 It is wonderful to see so many people and as a result as you could tell we had a bit of an issue with you being able to come in here. I apologize for that. We were not able to come into the room until the previous session was done and some of the dishes could be moved out of the way. I'm sorry about that. Again it is wonderful to see so many people. My name is Farina Menek. I'm going to be moderating this session around living longer, living better, insights from the Canadian Longitudinal Study on Aging also referred to as the CLSA. This is a very unique session because in the room we have both CLSA participants but also CAG attendees and currently there is a conference going on by the Canadian Association on Gerontology and we are combining a CLSA participant event with that conference. CAG just so you know is the premier multidisciplinary association in Canada for those who research work and have an interest in the field of aging. So I do want to acknowledge and thank CAG for allowing us to piggyback on to the conference. I would also before we get going I'd like to acknowledge the staff, CLSA staff, so CLSA staff please come a little bit up wave so people can see you. All right I did not see Catherine ish you're also CLSA folks please wave your hands that's more people involved in CLSA. I'm going to just briefly go over the program for this session and just to note if the CAG attendees the program order has changed a bit and the people involved so I'll let you know that is just as a count just for our own information who in the room if you could raise your hand who is a CAG attendee conference attendee. All right there's a few of you you know what this is kind of funny they're all kind of around the edges the rest are CLSA participants anyway but thanks for coming to this session. So let me get give you the overview. First of all again I'm Ferrena Menek I'm a professor at the University of Manitoba I'm the lead research investigator at the Manitoba site of the CLSA. I will be chairing this session so my role is to keep presenters on time so should you see me standing up here waving a paper that simply giving them two minute mark if they do not stop I will give them this sign I am not trying to be rude to them they all know me and they also know that I will stand up and stop them should they talk too long. All right we will be starting with the first presenter is Dr. Susan Kirkland who is a professor at Dalhousie University from Nova Scotia. She is also the co-principal principal investigator of the CLSA. Dr. Kirkland will give an overview of the CLSA. Next we will have Dr. Holly Touko who is a professor at the University of Victoria and she will be presenting on cognition. Next we have Dr. Cassie Pecora Fuller who is a professor at the University of Toronto who will be talking to us about hearing and vision and how it may relate to a social participation. And lastly we have Dr. Praminda Reina who is a professor at McMaster University in Hamilton who is the lead principal investigator of the CLSA and he will be talking about frailty and then wrap up this session. Please hold off with questions until we are through the presentations. I hope to have some time. I know with a big group like this there will be many more questions than we can actually accommodate. By the way we will have microphones. There is one there but we will have a microphone going around. There will be many more questions than we can accommodate. I know that so some of us will be here at the end of the session and you can ask us directly one on one if you have any more questions. All right. Without any further ado Dr. Kirkland. Thank you Verena. It's a pleasure to be in Winnipeg and it is an absolute joy to see all of you here today. It's so exciting and so rewarding for us so thank you so much for coming. Verena. Okay well I can start talking. Oh there we go. Okay so I'm going to talk to you today a little bit about the overall study design of the CLSA and some of the milestones that we've encountered along the way and just give you a very quick synopsis of yourselves and then the other presenters will give some more details. I'm going to start off by telling you something that you already know. Canadians are living longer and they're making up a larger share of the population. So right now about one in six Canadians is over the age of 65 but by 2025 which is actually not that far off one in five will be over the age of 65 and that's over 20 million people. What's really interesting is that we know that over time life expectancy continues to increase and it continues to increase by about two years every decade and what we see now is that life expectancy for birth we know it's higher for women than it is for men. If you're a woman your life expectancy for birth from birth is that you can live 83.3 years and for men it's 78.8 years but what's really interesting is if you make it 65 you can expect to live longer than that. So for women they can expect to live enough years and for men they can expect to live another 18.5 and if you make it to 100 men and women combined can expect to live another 2.6 years but what this points out to us is it's not important just to live long. We really need to live well. It's not about number of years it's about quality of years and so we really need to shift our focus we really need to be thinking about not just studying what people die of or how long they live or what diseases they get. We really need to shift the bar we really need to be thinking about healthy aging. We really need to be thinking about things like how do you maintain function and how do you maintain ability and how do you maintain independence and how do you keep quality of life and autonomy and independence and those things that you know are really important to us every single day. So that's where the Canadian Longitudinal Study on Aging comes in and that's where we take our focus we're really trying to think about what does it mean to age in a healthy way and we're not just looking at one aspect of aging we're not just looking at you know social aspects of aging and what it means to participate in your community we're not just looking at the psychology of aging and what your mental health is like we're not looking just at your genetics and what kind of genes you have what we're trying to do is put it all together and really understand in a big way what it means to age and to age well and so this is a very large team there are three principal investigators two of us are here today and a number of experts from across the country in a wide range of disciplines have come together and this really is quite unique it's a very Penn Canadian study with expert experts from all the way across the country contributing to it it really is the largest study of its kind to date in Canada and the three of us who are the principal investigators are all epidemiologists so that means that we're really interested in studying health and conditions in a population and from a population perspective and we spend a lot of time on design and methodology so it really has been an incredible experience and in fact it's it's it's a once in a lifetime experience to be able to design a study of this magnitude and not just design it but actually turn around and implement it and and actually have it be a success so it's it's been quite an amazing journey for the three of us and we've been working on this study since 2001 as epidemiologists we thought okay so how can we design a study like this how can we get the best information that we possibly could and there are larger studies than this but they don't catch as capture as much information they're smaller studies but they really can't answer questions there's studies that only look at people who are over the age of 65 and we know that you don't just you know flip a switch the day you turn 65 we know that it's a process and we're interested in studying that process of aging so those are all the things that went into the design we really wanted it to be a Canadian study but we knew we couldn't bring every single person into a center and capture detailed information on them so we have one arm of the study which we call the tracking where people are followed by phone and they're randomly selected from across all of the provinces and some of you are tracking participants then we have another arm where we set up 11 sites across the country and we go into people's homes and then we also have them come to a data collection site and we capture much more detailed information and clinical types of information from them and we also collect blood and urine but what's really interesting is we have all the questionnaire information and we can put it all together for all 50,000 people and as you know we come back to you every three years and we ask you a lot of questions what's really interesting is that because of this design it means that we can actually roll it up and put it all together and in many ways we can talk about what the situation is for Canadians for older Canadians it's not just about you know small samples and older adults here and older adults there we can actually talk about this prevalence of some conditions or some situations for older adults in the Canadian population. I'm not going to go through this but you know we ask you a large number of questions on a whole bunch of different areas but this for researchers this is an absolute pot of gold. You also know that we take a large number of samples from you we ask you a lot of or we make you do a lot of clinical tests but for people who are on who do the phone part it's interesting to see what the what the other side of the study does and so there's a large number of clinical measures and physical measures that we also take. What you don't get to see is where your blood samples go so these are the these are the nitrogen tanks that are actually housed at McMaster University and there's actually 31 nitrogen tanks and all of your samples are stored there and they lay in wait until researchers apply to use them and I think it's really important for you to understand that the information that you provide is available to researchers across the country but also internationally but we take very very seriously the fact that we we do everything that we can to protect your privacy and your confidentiality. We do everything that we can to secure the data and the biospecimens in a very safe way. We also make sure that we use them optimally we know especially for the biosamples that they're not an unlimited resource so we want to make sure that when they're used they're used for the best purpose that will that will aid the health of Canadians and they are made available to all researchers but all researchers have to apply to use them and they have to be approved to use them through our data and sample access committee. So we are now at the point where we have recruited 51,338 participants of whom you are some of them. We have all of the baseline data that we collected initially now well I shouldn't say all but the majority of baseline data that we collected now available for researchers to use. We'll follow finish up the first follow-up in the spring of 2018 and we have now I put 99 here but but by next week we'll have about 120 projects that have been approved to use this information to really try and capture what's going on and you'll hear some of the work that's going on next and this just gives you a little word cloud this was actually in the early days it would change if we did it again now but these are some of the the themes that people are exploring using this information. What's really interesting is that we can get at subpopulations or subgroups that sometimes are really really hard to get at. So for example we now have one of the largest groups of veterans that's ever been studied and we did that because we specifically put a question on in the CLSA that identifies veterans and I'm sure you've answered that question so you know what it is. We can also begin to start looking at other smaller groups like Aboriginal populations and these groups of people are crying for information about themselves and their populations so the CLSA can help to address that. We have a Francophone population and again the Francophone population it really is looking for information about that population. We also have ethnic groups, we have urban and rural groups, we have people who are living with chronic diseases, we have caretakers, we have retirees and these are just only some of the ways we can start to slice the data and make some sense and answer some things that we really want to know. I'm just going to leave you with a couple of interesting facts you're going to hear a whole bunch of information this afternoon but did you know that 19% of all CLSA participants chose to answer the questionnaires in French that 84% live in a house that almost 50% of CLSA participants have a pet that 93% voted in the last election that's pretty amazing. 16% were born outside of Canada 23 almost a quarter of you use some kind of assistive device for mobility for hearing or for vision and the majority of people say that their health is good there was only 10% who said that their health was either poor or fair and also 86% are satisfied with their lives. There's much more to hear and I'm not going to take up your time but I would just like to introduce you to some of the lead investigators and you can see this is the operations committee and the operations committee are the group that are responsible for running the data collection sites that you come to and also the scientific leads who are responsible for the content of the questions that you answer. We also have in addition to CIHR who funds the operations of our study and CFI who is the major contributor to the infrastructure so the space that you that we have in the equipment that we have we have a wide range of partners who have also contributed and I'd like to just recognize them here and then lastly but certainly not least we are so thankful to you the participants who really do give up your time and come back time after time to provide us with this really valuable valuable information. So thank you. Good afternoon. I'm Holly Cuswell and today I've been asked to speak to you about some of the research my team and I are currently working on at the University of Victoria. In 2016 we received funding from the Alzheimer's Society of Canada in partnership with the Pacific Alzheimer's Research Foundation to examine cognition for the Canadian Longitudinal Study on Aging and I will apologize for my notes but I know that Verina is a task master and I don't want to forget to say anything important so I am going to look down on my notes every now and again so I get everything in in my limited time. So okay where do I have to the green one? Yes. Where do I point the green one? That's not my presentation. I don't have any octopi. Okay so there's my slide. So before we begin I will define our terms so we all know are on the same page about what I'm talking about. So the dictionary definition of cognition is conscious mental activity for the activities of thinking, understanding, learning and remembering. So these activities are often referred to as cognitive functions and there are different types of mental activities that we engage in as we go about our daily lives. So cognition can be disturbed for various reasons and a change in cognitive functioning can affect a person's everyday behavior. For example Alzheimer's disease and other dementias are neurological or brain disorders that interfere with cognition or cognitive functions. So typically we think of Alzheimer's disease as affecting memory and new learning but as the disorder progresses other cognitive functions are affected as well and will affect everyday behavior. So it's often changes in these cognitive functions that brings a person to clinical attention. Physicians, psychologists and other health care providers typically perform some type of assessment of cognition where there's a question to determine how a person functions in relation to other people with similar characteristics. So of a similar age or similar sex or educational background or cultural language. So there are both medical and non-medical factors that contribute to one's cognitive abilities and must be taken into consideration when we're assessing a person's cognition. There are many reasons why someone's cognition may change. It could be you're really tired like Vanessa, one of my team, she didn't sleep last night so she's not functioning really well today. If you are physically ill you have the flu. You know that you just don't function as quickly as you would otherwise. If you're on some types of medication, if you look on the label sometimes it will say you shouldn't drive if you're taking this medication or you shouldn't do other activities that require concentration or due to a limited sensory function. So if you can't hear what's being said to you it may appear that you can't remember what was said but you didn't hear it in the first place. So lots of reasons why cognition can be disturbed. So knowing how a person with certain characteristics are expected to perform on measures of cognition is fundamental for being able to identify medically relevant cognitive changes. So you've seen this slide before. It's the depth and breadth of the CLSA and all the wonderful things that we ask you and the piece I have in red there are the cognitive assessment activities. In the comprehensive we have 30 minute battery. In the tracking cohort it's a series of four measures that are given over the telephone. So we have lots of information about the physical health and lifestyle as Susan mentioned. So also as you noted from what Susan said on her last slide the vast majority of the CLSA participants report themselves as being reasonably healthy. So we have a benchmark for comparison with other Canadians. So we have a pretty healthy population in the baseline part of the study. So with our cognitive measures we can use these to create comparison standards for Canadians that can be used to help identify changes in cognition that would be greater than would be expected. You've also seen this picture before and again down in the bottom corner there in red are the cognitive assessment components. We look at memory, executive functions or control functions if you like and then reaction time. This is our team across the country that we're working with. So you'll see me with a different haircut there and a different jacket. And we have Megan O'Connell at the University of Saskatchewan. Martine Simard at Laval University in Quebec City. Vanessa Taller who's tired today because she didn't sleep last night from the University of Ottawa. And then on the bottom left we have our team at UVic. So Stacy Ball, Dr. Helena Cadillac and David Holt and then Lauren Griffith who Parminder will be imitating today. He's stepping in for her today. So Lauren is at McMaster University. So with this team across the country we're developing these measures. We meet every second week by a video conference and talk to each other about what we're doing and share our information. It's one of the great advantages of CLSA as we are able to use this video conferencing system and meet regularly without the expense of flying back and forth across the country. So with our funding we are going to examine how Canadians typically perform on measures of cognitive functioning so we can understand the health and lifestyle factors that affect cognitive functions. And then with this knowledge we can develop Canadian comparison standards for English and French speaking Canadians administered measures in the same way. So we'll look at the ones administered by telephone separately from the ones administered in less. So we have this very large sample as has been mentioned and we'll be able to take many factors that affect cognitive functioning into consideration that other research in the past has not been able to do. This will provide us with more accurate standards to be used with other Canadians for identifying changes in cognition that may be related to certain non-medical or medical factors. So once we've created the Canadian comparison standards we'll create and how we're beginning to do this now create computer algorithms and other tools for interpretation that can be used by health providers in clinical practice. And we had a workshop about this earlier in the day today. So this will lay a foundation for the refinement of these comparison standards as new information becomes available over time. So we can look how they function as we all age. So before I go on, I want to mention why it's important to have Canadian standards for these measures of cognition. First of all, most existing normative standards are based on non-Canadian samples. And this is particularly important for the primarily French-speaking segment of the Canadian population as little comprehensive information is available for youth in making comparisons when identifying changes in cognitive functioning. And even for the English-speaking members of our society, relying on data collected elsewhere in the world may not provide the level of sensitivity to change desired within our own health care system. Also, existing normative standards may be outdated. The collection of this type of data for creation of normative standards can be expensive and time-consuming. And for these reasons, it may not be collected often. And existing data may be out of date and not relevant to the current population. Because believe it or not, the cognitive functioning of populations change with different cohorts. So people who were educated in the 1950s have a certain level of cognitive functioning. Those educated later on, it's different. Not to say better, but different. So we need to keep current. Existing normative standards for measures may not cover the full spectrum of ages from midlife to later life. Sometimes research, the age range of interest may be restricted for various reasons and didn't cover all the age groups. So for many years, people over the age of 65 were not included in normative standards. Or they were only developed for people over the age of 65. And we are in the CLSA interested in the aging process. So we started at age 45 and we're going up from there. And having measures that are the same for all people of all ages is very important in that context. The next reason why it's important to have Canadian comparison standards is because the collection of data for the creation, as I mentioned, can be expensive and time-consuming. So in the past, small sample sizes have typically been used to create these standards. And when you have very small samples, you can't look at all the factors that you want to look at. So we'll be able to do that with this data set. And typically, the normative standards have been developed on individual measures. So one measure at a time, and this, again, is for costs and time reasons. Even though in clinical practice, these measures are often used together as a battery. So you're given a number of measures at the same time. So when individual tests are combined in this way, there's an increased likelihood that an error will be made. And that error means that people will be identified, could be identified as impaired when they're not. Because it's important to control for that combination of tests when you're looking at the results. So we feel it's very important that we have our own Canadian standards and that we take all of these things into consideration when developing these standards. So first of all, to begin, we needed to have a plan. So we're midway through the process now, but our plan was to select a neurologically healthy sub-sample from the CLSA and then to examine performance on each measure. And sometimes, for whatever reason, there are impossible scores in there. So we have to take those out or they'll mess up our analysis. So we have to look at that. And then we need to describe performance on each measure to identify the possible important influences. So does this measure change with age? Does it differ between men and women? Does it differ between people with different levels of educational attainment? Does it differ between French and English speakers? Does hearing play a role? Does vision play a role, etc.? Does general health play a role? So we look at all those factors. Then, once we've looked at all that, we try to characterize each measure taking into account the important influence for that particular measure. We've, as I mentioned, we're partway through. We've done this with the tracking data and we're moving on to the comprehensive data very soon. This is all with the baseline, the first data collection set. Then, we'll combine the measures to minimize the over-identification of poor performances and to increase the specificity as to typical performances. And then we will propose our user friendly tools for interpretation that can be used by healthcare providers in clinical practice. And we showed our first mock-up of that tool this morning and got some feedback from the participants at the Canadian Association on Gerontology to help us design the best tool possible. And then, we will consult with health providers in clinical practice and researchers. Again, we'll go out again. We've done it once here. We'll go out twice more concerning the adequacy of our methods and our tools to make sure we've thought of everything. And then we'll rework our tools to address concerns and maximize their utility for easy access by clinicians and researchers. No point to develop a really fancy tool and nobody uses it, right? So we have to find ways to make it useable. So just a little insight into what we found out so far. So we began by looking at performance of the neurologically healthy CLSA participants on the measures of cognition. And I'll briefly describe three different sets of analysis we've undertaken. So first, I'll talk about comparisons with other studies that use similar measures. Then we looked at the relation between number of medical conditions and performance on the cognitive measures. And then I'll tell you a little bit about observations of how CLSA participants remember to remember. So first off, with the tracking cohort, the approximately 20,000 telephone interviews, we have our four measures there. And we do collect them over the telephone, which is different from other studies. So we wanted to see, does that make a huge difference collecting things over the telephone? So we have similar, okay, similar scores to other studies in the field, which tells us that collecting our data over the telephone is an acceptable approach and tells us our data will be relevant for application by other people as well. Our second thing, do medical conditions affect the scores? Short answer, no. Again, our population, you, are very healthy people. And so we did not find a relation between number of medical conditions and cognitive performance. The remembering to remember, this is from the comprehensive data, the 30,000 people who go to the data collection sites. And they're asked to perform a number of tasks. And one of these tasks is have people do specific tasks when a timer sounds or at a specific time. And this is a relatively new measure. And we've taken a close look at performance of our neurologically healthy sample in English and French. So basically, when we examine performance on this measure, men and women, age groups, okay, so we saw that overall men and women don't perform differently on either the event or the time based tasks. Similarly, we saw that overall French and English speakers do not perform differently on the event and time based tasks. Age groups do, for both English and French speakers, do perform differently on the event and time based tasks. And English speaking groups differ in educational attainment, but the French speakers do not differ on these tasks by educational attainment. So we're seeing different things in the English and French samples. So those are just our preliminary papers, three papers, a one on each of these areas. And so we have our ongoing research, we will continue with our analytics to look at the comprehensive data set now and to take our prototype or mock up of our web based tool around for clinicians to look at. And then we'll hopefully by the end of all this, we anticipate sharing all of this information with researchers, clinicians, and other interested parties, like yourselves. As we take each step in the process, we'll come out and share that information about how we're going about exploring this current extensive collection of information for Canadians. Okay. Oh, so many bright faces. Are you enjoying this event? All right. Well, I'm having a great time. We're all having a great time. So CLSA is a great thing for Canadians, whether you're in the study or doing the study. So I am going to tell you a little bit about one of the topics of great importance to me and my colleagues. So I guess you got the idea we work in teams, and there's a lot of us. So a few who have worked on this are Paul Mick, who is a ear, nose, and throat doctor in Kelowna. Walter Widdich, who is a professor in the School of Optometry at the University of British Columbia. Don Guthrie works in health information in Waterloo, Ontario at Wilford Laurier. And Natalie Phillips is a neuropsychologist. So even on our team, we have hearing people and vision people and people that work on population health. And we really just want to see some of these important connections and how they could change the way you might live better and the way might meet we might do health better. So people have started pressing the green button. Okay, the octopus has returned. So why do I have an octopus here? I was watching TV one night and they had this show about octopus. And they went into how octopus is a social creature. And they survive how do they survive by changing their shape? Right. And I thought, thank goodness, I do not have to do that. You know, I'm lucky if I can sit in the chair. But what my health promotion colleagues would say is that health is the capacity of people to adapt to respond to or control life's challenges and changes. And we have lots of those things as we get older. But we are not a solo creature. We are social creatures. So I would say that how do we survive? How do we stay well is because we can adapt socially. And in fact, there's a paper that has been in many, many citations at this conference. That has got us all thinking and it actually says that social relationships are one of the strongest things that are actually related to how long you live. Okay, so I think, you know, this, we are kind of the social octopus. And there's science that would back up this fact that I'm sure you all believe. So I think of the words of one of the women with hearing loss, who I had an interaction with at one time, and she said to me, because I'm interested in hearing loss and I'm interested in aging, she wanted to tell me that it was really important to her. She says, when you are hard of hearing, you struggle to hear. When you struggle to hear, you get tired. When you get tired, you get frustrated. When you get frustrated, you get bored. When you get bored, you quit. But then she says, I didn't quit today. So you guys are all here. So I'm guessing you are not quitters, which is very good for us to study you. So I think you can see maybe there's something going on in those ears. But it creates some cognitive challenge. It creates some emotional stress. And then ultimately, you decide to stay home. And then you fall into that cycle where other things are going to start to go wrong with your health. And indeed, in the last decade or so, we have seen more and more headlines about how sensory loss, hearing loss, which is going to affect about half of the people once they get to retirement age, and it's going to affect 80% of the people by the time they get in their 80s, very, very common, third highest common chronic disability in age. And it is connected to a whole lot of things, mortality, dementia. It actually is predictive of incident dementia 10 years later. Depression, falls, injuries, frailty and social isolation, which has got this huge connection to how long you're going to survive. So I don't know if you saw any headlines in the summer, but there was this paper in the Lancet, which is a big fancy medical journal. And it was looking at, you know, some of the risk factors that come at different stages of life, and which ones could we possibly do something about? And hearing loss is one that starts early. You know, it starts when you're in your 40s. Average age of first time hearing aid use is 70. But these kind of cascade of problems into social isolation are happening later. So could we nip this in the bud by doing something about sensory issues? And to answer that kind of question, the CLSA is just a tremendously valuable way we can try to look at this, the connection of hearing to these other things. So it's kind of like we're having this big Humpty Dumpty experience, putting all these pieces together. So we wanted to know is hearing loss and also vision loss and combined sensory loss. What does it have to do with how many people you interact with, with the kinds of activities you do that you participate in, about how available social support from your friends and family and others is, and how lonely you are. Because loneliness is also something that we've become increasingly concerned about. So this is just based on the tracking data. And we have your comments about is your hearing, using a hearing aid, if you have one, excellent, good, fair, or poor. Right? You told us that. We have a similar question about vision. So you told us that. Now we have this comprehensive data that you gave in the clinic so we can actually get into more detailed measures, and we're just starting to analyze that. And then for the outcome measures, we have four kind of areas of social activity that we can look at. So I don't think those pictures are any of you, but you know, you're pretty, pretty out there group. So who knows? Okay, so you answered these questions. So do you remember answering this question about social networks? So we're measuring how many people you interact with, you get a point for being married or having a domestic relationship. And you can get more points to get to the maximum of 10. If you interact with your children with your friends with your neighbors, people in your religious group. Okay, so we're looking at how many people are you interacting with? What are your connections? We are looking at how many activities you do. And so for our purposes in the analysis, we said that you have low social participation if you don't do any of these things at least once a week. And that number eight there, any other recreational activities with others? I don't know if any of you really do fencing with your walkers, you know, but I guess some people do. So what are you actually out there doing? And then the next measure is social support. So do you have people who can help you out, who can take you places who can listen to you, who can give you love and support? So we're also looking at availability of social support based on the questions you answered. And then we have a slightly different idea about loneliness here, which was just one question that you answered. In the past week, how often did you feel lonely? And so you are not lonely if you never felt this if you answered less than one day a week. Okay, so you can be lonely even in a crowd, which I think is what I'm trying to get out with that picture. So these are thanks to our social group who developed these measures. Now us sensory people can start to learn about social matters. And just one, I just have one slide to summarize what we found. So the people who said they had good hearing and good vision are the comparison group. So compared to people who have good hearing and vision, people who have vision loss or combination of hearing and vision loss, they actually were worse off down all of these social measures. Interestingly, the people with hearing loss who self reported hearing loss, so maybe some of them are great hearing aid users, doesn't mean they didn't have a hearing loss, but the ones who had, who had, you know, difficulties that they hadn't resolved yet. Really where the action was here was on they didn't have social support and they felt more lonely. Okay, so, so I think that's important. And finally, I'm really happy as somebody who's worked clinically as an audiologist and as a researcher in psychology, you know, I think finally we have made a breakthrough in terms of how we understand age-related hearing loss. And it has, it's changing. I think it's already changing. We had a presentation here yesterday that, you know, the people who are doing the hearing care are, have stopped thinking about your ears and they started thinking about your life because we realize that, you know, what's going on in your ear is connected to your life and ultimately to the rest of your health. And that, that could change how we practice. And I think it's also, you know, there's a message here for all of the other people in health care to whom you go, that when you go and they are trying to help you with whatever your other health problems are, that they can do a better job if they can communicate with you better and know about your hearing and vision needs. So I think working together is going to get us all further ahead. And just to look at the future, now that we have the data that you provided in the sites, in the test sites, we have more we can, we can use. And we are going to try to get to the bottom of some of these connections that have become known. You know, we know this connection to sensory loss and cognitive loss, but we don't understand why. And one of the possible explanations is people with sensory loss, you know, start to have this lack of social engagement. And then that in turn, their brain doesn't get so much exercise and then they have cognitive loss. So what is there to that hypothesis that we can actually get at with CLSA? So I think, I think we're going to really learn a lot by putting these pieces together. And do you know where that is? Is that in Manitoba? It could be many places in Canada. I think it's actually Palmic's photo of Kelowna. So we can all go visit Paul and talk more about hearing and social factors. Thank you very much. I guess as Holly said, I am presenting on behalf of Lauren Griffith, who's unfortunately not, she's actually fortunately attending her sister's wedding in Boston today. And I actually right now don't know who I am because as I was sitting at this table, I was greeted in Italian. And I said, I sort of try to pay attention. And this gentleman thought I was Italian. And that reminded me of a story when I was in Hamilton, a taxi cab came to pick me up to take me to the airport. It was an old Italian gentleman. He had a little hat on. And as I get into the taxi, he goes, Dr. Reina, are you Italian? I said, no. I stopped for a few minutes and I said, how come you asked me that? He goes, sir, your last name, Reina. I said, what's wrong with my last name? He goes, oh, that's a very common name in Calabria, Italy. I said, oh, that's really good. He goes, sir, no, that's not good. They are really bad people. They are one of the biggest mafia in Calabria. So I'm representing the CLSM mafia here today. I'm going to be talking about frailty. And I will define what that means. And this is the people at the bottom, Lauren Griffith, her master student, David Cantor, David Hogan, Chris Patterson, and Julie Richardson, and then myself. This is a team which you already getting the idea that teams are formed to answer many of these questions and use the CLSM data. And I think it's important to note that you guys here sitting and coming to our answering telephones and coming, allowing us to come to your home or coming to data collection sites are giving lots of data, which is complex data. So you need multiple types of brains to be able to sort of what we are trying to study. And I think it's a, it's just a tremendous opportunity for all Canadians and people around the globe what this study will provide in the coming years. And I'm going to put a plug in here right up front. The only reason what we are saying, what Holly was describing, what Susan described, or what Cathy described, couldn't be done unless you were providing your time to provide these data. And it's going to be even more important that as the study goes forward you stay in the study as much as long as you can because the the validity of this type of science is based on your participation. And we hope you will continue to engage with this initiative. So there is lots of things that we hear in the media, in many other circles. You know, one of the, my pet peeves is when I were I hear somebody in the media talks about gray tsunami or some sort of a negative connotation with aging because aging is an asset. This is one of the biggest achievements of the modern medicine public health. We are living long in a healthy fashion all around the globe, not just in Canada, but even some of the developing countries those patterns are changing. But this is what the perception of aging is. People think as people start to get old, they start to decline. Some of that happens, that the natural aging process. But people think it's always going to result. All older people have the same pattern and they get dependent and they become burdened on the society. But the reality is much, much different. In fact, there is no typical older person. Actually, there is probably 400 of you in this room and each one of you have a very different story to tell and you have very different experiences related to your day-to-day function. So there is no typical older person. So the question comes, how do we sort of understand that heterogeneity in older individuals? And if we think about health and functional abilities, not in older people, but in all people, it is not random. There are certain things that have happened that actually makes us age differently. Our genetics, that play a role. That's why we collect bloods and urine samples from you so we can study that part. We also want to understand where you live. How does that data actually contribute to how you age? If you live in neighborhoods where there is no transportation, you're not likely to go out. That actually is going to change the trajectory that you are going to take in relation to your aging process. Your behaviors, if you smoke, if you don't do exercise, is going to have negative impact as to what happens to that aging process. And also, we need access to service, whether they be health care services or social services. All those things come together to impact the trajectory we take. And this is supposed to be one single slide. One of the interesting things about aging is as we start to age, we actually start to differentiate. If you look at the early years in life, most people, if you took few young people and put them right next to each other, they pretty much looked the same from their capabilities point of view. There might be small variations, but you can't really tell that they are different in any shape and form other than their facial features and the color of the skin or something like that. But as we get to the middle age, we actually start to differentiate. There are different trajectories we take. And the question comes, one of the important questions from the CLSA point of view that we want to understand, how do you keep these people about this frailty threshold? So there are different spectrums of frailty that people have. How do we understand that? And what triggers that frailty trajectory for someone to become functionally dependent or go on to die prematurely? So that's what the whole idea about the frailty is to understand the heterogeneity in the population. So what is frailty? Frailty is a clinical state in which there is an increase in individual's vulnerability for developing increased dependency or mortality. And it usually happens as a function of some sort of a stressor. And stressor is a generic word here that we are using. It can be a chronic condition. It could be a life event that the death of a spouse or the death of a family member or getting a new diagnosis or your experience in hospitalization because I don't know how many of you probably had this experience. When I used to talk to my grandmother, no matter what happened, she was not going to go to the hospital because she had seen again and again the people who went into the hospital never came over life. And that was the issue that because we used to actually make people immobile, keep people in the bed and let them rest. And that is the worst thing you could do to anyone in relation to frailty and muscle loss and decline in health. So those types of stressors can play in starting the frailty spectrum. And from a CLSA point of view, from a population point of view, why do we want to measure frailty? We want to identify people early if they are pre-frail, so something we can do, so we can delay any form of disease and disability those people might experience later in the life. If we identify people early, you can design better prevention and treatment options for those individuals. And from a population health point of view, from a public health point of view, if we understand the frailty of a given population, we can design public health intervention to shift the whole curve to the left, that the curve you see here. So we can say if we can delay the frailty by seven years, we will actually improve the quality of life by almost 10 to 15 years that you couldn't achieve by the moving or treating any single disease. So it's an important concept that actually can make the later years of one's life much more enjoyable. So that's why we are trying to understand and study this phenomenon. And there are challenges that have been there, and hopefully CLSA will address many of those challenges. And any good measure of frailty should be able to help us understand how is it a biological thing? Or is it a social issue? Or is it a functional issue? How does actually frailty begin? Because frailty is something to do with your underlying reserve, your resilience. And how does that resilience change is an important concept to understand. And how does it relate to social, environmental and behavior factors? And you heard different talks had this theme already. If you sort of have a hearing problem or vision problem, it starts to contribute to your frailty. And that contribution of the hearing and vision to frailty has implication in relation to let's say social isolation and loneliness, which is deadly. In fact, I was reading a paper yesterday that said loneliness equivalent of smoking 15 cigarettes a day. It is a major, major health issue around the globe. And to answer some of these questions, you require longitudinal data. That's why Canadian longitudinal study and aging becomes a really important platform to be able to answer these questions. Varena, how I'm doing with time? What's the time? Okay, good. You know, you guys don't know Varena is actually from Switzerland. Time is really important to her, right? So I want to make sure I don't stress her out, because that could trigger frailty here. And as I said, when we look at the biological things, you look at social things, you look at behavioral things, so you need to design a study that can bring all sorts of those factors. So when you next time go answer a telephone call or you go to someone comes to your home or you come to data collection, keep in mind, all those pieces of information are critical, even though it takes a little bit of time, it puts demands on your time, but it is absolutely critical pieces of data to be able to answer some of these very important questions that will have implication not in 30 years, 40 years, 50 years, but in the next 5 to 10 years. So I'm trying to emphasize that your contribution is what is making all of this possible. Of course, the money from the government helps too. So one of the objectives that David Cantor, the master students project was to create a frailty index because when we go walk around and we see, we can actually look at and say people, yeah, that person looks frail or they are some weak or something is not right with them. But from a research point of view, you want to be able to quantify in a reliable, valid fashion so you can study that phenomenon. So we, one needs to create some sort of a measure that can quantify frailty index. And one of the frailty index that we use which is developed by a Canadian Ken Rockwood is that which basically looks at all sorts of deficits that you have. And of all the deficits that might be possible, how many deficits you have and that determines the degree of frailness in an individual. And then you want to say, what do we think is related to frailty? How can we validate that actually what we are measuring is frailty, it's not something else. So that was the intent of this project. And this is the distribution of that particular frail. Here you can see, you are hearing this theme again and again, majority of you are very healthy people. And that's not just happened because of the criteria we use to select people into the study. But there is still around 7% of people who are actually frail in the study. And they are going to be on a different trajectory than the people who are much more on the healthier spectrum of the frailty. And it's an important thing to know. For example, the 6.9% of the people scored frailty index of 0.25. That basically means is that the quarter of the variables that we measure have some sort of a deficit attached to it. So there was a some sort of an issue from a health point of view from a social point of view or a psychological point of view that affected their frailty. And frailty also differs depending on what type of a population you're looking at. Here you can see, even in the CLSA context with this much healthier population at the baseline, the frailty levels are a little higher in low income people. And there is some sort of income gradient as well. So what are the factors that relate to frailty that we wanted to look at in relation to understanding whether we are measuring frailty or not? It is natural to think that the younger people would be less frail. So the data showed yes, they were less frail. Males tend to be less frail. High income people are less frail and highly educated people are less frail. So on the other side, older female, more falls, more injuries, need home care, they were using some sort of assisted device and socially isolated. So one of the things I wanted to do, this is what we have done now. Now, I'm showing you this slide, not that you really need to understand this slide. I made it, I suffered for a couple of hours trying to make it up. I thought if I suffered, you should suffer too. Right? So let's suffer together. So one of the implications you heard from Kathy that social isolation is an important piece. And we know frailty as it becomes worse, people become limited in their abilities, disability sets in, and those factors, mobility impairment type of factors can have a major impact on social isolation. People become lonely, socially isolated. And there have been study done on primates. And I'm showing this as an example what else one could do with the CLSA data in the coming years because many of you are giving blood samples and urine samples. And you want to know how will that be used. This is an example of that. And in these primates, these studies were done. They had taken these primates, which are very social animals, and they put them in isolated environments. So they were socially isolated. So the body, the brain actually sense that as a stressor. And it started to make these changes in the brain. And it releases some chemicals and you start to seeing inflammation in the body. We knew this before. There was nothing special about that pathway. But what actually they showed was really interesting. And that is when they took the socially isolated animals and put them back into the their natural environment, they started to get infections. And they couldn't get rid of the infections of those individuals, which happens in people as well, pneumonia as a function of surgical intervention happens a lot. And what they found was that because of the social isolation trigger, what changes that started to happen in the brain, the messages were being sent to the bone marrow where the stem cells are created. And those stem cells result in all these little cells at the bottom, which are in our bodies right now in our blood circulating and fighting all the infection couldn't be replaced. So as the infection happened, whatever was in the system got used up, the new cells were not being created. So there was no system in our body to be able to fight these infections. Now, this was done in primates. We have all this data collected in the CDLSA in the coming years. We are going to be able to test these hypotheses that, is that happen in humans or not? Or is there some other phenomena that is happening? And I think that couldn't happen. We couldn't do studies like this and design interventions or differentiate people what is a biological origin versus a social origin. If we understand these phenomena, in this case, we wouldn't have to give a pill to people. We will just have to make sure that people are not socially isolated so we can have a social intervention because we have medicalized many of these things in our society. So these types of things are able to allow us to be able to isolate those phenomena. So in summary, changes in frailty we are going to be able to see and allow us to develop trajectories and assess how people actually decline and what are the triggers of those. And obviously, all of this, what we are doing is to help us design new interventions, evaluate these interventions so we can change the trajectory of this frailty and make people live in their homes and in their communities as long as possible or place of their choice. Thank you. You can see how intimidating I am. It's my students too. They're well trained. They know that we keep on time. We have some time, which is again great if you have any questions. So we have about we have the the session is only 20 minutes longer. So of course, if you have to leave now, feel free. But we do have 20 minutes for questions after that. We'll we'll have some of the presenters need to leave. They have to go to the airport, but some of us will be here. So you could be coming up. We have a microphone. I'm just looking the microphone. Yes, we have a microphone. Are there any? We have two microphones, one on each side. So any questions at all to any of the presenters about CLSA findings? We have a question here in the middle. Yeah, no, if you could please still if you could please just use it anyway. I know they're loud voices, but it's a big room. It's a very large room. I just want to personally thank the CLSA for this opportunity to come and hear a little bit about what's going on. My question is, is there without detracting from the research any thoughts about a website where we could go and look? That's a good question. And we as the projects are being done, we are putting little summaries on our website right now. You can see that have been approved to use our data. As the results start to come out, we are going to put the links of these papers on our website and people who are interested, they can click and read. I think, I don't know if any of the punders are in their room. If we do get some resources to translate some of this information in lay blogs for our participants, that will be tremendous. But right now we are just going to be sort of going through these stages. The papers are just beginning to come out and we are putting the hyperlinks to that so you can go and read it. So please visit our website. We actually were talking yesterday. I don't think it's easy for many of you to go to our website to find those papers. We are actually going to bring them more to the forefront so you can find those types of pieces of information much, much faster and in easy fashion. Also just to add increasingly the newsletter, are you receiving the CLSA newsletter? I see a few nods. You should be if you don't let us know. Increasingly, we do have some results in there and I think that's just gonna get going as there are so many projects happening across the country, but so you'll hopefully see a lot more of that. My question is, do we know what percentage of the population has dementia? I'm assuming it's age related but there are more elderly people with dementia than younger? That's a very good question and thank you for asking that. We don't know in the CLSA right now and the reason why is because when we enrolled you into this very large study and were asking you to participate for a very long period of time, we had to make sure that you were able to give us consent to do that. And so one of the requirements was when you entered into the study that you had to be essentially cognitively competent. But as you know, one of the things that we're doing is trying to follow people as long as we can even if they develop cognitive decline over time and that's why we ask you to identify a proxy. That's why we ask you to give us an indication of how you'd like to be followed into the future. So we will be able to determine that later down the road but we certainly can't do that at this stage. Just from other studies, there was a previous study called the Canadian Study of Health and Aging that actually looked at the prevalence of dementia and Alzheimer's in Canada. So we have information from that study that approximately 8% of the population over the age of 65 has some form of dementia and it goes up with age. So we know from our previous studies that that's the prevalence and the incidence but not from this study. Hello, I'm wondering about the problems with the number of people who have hearing disabilities and it's very, very hard for people to ever get a hearing aid. Financially that's a huge problem and I don't know if there's any movement in that area to help people with their hearing. I understand how debilitating it is. I could add to that that I really appreciate all your work, thanks. It's a very big issue and again it's something that's hard to study but in addition to the study that Kathy's doing, we're also looking at hearing and vision and mobility loss and one of the things that we're trying to look at is what are unmet needs. So of the people who report that they have a hearing loss or of the people who we test and we see that they have a hearing loss, then what proportion actually don't have access to a hearing aid or some kind of aid or report that they're not using those aids. Now that kind of information won't automatically translate into getting hearing aids for people who need them but it's information like that once it gets out there that can be used to increase the case for increased coverage, for example, for hearing aids. Yes. Nice to learn, yeah. I don't, okay, so we can talk later. Like health in Canada, it depends a lot on the province you're in. So if you are in the province of Quebec, you have a certain amount of hearing loss, you get your hearing aid. In Ontario, if a clinician thinks that you need a hearing aid, the government will subsidize it. So it depends on the province you're in, how exactly the funding goes. And I think it's an evolving story and there's lots of effort that people are putting into that. But I think really for me, it takes, it's not the hearing aid which is really the story in a way because people wait 10 or 20 years on average before they get their hearing aid. And what I want to know, I know what happens when people get to a clinic and I know what happens when they have decided to get a hearing aid but what I can learn from CLSA is about what happens in those 10 or 20 years while you're kind of having trouble and things are getting harder, but you haven't yet made the decision to go and try to get one. So I think there are a lot of environmental things. There's a lot of, we have this age friendly initiative that has been talked about widely at this conference. So what can we do in your municipality so that you can still participate in events because acoustics is something that is not optimal. If you had a wheelchair, you would expect there to be a ramp. You would expect there to be an elevator, but we haven't kind of tackled either the physical environment or the social environment for people with hearing loss. So personally I really enjoy having this social engagement emphasis instead of just get a few more decibels. It's not about the decibels, it's about staying socially engaged and there are lots of ways you can do that. And you may have followed this that these days, people who make hearing aids are really worried because you can get an amplifier on your cell phone and you can get these devices which are dirt cheap and are actually as good as many hearing aids. So that's kind of a turning point in the field that things are getting cheaper and they're converging with other communication technologies. And so finally the clinicians can actually work with you as human beings instead of just as ears. So I think the story of hearing aid cost is kind of, we'll have a different discussion in 10 years time. But I think the important point that comes out of this comment or question you had is that in the context of the aging population and at a population level, we have many data gaps that don't allow us to be able to have a conversation with the policy makers. And I think CLSA is going to fill that gap, it's going to give us data, not that they are going to be always going to listen to our data, but after a while it's hard to ignore data. Evidence in your face, people are going to look at it and I think that's one of the things the CLSA is going to do in the coming years is sort of minimize that gap we have in relation to information that will result in designing programs and policies that help many people across the country. Yes, sir. Yes, my question is, has there been any effort to follow the exceptionally healthy, the exceptionally well-preserved people and see what works? I would think that this would be the biggest benefit of a study of this sort. Maybe I can tackle that a bit. In the CLSA, we will have opportunity to follow these people from a general population perspective, but there are these communities around the world called, there are six blue zones and these are in places like Sardinia, Loma Linda, California, Costa Rica, Okinawa, Japan, where the majority of people are actually centenarians and very healthy, they don't have many diseases and people have looked at those populations but they are super-agents, they are very different and one of the things, obviously genetics has something to do with it. Also, how the older people are actually perceived in their communities. The young kids, young people, actually don't have a concept of age. There's a very interesting, if you go to YouTube, if you have access to the internet, there is a documentary through the National Geography Geographic that they talk about these blue zones. They all have some sort of a, what we call the Mediterranean diet. They either live by the ocean or live by the mountain. So there is this multiple environmental, the building blocks I was talking about in my talk, that's what these people have. And one of the things that comes out biologically is that they have a good cholesterol. The levels of good cholesterol are much higher, which we call HDL. And when I was an undergraduate student, I used to remember it by saying happy cholesterol and a lousy cholesterol. So it's the happy cholesterol that they have lost more than general populations. So we have some information from there. Yeah, but I think, thank you for my opportunity. My question relates to just how close and current you want to be monitoring the participants. If a participant has a significant change in health, would CLSA like to be notified or would we just wait until the next interview? That's a very good question. The way that information is processed in the CLSA, we only have the opportunity to capture it every three years. But it's very important to us to understand when you have a major change in your life, whether it's a health event or some other event that really has changed things dramatically for you. So the best thing to do, you can call us or email us and let us know, but we can't actually put that data into your file in a useful way until the three year period. So I think we can capture it and we can make notes, but it's not truly going to show up in the data until the three year point. So it's very important when you do have your interview that you let the interviewer know. Just to add to that comment, lots of things happen in one's life and if for some reason that event might make it difficult for us to contact you in the future, it is important that you let us know where you are and what's going on with you so we can find you for the time when the interviewer comes. But in the meantime, you can actually keep a little diary of those events. So when the time comes for us to collect that data, you can actually provide that information and we can capture it. So that's one mechanism to be able to capture that critical major event that might happen in your life. My turn. Okay, how about? Okay, I'm interested in the delineators that you use to deal with cognitive loss or dementia. My experience here with my medical practice is that the only things that they use will show any information so far into the process. There's nothing at the beginning to indicate cognitive loss. There's no measures that are being taken. So whatever you have developed to deal with that over time is that going to be available to physicians to be able to use? Certainly with respect to the cognitive data we're working on, that's our goal, yes, is to have that publicly available for practitioners of whatever goes out there to use for the cognitive data. You wanna speak to other data? Again, one of the goals we hope for is that the tools that we use will be available as well. Yes, sir. Thank you. First of all, I'd like to congratulate you all on speaking English I could understand. I was half expecting a bunch of words that were way over my head. And it was really pleasant to be here and have a downed earth information. Secondly, not near as important, but just to cause trouble. Next time could you hold a place where the parking is cheaper? I am sorry about the parking cost, I know. First of all, I want to thank you for a wonderful time to share. I happen to be one of those who has now reached the 80s and I'm beginning to deal with hearing loss and mobility problems. And remarkably, one of the things that has caused me more stress than some of the things you guys mentioned is the new revolution of the social media. My grandchildren, they spin around on their cell phones like you wouldn't believe and they lose me so quickly that I don't know what to do. And I wondered whether you might go ahead and make sure that CLSA also includes the study of the social media as the research goes on. Thank you very much that question. We actually have some questions in the CLSA as to the use of social media and we are probably in the coming years going to beef it up a bit more as we understand that phenomenon exactly related to the question that you were raising. Thank you. Even though we are here talking about CLSA, I think a fellow who was just talking. Anyway, there is actually an enormous other research enterprise called HWELL which had many presentations at this meeting and it is led by people who are engineers who are trying to make devices which you can use and which you don't know about. So other researchers are working on those products. Now. Hi, thank you. Teeny question. The importance of sleep. I am just wondering how much that you've collected. Much relevance in your studies has that come up with? Because I for one, and I'm sure there are many that have a form of sleep apnea or sleep disorder, which is older. And if you don't get a good sleep, sometimes maybe you don't want to socialize, et cetera, et cetera, and does it do a number on high blood pressure? Other, you know, it can contribute, I believe, to other health problems. It's just a curiosity on my part. We do have a number of questions on sleep in the CLSA and there are a number of teams who are working on sleep and quality of life and various other aspects related to it. And we do have questions on sleep apnea as well. So I don't think any of us are directly working with the sleep questions, but there aren't teams who are. There is a just project using CLSA data that had been put together and we were just looking at the paper itself, which has looked at the sleep and obesity. And so in the coming year, a lot more will be coming out and please go and watch on our website as these papers emerge and you will see some interesting findings. Oh, okay, one last question. Okay, my question is about the social interaction of the isolation. I am on the ones where you just phoned me in and I think it's important that we note exactly what we're doing. So I didn't notice anything about work in that social interaction. We're farmers, so our social interaction is on the farm. And there will be other self-employed people whose social interaction is their business as well as their social life, like our whole life is farming. So just to point that out, I just thought that was an interesting part. You're right in probably the measures that we described here, that part was not probably incorporated as much. But CLS, it does collect information as to what happens at workplace and it has some participation questions that also relate to work that could easily be incorporated in the future analyses as the interactions that happen at workplaces as well. In that little preliminary study we did, you know, you would, based on the description you gave, you would not have counted as a person. We had an interesting conversation in the poster session today with someone from Stats Canada and CLSA and Stats Canada have worked closely together. And I think we were at the same post of arena. And the conclusion of the person from Stats Canada was that social isolation was a bigger problem in Toronto than it was in small rural communities. And we had to scratch our heads over that. But, you know, people are thinking about what you asked in your question. We'll take one last question. We have some of our presenters have to go to the airport. So one last question. Not a question, a statement. I came by bus. It cost me a dollar, 18 cents. I got an hour, time for transfer. It's on those new little cards you can get. Almost every everybody can get to this part of Winnipeg by bus. They have buses that lower down. You get a special place to sit if you have a wheelchair or anything. I'd strongly encourage people to come by bus. Good ending. Thank you very much. Again, thanks very much for coming. Hope well we'll stay in touch and we'll see you at your next visit at either the Deer Lodge Center or via phone. And thanks to the presenters.