 On behalf of the McLean Center for Clinical and Medical Ethics and the Grossman Institute for Neuroscience, Quantitative Biology and Human Behavior, I'm delighted to welcome you to the sixth lecture in our 2015-16 series on neuroethics. As you know from the brochure, this lecture series will continue in the winter quarter with ten lectures and then six final lectures in the spring quarter. So we're really just about a third of the way through the year program. This lecture series was organized by John Moncel, John the Director of the Grossman Institute, by Peggy Mason, Professor of Neurobiology, and by Dan Salmezzi from the McLean Center. It's my pleasure now to introduce our speaker today, Jason Carlawish. Jason is a Professor of Medicine, Medical Ethics, and Health Policy and Neurology at the University of Pennsylvania. At the University of Pennsylvania, Jason directs Penn's Neurodegenerative Disease Ethics and Policy Program. He recently became the co-director of the Penn Memory Center and is the director of the Alzheimer Disease Center's Outreach and Recruitment Corps. He also directs the CDC-funded Healthy Brain Initiative Center. His own clinical practice focuses on the diagnosis and treatment of people with Alzheimer's disease and related disorders. Jason's research has examined ethical and policy issues encountered in taking care of and doing research on older adults who have cognitive disorders like Alzheimer's disease and Parkinson's disease and cognitive aging. Most notably, he developed the ACED, the Assessment for Capacity for Everyday Decision Making. The ACED is an instrument that assists in determining a person's capacity to manage their own functional deficits and it's an instrument that's been adopted widely by providers in care management and in adult protective services. Currently, Jason is studying how to apply precision medicine to the brain and how to develop assessment tools for adult protective service investigators to assess and determine their client's capacity to manage risk. Today, Jason Carlawish, who's come to us from Pennsylvania in the middle of a snowstorm, will speak to us on the topic you see behind me, from status to capacity autonomy in endless trial. Please join me in welcoming Jason Carlawish. Thanks. Well, thank you, Mark, for that gracious introduction. It's really quite kind of you. It's a pleasure to be here. This is a homecoming as well for me. Some 25 years ago or so, a quarter century, I was a McLean Center fellow, just this tall and it's a real pleasure to be back here. And I can say with all candor and honesty and at risk of even getting choked up perhaps that if it wasn't for that opportunity, I don't think I would be back here today and presenting this work to you. My mic. Okay, if the back can here, you can come forward. As Mark said, in addition to my research work, I do work in the diagnosis and treatment of older adults with late life cognitive disorders, most commonly caused by Alzheimer's disease and it's expanding phenotypes. Usually I see those patients on Wednesday. They've obviously been rebooked. In my past, I used to do work in the inpatient setting and here's an example of the kind of patients that we would often encounter. We're an 85-year-old woman hospitalized for pneumonia and she's now ready to be discharged back home. Her friend and neighbor returns from the patient's apartment. She's discovered two mispaid bills, a ledger with some cash transfers to a daughter and two full bottles of medications. And the patient's daughter says, everything's fine, I'm looking after a mother fine and the patient can go home to her apartment. And the case manager asks you, can we send her home? You ask the patient whether she'd like a nurse to come over to assist with her medicines and review how things are going at home and the patient says, no, I don't like that compared to what I do. I don't like people coming over to my private place and I don't want my daughter bothered. I presented this case to medical students once and one medical student boldly raised his hand and said, I don't understand what the ethics is here. And I understand from the perspective of the usual cases where capacity arises, it's around decisions that are usually seemingly more high octane, such as whether to take one treatment or another or whether to enroll in research. This, though, I would argue is very much not just a case of capacity, but I would argue also raises issues around matters of undue influence, namely what is the role of the daughter's family. Haunting this case, of course, being an 80-some-odd-year-old, or adult who's been hospitalized, raising risk factors for both acute delirium as well as potentially concern of chronic cognitive problems from a neurodegenerative dementia or some other cause of cognitive impairment. You have this evidence of functional impairment and the worry is this can this person make this decision, which essentially is the decision about how she'll live when you send her home to her house. And I'll return to this case later in the day, later in the course of my talk and talk about it. But I think it frames the issues that we are beginning to see matters of capacity beyond the usual high octane matters related to treatment and research decisions and into matters such as this. And one of my points I want to make to you is we've left a sort of era that kind of treated people on the basis of matters of status. Who you were and what you were, a white property holding mail could do certain things that just weren't available to or possible for a woman, for example, or a person of color. Disease labels no longer can suffice to say what someone can or can't do. And instead, our focus very much now is on someone's ability to make a decision, or if you will, in a word, their capacity. I think the answer to the question, why does this matter, is I think self-evident by now in the 21st century, we believe that it's good that adults make or at least participate in their medical decisions and other decisions if they want to. We believe firmly in this ethic, I almost sound like I'm doing the Nicene Creed here, that the voluntary choice of a competent adult is a core ethic. And that non-competent patients need someone else to protect their well-being, such as a family member. Several years ago at the University of Pennsylvania, we decided to deliver cutting edge, high octane ethics lectures to the medical students in the first year to inspire them about ethics. And so they asked me to do the lecture on informed consent. And I prepared this lecture and did it. I noticed that most of my topics around informed consent were papers that were sort of dated before 1990. And I ended up giving a very much of a history-based lecture. And they never asked me back. And I asked them why. And they said the medical students found it all very interesting, but they found it so obvious. Why would anyone have thought that there should be any debate about whether you would get the informed consent of a patient? Why would there be any, we want to more talk about field transplants, et cetera. So this ethic of informed consent is operationalized through the concept of capacity, one aspect of the ethic of informed consent. And assessing capacity becomes a technique really to assess the clinical significance of someone's cognitive, I would argue mostly, but some degree, mental impairments. I would also make the point that this case matters in cases like this. Because capacity assessments, I would argue, from my own work and just my own clinical work, they actually improve your conversations with patients and families to make them more efficient and more focused. Even when actually matters of capacity are not in question. I won't devote that point in greater detail, but I often find that matters of capacity are lost and caught up in issues of sort of law, et cetera. And forgetting that when you start to look at what the instruments ask you to do and what you're asked to assess, they really are ways to better focus conversations with patients even if there's no prima facie reason based on risk factors related to disease, et cetera, to be concerned about their capacity. So when we talk about diminished capacity, what do we mean? And what we mean is that there's impairments in at least one of the four decisional abilities, at least one of them. The ability to express a choice just to say what you want, which that patient did when she said, I don't want my daughter, I don't want anyone coming over, that she just expressed a choice. The ability to understand information, that is to say, say back in your own words the meaning of facts that were taught to you. The ability to appreciate information, the ability to reason. I'll talk about those two abilities in a bit more detail. So when I say that someone has impaired capacity, what I am saying is that I've assessed at least one of those decisional abilities, one arguably that I should be assessing. And that that ability, I believe, is impaired. That they're not performing as well as I think they would and therefore they have impaired decisional capacity. And so when we speak of capacity, we're speaking of a continuum of at least one of the decisional abilities. And when we speak of someone being competent, we're sort of making a judgment that they have enough capacity to continue doing what we expect adults to be able to do, which is make decisions. And so we use assessments of capacity to make judgments of competency. So in one slot I've sort of summed up the last bit of the 20th century's extensive legal and ethical scholarship to move what was a very protean idea into these very straightforward concepts, which are now being operationalized in instruments, which I'll show you data about. So one key fact I'm going to also put out, and I'm going to show you lots of data in a minute, is that as people lose cognitive abilities, they're at risk of losing their decision making capacity. So this very plain statement, which seems so obvious as to say so what, is a key assertion, which is you can't use an assessment of cognition to substitute for an assessment of capacity. But you would be foolish not to be concerned about someone's capacity if they had cognitive impairment, but the one does not equate the other. It's an important point I've found in translation work, working with people in the adult protective services world in particular, which I'll talk more about later, that for example, an assessment of capacity there is performing the short portable mental status questionnaire, the SPMSQ, and that is an assessment of capacity. That is just simply conceptually wrong, and therefore leads to a host of ethical problems, which I'll show you. But everything I've talked about here might sound very plain and straightforward, again like the medical students at Penn, not terribly interesting. But it's important just to remember a bit of the history that we come from. And I try to illustrate that history here both in words and in pictures. The pictures are of course, some of the lead actors and madmen. There's Don Draper and other characters. And it was a different era back then. It was an era where you could write this letter to the editor of the journal of the American Medical Association, and you could get this letter published to the editor as a radiologist who has been sued. I have reflected earnestly on advice to obtain informed consent, but have decided to take the risks without informing the patient and trust God, judge and jury, rather than evade responsibility through a legal gimmick. Now, I would submit that if Dr. Demi were around today and sent the same letter to JAMA, I doubt it would get published in JAMA. And I doubt I would hope you wouldn't even think of writing such a letter. But I think a letter like that, just like the antics that we witnessed these characters in Mad Men, shows you how different we, and how recent it was, a time when the notion that someone, an adult could make a decision and had that just right as being a human, was something that had to be earned, it had to be won. You had to even establish yourself as an adult, as a person. My mother remembers trying to get credit for a credit card and being told that she couldn't. Her husband could give her credit, but she had no credit, for example. And so on. And that itself could be a source of a lecture. Because the history we're looking at is that by about the 1970s, when we were talking about capacity, we largely were focusing on issues and equating it solidly with mental illness. That it's something that's a problem in the mentally infirm and the mentally ill. And for example, in a chapter I wrote for Bonnie Steinbeck's edited Oxford Handbook of Bioethics on research on cognitive impaired adults. I spent a lot of time looking at, in the 1970s, how we talked about capacity and competency. And when I looked at, for example, the transcriptions of the meetings and the reports issued by the National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research. It's interesting to read their deliberations over matters related to how we would decide in a research context whether someone's capable of giving informed consent. And their discussions of capacity focused largely on three concepts. That capacity was someone's ability to give rational reasons. To reach a reasonable result. And then there was this idea of competency, which was quite protein and really derived from just rational reasons and reasonable results. So in other words, the concept of capacity then was, are you giving me reasons that I think are appropriate? In other words, are you choosing the way I would want to choose? Or are you picking something I think that someone should pick? It had nothing to do with what you really want. It's, are you reaching a decision that I think is the right decision? Had no emphasis on whether you understood the facts and had no emphasis on how you applied those facts to your daily life. And given a social order that was dominated by Don Draper and the like, it of course meant, and Dr. Nicholas Demi, it of course meant that what was reasonable rational was filtered through the Dr. Demi's perspectives on what was reasonable and rational. By the 1990s, you see a transformation moving away from mental illness as the focus and mental infirmity to a recognition that we're thinking about disorders that impair your decisional capacity. So we've introduced thoroughly a non-existent concept in the 70s, namely decisional capacity. And now we've argued that we want to focus on not simply certain kinds of disorders, certain kinds of categories of illness like mental illness, but just disorders that may impair decisional capacity. And so you'll see in some of the last reports of the National Commission's attempting to rewrite research ethics rules. The moving away from talking about mental illness as the focus and for example, recognizing the critical illness, emergent illness, neurodegenerative diseases can all impact on decisional abilities, just as much as if not perhaps the evidence suggests more than mental illness. So all right, well that's a bit of conceptual and historical background. What I'm now going to do is kind of take you through a whirlwind of where we're at now in the 21st century. So with this conceptual model established about what we talk about when we talk about capacity, with the grounding in this concept of the decisional abilities, let's now work through what the next step was in the field, which was to say, well, let's measure it. Let's measure someone's decisional capacity. Let's take it from something that you kind of know it when you see it, or it's based on just what the person tells you is what they want to do. And instead, let's measure their abilities to understand, appreciate and reason. And so the history of the last part of the 20th century was kind of this explosion of the measurement of decisional capacity. And I and several others are quite guilty of wading into that instrument development field and deploying that in a variety of patient populations. And in my own work, I use the phenotype of Alzheimer's disease, dementia, as the sort of phenotype with which to study a decisional capacity. And so for example, what I have here is a comparison of the ability of 59 patients with mild to moderate stage Alzheimer's disease, dementia performing on a measure of their ability to understand information on a research informed consent form. And I've plotted out their scores broken down by those categories, high scores meaning a high performance on this understanding measure and low scores meaning obviously poor performance. And I've juxtaposed this with the performance of their caregivers or their study partners. So one of the points of this slide is one way that you start to study capacity in addition to measure, when you measure it is you say, well, it's all very well to measure how someone is doing. The question is, is so what about their scores? In other words, what does it mean to get say something below 20 on this 26 point scale of understanding? And this is just them being able to say back what the informed consent form says, just saying back the facts. And I think what, the one way to do that is say, well, let's look at a group of people who we plausibly ex ante think should do well on a measure of understanding, namely their study partners, the people that are bringing them in, giving them study drug, having them come back for MRIs, reconfirming the appointment. So they're showing a lot of functional abilities. And so I think what you can see here is a hint that probably scores above about a 21 or so tend to be kind of sort of how normal non-cognitively impaired people do. And so what you begin to see here is that you've got a big chunk of patients with Alzheimer's disease who arguably because of the severity of their cognitive impairments probably have difficulty understanding the core facts and the consent form, but a small proportion, about a quarter in this group, that are doing as well as their family members. So just because they have the label and they're in a clinical trial, in this case, to test a drug to change that clinical history, some of them are actually capable potentially at least understanding the information. So we can switch now to treatment decision. And here we give a paradigm. We presented patients a model of a non-steroidal anti-inflammatory drug, risk of GI bleeding, potential slowing of the course of disease. Way back when we thought those drugs might be beneficial, so we used it as a model. And on this six-point scale, the ability to understand the risks, the benefits, and the indication of that medication. Again, I think you can see compared to their family caregivers, a quarter of the patients, mild to moderate AD, doing as well as their family members on that ability to understand. And a big spread, though, of people showing some real profound difficulties, understanding, for example, the risks and benefits of a medication that's being presented to them for the treatment of their Alzheimer's disease. And you can do statistical comparisons and say that the groups differ, and that helps to further validate that these measures are capturing some more signal than noise, for example. But why stop there with research and treatment to classic decisions and medical practice? Why don't we talk about measuring someone's capacity to vote? And so you can do that. And so we developed an instrument with Paul Appelbaum to measure someone's ability to make a voting decision. And so here, pardon the arrangement, but high scores are going downwards and means better capacity to vote. And these are 34 patients with mild to moderate to early severe stage Alzheimer's disease dementia. And again, you can see about half of them doing is getting a top score on the DOE score. I'll explain what it is in a minute and a spread beyond that. So again, just because you've got Alzheimer's doesn't mean you can't make a voting decision. But certainly, there are some patients arguably who have impairments in that voting decision. I put this out there because I consider this scale sort of a dangerous little piece of work that we did. If you live in the state of Vermont, all 30 Vermonters, or the country of Canada, for example, matters of whether you should have capacity to vote are not at all on the books, whereas there are many states in the United States that actually will say that a person who lacks the capacity to vote should be disenfranchised and have their voting rights taken away. Let me just dive a bit into how do we get these kind of numbers, and I'll just show you how we assess the capacity to vote. So in this case, it's very decision-specific. We say, well, imagine there are two candidates who are running for the governor of Illinois, and that today is election day in Illinois. What will the people of Illinois do today to pick the next governor? And if they say something like, well, they would go to the polls and vote, they would vote, they would cast a ballot, that would be a completely correct response. So they're showing an understanding of the concept of voting. That's the nature of voting. And then the effect of voting is, when the election for governor is over, how will be decided who the winner is? And well, whoever gets the most votes wins would be some way to operationalize that. And we also created a choice question. We presented them two candidates and asked them to see could you pick between candidate A and candidate B. So where did we get this doe score? And so many years ago, several persons who were under guardianship for reasons of mental illness in the state of Maine were disenfranchised from voting because Maine had a rule that a person who was under guardianship for reasons of mental illness could not vote. And the three does that were their names, the court names, sued because they said that just because I'm under a guardianship because of mental illness doesn't mean that I should have my right to vote take away. You have to specifically adjudicate and decide that I lack the capacity to vote. Moreover, what if I was under guardianship because of traumatic brain injury having come back from Iraq? Well, then under your statute, I wouldn't have my right to vote. So why is it because it's a mental illness? So this made it all the way up to the first circuit, the federal court, and they saw this as plainly unconstitutional violating equal protection clause, et cetera. And moreover, the judge was annoyed, the panel, that there was no articulation in the law for how you would decide someone lacked the capacity to vote. Well, there's nothing in the law. So it's just sort of like, I know it when I see it. And the judge said, you want a standard that arguably would simply say someone has to understand the nature and effect of voting. What is voting? Well, I just showed you the two questions. And so we operationalized that into this instrument. So it's an example of you pick a decision, you decide if someone needs to have capacity to make that decision, and then you go ahead and say, well, what would you have to show to show adequate capacity? And what's interesting about the DOE standard is the judge said nothing about giving reasons for who you voted for, said nothing about appreciating how voting would or wouldn't affect you. All it was was understanding these two basic things. And if you could do that, you could vote. And so we created this to say, if you're in a state that is going to insist on in guardianship whether someone retains the right to vote, we're trying to give you an instrument to make a fair judgment about that particular very valuable right. So I've given you a whirlwind of how you go from sort of conceptual theory of, we think this is a decision for which there should be a capacity issue. And this is what it would mean to have capacity. And therefore, this is how you should assess it. That's the science of capacity 101 just summarized. I personally think, actually, we should not assess the capacity to vote. So now I'll expand. I think that the capacity to vote should simply be decided as a performative functional measure. And so what I mean by that is, if I ask you, do you want to vote? And you say, yes. I then say, well, then here's your ballot. Do you need any help? And you say, yes. I can't see. I can't hold the pen. And I say, well, then I will read it to you. And I read you the ballot. And I say, well, who would you like to vote for after each one? And you make your pick. So it's me purely assisting you along. And if you can't pick, and you're saying, well, I want Nixon, or I want the guy with the wavy hair, or whatever it may be, well, I'll just read it to you again. This is what I have. Who do you want to vote for? Enough on that. I hope that it's evident to you, give me a decision. And my colleagues and I will go out and get you an instrument to assess capacity. And this starts to get at my theme of autonomy in this endless trial. In other words, you want to enroll in research? Let's use the MAC Cat CR, MacArthur Competency Assessment Tool for Clinical Research. Want to choose a treatment? Let's use the MacArthur Competency Assessment Tool for Research. Want to decide if you can vote? How about the cat fee? What about solving everyday functional problems, like the case I presented to you about your ability to manage your troubles managing medicines? I'll use the assessment for capacity for everyday decision making. What about deciding whether to have a genetic test? I'll give you the competency assessment tool for genetic testing. Give me a decision. I'll give you an instrument. It starts to become autonomy on endless trial. But that's where we've put ourselves having left a world where, oh, he has schizophrenia. He can't make a decision. Or she's a woman who would ever ask her anyway, et cetera. Now that we take capacity seriously, that it's something that we have that determines our ability to make decisions and we think it should be fairly respected, we create now this world of the need to assess our autonomy for each decision, depending on the context, et cetera. So let's blow through some more data here. Back to that treatment decision one, because I like this one. So anyone that's cared for or lived with or a person with Alzheimer's disease probably is a little intrigued to the notion of asking patients with Alzheimer's disease about taking a treatment for their disease. It struck me as one of those kind of like, wow, that would really be interesting, because one of the forms of the phenotype of the disease is sort of a relative lack of kind of awareness of what's going on. And so it would be interesting to see if you actually sat patients down and walked them through an exercise to determine their ability to decide whether to take a treatment for their own disease, what you'd get. So let me show you what we got. Now, I showed you the understanding data. You've got about a quarter to a third of the patients doing as well as their caregivers as a kind of a normative comparison group on the measure of understanding, but a lot of impairment. Okay. What about their ability to express a choice? Look at that. Almost 80% of the patients can tell you that they do or that they don't want to take the medication. Now, anyone who's ever cared for or lived with a patient with this disease, it's utterly fascinating that down to profound impairment and cognition, severe stage based on global measures, you give a patient a decision and they can often give you back a choice, like this, 80% of them could express I do want to take the medicine or I don't. And if that was your only standard for how you decided whether this person was capable, if all you said was just tell me what you want and I'll respect that, then you would argue that the majority of patients with Alzheimer's disease are capable, they have capacity to make a decision about taking a treatment. They're the data right there. They were showed this medication and they were asking, would you want to take it? If you demanded whether they understood the risks and benefits, you might drop that proportion by a fairly substantial amount. But you see the issue here, depending on how you go into it and what you want to know to make the decision, you're going to get back a very different judgment. And I often find in my clinical practice, a lot of families and clinicians, it's all about just the choice. Well, they wanted it. And it's all especially then about reasoning. So, I don't want my daughter to come over, expression of a choice, because I'm a very private person and I don't want to be bothered and she's really busy, that's a lot of reasoning, consequential reasoning. And again, if you've ever cared for these patients, you get, that's what you'll get. In fact, most of us when we make a decision, that's what we get a lot of. This is why I want it and they'll tell you my reasons for it. And I have no problem with reasoning, I'm not objecting to it. And you can see here, patients generally also retain, you know, a fair chunk of them there, about 30, 40% are reasoning as well as their caregivers are on this reasoning measure. I don't want it medicine. I don't like taking pills. I got enough pills, et cetera, et cetera, et cetera. But there's this issue I gestured to earlier, which is something happens when a mind starts to fail. This is a great study from 1994. I didn't even know, anyway, whatever. And what this is, is 6, 12, 18, 24 months. And this is a score on a functional measure. Higher scores mean greater ability to manage your medications, do cooking, prepare, clean your house, take care of your bills. And what this is, is patients with Alzheimer's disease and a family member, typically a spouse, filling out the same functional rating on the patient. So Jason Carlawish fill out the rating of your relative and relative with Alzheimer's, you fill out the rating. And then a comparison group of cognitively normal older adults and a family member. And what they're showing here is this gap from the get-go between how family members and patients rate function. Patients are rating themselves better. And then by following over time, they're showing a relative preservation and how the patients rate themselves with a progressive sign of the very disease itself, the disability in performing ADLs. And the comparison group here of the cognitively normal older adults to show that this just isn't some artifact of differences in age or relationship. This fact haunts the disease. And so how does it play out in capacity? Well, this is the ability to appreciate. So appreciation is one of the stickier wickets in the capacity literature. And I'll talk more later about how in the future, this is the one ability that needs far more thought and attention. Namely, applying facts to yourself. So do you think it's possible that this medication could harm you? So that's saying take this risk of this medication, GI bleeding, apply it to yourself, your health, your values and come back to me and tell me whether you think it could harm you. And I think what you can see here is that about half the patients could appreciate how this medicine could harm them. They could tell you an answer that was a sort of plausible explanation of appreciation of the risk of the medication. But it's when you look at their ability to appreciate the benefit of the medication that would slow Alzheimer's disease that you see a stark difference compared to their ability to appreciate risk in their ability to appreciate benefit. Only a small fraction were able to sort of say very clearly, well, why wouldn't I take this? My brain is failing. I have troubles managing my money and my medications. I've lost my driver's license. Who knows where the slow motion train wreck will take me. Of course, I'll take the medicine. And a big chunk of them just not able to see the medication capable of benefiting them and then a chunk in the middle. And so we look, I'll give you more data on that in a minute, I played out. So then what we do is we say, well, it's all very well to get these separate decisional measures, but I told you that it's an omnibus judgment. In other words, you need to integrate all these data and make a judgment whether someone's capable. Now, if, for example, it's a question of voting capacity, you'd only be looking at the understanding measures on the DO instrument. But if you believe for a treatment decision, well, I wanna know if they can express a choice, if they understand information and I wanna see their reasoning and appreciation, I want it all, then based on that you would then make a judgment that having heard this interview, do you think that this person's capable of making the decision? And that's what we did. We had these interviews audio taped and we played them to three independent consult liaison psychiatrists and said after you listen to this interview, I want you to judge whether you think that this person is able to make his own or her own decision about taking the medication. And they either judge them capable or not capable. And so what I'm gonna show you now is how each expert rated, having listened to all 48 interviews, whether the person was capable or not capable. The experts knew that they had Alzheimer's disease, but one key fact that they didn't have, they had no data on the severity of their Alzheimer's disease. They didn't have a mini-menal, they didn't have a functional rating scale, et cetera. And if there ever was a neat study to do, it would be to randomize experts to having and not having that data because I think it highly influences judgments. Nonetheless, we gave them just pure decisional ability. And I just wanted to sort of now kind of break the fourth wall as they say in the theater world and get a sense from you guys having seen these decisional ability performances of these real patients with real Alzheimer's, I want to kind of get a sense from you all, play the expert. Of those 48 patients, what proportion do you think were judged capable of making the decision? In other words, do you think that all of them were judged capable by each expert? Do you think that none of them, do you think a third, a half, two thirds? What do you think? Can I get sort of the greater than a half judge capable? What do you call it out? Open it up. Yes, in the back. Yeah, yeah, yeah, yeah. Yep, English speaking, yeah. What do you think? About half. Can I get above half? Can I get below half? 25%. 25, I see 25. Good. About half. Depends on which expert. Interesting issue. So one expert, fairly conservative, Dr. Siegler. One expert, a little more generous. And then whatever. So what we did was we took the consensus of two out of three of these, in other words, where two out of three agreed, or three out of three, that would define someone. And that consensus came up with about 40%. But I think what you can see here is some degree of variability. So we run a CAPA, which adjusts for randomness in agreement. And what you can see here are CAPAs amongst these experts, Omnibus as well as Paird, that are decent enough for some of our diagnostic tests, for example. So it's suggested if you give a group of experts these structured interviews, have them listen to them. You can get some agreement amongst the experts and arrive at a conclusion about whether a patient is or isn't capable of giving their own informed consent to take a medication. It gets funky though, because if you start to look a little closer at sort of things they didn't know about the patient though that explain it, they both helped to validate the measure of capacity, but also better understand the phenotype of what it's like to have Alzheimer's and really kind of better understand sort of more nuanced ways of understanding the experience of the disease and how sick someone is or isn't. So we also during the interview, and the experts didn't have access to these data, asked them these questions, the patients. So we asked the patient, do you have problems with your memory or thinking? Would you say yes or would you say no? And if they hedged and said, well, really got into a yes or a no there. And you can see about 50% of the patients said yes, I have problems with my memory and thinking. Now I think that's very interesting alone, because that's asking people with Alzheimer's, do you have the symptom of the disease? And about half of them say they have the symptom of the disease, and about half of them say they don't have the symptom of the disease. If they said yes to that, we then said, well, do you think that those problems will get worse? Which is gesturing to issues of prognosis. If they said no to the first question, they were defaulted to no here, cause it's a little awkward to say, I know you don't have problems, but do you think if they had them they would get worse? And there you see about a third of them now saying, I have memory problems, and I think that they're going to get worse. So they're aware of their symptoms, and they're aware of their prognosis. And then we asked them about their diagnosis. Do you have Alzheimer's disease or dementia? And again, yes or no. So what I did was I took those answers of what are arguably kind of insight, if you will, like no-signosia or no-signosia, and paired them, crossed them with whether the expert consensus had judged the person competent or not competent, the 40%. And what you can see in the data already there is that if you were endorsing symptoms, if you were endorsing that your symptoms would get worse, if you were endorsing the diagnostic label, you were more likely to have been judged competent. And remember the expert didn't have the answers to these questions, but I think it validates that there's something about the abilities here to make a decision on treatment that are tied in with a very appropriate, if you will, covariate, which is how aware are you of your problems and their future course. Raising, I think, the value, looking forward to better understanding the neuroscience of the loss of awareness in the disease, which is characterized by just these issues of loss of awareness. We've actually, just to throw a spoiler out, just ran a data set, which we're writing up, where we found that amongst individuals with mild cognitive impairments, I've labeled them as cognitive impaired, but they don't meet criteria for dementia. And amongst patients with mild stage Alzheimer's disease, so someone who I've labeled as having Alzheimer's dementia, but the stage is such that, in routine encounters with them, you might not pick it up. What we found is that patients who are aware of those diagnoses, so they're all labeled, I labeled them and my colleagues, but if they're aware of it, if they say I have Alzheimer's or MCI, that they performed uniformly worse on all measures of quality of life that we gave them, raising some interesting issues around adjustment to diagnosis, et cetera. But back to capacity. Haunting us all in this is issues of your cognition. So how does cognitive impairment explain your performance on these decisional abilities? And what I'm gonna show you now are some data that looks at the comparison of performance on measures of overall cognition with whether your judge competent. And so here I just broke the mini-mental into the standard cut points that have been used for staging the severity of Alzheimer's, greater than 24, very mild, 19 to 23 mild, 12 to 18, moderate stage. And you can see here the proportions appropriately dropping, if you will, it makes sense of whether you were judged competent or not. The experts didn't have access to these mini-mental data. If, I mean, once, I think the health services researchers are sort of awakening in the room now, I've done a sensitivity and specificity curve here for you, showing you that depending on what mini-mental point you can pick, you obviously are playing with your sensitivity and or your specificity for classifying someone. And so you can start to see that the mini-mental, based on these numbers in no way adequately could classify everyone in the area into the curve, if you do an RSC curve, is inadequate. But you can start to see depending on what you want your error to be, you can use your mini-mental to raise or lower your pre-test probability that someone may have difficulties making a treatment decision. And I can say to you across multiple studies in the well-characterized Alzheimer's phenotype, not FTD, not DLB, not dementia otherwise unspecified, but in a pure AD phenotype of late onset AD, the mini-mental has a curious quality around a low 20s or so where you really start to see people plummet in terms of their ability to make decisions. And given that the sensitivity and specificity are highly dependent on the prevalence of the disease, you can even push it. I won't bore you with this, and you can say, well, let's look at actually what the positive and negative predictive value, that's what you really wanna know, right? When you're given a test score, how does it predict the likelihood that someone will or won't have capacity? We wrote this up, it's given the prevalence of the disease that you think, you have to make some estimate. If I've got mild to moderate patients, what's the prevalence you think of having a lack of capacity consent? And then you just have to decide, well, depending on what understanding score I pick on that research understanding score, I will or won't increase or decrease the positive or negative predictive value of that score. And it's just a call you have to make. I'd rather be in this realm, I don't think it's pseudo-quantified, but I'd rather be in this quantified realm than in the sort of I know it when you see it, they don't have it realm that we used to live in, recognizing its limitations. All right, back to our case. This woman who was hospitalized for pneumonia, ready for discharge, comes in on mispaid bills, cash transfers to the daughter, so troubles managing her meds, troubles managing her medications, two IAEDLs that are impaired, some concern about coercion. Should we send her home? So we developed an instrument to measure someone's ability to solve their everyday functional problems. And there are the two references here. I'm not gonna walk you through the data on this, I opted not to, but I just wanted to give you sort of the conceptual problem that I think haunts the 21st century in America. That's pretty heavy. So, are you able or not able to perform an IAEDL, manage your money, manage your medicines, manage the transportation, cook a meal? I mean, those are the IAEDLs, so the things that get you out of your parent's basement, okay? They're not back off into the grown-up world. And you're either able or not, ultimately. There's a middle ground, you know, trundling along. And then the second question I think that is, are you able to decide how to manage that IAEDL impairment? And most of us are living in this upper box here. We can do it, and if we were asked to try to figure out how to manage it, if there was a problem, we could figure it out. And the two off diagonals, I think are okay. So, I lose the ability to manage the cooking because of, say, very bad macular degeneration and bad osteoarthritis or rheumatoid arthritis. But, you know, I figured that out. I'm barely able to get a meal going, so can we, and I solve it. I arrange for meals, et cetera. So, I'm here. I've solved my functional problem. This is an interesting one, you know, sort of, if you can do it but couldn't solve it, it's sort of like someone who's very highly trained, but when pressed with the matter, can't solve it, but in the end it functions the bottom line, I'm not worried. It's this off diagonal, which is the big problem, and I'll show it to you in a minute. Namely, you're having trouble managing your money and your medications, and when I've given you a solution for it, you can't solve it. You just can't work it out. And this is the stuff of the 21st century's big problem, which is the elder abuse and neglect, because these oftentimes become cases of just that. And so here's an example of a very important area that needs a lot of work. This is the state of California. That's not the very important area that needs a lot of work, but it does need water. And so what this is a fascinating paper by Laura Moschieta, she took thousands of adult protective service cases and graphed them by county, because all APS cases, adult protective service cases, are county-based. So every county has an APS, has an investigating service. And what she looked at was, what's the variability in findings of either an unfounded abuse case, an inconclusive case, or a confirmed case of elder abuse and neglect, where, of course, the key issue there is, to be a confirmed case, there's functional problems, something going wrong, and the person can't solve their way out of it, okay? That's what gets you a confirmed case. In other words, they're here, okay? And I hope what you're bothered by is, so this is the proportion of those cases. So 024, 25 to 39, 40 to 100. And so she sort of graphed out, and it's this variability that should be disturbing. This reminds me of a number of the stuff back in the, what was it, the 80s mark when, like cardiovascular procedures, like it depended on where you lived in the United States, whether you got a calf, and that was like the big wake-up call, like just because you go to a doctor doesn't mean you're gonna get consistent care. Thus was born the fields of health services. So they've applied that, and this is very, these are very disturbing data. It just basically says that it's a mess out there. And actually, if you talk to the APS workers and investigators, they'll tell you that. They'll say like, we do the SPMSQ, we do the mini-medal, we don't know what we're doing. And they know it, and this has to change. This is a huge policy issue. And there are thousands, hundreds of thousands of older adults who are, as a result, not getting adequate attention until that's taken care of. It's a huge issue. Let me move to our next issue. This is all of us plotted out from age 20 to 80. These are cross-sectional data. And what this is showing is our performance. This is a totally new topic. What this is showing is our performance on measures of our crystallized intelligence, the knowledge we've accumulated over life. And one of the great things about getting old is it doesn't really go away if anything may go up over time. There is a lot of variability. Some people really never learned a lot, but that's the way they are. And some people learned a lot, and that's the way they are, and that's just the way it is. Language, skills, doing things, et cetera. There is, though, something that happens after about the fifth, sixth decade of life, and that's illustrated here, which is the decline in fluid abilities. These are all adults who have been judged free of a nostologic illness, in other words, no neurologic or psychiatric illness that would plausibly impair their cognition. And after you take those people out of the pot and measure cognition, this is what you see. You see relative preservation of crystallized intelligence but a decline in these fluid abilities, like processing new information, thinking logically under time situations, solving problems. And it's this decline here with age that is the source of a new challenge in capacity and ability to make decisions. And you see that played out here on these two graphs. So this is a fascinating paper, What is the Age of Reason, from McGarrow-Wall and colleagues, which looked at the ability of thousands of adults from a large dataset they had access to to perform a variety of financial tasks. These are real financial tasks being performed by real adults. And what this is depicting, this U-shaped curve, is the ability of these adults to have what's called the Eureka moment with a credit card. So if you've got a high debt on a credit card and you wanna pay that debt down, there are credit card companies that will give you a card that they'll say you can roll that debt onto our card and just pay it down at a low interest rate and we're just so happy to have you doing that with our card. And it's a great low interest rate and you really are happy. And why does the company do that? What's in it for them? Well what's in it for them is that if you use the card to go buy a Starbucks coffee, they charge an enormous interest rate on your purchases. And that's how they make it. Now the Eureka moment is when you use that card and you're like oh my God, like they're charging me this huge interest rate on my purchases and then you realize all I need to do is just use this card to pay down the debt. I'll use my old card or another card to actually make purchases. And many people though never have the Eureka moment. They just keep on using that card and accruing a lot of interest and extra charges on their charges that they make as they pay down their credit card debt. And this card depicts the proportion of people who have the Eureka moment, meaning within about three months they stop using the card to purchase and they go back to some other card. And what you can see here are the still developing brains of 18 to 24 year olds. And you can see here the progressive development of your capacity, your crystallized and fluent intelligence both developing. And it's around about the age of 50 or so that you start to see this decline. Namely, your knowledge of the world is there but your ability to kind of solve your way through the problems of the world is declining. And what is fascinating about this paper is the same finding across a variety of financial decisions, reverse mortgages, et cetera, the same U-shaped curve. Now the problem, of course, is it's all very well for these people to kind of figure it out, make some mistakes and whatever, they'll get on with life. The problem here is if you start making mistakes, et cetera, you can't go back to work and make it up and whatnot. So this is why this becomes a public health issue. It's why it's not just a personal private issue but a public health issue. It gets even more interesting when you look at this rather complicated graph from Natalie Denberg and colleagues where essentially what they're showing is the gamblers refers to people's performance on a measure of frontal lobe function. These are all older adults who are cognitively normal by standards currently of diagnosis. If they came to the memory center to see me, I'd send them out as subjective cognitive impairment if they had a complaint or normal if they didn't have a complaint. There's no ICD-9 or ICD-10, I think now, code that I could make some cash on for them. And then they had a group of young people and what they showed was how the young people performed versus the older people who either did or didn't do well in the frontal lobe measure. And what they were looking at were fraudulent ads that the federal trade communication had pulled because the ads were fraud. So they showed them real fraudulent ads and they asked them how likely would you be to buy this product? And what they were showing here is that these older poor gamblers were more likely in that limited disclosure setting around the fraudulent nature to wanna purchase the product. So in other words, they were set up for scams. They were set up for scams. It's a very experimental study, more work is done, but what I'm trying to do is expand the way we think about capacity. Everything I've talked to you about is largely in kind of the cognitive domain. Sort of our ability to memorize, learn information, reason through it, et cetera. But there's another part of our brains, which is a very important part of our brains, which is our social cognition. Our ability to assess and use emotions, our ability to use emotions to assess the sort of trustworthiness of another person, both familiar and non-familiar. And there's something that goes wrong with social cognition with changes in aging, not uniformly, not in all. And that's the relatively neglected area of our capacity studies, which together lead to age-related changes in brain and behavior. And so it's together lead to troubles managing money doing the kind of math of it, but then also vulnerability to fraud, okay, making bad decisions, which together lead to why older adults are particularly uniquely at risk of financial exploitation and risk. So this is another area, moving into the particular area of financial capacity, but more generally in terms of decisional abilities that needs work. So looking forward and I'm wrapping up here now, the neuroscience of capacity, well, we need to have a better understanding of the role of social cognition and its role in capacity. It's an unstudied area, except for the few studies, slides I've showed you there. We need a better understanding of the impact of cognitive aging on capacity. All the data I showed you and other colleagues have been disease phenotypes, Alzheimer's, schizophrenia, traumatic brain injury, major depression. It's time to move into normal, quote, normal older adults and look at how those age-related cognitive changes impact on decisional abilities. Another area looking forward is the social and political order of capacity assessment. The ability, these data came from just a bank. Banks are sitting on capacity data. They know it. They will tell you, we see it. We see money going off to Jamaica. We see cash transfers that are out of character. They are screening for cognitive impairment. They know it and they are slowly wading into this water. Recognizing that the bank of today is sort of a kind of a, kind of a geriatrics practice of tomorrow in some sense, because most private wealth is held by older adults in America. And finally there's a role around the dissemination and translation to practice and I would argue that one of the biggest areas, medicine, like I said, those medical students, they were like, why are you telling us this? What's the ethics? Why wouldn't you get informed consent? Help me. You could have given that lecture in the 80s and it would be like this firestorm of debates about. Well, the one field now though, much like medicine back when Dr. Demi was saying, I'm gonna trust God and whatever else is the world of elder abuse and neglect. They know that their current practice is simply not up to the science and ethics of law of the field and they know that and they're woefully underfunded and under-trained and they want to move into that new world. And so that's a new big area in terms of dissemination and translation. So I've really enjoyed my opportunity to talk to you today. That's my Gmail address and I have a website with some stuff I've done. You can take a look at that. And then I'm always pitching our website that we've done, making sense of Alzheimer's, actually it's .org, I'm sorry. I guess I could change that right here but it's .org. Which is a website of a variety of narrative, video and audio treatments around trying to live with and make sense of having Alzheimer's disease. I think Mark, we're open for questions and discussion. So thank you very much. I really enjoyed it. This talk is open for questions or comments. Very nice talk, Jason. Well, thank you, Dan. So getting back to your case, how far do you push it? I mean you have a woman who says, everything's cool, daughter seems okay, but the neighbor is a little bit paranoid perhaps or maybe not or maybe she's right. How do you, in a case like that, I mean as a medical doctor is getting ready to discharge a patient, how far do you push it? What do you do? Well, I have this feeling that actually you probably have a good answer to that. And I would open you to take the mic back and give that answer if you'd like. I guess you first. Arguably you're not going to solve it at the discharge visit. It's not going to be solved there. And clearly this is someone who there's concerns about undue influence in addition to the concerns about undiagnosed cognitive impairment that just hasn't been recognized. You know, the bottom line is and the tragedy of the transfer from hospital into the world of the unknown. I mean this is just the kind of case where a transition of care model is needed. So, you know, before they leave they have an appointment at, you know, the memory center end or the geriatrics practice for follow-up with clear communication of just this problem as opposed to the, you know, every other page of the hospital chart copied kind of situation, which often is the case. But I think that's, you know, this has raised a concern that needs follow-up as opposed to we're going to settle it here. That's kind of my initial thinking on that. Yeah. Other questions? Peggy and Linda. Great talk. Well, thanks. It reminds me of the time that we had, for whatever reason, we had the decision-making capacity for a friend who was 95 years old and remembering maybe 10 or 20% of things that were happening. And she needed a pacemaker. We said no. But then we asked her and she said yes. And forever regretted it. Forever regretted it because then it took her into this old age period where nothing was working. Except the pacemaker. Yeah. Because the heart would not give out. But my question was, you mentioned at the beginning that assessment of capacity is useful even when capacity is not in the conversation. And I, that sounds very interesting. Could you give me an example? Yeah. So, in my own domestic life, oftentimes I'll, you know, with family, I'll say, well, when you look at, I didn't show you, except for the DOE instrument, the actual questions that you asked to assess understanding. And when I look at them, I'm like, oh, these are great questions just to make sure the patient in whom I'm not suspecting any capacity problems gets what I've told them. So, you know, I've got a 45 year old high functioning son who's bought his mother in for an assessment. They never do that, it's usually a daughter. But anyway, and I'll go through some facts and I'll say, you know what, I put a lot on the table. Can you just tell me in your words what I've just said? Now, I am actually assessing her understanding and I've actually scripted it to the, but I'm not worried about her understanding, but I am worried just because she has some decisional impairment, but I'm worried I've just given her a dump of data and I have no idea how she's interpreted. So I do find that those, can you tell me in your words what I just said, are very useful lines that are assessing understanding. And you know, and I also find the appreciation questions very helpful like, you know, do you think this could benefit you? And I just kind of want to get a sense of what their values are. So it's a useful way to make sure people have learned the facts and to get a sense of what their values are. Because I think in ordinary practice, when we're dealing with quote, normal people, we're just fine with whatever choices they tell us. And you know, part of our role is to make sure they actually get what we told them, and also that we have some sense that it accords with their values and what they want or don't want. I mean, I think that's, from a neurobiological point of view, you would say that the person has a cognitive and perhaps emotional load on them in that situation. And so assessing capacity or assessing understanding in the face of that additional load is completely appropriate and acknowledges the fact that we're not one static individual. Yeah, yeah. Join others in thanking you for the talk, which I thought was terrific. Thanks, Dan. The emphasis, though, was all on, and appropriately so, on sort of functional assessments of capacity. And I was wondering if there's work going on that you're aware of at the sort of neuroanatomical, physiological correlates of these sorts of things. So, for instance, does appreciation map to a different part of the brain than does understanding, those sorts of things, which are closer to a lot of what we've done in the... There's some scrappy literature of people who basically put people in an fMRI and have them do an interview and see what lights up. I know that sounds very, my language is probably... But the answer is no, the sort of neuroscience of the decision abilities that worked out. They're very... Understanding is tapping into enormous numbers of networks, the semantic memory, working memory, et cetera. What I do think there's a neuroscience that needs to be teased out is the level of emotional processing and its impact on decisions and then the appreciation issue. And I've sort of been hunting, actually, for kind of a postdoc person to help work on how is it that appreciation starts to... What is the neuroanatomy of that? And there are people working in that space, but it's far less developed than this measurement, very practical, if you will, measurement issue. Thank you. Yeah, in a legal case where someone is challenging a will or some other document and concerned about the distribution of assets and concerned about the person who's making the distribution in terms of their mental capacity or their mental ability, the two usual legal standards are competency or undue influence. Both of those have very high bars to get passed. And it seemed like you were giving a more nuanced explanation with your capacity argument or point. And I wondered if you could expand on that, if you think there might be a way to perhaps get into some legal changes that would be helpful. So I don't do forensics. I sort of made a conscious choice early on to kind of stay away from forensic work. But colleagues who do do it, one of the key things you ask is, all right, so the case is can this person make a will? And then what does the law say about what it would mean to be competent to make a will? And the law, I believe in the case, will lays out like knowing the nature and extent of your bounty, I think is the phrase. So you'd want to operationalize whether someone knows the nature and extent of their bounty by asking the questions to get at that. There may be other things. I once got called by the way on a case of whether a guy was competent to divorce, which I don't know what you would do to be competent to divorce. But that's how I would think about that issue. And I know there are colleagues- Or to get married. Or to get married, that's right. I think you just have to basically be able to stand or something and walk into the room. There's no standard for a competency to marry. Yeah, it's a performative competency. But that's how I would think about that. And then the end to influence is a completely separate issue from capacity, which is, you know, they may be fine with thinking through their nature and extent of the bounty, but there's clearly some external pressure that's either forcing them one way or the other. That's a separate assessment or a separate issue. That's how I would distinguish them from that. So Alzheimer's disease used to be a crisp and clear diagnosis. We used to call it the pre-senile dementia around the age of 50 before 60. Now we have a spectrum of the conditions that we call it Alzheimer's disease. And I just wonder if there is a certain level of a score because names have meaning when we have diagnosis and diagnosis have consequence. Legal, emotional, family, you know? So at what level we call someone Alzheimer's? It's just like cancer. Nowadays, grade one, the cancer of a breast, maybe we shouldn't call it cancer. So everybody is hyperactive, we call it AD-AD. And so these diagnosis has a lot of social consequences. And I just wonder at what level of memory situation actually we could call it Alzheimer's rather than call it this amount of memory problem? Well, let me say all the data I was presenting were all patients who were kind of classic Alzheimer's disease dementia, all my data. So in other words, they met criteria for dementia, that cognitive impairment that impaired their ability to do their usual neighborhood activities and based on their workup, the most likely disease to explain it was Alzheimer's. You're raising a very interesting point which is the expansion of that diagnosis which could be the source of next year's neuroethics which is the use of biomarkers and other measures to transform the way we think about the diseases of the brain. I would agree that the label of Alzheimer's is a moving and evolving language and we're living that history now. It's a very active dynamic process. I will say I had recent occasion to reread the 1976 editorial by Robert Katzman called Alzheimer's Disease, a major killer, a major killer. And his premise was the neuropathology and clinical presentation of senile dementia and presynology are the same. We should call them the same thing. And so he suddenly with one stroke of an editorial fused together what were two separate things together because of essentially an argument based on anatomy and physiology and whatnot. What's of course interesting is that if you fast forward to now, the brains of a late onset Alzheimer's patient are loaded with lots of pathology other than plaques and tangles. And so you could argue, well, maybe we should be using Katzman's editorial but the Katz out of the bag and the term has expanded far beyond. I'll leave you with this. The National Alzheimer's Plan in the United States that's Obama signed into law. It's a very active National Alzheimer's group that all members have represented from various commissions and departments in the public. And they use the term Alzheimer's and they make it very clear that it covers not just Alzheimer's but Lewy body disease, frontal dementia, Parkinson's disease and the dementia scene and Down syndrome. And then Alzheimer's is this arching term now. So it's almost becoming like cancer. It's this term that covers everything. Interesting. Again, thank you very much for your presentation. It's excellent. One thing I would comment on is that it seems to me, correct me if I'm wrong, that you're tracing an arc in the field of protean theory and abstract thought towards now more functional assessments. And the problem with the functional assessments is there's just this whole toolkit of them and people are being assaulted by different practitioners with different toolkits. I would suggest that maybe the next step in my field is more intellectual disability is in the arc that we've traveled, it's a very similar arc from abstract conceptions of what is intelligence to kind of functional metrics to now kind of an emphasis is much more on what supports does this individual need? Not where are they uniquely out of context placed abstractly but in the real environment they're in with the tasks they have at hand, which is a little bit of what it sounds like you're suggesting. And there are lots of tools now that are being developed that are much more in that direction, the sports intensity scale and other things that states are now taking to get away from that ectotonous variable of competent, incompetent or other things like that. Could you comment on those? Yeah, Mark was telling me your developmental peeds. So you have the advantage that you're fundamentally taking care of people who are growing up and childhood is not an illness. I think, I don't know. Yeah, adolescence was, oh boy. You know, the problem I think in aging is we're still fighting a war of where does, is it even proper to talk about normal? You know, where does health and disease begin? And with this looming thing of the epidemic of Alzheimer's, the silver tsunami that will bankrupt America, I mean the rhetoric is just hot. I don't think the field's ready yet to adopt your view because that would start to normalize it. And you know, I think the arc of history would need to include the development of diagnostics and treatments, kind of cool off the kind of, you know, it's gonna drown America. Okay, we've got some treatments, we're gonna manage this. Okay, well now how are we gonna normalize this again? I think that it will be the next phase. But right now, it's about, you know, we gotta drug our way out of this mess. And so I don't think that that perspective is one that fits that current political order, unfortunately, I do. That's just the sad thing an older adult now in some sense. Please join me in. Thanks. Thanks, man, I had a lot of fun. Thanks, man. Thank you. Great job.