 So again, today the webinar is entitled, Risk and Protective Factors for Elder Abuse in Canada, Findings from the CLSA, and it will be presented by Dr. David Burns. Dr. David Burns is a professor at the University of Toronto in the Factor in Montage, Faculty of Social Work. He holds a Canada Research Chair in Older Adult Mistreatment Prevention. He completed a PhD at Columbia University, School of Social Work, concentrating in gerontology and advanced practice. Dr. Burns' program of research focuses on elder mistreatment, including the development of basic knowledge and the design evaluation and measurement of interventions to prevent and respond to elder mistreatment. He advises major international organizations on elder mistreatment, such as the World Health Organization and National Institutes of Health, as well as federal and regional governments in Canada and the United States. Dr. Burns also works with nonprofit organizations such as state level adult protective service programs, and he does this on the development implementation and measurement of elder mistreatment response and prevention programs. So I think we have a very exciting and experienced presenter for us today and a very important topic. So I will now turn it over to you, Dr. Burns. All right, thank you. Okay, so thanks for everyone for joining today. I'm going to do this presentation and leave some time at the end. If you have any questions or comments and certainly welcome that. And before I start, I do want to acknowledge a couple of entities here. First of all, the CLSA, thank you for the invitation here. I also want to thank you and acknowledge access to this data. It's a wonderful resource that we have here in Canada for those of us who are studying aging issues across all sorts of domains. And so yeah, that's great, thank you. Also want to acknowledge the Public Health Agency of Canada for your support and ongoing work with you. Most recently with Megan and Ayes and Erin, just so everyone knows, there is a full report that is forthcoming in the near future that will be posted on the Public Health Agency of Canada website and that will have more details than I'm able to share here today. Okay, so I'm going to go through this fairly quickly, but I assume that most people out there joining today are aware of the aging population in Canada. But in the event that there are some of you who are kind of joining our group for the first time, just a couple of slides, basic kind of background. So this sort of demonstrates the structure and the shape of the shifting population aging. And so we see that from the early 1970s up until the projected 2030, the shape or the structure of our population as it relates to age is changing from, the majority of the population being younger towards more of a rectangular shape there. You can post this in the chat, but any reasons why is this happening? What are the major reasons this is happening? Like especially by our health care low birth rate. Okay, and so we see that these trends are certainly happening across the country. And this gives a nice representation here again with from early 1970s projected towards 2080, the proportion of the Canadian population who are older adults, you can see like that right now we are right in the middle of the steepest kind of change in rate here. And where I live here in Ontario, just kind of bringing it a bit more locally, we've just recently gone through really what's quite a remarkable time in our history. So this gray line here represents the proportion of the population in Ontario who are children can be ages of zero to 14. And this blue line represents those who are older adults. And for the first time in the history of our province, the proportion of the population who are age 65 or older, crossed that the proportion that were children back in 2016. So again, for those of you who aren't in our kind of aging kind of circles here, just to kind of emphasize we're going through a really important time in our history. And so what does this mean for the issue of elder views that I'm going to talk about today? By the way, anytime you see EA that refers to elder abuse and the term elder abuse is often used interchangeably with terms such as elder mistreatment or elder maltreatment. But what does this population aging mean for the issue of elder abuse? So it means that in the absence of developing effective prevention strategies, the absolute scope or the absolute numbers of elder abuse cases out there will expand, will grow in proportion with the older adult population growth. And unfortunately, our knowledge of effective prevention strategies represents the largest gap in our field. And so that's really what motivates what we're talking about here today. Prevention development is predicated in part, I would say in large part on our understanding of elder abuse, risk and protective factors. So in order to develop targeted mechanistically driven prevention interventions, we need to know what are those factors that are increasing or decreasing the probability or likelihood of older adults becoming victims of elder mistreatment. And this applies to all levels of prevention. So whether we're talking about primary, secondary or tertiary, so to develop larger population, public education and awareness campaigns or to develop educational and training materials, we need to know about risk and protective factors. Same thing with screening tools that may be used, for example, in primary care office settings or emergency departments, for example, we need to know like what are those factors that place older adults at risk. And then certainly, and this is sort of the area where I spent a lot of my time is when we develop interventions that respond to actual cases of existing cases of elder abuse out in the community, we need to know what are those factors that we should be targeting to kind of reduce an older adult's risk of re-victimization. So just so we're all on the same page, how do we define the issue of elder abuse? So it's an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult. So there's a lot there, but essentially, it does occur in relationships involving an expectation of trust. So it does not include, for example, scams or frauds that may be perpetrated by somebody in a different country who's unknown to the older adult. It doesn't include the issue of identity theft, for example, where the older adult has never met the person who may be doing it. And while it's a closely related issue, it doesn't formally include the issue of self-neglect because that doesn't occur in the context of a relationship. While there are varying definitions out there across Canada and the world, we almost universally accept that it does include the following subtypes. So emotional, physical, sexual and financial abuse as well as neglect by others. I think fortunately we've gotten to a point where people really do recognize this as a really serious problem and very grateful for various levels of government really acknowledging and putting it, giving it attention these days. It certainly is a serious issue with large consequences. So we know that there's a few studies that have followed older adults over time. So for example, over a nine year period, victims of elder abuse have a higher likelihood of premature death compared to those who don't experience elder mistreatment. And there's all sorts of physical and mental health sequelae as you can imagine. And that at a societal level, victims of elder abuse have higher rates of hospitalization, emergency room use, nursing home placement, et cetera. Okay, so what we're talking about today is really, so how big is this problem and what places older adults at risk or may protect them as well. So when we talk about how big is this problem, we have to consider a couple of different concepts or rates. One is incidents, which is really the rate of new cases entering the population over a certain period of time. And then prevalence, which is the rate of cases out there at any given time. And certainly most of the research out there has focused more on prevalence than incidents. I recently was involved in a study that looked at incidents and I'll give you that reference at the end of this presentation, but today we're focusing more on the issue of prevalence. When we think about risk and protective factors, we generally try to understand and analyze them through this ecological systems perspective. So we understand that this is obviously the older adult, the victim is central to this issue, but it does occur in the context of a relationship. And so we also, in addition to understanding risk and protective factors attached to the older adult victim, we also try to understand factors that are attached to those trusted others out there who may be at risk of perpetrating elder abuse. We try to understand what goes on in the relationship between them that may place them at higher risk and then look at the family system, the home environment, their social environment, and then social determinants of health to try to really understand the full scope of risk factors that place older adults vulnerable. So leading up to this research, the field has come a long way in its understanding of risk and protective factors. For a long time, it did rely largely on studies using convenient samples drawn from, you know, healthcare or social service settings, which obviously have a high degree of selection bias and threats to external validity. There was a period of time where we were using population-based samples, but then using agency records to identify victims, which also carried a lot of bias. And then in the last sort of 15 years or so, we've been getting more into actual population-based studies interviewing older adults directly. And this has been great and carries a lot more external validity. And the CLSA is one example of this type of study. Where the CLSA helps us advance the state of the science is that it's, you know, as I was talking about today, is that we can actually look at this somewhat longitudinally over time. So here are the research questions that were pursued. What is the one-year prevalence of elder abuse in Canada and what factors are associated with elder abuse victimization over a three-year period? And these findings have also been published in this paper here in Nature Aging, which you can access online. Okay, so just some details about the CLSA methods and please if I, if I'm saying any of this incorrectly, please feel free to jump in and correct me. But essentially, at baseline, a random sample of over 50,000 adults aged 45 to 85, using both telephone and in-person interviews. The current findings that I'm showing you today were based at the time on the most recent and available waves of data collection, baseline and follow-up. In 2018, in their first follow-up, an elder abuse module was included for the first time. And so not in 2015, but yes in 2018. And it was administered to older adults who were aged 65 or older. And so the analytic sample for this particular study included those older adults who completed both baseline and follow-up interviews and were age 65 or older at the time of follow-up. Okay, and then it is worth mentioning, of course the sample is disproportionately skewed towards more of a white, higher income and well-educated sample of older adults. And we did use data waiting to account for sample misrepresentation in this study. Exclusions, so the baseline sampling strategy did exclude those living in the three territories on federal First Nation reserves and other First Nation settlements, full-time members of the Canadian Armed Forces, those living in institutional 24-hour long-term care settings, those with temporary visa or in transitional health coverage, those with cognitive impairment, and those who were unable to respond in English or French. Okay, so in terms of the analysis that was used to come up with these findings, we used multivariable logistic ordinal or multinomial regression modes. And so what I'm showing you today is we're analyzing independent variables from baseline to predict the potential of elder views or elder view severity at three-year follow-up. And so this does go sort of above and beyond what is mostly out there in terms of sort of cross-sectional data at one time. So that was very exciting. Selection of the independent variables into the multivariable models was based on their significance in the bivariate analyses as well as tolerance and various inflation factor diagnostics. And then all models regardless of those unadjusted bivariate levels of significance, all models did control for at minimum sex, race, culture, and age as basic social demographics and whether or not the interview was conducted in person or over the telephone. And then I conducted analysis for elder views as a whole, as a global phenomenon, but then also separate analyses based on the separate subtypes that were covered in the CLSA. So as a note, the CLSA does include emotional abuse, physical abuse and financial abuse. It did not include neglect or sexual abuse. And having been a part of a couple of different population-based studies, it actually would be somewhat abnormal to have enough information on the issue of sexual abuse anyways. Okay, so here are some of the findings. So the one-year problems. So we found an overall one-year prevalence of elder views of 10%. You can see the confidence there is fairly tight. In this data set, we see that emotional abuse comes out way ahead, and then followed by financial abuse and physical abuse. And that is somewhat, I would say, in some other studies, we would find, I would say higher rates of financial abuse relative to emotional abuse, but certainly that physical abuse rate is very consistent. So this is a fairly large rate. This is telling us that about one out of every 10 older adults who live in Canada experienced some form of elder mistreatment. Each year. And so we now have a couple of population-based studies to base our prevalence estimates on that range from 8.2 to 10%. We conducted a systematic review a few years ago to look at the global prevalence of elder abuse. We found that in North America it was about 9.5% after pooling the data across population-based studies. So the rate that was found here is very consistent, and a lot of people would argue that at this point we don't need to do more prevalence studies. We know, we're pretty sure that it's about 10%. And that obviously translates to a lot of older adults here in Canada, about 970,000 people who are ages 60 years or older. You know, it's hard to know which direction that this estimate may be biased. Most studies do not include particularly vulnerable subpopulations of older adults. So for example, older adults with cognitive impairment, older adults who live in institutional settings. We also know that older adults tend to under-report personal problems. So these are all reasons that this 10% estimate may actually be an underestimate. Having said that, it's also possible that some of these questions are overly sensitive and may capture cases that aren't necessarily abuse, but may represent more routine family conflict. So it's difficult to say, but it is fairly consistent this 10% prevalence rate. And then again, without effective prevention strategies in place, there's no reason to think this is going to change. And so the scope is just going to keep going up and up. Okay. So in terms of the findings, as it relates to risk and protective factors, again, I would ask you to refer to the final report when it does get posted, which will provide a lot more details. There were a lot of findings. I had to kind of decide how to present them here, but essentially I'm showing you those factors that were the most consistent across subtypes, either in relation to the global phenomenon of elder abuse or in relation to each subtypes. So these are the ones that were associated with at least two or more of these types. And you can see that these risk and protective factors span several domains. So the ones that are highlighted or written in red are risk factors, and the one in green are protective factors. So from a physical health perspective, the number of chronic, diagnosed chronic health conditions as that goes up, an older adult is at higher risk. Similarly, is the number of functional impairments that an adult, an adult is living with goes up. So is there a risk of elder mistreatment? Staying with risk factors. So mental, it's not just physical health, but mental health came out as a very strong and consistent domain. So people living with higher numbers of depressive symptoms were at higher risk. People living with higher numbers of PTSD symptoms were at higher risk. One of the things that was really, really interesting is historically, people who reported having experienced sort of more severe levels of child maltreatment at an early age were much more likely to experience elder abuse in their older adulthood. And this is something that I think is really fascinating from a life course perspective. The whole environment as you have more people living in the house, the risk goes up. And then having inadequate income to meet basic needs also increases risk. In terms of protective factors, one of the strongest and most consistent was life satisfaction. So older adults who were reporting higher levels of life satisfaction were less likely to be victims of elder mistreatment. Those reporting higher levels of total social support were less likely. And so social support came out as a very consistent protective factor. And we can certainly discuss some of these later on. I would say surprisingly, females came out as less likely to experience elder mistreatment. Although at a descriptive level, there were certainly more female victims. Proportionally, they were not more likely. And then lower education, people with lower education were less likely to report elder abuse. One that I want to just highlight, just because this finding also that came out of this, so black identifying older adults as being at heightened risk of financial abuse, this is a finding that has now been replicated across five population-based studies here in Canada and in the US. And it's five population-based. That's the best data we have. So this is something that I think is one of the, if not the most consistent risk factor, at least for financial abuse. And it's something that we need to think about a lot more and try to understand further. This doesn't come from the CLSA, but just in the spirit of that ecological framework, these are what are understood as being strong risk factors that are attached to the trusted other. In other words, adult children out there, spouses, grandchildren, friends, neighbors, et cetera, who may be in a position of mistreating an older adult. So those living with higher levels of caregiver stress, mental illness, substance use issues, dependency upon the older adult, and those who have been abused by the older adult as a child, they are at higher risk of perpetuating abuse. And so just sort of shifting here. So up until this point in the presentation, I've been talking about the issue of elder abuse in sort of dichotomous terms. So I've been sort of discussing this issue as something that either occurs or it doesn't. And this is obviously, this is necessary for thinking about when we're trying to understand a prevalence rate or risk factors among older adults in the general population. The problem with this dichotomous kind of operational view of the issue is that it does kind of obscure and hide the wide variation of sort of lived mistreatment experiences that do occur within that yes category. And so one of the things that the field is doing is to sort of, I would say five years in particular, is to try to understand this issue through more of a spectrum of severity, not just putting everybody in the same kind of one category of yes. And there's different ways that severity has been looked at to date. So we've done some work where we're looking at the subjective appraisal of the issue from the perspective of the older adult themselves. And then there's work that's been done on what I'm going to show you today is more the frequency of mistreatment behaviors, the multiplicity of behaviors, meaning that within any given subtype, let's say emotional abuse, there may be eight different types of emotional abuse. So how many of those different behaviors were experienced? And then the multiplicity of actual mistreatment type. So was the person experiencing emotional abuse? Were they also experiencing physical abuse, financial abuse? Another way to kind of start constructing an understanding of severity. And there are all other sorts of ways to understand severity out there as well. So what we have found is that when we do look at severity, there is a dosage response with adverse outcomes. It also comports more closely with the way that we look at cases in the community when we are addressing them. And so it's actually uncommon that the goal is to take a case from a yes, like a purely yes status to a purely no status. And the reason for that is because unlike, for example, child maltreatment, when we're working with these cases, older adults have the right to self-determination and autonomy. They get to choose what their sort of resolution looks like. And it's very rare that they would kind of want to pursue some path of intervention that would actually lead to a complete no, like there's no more risk. Because what that would mean is that it would mean severing their relationship with their perpetrator, who's often a child, grandchild, or it would mean moving out of the home. So that's obvious. So we're often following more of a harm reduction model. And so some kind of severity lens or spectrum lens are more realistic. And with that in mind, if we can understand risk factors severity, for severity, then we can start sort of understanding which interventions can sort of target those factors that either increase or ameliorate severity. Okay, so with all that in mind, okay, and also from a measurement perspective it just creates opportunity for more sensitive measurement over the course of intervention. I'm not gonna spend too much more time on this. Okay, so we were able to look at this to a certain degree with the CLSA data, which was great. And so the research question here was what factors were associated with elderly severity among victims over the three-year period? And so in this analysis, we were only looking at the subset or the subsample of older adults who had been classified as victims based on the prevalence work that I showed you before. So it's not the full CLSA sample, but rather among those victims there's a variation in severity what factors predict that variation in severity. And so the way we define severity in this particular analysis was based on frequency and multiplicity. So it ranged anywhere from this person experienced one sort of behavioral form of emotional abuse in the past year to they experienced that one behavioral form several times in the past year to they experienced several forms of emotional abuse in the past year, and then on the other end, multiple forms of that abuse multiple times over the past year. So here are the factors. So again, looking at similar domains we see that now self-reported health was actually the main kind of physical health indicator as opposed to the number of diagnosed chronic health conditions or number of functional impairments. Mental health, the PTSD symptoms came out as important when we're looking at severity. By far the most consistent and kind of also in magnitude risk factor for severity across types, all types was whether or not the person lived with the perpetrator. Now this makes sense. I think this is intuitive. If you live with your perpetrator you're at much higher risk of more severe forms of mistreatment. And so this obviously has really important implications for the way we intervene on the problem. Interestingly, when we look at social determinants when we're looking at prevalence females were at lower risk now that we're looking at severity it comes that female identifying older adults are at higher risk of more severe forms of mistreatment. And then again this issue of child maltreatment very consistent and I just, you know it's really interesting moving forward. So people who experienced child maltreatment in their early life more likely to experience more severe forms of elder mistreatment later in life. So what are some of the kind of key messages here? So one is that it was very exciting to get into a more longitudinal design to look at these risk and protective factors over time. Again, one in 10 older adults experiencing elder abuse within a given year. Which is obviously a bigger rate. I think reinforcing and replicates prior findings as well. As it relates to physical health status healthcare providers are in a position to play a very important role here particularly as it relates to identifying and screening older adults who are at risk of elder abuse. So many of you out in the audience today may be healthcare providers and if you do work with older adults on a routine basis what this is telling us is that you probably fairly often do come across an older adult who is either experiencing elder abuse or is at higher risk given the one in 10 finding. But it's not just physical health. I mean those of you out there who are working in the domains around mental health. It's also a very important domain of risk predicting elder abuse and so understanding and helping people with that as well. And then as I've said before I think that this link with child maltreatment it does carry important implications across research and practice. So the implication here is that we really shouldn't kind of keep looking at these we need to look at these issues of family violence from a life course perspective rather than conceptualizing them as just discrete life stages. So often like we kind of silo ourselves there's child maltreatment researchers and practitioners there's people who work on domestic violence and intimate partner violence and those of us who work on elder abuse but really these things are connected. I mean in other studies there's also connections between domestic and intimate or violence with older abuse. So the way we practice with victims needs to take these things into account. Social support, social connectedness hugely important protective factor and just the reality that these factors do span across several domains. And then I mentioned before that in addition to looking at prevalence it is very important to understand incidents. So the rate of people experiencing this issue for the first time over a given period of time and if that is something that you're interested in this was a population based longer to rural elder abuse study that looked at ten year incidents and factors associated with that incident. And I believe that's it. I will leave it there and if you have any questions please feel free to ask them in the chat. A couple were already answered in the Q&A. There was one, I don't know if you want to touch on it again but I think a couple of participants noted the lower education and being a protective factor and I think you already did mention that this had to do with more of the responses bias than anything else. Anything else to add on that? No, I would agree with that. I think that's right. There's a reporting bias going on there. That's also really consistent like any study that population based study that I've been just out there that's often the case and I think there is a reporting bias that people who are more educated are perhaps more likely to be sort of aware of and more willing to report on the issue. I agree. And then I think the next question it's longer but has the study considered investment advisors or financial advisors that convince elders to invest money and they get paid a fee and the elder loses money by trusting the advisors with their expertise and knowledge, losing money later in life after having worked a lifetime is very upsetting and impacts the years that they have left. So I guess anything related to that in your research? Well, I think that so I appreciate that comment and it is a really serious issue. It does happen. I've personally been involved in cases involving financial advisors and investors who did take advantage of older adults and I think that certainly the findings again if you look at the report when it comes out there's findings that are specific to financial abuse those risk and protective factors would apply to those types of relationships with financial advisors as well. So financial advisors would be viewed as somebody who is in a relationship of trust and so I think that those findings would be certainly applicable to older adults who may be more vulnerable to that type of mistreatment for sure. And I guess the idea of the maltreatment or abuse happening in childhood and then later in life question is is it that it happens across the lifespan or is it within these different parts of life? Anything on that? So it's a really good question I don't know the answer and I think that's a whole line of inquiry out there what is it that connects these things? Because they do seem to predict one another. So is it from a psycho-emotional perspective that if you experience child maltreatment that kind of sets up your perceptions of self and kind of expectations for self and the types of relationships perhaps that you are familiar with and deserve and you're more likely to enter those kinds of relationships or have those kinds of relationships in your life moving forward that's one sort of possibility another may be that we know that child maltreatment is associated with for example mental health outcomes that are in turn risk factors that may be sort of a mediating kind of pathway that goes on there but I don't know that's a really important question Next question is about the link to mental health or the predictor of mental health as a key predictor of elder abuse have you looked at the association between mental health and elder abuse from the perspective of poor mental health as an outcome for abuse of abuse? Yes, so poor mental health has been found to be an outcome as well Yep Great, so we won't move on and now there's two questions from Cliff First question is do you have any plans to stratify these models by race or ethnicity to explore differences in risk factors for severity and prevalence across identities and then the second question is will you be replicating these analyses with CLSA's Indigenous cohort? Yes Yes, I do have plans to look within specific subgroups I mentioned this finding that black identifying older adults as being at higher risk for financial abuse so looking for example within the sub-sample of black identifying older adults to try to understand what's going on within this sample that places people at risk and I appreciate you mentioning the Indigenous sayable I admittedly I'm actually not aware of it too much but that sounds incredibly important and I'm going to look into that, thank you Just to clarify the CLSA does not have an Indigenous cohort we do one of the questions that baseline is participants can self-identify we have developed we have been working on our data access and policies and procedures around use of the data that relates to identify those participants that identify as Indigenous and more information about that can be on our website just to clarify that Okay so we will move on then to the next question they're coming in fast now I'm assuming that you use pooled data from both tracking and comprehensive is that right and if it is yes then I assume you use the pooled weights generated by CLSA Yes, all of that is correct Yes So next question are you aware of similar studies in the territory so I presume similar studies of yours because the CLSA doesn't include the territories within the cohorts have there been similar work that include those participants I am not aware of that but it's something I would be interested in being a part of obviously one of the exclusions here were people living in the territories and so I think that that would be really important to pursue Lots of opportunities Okay so next question is can we go back to the fact that being female is a preventative factor overall is surprising to me given the rates of gender based violence overall just having a hard time wrapping my head around it so any comments about that Yeah, I agree it was a surprising finding So globally we find that females are at higher risk but interestingly when you look at the studies that have been conducted in North America it's inconclusive I mean you know this actually isn't the only study that has found females as being a protective factor there are also a couple of studies who have found female identifying overall adults as a risk factor and then there's studies that don't have any finding other ways so I agree with you it's surprising given gender based violence dynamics and certainly I think the severity findings there that found that females were at higher risk of more severe forms of mistreatment are indicative of the power relations that are involved in the dynamics of the victim-perfecture relationship and that but I don't know it's a tough one for me as well the age-associated vulnerabilities I don't know if that somehow has some kind of an effect on these things but it's a good question And I guess are you aware of any agencies in Canada that focus specifically on protecting older adults from abuse that you may have worked with or want to work with? I mean I so in terms of I across Canada I can't speak too much so in New Brunswick there is an adult effective services program similar to what you find in every state in the US here in Ontario we actually just started a program called RISE this is based on years of research and kind of evaluation but it's developed a community-based elder mistreatment response program that we work in partnership with elder abuse prevention in Ontario and work with and respond to cases involving older adults who are at risk of her experiencing mistreatment so a couple of examples here in Canada and there's also one of our participants also noted that Canadian Network for Prevention of Elder Abuse would be another resource so CNPA I am on their board and so that's a fantastic organization Canadian organization we don't do direct practice work with older adults but certainly hugely important organization in terms of education advocacy and all sorts of things great okay well we have a few minutes left and a few more questions to get through so I'll try to push through them if frequency is available did you consider using response cut points to estimate the incidence of elder abuse so yes if I'm understanding the question correctly okay so for financial abuse and physical abuse we did not use threshold cut points in other words if somebody reported one incident of financial abuse or one event of physical abuse that was viewed as enough of a threshold to classify them as a victim however with emotional abuse we own for most of the items we only counted them as a victim if they identified the frequency as having happened most of the I think it was something like most of the time in other words if somebody said they were yelled at but it only occurred once or twice they weren't viewed as a victim of elder abuse but it is something that happened more often than they were and that kind of threshold is consistent with more recent research great and the next question is two questions in one do we have a sense of relative elder abuse prevalence across the provinces in Canada and then does any literature out there look at the impact of elder abuse on driving older adults out of their home towards hospitalization or assisted living etc right I mean the CLSA data could be used to look at province by province rates I think that's something that could easily be done I didn't do that but that could be done and then for the second question yeah I mean what we the research has found that older victims of elder abuse do have higher rates of hospitalization and placement in alternative care long term care settings and the next question from Pam I think it's more of a suggestion to delve into relationship history within CLSA and that's something that I can definitely take forward or David you could as well as a research for CLSA so I think we'll go on to is that suggestion that there are variables that I could use or is the suggestion that that's something that the CLSA can think about as adding new variables that's a good question I took it as the CLSA adding other variables to look at that that being said that I think you could probably look at what's already being collected and make some you know look at different types of relationships as they change right as we as the CLSA has more waves of data collection that could probably be done but a good point yeah that's a great idea so we'll go on to social support could you elaborate on social support how that was measured in the study and if you have any suggestions on how government policy or programs could support older adults with that aspect it's a big question yeah so the CLSA actually has a lot of different indicators of social support and you know the finding that I showed you here today was kind of like like a total measure of social support that includes different forms so tangible social support I think emotional social support and a couple of others I think the you know one of the things that kind of comes out when you get into the details of the report is that it's not necessarily the quantity or the absolute size of one's network but rather it's also the quality of relationships in their life and you know I think there's a lot of policy implications here I mean you know there's things like you know friendly visitor programs or you know volunteer phone calls to older adults you know certainly the work that we do with the RISE program a big part of it is to try to strengthen the social supports around older adults I think there's a lot of creative ways that you can introduce or strengthen social support in the lives of older adults so I think that's an important question and we are perhaps we'll leave it with the last comment we have here which I'll just relay and then we can wrap up comment from Sarah given the relational component of elder abuse I think it would be insightful to explore 2S LGBTQI plus older adult experiences these adults are more likely to rely on informal caregivers and these caregivers are more likely to be chosen family rather than biological family they are also more likely to have distrust in their doctor and not disclose sexual orientation or go back into the closet to receive care I think overall this is something else that definitely could be looked at in the future yeah it's hugely important I appreciate the comment we actually did look at it to the extent that we were able to in this and again if you look at the report there are some more detailed findings around different identifying social identities in this case they may not have been related to two or more types and that's why I didn't put them in the slides here today but there are some kind of nuanced findings that you can take a look at great well thank you again to our presenter today we definitely appreciate your participation and thank you to all of our participants in the webinar as well for your interest and also for participating in submitting questions I'd like to remind everyone that the next deadline for data access applications is January 17th of 2024 please visit the CLSA website under Data Access to review what data is available as well as additional details about the application process I'd also like to remind everyone to complete their anonymous survey upon exiting the session today and the next CLSA webinar is going to be entitled examination of the increased risk for falls among individuals with me osteoarthritis it will be presented on November 30th at 12pm by Jessica Wilfong of the Schroeder Arthritis Institute which is based at the University Health Network in Toronto registration details are available on the CLSA website and they've also been posted in the chat box and finally remember that CLSA promotes the webinar series using the hashtag CLSA webinar and we of course invite you to follow us on twitter at CLSA underscore ELCB so again thank you very much everyone and have a wonderful rest of the day