 Good afternoon, everyone. My name is Mark Ramos. I'm one of the Associate Scientific Directors of the Canadian Longitudinal Study on Aging. And I'm the moderator for this webinar. It gives me great pleasure today to introduce Paul Mick and Kathy Picora Fuller, who will be presenting on hearing loss and healthy aging using data from the Canadian Longitudinal Study on Aging. This marks our second webinar in a row where we are actually reporting on projects that have been conducted using data from the Canadian Longitudinal Study on Aging. And as we move thinking ahead into next year's set of webinars, hopefully we will be able to present to you with more projects related to the analyses of CLSA data. So I'll just introduce the speakers. Paul Mick is an otolaryngologist, so that's a head and neck surgeon, and he practices in Cologne, BC. He did his medical degree at the University of Alberta and his residency at the University of British Columbia. He did a Neurotology Fellowship at the University of Toronto and a Masters in Public Health with a focus in epidemiology at the Harvard School of Public Health. His research program investigates the impact of age-related hearing loss on health and public health interventions that address hearing loss in populations. Kathy Picora Fuller is a professor in the Department of Psychology at the University of Toronto, Mississauga. She's also an adjunct scientist at the Toronto Rehabilitation Institute and the Rotman Research Institute at Baycrest. She combines her clinical experience in rehabilitative audiology with experimental psychology, and she has earned an international reputation for her interdisciplinary approach that links research on auditory and cognitive processing during everyday life. So I'll stop talking, and I'll pass the reins over to Paul and Kathy for their talk. Okay, so can you hear me, Mark? Is that good? Paul, Kathy, please go ahead. Okay, so it's Kathy, and I just want to say a few words before Paul is going to do the body of the talk. And I wanted to mention that it's fantastic that sensory measures, actual hearing tests, actual vision tests have been included in CLSA since the beginning, and I started out in the very first meeting of CLSA when there were the first deliberations about what it should look like. And I'm really happy that those measures were retained and continue. Paul and I are both part of the clinical working group. So we want to give you the impression today that, in fact, in the recent years, there has been more and more and more research coming out linking sensory declines with many other aspects of AIDS-related health. And Paul will tell you a bit about that. As Mark said, we're going to tell you about some of the hot off the press early look into some of the CLSA data. And perhaps even more importantly, just to really make everybody aware that we're really happy to collaborate with anybody else who is involved in any aspect of CLSA, because we really think that sensory decline connects with many other topics. And if you're not familiar with hearing or vision, we do have a group that is focused on that, and we're happy to help you out and share the knowledge. And we really hope that many more people develop some expertise in this area. So I'm going to turn it over to Paul now. All right. So let's begin. Good afternoon to everybody in Ontario and points east. And good morning to everyone, the rest of that. Most of this talk is going to focus on hearing because that's sort of my expertise and Kathy's as well, but our project, our CLSA project also looks at vision loss. So the objectives of the talk today is to first describe the epidemiology and pathophysiology of AIDS-related hearing loss. And then look at our study, describe the cross-sectional associations between sensory, so hearing and vision loss, and social factors in the first wave of CLSA tracking data. So this slide gives a life course view of AIDS-related hearing loss. Typically, it's the end results of a combination of a lifetime of genetic, medical, and environmental risk factors. Onset is usually in midlife, although diagnosis and treatment are usually delayed for seven to ten years because of insidious onset and slow progression. By then the impact of hearing loss may already be felt whether the person with it knows it or not. Epidemiological research into hearing loss focuses on identification of risk factors, especially ones that can be modified, and identifying the social, physical, psychological, and cognitive health impacts of the disease. And the reason for doing these studies is to better understand if hearing loss or its effects can be prevented or mitigated. For example, modifiable risk factors or presbychesis might be addressed with public health campaigns. Earlier diagnosis and treatment might lead to better clinical outcomes. And finally, downstream health impacts of hearing loss might be prevented either by increasing uptake of treatment for hearing loss or by addressing the health impacts that it causes among people with hearing loss. So because of the natural history of age-related hearing loss, the CLSA is an excellent platform for studying it. Many causes occurred during midlife or even earlier and may require long-term exposures. For example, some medications are a noise exposure. Thus, a long-term study including middle-aged adults is very useful. As I mentioned, the onset and progression are often relatively slow. So studies with short follow-up are not that helpful. A population-based study allows us to study preclinical changes that occur prior to diagnosis, which I mentioned are often delayed. Contextual factors that change over the life course, for example, working versus retired status, social life, social support, degree of hearing loss, or time since onset, may influence how hearing loss affects activity and participation. And objective measures, which are good for assessing biological questions, for example, the effect of medication use on cochlear function, as well as subjective measures, which are great for measuring the functional impact, are both used in the CLSA. So I'd like to go on and just explain what age-related hearing loss is from a pathophysiological perspective. So this is how hearing works. Sound waves travel through the external auditory canal, causing the eardrum and attached ossicular chain to vibrate. The vibrations cause the state bees, which is the third bone of hearing, to move in a piston-like motion, which propagates fluid waves within the cochlea, which is the spiral-like structure in the diagram. So within the cochlea, these fluid waves cause the thin basilar membrane, which is pictured here, suspended in cochlear fluid, to vibrate, and this deflects delicate hairs attached to the inner ear sensory cells. So these deflections open valves, allowing positive potassium ions to rush into the hair cells. This sets off an action potential that goes to the brain along the cochlear nerve. So these signals from the ear contain information about loudness, tone, and timing. The brain is extremely important for interpreting sounds so that what we hear actually conveys meaning. The brain takes the raw sensory signals and analyzes them in auditory language and emotional centers to parse directionality, lexical meaning, sentiment, timbre, melody, and rhythm. The quality of the signal from the ear affects how easily the brain can make these connections and inferences. So knowing that, we can describe what age-related hearing loss is. Autopsy and animal studies indicate that different pathological changes can result in the same end result of hearing loss. The main contributor is probably degeneration of the stereovascularis, which is the vascular and very metabolically active part of the cochlea that maintains the potassium gradient that drives action potentials. Other findings have included degeneration of the sensory hair cells and of the cochlear neurons, which may result not just in reduced sound sensitivity, but loss of signal fidelity and clarity. And this is why a lot of people say that they can hear, they just can't understand what is being said. Age-related hearing loss is also characterized by problems of speech understanding and noisy conditions, slowed central processing of acoustic information, and impaired localization of sound sources. Neural and cortical degeneration that happens with aging makes processing and interpreting the degraded signals from the ear even harder. So other than age, there are risk factors that influence whether a person develops age-related hearing loss. We know this simply by looking at population differences in age standardized hearing acuity levels. So this is one example taken from a study performed all the way back in 1965. It compared samples of South Sudanese people and attendees of the Wisconsin State Fair. And it shows quite clearly that hearing loss was much more prevalent among people in Wisconsin compared to their age-matched African peers. So we do know that racial background is a predictive factor. The whiter your skin, the more likely you are to lose your hearing. This may be because melanin is found in the street of vascularis and may have a protective effect by scavenging oxygen free radicals. But other differences in modifiable risk factors likely underscore these differences across geography. And we can see this by looking at differences across time in genetically homogeneous populations. So this is a sample from the Beaver Dam Wisconsin study. And people in Beaver Dam are mostly white. The study assessed the effect of birth cohorts on the risk of adult onset hearing loss. And if we use the 60 to 64 year old age group as an example, we can see clearly that the risk of hearing loss was lower for people born later in the century. And this group also did a study looking at parents and their children from Beaver Dam. And controlling for age, the odds of hearing loss were 31% lower in the children compared to their parents, highlighting changes in health and lifestyle that occurred over the 20th century. And clearly noise plays a role in these declining rates, at least in places like Canada and the United States. Occupational regulations and quieter machines have resulted in quieter work environments. In manufacturing jobs, the average noise exposure per shift steadily drops from over 94 decibels in the mid 1970s to 89 decibels at the turn of the century, according to OSHA. And maybe even more importantly, and not shown on this graph slide here, is that fewer and fewer people in developed countries are actually working manufacturing jobs. These reassuring figures, however, belie the reality that in the developing world where manufacturing is moved and where regulations mandating quiet work environments generally don't exist. As well, personal music players can pump out sound as loud as 121 decibels, depending on the type of headphone. It's recommended that an individual listen to at most one hour of music per day at 70% of the maximum volume. But with these criteria, 10 to 15% of teenagers listen at dangerous rates, which might cause hearing loss over time. There's actually emerging evidence showing that noise exposure at an early age may accelerate age-related hearing loss later in life. So in this study here, mice of different ages were exposed to noise at just a single point in their lives. And this noise was only loud enough to cause temporary changes in hearing. For the rest of their lives, they were kept in quiet environments. So this graph is essentially demonstrating that mice exposed to noise when they were young, represented by the blue line, experienced earlier onset and more severe age-related hearing loss over time relative to those mice of the same age who were exposed in later years. Among these mice, histologic degeneration was only seen in the cochlear nerve in mice who were exposed to noise at a young age and then tested at an old age, indicating that early noise exposure resulted in changes that manifested over time. And so essentially what these animal studies are indicating is that noise exposure at a young age could be dangerous. So with this increase in exposure to music at young ages, we may see greater rates of age-related hearing loss over time among today's younger generations. So noise is not the only environmental risk factor for adult onset hearing loss. It's a peripheral vascular disease, and this is because the inner ear is so metabolically active. It takes a lot of energy to maintain that potassium gradient that drives action potentials in the inner ear. So there's a lot of blood flow within the cochlea. In the Framingham cohort, the odds of prevalent low-frequency hearing loss was three times higher in women and almost two times higher in men with a history of cardiovascular disease relative to those without. And smoking is a known risk factor for age-related hearing loss. And in the picture on the slide, we see endothelial damage in mice with age-related hearing loss, which may be the mechanism of action. So moving on from risk factors that cause age-related hearing loss, what are some of the health impacts of having it? And so a number of studies have been done recently looking at this question. And there are a number of health states associated with hearing loss and cross-sectional or longitudinal observational studies, including those listed here. So I don't really have time to go over all of them, but we'll use dementia as an example. This is a study that's received a lot of press recently. It was published in 2011. This is data from the Baltimore Longitudinal Study on Aging. And a cohort of 639 dementia-free older individuals underwent pure-tone hearing testing in the early 1990s. The participants returned for follow-up every two years with a median follow-up of just over 11 years. Cox proportional hazards models were used to model time to incidents all cause dementia, diagnosed using the DSM-3 criteria, and the results were stratified according to level of hearing loss at baseline. So the risk of incident all caused dementia increased by 1.27 times per 10 decibel decrease in hearing and relative to people with normal hearing, the incidence of dementia was nearly 2 times higher in people with just a mild hearing loss, 3 times higher in people with moderate hearing loss, and nearly 5 times higher in people with severe hearing loss. So all of these associations are statistically significant. So to put the effect size into context, the authors calculated that the difference in age equivalent to the cognitive reduction associated with the 25 decibel loss in hearing was 7 years. And they calculated an attributable risk of 36%. In other words, 36% of the risk of developing dementia among individuals with hearing loss could be attributed to their hearing problem under the assumption of a causal relationship. So what are some possible mechanisms? We don't really know, but there are some theories. First, there may be an impact on brain structure. As we've seen in longitudinal MRI studies, accelerated diminishment of whole brain volume and areas of the right temporal lobe in people with hearing loss. Such changes could be secondary to reduced neural stimulation of the auditory cortex from impoverished auditory stimulation with possible cascading effects for memory and cognitive processes dependent on the right temporal lobe. Alternatively, or also hearing loss results, as I mentioned, in degraded speech and sound signals, which then demand increased attention, working memory, and processing resources for them to be interpreted by the brain. So this constant cognitive demand may divert resources from other central processes or reduce cognitive reserves, meaning that the symptoms of dementia could occur at an earlier stage of neuropathological load. Or hearing loss could lead to reduce social engagement, which I'll go on to talk about next. Or finally, there may not be a cause-and-effect relationship. Instead, these associations could be caused by a common neuropathological process. For example, the neurofibrillary plaques, et cetera, that occur with dementia might also be affecting hearing or unmeasured confounders. So as I mentioned, the link between hearing loss and dementia could be mediated through social isolation. The evidence supporting this link between isolation and dementia comes from epidemiological and basic science studies. So we see here rats are randomized to live among their peers in cages containing abundant sensory stimuli at lower concentrations of inflammatory cytokines and higher levels of neurotrophic factors in the hippocampus compared to controls isolated in sensory-deprived conditions. They were also seen to have healthier neurons, and this corresponded to better spatial memory and better learning among the rats living in the stimulating environments compared to those who were isolated. So these animal studies support a link between social isolation and cognitive decline in dementia. All right. So I'm just going to move on to talk about our study for the next part of the talk. So sound and sight affect mobility and communication, and thus perhaps the structure and function of a person's social milieu. Studies examining relationships between sensory loss and social outcomes have either been qualitative or measured only single aspects of social function or focus on hearing or vision loss in isolation. So we know that some people with hearing loss compensate for their loss by relying more on vision and vice versa. So we felt it was important to look not just at hearing and vision in isolation, but together in our study. So for these reasons, we sought to determine if hearing loss, vision loss, or dual sensory loss are associated with social network diversity, participation in social activities, availability of social support, and loneliness in a nationally representative sample of Canadians aged 45 to 85, i.e., the CLSA tracking study, and whether age or gender modified these associations. And I'd just like to acknowledge my co-authors, not just Kathy, but my student, Maxim Parfinov, Walter Widdich, and our funding source, which is the CIHR via the Canadian consortium of neurodegeneration aging, as this is a sub-study of a larger study looking at relationships between sensory loss and cognition. So our research question, as I mentioned, are hearing loss, vision loss, or dual sensory loss associated with four measures of social structure and function, and whether age or sex modified these associations. We excluded people with any missing data, and the CLSA tracking cohort is a telephone survey. It's cross-sectional because we just used data from the first wave, which was collected around 2014. Our sensory exposure variables were dichotomous measures of self-reported sensory loss. In CLSA tracking, hearing is determined by the following item. It's your hearing using a hearing aid if you have one, dot, dot, dot. And participants can answer four slash nonexistence or death. Fair, good, very good, or excellent. And based on the distribution of responses, we define hearing loss as anyone responding either fair or poor slash nonexistence or death. And similarly, vision is determined by the item. It's your eyesight using corrective lenses if you have them, dot, dot, dot. The Likert responses are the same, and again, we consider some people who responded fair or poor slash nonexistence or blind to have vision loss. So these are the outcomes that we looked at, and we use these outcomes based on theory. Theory developed by Lisa Bergman and Thomas Glass, who have developed sort of a conceptual framework linking social measures to health outcomes. I mean, there's been lots of epidemiological studies looking at connections between social measures and declines in health. And Bergman and Glass have put these together into a conceptual framework, which I'll briefly describe here. So within a person's cultural context, they operate within social networks. A network can be characterized by the aggregates or individual interpersonal relationships that they have. So these relationships are also referred to as ties. Ties may be classified as weak, for example, between acquaintances or intimates, for example, between spouses. They may also vary in terms of frequency of contact, overall duration, type of relationship, and reciprocity. In other words, what you get versus what you receive. And most typically in epidemiological studies, social network would be defined by some sort of size criteria, number of ties, for example. So social networks can encourage participation in social activities, which may in themselves be therapeutic or health promoting. And facilitate the exchange of social support. Social support may be defined as the verbal and nonverbal communication between recipients and providers that helps manage uncertainty about a situation, the self, the other, or the relationship and functions to enhance a perception of personal control. So factoring analyses have identified different domains, including emotional or informational support. This would include empathy, listening, or advice, affectionate support such as love or hugs, and tangible social support such as money, help with chores, meals, and transportation. So social support and participation may influence health by one of three mechanisms. They may promote healthy behaviors, for example, a better diet, exercise, you know, visiting a doctor, accessing health care, adherence to treatments. Alternatively, or in addition, social support may generate self-esteem, self-efficacy, coping skills, and a sense of well-being. Experiments have also shown that in stressful or challenging situations, social support reduces physiologic stress responses and cardiovascular reactivity. So there may be a physiological link as well. So in our study, this is how we measured those things. Social network diversity was, so in other words, the number of different types of ties that a person has in their social network was determined using a slightly modified version of the social network index. So as originally described, the social network index measures 12 possible social roles. In our analysis, participants were scored out of 10 instead of 12 because the CLSA doesn't measure frequency of contact with parents or parents-in-law. Each participant was scored one point if they were married or in a domestic partnership, and they also received one point each if they had interpersonal contact, at least every one to two weeks over the past year with children, other close family members, friends, neighbors, or colleagues, schoolmates, fellow volunteers, members of religious community groups, and non-religious community groups. Social participation was measured using eight items developed for the Canadian Community Health Survey. We classified people as having low social participation if they did not participate in any social activities at least once per week, and the activities are listed here. So I've already stated this definition of social support. We measured availability of social supports using the Medical Outcomes Study Social Support Survey, which is a validated scale of overall social support and four domains of social support. These domains being emotional, informational, tangible, affectionate, and positive interactions. Overall score and further score for each domain participants were categorized as having low availability of social support if their scores were below the median. And finally, we looked at loneliness, which is the subjective sense of being alone regardless of how large a person's network is. So, you know, you might have many children or friends or neighbors or whatnot, but you still might feel lonely, and this is captured in loneliness. This was determined using the item in the past week, how often do you feel lonely? And people were considered lonely if they responded some of the time, occasionally, or all of the time. And again, this was based on the distribution of responses. In our statistical methods, we looked at associations between hearing loss, vision loss, and dual sensory loss. And each of the four different social structure and function outcomes. Linear aggressions were used for the social network index as it was treated as a continuous variable, and the other outcomes were binary, so we used logistic regressions. And we accounted for many confounders in our models, age, sex, income, education level, smoking status, and other measures of cardiovascular disease. And so here are the characteristics of the sample population. I'll just mention that 10.6% of people have reported hearing loss, which is consistent with studies done in other countries. About 8% had vision loss, and 1.9% had dual sensory loss. The social network index was pretty well normally distributed with a mean at 4.25 out of 10. 17.6% reported low social participation, so not participating in any social activities during the week. For the most part, people had pretty high ratings of social support. The numbers here are the median, and they range between... The overall median was 87.8, and within the different subdomains, they range between 87.5 and 100. And 21% of people reported feeling lonely at least one day per week. These are the univariate results, and to summarize, people with hearing loss were more likely to be male. People with vision loss were more likely to be female. People with any sort of sensory loss were older, more likely to have medical problems, and more likely to have poorer scores on all four of the social outcomes. And so here are the multivariate results. Beta, so we're looking now at social network diversity. So beta indicates the adjusted average difference in social network index score, which is out of 10, between participants with and without sensory loss. Hearing loss was not associated with social network diversity, but there was a significant association between vision loss and reduced social network diversity among men, but not among men. Dual sensory loss was significantly associated with reduced social network diversity among the older group, but not among the younger group. And these are the results, the multivariate results for social participation. Odds ratios here describe the relative odds of participating in zero social activities per week, versus one or more, among participants with sensory loss compared to participants with normal hearing or vision. So we see that vision loss, again, but not hearing loss, was associated with reduced social participation. Dual sensory loss was also associated with low social participation, but only in the 65 to 85-year-old age group. These are the results for overall availability of social support. Here, odds ratios describe the relative odds of having low availability of social support among participants with sensory loss compared to participants with normal hearing or vision. And here we see that actually all forms of sensory loss, so hearing, vision, and dual sensory loss, were each independently associated with lower overall availability of social support. And this is true for all the different domains of social support. And finally, the results for loneliness. Here, the odds ratios describe the adjusted relative odds of being lonely for one or more days per week versus zero days per week among participants with sensory loss relative to people with normal hearing or vision. And similar to social support, we see that hearing, vision, and dual sensory loss were each independently associated with loneliness, and there were no significant interactions with age or sex. So here are the summary of the findings. These check marks indicate significant associations. We see that vision loss in men and dual sensory loss in 65 to 85-year-olds were independently associated with low social network diversity. Vision loss and dual sensory loss, again in the older group, were independently associated with low social participation. And hearing, vision, and dual sensory losses were each independently associated with loneliness and reduced availability of social support. So here's how we interpreted our findings. We see that when looking at social network diversity and social participation, we saw that vision and dual loss but not hearing loss were associated. And this may be secondary to problems with not just communication but also mobility and transport. All those studies have shown some association between hearing loss and falls and driving accidents. Hearing loss may not affect mobility and transportation as much as vision loss does, which may explain why people with hearing loss are still able to get out and see their social connections and participate in various activities. However, so basically we think that maybe people with hearing loss may be able to change their social activities to accommodate their disability rather than abandoning activities altogether. So for example, they may participate in more one-on-one rather than group interactions to reduce the communication challenges of attending to multiple talkers and background noise. Or they may attend activities but not fully engaged. So they may be the people that, you know, they still can make it to the party but they'll be sitting in the corner. In contrast, it might be harder to find alternative social activities that can be maintained with even partial success for those with poor vision. So they may be the ones staying at home. And so why the sex interaction? Well, it may be that men and women use different coping strategies to compensate for their vision loss. A greater tendency among men for harmful coping strategies, for example, you know, abandoning relationships rather than working to maintain them or adjusting their behavior to accommodate the vision loss. There may be a greater tendency among men for the more harmful strategies. This proclivity hasn't been specifically observed in the literature but some observations have been made suggesting that women may have more preexisting positive coping strategies such as self-efficacy, planning for the future or positive attitudes compared to men to help them adjust to new onset vision loss. So, you know, these findings are concerning because social support facilitates positive coping mechanisms that mitigate the effects not just of sensory loss but other chronic disabling conditions and aging. Living with a chronic health condition often entails relying on others for help with instrumental tasks and emotional support, you know, things like trips to the doctor, etc. Unfortunately, individuals treated for sensory loss typically receive little if any relationship in communication counseling. The focus of therapy is usually on augmenting the sensory abilities, for example, with hearing aids or lenses without addressing activity and participation consequences, for example, with auditory or visual rehabilitation programs. So, individuals with sensory impairments, we feel that individuals with sensory impairments might also be targeted for community interventions that aim to increase engagement and reduce low maneness and isolation. One challenge in trying to improve access to services, though, for patients with age-related hearing loss or uncorrectable vision loss, is that many doctors or health policy decision-makers don't prioritize their sensory problems. And perhaps as a consequence, there are barriers to effective treatment, but they're rarely addressed in public health campaigns. So, hearing aids remain underused because of cost, stigma, or delayed diagnosis of hearing problems. Auditory and visual rehabilitation programs are underused because they're not available, there's a lack of awareness, or they're not funded. In most jurisdictions, implementation of universal design features that help people using public spaces, buildings, technologies, or transportation systems to adapt to their sensory impairments are insufficient or not mandated. So, because of this, because there's a large group of people out there who aren't accessing health for their sensory problems, we feel that a public health approach is needed to address these barriers rather than just a clinical approach. And this kind of takes me back to some of the original slides where I suggested that the problem could be looked at in a primary, secondary, and tertiary prevention type of way. So, limitations to a study prevent causal inference. It was cross-sectional, and therefore the level of social functioning may have, you know, conceivably affected ratings of sensory ability. Residual confounding by unmeasured factors can't be excluded. Exposure misclassification may have occurred since hearing and vision were assessed by self-reports. But on the other hand, self-report may be the best method of assessing functional disability since objective measures such as audiometry or visual acuity testing don't take into account how individuals compensate for their losses. And the study results may not be generalizable to specific subpopulations or populations outside of Canada. But this is the first population-based study investigating the association between sensory impairment and the social lives of Canadians. The finding of modality-specific associations between sensory loss and different domains of social function is new. Our study contributes to a growing literature implicating sensory impairments as important determinants of health. Further research is needed, of course, to determine mechanisms underlying the associations and whether addressing sensory impairment yields benefits outside of simply improving sensory function. So, that's it. Thank you very much. Once again, I do see a question from a member of the audience, and we'll get to that question shortly. If any of you have questions, now's the time to avail yourselves of the chat feature. If you have any type of questions or call or capture to answer, I've got a couple of questions they just to get evolving. You presented some results earlier, some were statistically significant, some were not statistically significant. Would you say that they are clinically meaningful, or would you say that they are the exact size and large enough to give those statistically significant results meaning clinically? Well, I mean, I would say so because we're talking about such a large group of people with sensory loss. And so if, for example, we're saying like there are some odds ratios between like 1.2 and 1.5, that would be a 20 to 50 percent greater odds of being lonely or having lower levels of social support. And when you extrapolate that to the large number of people in the population, so for example, some studies have indicated that if you're over 65, your chance of hearing loss is about 50 percent. Then we're talking about potentially, you know, fairly significant problems at a population level. Can I jump in? That's Kathy. Can you hear me, Mark and Paul? Yeah, please go ahead. So I think the other thing that, you know, we will be going on and looking at the rest of the CLSA data where people have come into the clinic and we have objective measures and we have a lot more to work with. And, you know, in this tracking data, you have a huge number of people, but they are not necessarily people who have thought treatment. We haven't been able to get into with this data set, you know, who is wearing a hearing aid, who has had any help for their hearing. So are the people who are lonely and having less than optimal social support, are they the ones who are not seeking treatment or are they the ones who will be the ones who will seek treatment? So all of these kinds of questions I think are really important to ask, but I think, you know, it really is something that we need to understand. Great. Thank you. One other question. I know you didn't look at this, but this is just a curio that maybe you could answer. Can the results be in some way influenced by language? So for example, if you stratified by English versus French speaking participants, like you found something different, or is language not related to how hearing might affect things like social support, et cetera? I don't know the answer to that one. I know that there's probably a lot of contextual factors that we haven't looked at that we could going forward, given the size of the CLSA. So I mean, yeah, so whether language is one of those contextual factors, it's hard to say. So are you thinking, Mark, that when we get to the full set of CLSA data, that it would be interesting to look at people who are second language speakers or who are bilingual, that sort of thing? Yeah, that's pretty much what I was getting at in the sense that could language in some way have an impact on your results. I think language should also be quite connected to issues around immigration and the kind of social support that people have when they're restarting their life and that sort of thing. So I think the Canadian population is going to be fascinating to look at to get at some of those things because really we have no literature on that. Great. Thanks. It would be certainly interesting. So we have a question from the audience from Mike. Can the interpersonal contact be by phone or email or must it be face to face? So I think he's referring to the social network questions or the social participation questions and the type of contact. With the social network, it can be any type of contact with the social participation items. They have to be face to face and also outside of the house. So they asked about family or friendship activities outside of the house over the past one to two weeks or group activities outside of the house or volunteer activities, et cetera. So the answer is yes for the social network items and no for the social participation. Great. Thanks. From the CLSA's National Coordinating Center in Hamilton, we have a question. Will there be a follow-up study looking at the physical assessments of hearing collected in the CLSA? Sorry. I missed the what type of the physical? The physical hearing assessment. So for example, the ideology test. So they're wondering if you guys will do a follow-up study where you include those physical assessments in your work. Yeah, we're definitely very interested in doing that. And we'd like to, because that will allow us to look at differences in terms of severity of hearing loss. Another thing that will allow us to do is to stratify according to treatments. So we can look at people who are using hearing aids versus those who don't and see whether that makes a difference in terms of some of these associations. And it would also take away some of the measurement error that might happen when you have subjective items. Maybe I'll just say Paul and I are actually working with the CLSA staff now on cleaning up the hearing results. So in the future, if anybody else is working on another research topic and they would like to look at hearing as a factor in their study, then certainly Paul and I have a lot of familiarity with how hearing and vision have been measured and how they could be connected to a wide variety of questions. So we definitely have some questions, but we hope lots of other people will have questions that can include measures of hearing and vision. Great, thanks. A question here would be interesting to see if hearing aids make a difference to outcomes. Do you have any thoughts on that? Yeah, the exposure variables for the tracking study, they asked the participants how well they can hear or see using assistive devices if they use them. And so some people who stated that their hearing was good may have actually been wearing hearing aids. They may have actually had poor hearing but did well with hearing aids, just as an example. And the same is true with the vision item. And so we didn't really have the opportunity to stratify according to whether or not people use treatments or not. However, we could do that with the audiometric and visual acuity data that will be really shortly. So in previous studies and in different cohorts in the literature, the results have been mixed in terms of whether or not we see a separation of associations according to treatment use. And part of the problem is that many of these items that ask about treatment are fairly crude. So there may be an item about whether or not somebody has ever used a hearing aid, for example, but it doesn't really get into how well they use it or how often or whether they still use it or if it sits in the drawer. So, you know, in the literature with epidemiology studies, there isn't really a clear consensus about whether hearing aids, for example, moderate some of these associations with other health outcomes. There are people doing randomized controlled trials, though, in the states. So essentially, they are randomizing people to status quo control versus sort of gold standard free bilateral hearing aids, frequent follow-ups, auditory rehabilitation, and they're looking at some of these broader health outcomes in those studies. I think just another comment is, you know, one of the things Paul said during his presentation was that, you know, it's not sufficient perhaps to have just a clinical approach that there is an apparent need to have a public health approach. And I think that is going to be the story that comes out. And I think CLSA will allow us to have these rich social measures and other health measures and the sensory measures to try to put it together. But, you know, you can't get a hearing aid like you can take a pill. You know, getting a hearing aid isn't going to solve your problem. So people are motivated to get hearing aids and to seek treatment because they have social needs. And then pursuing those treatments, the benefits are ultimately social. So it's all bundled up. So I think that's a message too that I hope resonates with the audience that, you know, we really need to understand how people live their lives with these chronic conditions. Great. Thanks, Kathy. So just a couple of comments to close things out. Lorraine is suggesting that it would be interesting to consider employment versus retirement as a potential effect modifier or confounder. And we also have a question, do you have data on younger adults who have dual sensory loss in the CLSA? So CLSA, the minimum age is 45 years. So if you define a young adult as someone who is 45 years, then CLSA would include them. I don't know, Kathy, Paul, if CLSA has data on individuals with dual sensory loss? Well, I mean, yeah, we do. We looked at that in our study. I mean, it wasn't except we just identified people who had both hearing and vision loss. And so, yeah, we do. But as you mentioned, nobody younger than 45. I think the other thing that is the case is, you know, the focus of the study is on aging. And what Paul has explained a lot is hearing loss associated with aging, age-related hearing loss. But some people might have been born with a hearing loss or a vision loss, and then they get old. So there will be in the large CLSA sample people who are older, but they had their sensory deficit maybe since childhood. So we could look at age of onset. And I think it's very likely that the people who have lived their entire lives with these sensory impairments are a different story than the people who have acquired them late in life. And we should mention that our colleague, Walter Wittich, who is one of the co-authors on the paper that Paul presented on the CLSA data, he is in Montreal and dual sensory loss and deaf blindness is exactly his research topic. So we have a great resource with him. If people are curious about that topic, he's the person to ask. Great. Thank you very much. So it's 1 o'clock. But just please hold on for another minute because I have an interesting announcement about some funding opportunities coming up that you'd like to hear. But before I do that, Kathy and Paul, thank you very much. This was certainly an interesting and exciting presentation to hear. It's glad to see that after so many years of hard work, the CLSA data are being analyzed and we're seeing results that are starting to be disseminated to the scientific community. So thank you very much. It's a very, very interesting presentation. And we look forward to having both of you come back to the webinar series at some point in the future to present further results. Thanks. Okay. So just a bit of a promotion. Our final webinar for the 2015-2016 webinar series is going to take place on June 21st from 12 to 1 p.m. One of the CLSA principal investigators, Susan Kirkland from Dalhousie and Halifax, will be talking about an update on the current status of the CLSA. So she'll be able to speak to you more about timelines for release of some of the other data that we're collecting, such as the physical assessments. We talked about audiometer before. So she'll give you an update on stuff like that. And this might be an interesting presentation to listen to because at the end of August, CIHR, I think Laura, we can switch to slide 55. At the end of August, CIHR is going to have a funding opportunity that is designed specifically for researchers who wish to analyze the alphanumeric data from the CLSA. So that's the questionnaire-based data. And the deadline for the competition will be August 30th, maximum $70,000 per research group. And if you are interested in hearing more about this upcoming funding opportunity, again, do it at the end of August 2016. There's a link here. And there's also going to be webinars in English. And I'll say next week to give researchers more information about this exciting funding opportunity. And you'll be able to find links to all of this stuff on the CLSA website. I'll attend Susan Kirkland's presentation to find out what's up with CLSA and then consider this funding opportunity. Some individuals have asked about whether the slides will be available. And if Paul and Kapi have no objections, we can certainly make the slides available on the CLSA website. Just Google CLSA webinar. And we also have on the CLSA webinar page a video recording of the webinar, which you can access for the future. And we hope to have that available sometime next week. So again, thank you all very much for attending. And we look forward to seeing you back on June 21st.