-01483-4, $3.50.)

Advisory Panel on Alzheimer's Disease. Fourth Report of the Advisory Panel on Alzheimer's Disease, 1992. NIH Pub. No. (NIH) 93-3520, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1993. (Available from the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, GPO S/N 017-024-01508-3, $3.75.)

Light, E., and Lebowitz, B.D. Alzheimer's Disease Treatment and Family stress: Directions for Research. DHHS Pub. No. (ADM) 89-1569, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1989. (Available from the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, GPO S/N 017-024-01365-0, $14.00.)

National Institute of Mental Health. If You're Over 65 and Feeling Depressed ... Treatment Brings New Hope, DHHS Pub. No. (ADM) 90-1653, 1990. (Single copies available from Public Inquiries, NIMH, 5600 Fishers Lane, Room 7C-02, Rockville, MD 20857. Available in packages of 50 from the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325, GPO S/N 017-024-01376-5, $23.00 per package of 50.)

National Institute of Mental Health. Plain Talk About Mutual Help Groups DHHS Pub. No. (ADM) 89-1138, 1989. (Single copies available from Public Inquiries, NIMH, 5600 Fishers Lane, Room 7C-02, Rockville, MD 20857.)

Taylor, R. Evolutions: Brain imaging, The Journal of NIH Research, May 1990, Vol. 2, p. 103.

U.S. Congress, Office of Technology Assessment. Congressional Summary, Losing A Million Minds: Confronting the Tragedy of Alzheimer's Disease and Other Dementias, OTA-BA-324, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1987.

U.S. Congress, Office of Technology Assessment. Summary, Confused Minds, Burdened Families: Finding Help for People with Alzheimer's and Other Dementias, OTA-BA-404, Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1990.


Sources Of Help
State Agencies on Aging


These agencies coordinate services for older Americans, providing information on services, programs, and opportunities. (* In-State Toll Free Number)

Alabama
Executive Director, Alabama Commission on Aging
770 Washington Avenue, Suite 470
RSA Plaza
Montgomery, Alabama 36130 (205) 242-5743

Alaska
Executive Director, Older Alaskans Commission
P.O. Box 110209
Juneau, Alaska 99811-0209 (907) 465-3250

American Samoa
Director, Territorial Administration on Aging
Government of American Samoa
Pago Pago, American Samoa 96799 (684) 633-1251

Arizona
Administrator, Aging and Adult Administration
Department of Economic Security
1789 West Jefferson - 950A
Phoenix, Arizona 85007 (602) 542-4446 *1-(800) 352-3792

Arkansas
Director, Division of Aging and Adult Services
Arkansas Department of Human Services
1417 Donaghey Plaza South
P.O. Box 1437, Slot 1412
Little Rock, Arkansas 72201-1437 (501) 682-2441

California
Director, California Department of Aging
1600 K Street
Sacramento, California 95814 (916) 322-5290

Colorado
Director, Aging and Adult Services
Department of Social Services
1575 Sherman Street, 10th Floor
Denver, Colorado 80203-1714 (303) 866-5905

Commonwealth Of The Northern Mariana Islands
Administrator, Office on Aging
Department of Community and Cultural Affairs
Civic Center
Commonwealth of the Northern Mariana Islands
Saipan, Mariana Islands 96950 (670) 234-6011

Connecticut
Director, Division of Elderly Services
Department of Social Services
175 Main Street
Hartford, Connecticut 06106
(203) 566-3238 *1-(800) 443-9946

Delaware
Director, Delaware Division on Aging
Department of Health and Social Services
1901 North Dupont Highway - Second Floor
New Castle, Delaware 19720
(302) 577-4791 *1-(800) 223-9074

District Of Columbia
Director, District of Columbia Office on Aging
Executive Office of the Mayor
441 - 4th Street, N.W., 9th Floor - South
Washington, D.C. 20001 (202) 724-5622

Florida
Secretary, Florida Department of Elder Affairs
Building 1 - Room 317
1317 Winewood Boulevard
Tallahassee, Florida 32399-0700
(904) 922-5297 *1-(800) 342-0825

Georgia
Director, Division of Aging Services
Department of Human Resources
2 Peachtree Street, N.E., 18th Floor
Atlanta, Georgia 30303 (404) 657-5258

Guam
Administrator, Division of Senior Citizens
Department of Public Health and Social Services
P.O. Box 2816
Government of Guam
Agana, Guam 96910 (671) 734-2942

Hawaii
Executive Director, Hawaii Executive Office on Aging
335 Merchant Street, Room 241
Honolulu, Hawaii 96813 (808) 548-0100

Idaho
Director, Idaho Office on Aging
Statehouse, Room 108
Boise, Idaho 83720 (208) 334-3833

Illinois
Director, Illinois Department of Aging
421 East Capitol Avenue
Springfield, Illinois 62701
(217) 785-2870 *1-(800) 252-8966

Indiana
Commissioner, Indiana Department of Human Services
420 W. Washington Street
P.O. Box 7083
Indianapolis, Indiana 46207-7083
(317) 232-9020 *1-(800) 545-7763

Iowa
Executive Director, Department of Elder Affairs
Jewett Building, Suite 236
914 Grand Avenue
Des Moines, Iowa 50309
(515) 281-5187 *1-(800) 532-3213

Kansas
Secretary, Kansas Department of Aging
Docking State Office Building, 150-S
915 S.W. Harrison
Topeka, Kansas 66612-1500
(913) 296-4986 *1-(800) 432-3535

Kentucky
Director, Division for Aging Services
Cabinet for Human Resources
Department for Social Services
275 East Main Street
Frankfort, Kentucky 40621 (502) 564-6930

Louisiana
Director, Governor's Office of Elderly Affairs
4550 North Boulevard, P.O. Box 80374
Baton Rouge, Louisiana 70806 (504) 925-1700

Maine
Director, Bureau of Elder and Adult Services
Department of Human Services
State House - Station 11
Augusta, Maine 04333 (207) 626-5335

Maryland
Director, Maryland Office on Aging
301 West Preston Street
Baltimore, Maryland 21201
(301) 225-1102 *1-(800) 338-0153

Massachusetts
Secretary, Massachusetts Executive Office of Elder Affairs
1 Ashburton Place, 5th Floor
Boston, Massachusetts 02108
(617) 727-7750 *1-(800) 882-2003

Michigan
Director, Office of Services to the Aging
P.O. Box 30026
Lansing, Michigan 48909 (517) 373-8230

Minnesota
Executive Secretary, Minnesota Board on Aging
444 Lafayette Road, 4th Floor
St. Paul, Minnesota 55155-3843
(612) 296-2770 *1-(800) 652-9747

Mississippi
Director, Division on Aging and Adult Services
Department of Human Resources
750 North State Street
Jackson, Mississippi 39202
(601) 359-4925 *1-(800) 222-7622

Missouri
Director, Division of Aging
Department of Social Services
615 Howerton Court
Jefferson City, Missouri 65102-1337
(314) 751-3082 *1-(800) 235-5503

Montana
Coordinator, Governor's Office of Aging
Capitol Station, Room 219
P.O. Box 8005
Helena, Montana 59604
(406) 444-5900 *1-(800) 332-2272

Nebraska
Director, Department on Aging
301 Centennial Mall South
P.O. Box 95044
Lincoln, Nebraska 68509-5044 (402) 471-2306

Nevada
Administrator, Division for Aging Services
340 N. 11th Street, Suite 114
Las Vegas, Nevada 89158 (702) 486-3545

New Hampshire
Director, Division of Elderly and Adult Services
New Hampshire Department of Health and Humans Services
115 Pleasant Street
Concord, New Hampshire 03301
(603) 271-4394 *1-(800) 852-3345

New Jersey
Director, New Jersey Division on Aging
Department of Community Affairs
101 South Broad Street - CN 807
Trenton, New Jersey 08625-0807
(609) 292-0920 *1-(800) 792-8820

New Mexico
Director, New Mexico State Agency on Aging
La Villa Rivera Building, Ground Floor
224 East Palace Avenue
Santa Fe, New Mexico 87501
(505) 827-7640 *1-(800) 432-2080

New York
Director, New York State Office for the Aging
Agency Building #2
Empire State Plaza
Albany, New York 12223-0001
(518) 474-5731 *1-(800) 342-9871

North Carolina
Director, North Carolina Division on Aging
Department of Human Resources, Kirby Building
639 Palmer Drive, Caller Box 29531
Raleigh, North Carolina 27626-0531
(919) 733-3983 *1-(800) 622-7030

North Dakota
Director, Aging Services Division
North Dakota Department of Human Services
1929 North Washington Street
P.O. Box 7070
Bismarck, North Dakota 58507-7070
(701) 224-2577 *1-(800) 472-2622

Ohio
Director, Ohio Department of Aging
50 West Broad Street - 9th Floor
Columbus, Ohio 43215 (614) 466-5500

Oklahoma
Division Administrator, Aging Services Division
Department of Human Services
312 N.E. 28th Street
P.O. Box 25352
Oklahoma City, Oklahoma 73125 (405) 521-2327

Oregon
Administrator, Senior and Disabled Services Division
Department of Human Resources
500 Summer Street, N.E., 2nd Floor
Salem, Oregon 97310-1015 (503) 378-4728

Pennsylvania
Secretary, Pennsylvania Department of Aging
400 Market Street, 6th Floor, MSSOB
Harrisburg, Pennsylvania 17101-2301 (717) 783-1550

Puerto Rico
Executive Director, Puerto Rico Office of Elderly Affairs
Call Box 50063
Old San Juan Station, Puerto Rico 00902 (809) 721-0753

Republic Of Palau
Director, State Agency on Aging
Department of Social Services
Republic of Palau
Koror, Palau 96940

Rhode Island
Director, Department of Elderly Affairs
160 Pine Street
Providence, Rhode Island 02903
(401) 277-2858 *1-(800) 322-2880

South Carolina
Executive Director, South Carolina Division on Aging
202 Arbor Lake Drive, Suite 301
Columbia, South Carolina 29223-4535
(803) 737-7500 *1-(800) 922-1107

South Dakota
Administrator, Office of Adult Services and Aging
Richard F. Kneip Building
700 Governors Drive
Pierre, South Dakota 57501-2291 (605) 773-3656

Tennessee
Executive Director, Tennessee Commission on Aging
706 Church Street, Suite 201
Nashville, Tennessee 37243-0860 (615) 741-2056

Texas
Executive Director, Texas Department on Aging
1949 - 1H 35 South, P.O. Box 12786, Capitol Station
Austin, Texas 78711
(512) 444-2727 *1-(800) 252-9240

Utah
Director, Utah Division of Aging & Adult Services
120 North 200 West, Room 401, P.O. Box 45500
Salt Lake City, Utah 84145-0500 (801) 538-3910

Vermont
Commissioner, Department of Rehabilitation and Aging
103 South Main Street
Waterbury, Vermont 05671-2301
(802) 241-2400 *1-(800) 642-5119

Virgin Islands
Commissioner, Virgin Islands Department of Human Services
Knud Hansen Complex, Building A
1303 Hospital Ground
Charlotte Amalie, Virgin Islands 00840 (809) 774-1166

Virginia
Commissioner, Virginia Department for the Aging
700 East Franklin Street - 10th Floor
Richmond, Virginia 23219-2327
(804) 225-2271 *1-(800) 552-3402

Washington
Assistant Secretary, Aging and Adult Services Administration
Department of Social and Health Services
P.O. Box 45050
Olympia, Washington 98504-5050
(206) 586-3768 *1-(800) 422-3263

West Virginia
Director, West Virginia Office of Aging
State Capitol Complex - Holly Grove
1900 Kanawha Boulevard
Charleston, West Virginia 25305-0160
(304) 558-3317 *1-(800) 642-3671

Wisconsin
Director, Bureau on Aging
Department of Health and Social Services
217 South Hamilton, Suite 300
Madison, Wisconsin 53707 (608) 266-2536

Wyoming
Administrator, Commission on Aging
Hathaway Building, Room 139
Cheyenne, Wyoming 82002 (307) 777-7986


Alzheimer's Association, Inc.
919 North Michigan Ave., Suite 1000
Chicago, Illinois 60611
Telephone: (312) 335-8700
Toll Free: 1-800-272-3900 (Illinois) 1-800-621-0379 (National)

(Provides support through AA Chapter Family Support Groups; educational and patient care materials; information about local resources and services)

Alzheimer's Disease Education And Referral Center
P.O. Box 8250
Silver Spring, Maryland 20907-8250
Telephone: (301) 495-3311 Toll Free: 1-800-438-4380

(A service of the National Institute on Aging, the center distributes information on Alzheimer's disease, on current research activities, and on services available to patients and family members)



Message From The National Institute Of Mental Health

Research conducted and supported by the National Institute of Mental Health (NIMH) brings hope to millions of people who suffer from mental illness and to their families and friends. In many years of work with animals as well as human subjects, researchers have advanced our understanding of the brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and brain disorders.

Now, in the 1990s, which the President and Congress have declared "The Decade of the Brain," we stand at the threshold of a new era in brain and behavioral sciences. Through research we will learn even more about mental disorders such as depression, manic-depressive illness, schizophrenia, panic disorder, and obsessive-compulsive disorder. And we will be able to use this knowledge to develop new therapies that can help more people overcome mental illness.

The National Institute of Mental Health is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.



Acknowledgments

This is the second revision of the brochure by Margaret Strock, staff member in the Information Resources and Inquiries Branch, Office of Scientific Information, National Institute of Mental Health (NIMH). Expert assistance was provided by Barry D. Lebowitz, Ph.D., George T. Niederehe, Ph.D., Jane L. Pearson, Ph.D., Benjamin Wolozin, M.D., Ph.D., and Trey Sunderland, M.D., NIMH staff members. Their help in assuring the accuracy of this pamphlet is gratefully acknowledged. An earlier version of the brochure was written by Gene D. Cohen, M.D., Ph.D., former Director of the NIMH Program on Aging, in 1987. It was printed as a cooperative public-private effort by the American Association for Geriatric Psychiatry.

National Institutes of Health
National Institute of Mental Health

NIH Publication No. 94-3676
Printed 1990, Revised 1992, 1994

Bulk sales (Stock No. 017-024-01493-1) by the U.S. Government Printing Office, Superintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328.

 

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