 is the characteristics of caregivers and care receivers in the CLSA. And our speaker is Dr. Deborah Sheetz. So I'd like to introduce our speaker to you now. So here is a lovely picture of Deborah. Dr. Sheetz is an associate professor in the School of Nursing at the University of Victoria. She received her doctorate in gerontology and public policy from the University of Southern California. Dr. Sheetz is an elected fellow of the American Academy of Nursing, the Gerontological Society of America, and the Association for Gerontology and Higher Education. Her research interests focus on gerontology and geriatric nursing, and in particular, dementia and caregiving, technology in home care and creativity and aging. Dr. Sheetz is one of the lead researchers for the Voices in Motion Choir, which is an intergenerational choir for people with dementia and their family caregiver, that is reducing social isolation and stigma related to dementia. She's also leading the Ease eHome project, which uses voice-first technologies connected to smart devices to enable older adults with dementia to continue to live independently in their homes. Dr. Sheetz served as co-site lead for the CLSA at the University of Victoria from 2012 to 2018, and she is also widely published and serves on the editorial boards for several leading journals in the field of aging. So she comes very well esteemed with lots of experience to tell us about today. So at this point, I will pass it on to Deborah to get started. Good morning everyone. Thank you for joining us this morning. I'm pleased this morning to share with you some findings from a chapter that I wrote for a book called The Canadian Longitudinal Study on Aging Report on Health and Aging in Canada. I've provided the link to that entire report at the end of my presentation. So caregiving is a common role for Canadian families as the numbers of older adults with comorbidity, disability and frailty who need help with daily activities like meal preparation, and transportation continue to grow. And this presentation will basically describe some descriptive findings describing trends in caregiving and care receiving by sociodemographic characteristics and by self-reported health and type of care given and received. I want to acknowledge before we get started the co-authors for the chapter, Dr. Lynn Young at the University of Victoria School of Nursing, and Dr. Lauren Griffith and Dr. Perminda Reiner at McMaster University. Dr. Reiner is the PI for the Canadian Longitudinal Study on Aging, which is one of the largest and most innovative longitudinal studies in the world. Okay. So as I mentioned, my objectives today are to describe trends in caregiving and care receiving by sociodemographic characteristics, self-reported health, and types of care. We'll also describe a little bit quality of life for caregivers and care receivers, the impact it has with social activities and also with life satisfaction. This presentation basically offers a glimpse into the possibilities of the CLSA for exploring and comparing caregivers and care receivers on sociodemographic characteristics and other factors that can affect outcomes, significant outcomes such as health status, social activities and life satisfaction. All of these results are based on a sub-sample of CLSA participants who report either being a caregiver, receiving care, or what I would say is both, which is kind of an unusual category of people who are both caregivers and care receivers. So this slide here shows that for the first time in history in Canada, the share of seniors exceeds the share of children. The census showed that we now have 5.9 million seniors. This is projected to grow to 23% by 2023, and seniors will account for nearly one in four people at that time. The fastest growing age group are those who are 85 and older. I'm going to move to this slide, which shows that in the blue, you can see that the 85-plus group comprised currently about 13% of those age 65 and older. That's almost 800,000 Canadians and more than 8,000 centenarians. This oldest old group is growing nearly four times the rate of the overall Canadian population, and there are twice as many women over age 85 as men. Okay, most of you probably already are familiar with this graying of our society as it's called. In terms of trends in family caregiving, in 2012, about one in four Canadians, 8 million Canadians provided informal care to a family member or friend. It's basically Canada's aging population that's driving caregiving needs, and this caregiving can be short-term and episodic, for example, when someone's admitted to a hospital and then needs some support when they return home, or it can be long-term and quite intensive. For example, many older adults about half, up to half of all older adults over age 85 end up having memory problems related to dementia, and dementia, the length of that disease can last anywhere from eight years to about 20 years, and so that can be quite intensive. We know that caregivers of people with dementia, in particular, it can have a significant impact on their health and on their finances. Okay, while most older adults prefer to receive care in their home, home care isn't covered under the Canada Health Act even when it's medically necessary. So as a result, there's a lot of variability within provinces and territories in access and provision to home care services, and this is where caregivers really step in and fill a huge gap that allows people to remain in their home. Caregivers provide 80% of care needs for people with chronic health issues, and it's interesting to note that caregivers are also aging. One in four caregivers are over age 65. So caregiving is diverse and complex. It varies by type, nature, and also the duration of caregiver. And I mentioned how the duration can vary. I'll be talking a little bit more about the types of caregiving that are involved. They can have to do more with activities of daily living or things like helping with medications, finances, et cetera. And often it isn't just one caregiver, although there typically is one primary caregiver, but a number of people in a family can be involved in caregiving, but usually one person does play the lead. The economic value of caregiving is estimated at over $25 billion per year. This is actually an older statistic from 2009. We haven't got anything that's more current at this point. So it's definitely gone up. So what about the CLSA and caregiving, carereceiving? The CLSA is the first longitudinal study to collect such comprehensive data on Canadian caregivers and caregivers. It offers us such a unique opportunity to examine patterns of caregiving and carereceiving, including who provides care, what types of care are received, the impact it has on social relationships and social networks. It's looking at some of the negative aspects of caregiving and carereceiving, for example, the effects on work and psychological and physical health, as well as the positive aspects of caregiving and carereceiving. What will predict positive outcomes or what's the relationship with outcomes? How do assistive devices in the physical environment impact care and carereceiving? So it's quite a unique study, and there's much to be done with it. We're now in our seventh year of gathering data, and it'll continue to be an extraordinary platform for doing research on aging, and in particular on caregiving. So participants, you can see some of the questions that they're asked about caregiving, how many people provide care, how much support they've received in the last 12 years. It's interesting also who paid for care. Families willingly provide care. You know, it's one of the things that we do because we love someone, but it also has a significant impact on health and also on finances, and it does make a difference whether or not you're living together with the person you're providing care for or living apart in terms of some of the stream. So getting into the methods a little bit. These analyses are descriptive and use the tracking and comprehensive samples from 2012 to 2015. So it's a cross-sectional look at participants who were ages 45 to 85 years of age. These participants are being followed for 20 years, and the total sample size of the CLSA was over 51,000. When we actually look at the prevalence of caregiving, we had almost 20,000 people who reported that they were caregivers. We had about 4,179 who reported being care receivers, and I'll call them receivers just to shorten that up. And then interestingly, there's this whole group of people who report being both. So over 3,000 people reported being both caregivers and also receiving some care themselves. And this points, I think, to the impact of chronic conditions and some disabilities where people need support, but they can also provide support to others. So it's a very interesting group. These are unweighted analyses, by the way. Okay, some of the measures that I will look at today in terms of caregiving and care receiving and that group that I'll call both caregivers and care receivers are just some simple demographics describing the age, sex, race, marital status, and education of the caregivers. Also looking at the context, living arrangements and employment status, which provides us a sense of some of the challenges of caregiving, I think. I've also got some findings on health, self-reported health specifically, six chronic conditions, and a little bit on looking at ADLs, instrumental activities of daily living, which are things like shopping, preparing meals, and ADLs, which are things like assisting with personal care. And lastly, I'll conclude looking at quality of life among caregivers and care receivers and both looking at a measure for social activities and also looking at a scale for life satisfaction. In looking at social activities, the question that we asked was, in the past 12 months, how often did you participate in family or friendship-based activities outside the household? This was a five-point Likert scale that included it ranged from at least once a day to never. And life satisfaction was a five-item measure of global life satisfaction using a seven-point Likert scale, ranging from strongly agree to strongly disagree. And there, a higher score indicated greater satisfaction. Okay, so if we look at age, what we see here is that the prevalence of caregiving is highest among those who are ages 55 to 65. And in this group, the mean age was about 62 years of age. So the blue is caregiving and the red is care-receiving, and then we've got that group who are both. Care-receiving is highest among those who are age 75-plus, and among that group, the mean age was 67. So you can see some of the variability among caregivers and care-receivers here. I also wanted, I didn't present slides on this, but I thought I'd summarize. In terms of sex, women are more likely than men to be caregivers, care-receivers, and also in that both category. In terms of race, the Canadian Longitudinal Study on Aging is primarily white, although there was some over-sampling to ensure some ethnic racial diversity. So 92% of our caregivers, care-receivers, and both were white, more than 90%. In terms of marital status, about three-quarters of caregivers, 72% were married, compared to 56% of care-receivers who reported being married. So higher proportions, which isn't surprising. Many of these caregivers are likely adult children providing care to parents. One in five of care-receivers were widows, compared to one in ten of the caregivers. So twice as many care-receivers were widows. In terms of education, overall this is quite a well-educated cohort with three-quarters of caregivers having a post-secondary education. Among care-receivers, this number was about two-thirds. Okay, if we look at context in terms of living arrangements and employment status, we begin to see some of the factors that can impact on caregiving. It was most common for both caregivers and care-receivers to live with a spouse with nearly up to one-half of all of these three groups reporting that they lived with a spouse. But there was also one in five caregivers who lived alone and one in three care-receivers who lived alone. And we'll tie that into perhaps activities, social activities a little bit later if you remember that statistic that they live alone. Makes it much harder if you're living alone to engage in social activities, depending on whether you can drive or not. In terms of employment status, one-third of caregivers report working 30-plus hours per week, and one in five care-receivers also work 30-plus hours per week. That's quite interesting, that latter. But it shows that caregivers are juggling quite a bit. They're juggling work, often their own families, and this caregiving. Okay, if we look at health, when we look at health, it was self-reported health, and that's the classic global health measure where you ask participants on a scale of one to five, how would you rate your health? In the category of excellent to very good, two-thirds of caregivers report excellent to very good health. This does raise some concerns about the other third, though, who do have some health problems. And often this is because they are the older spouses of someone who is a care-receiver, and they've got their own health issues. Among care-receivers, only one-third of participants reported excellent to very good health. So care-receivers in general report poorer health than caregivers, and that was also true of those in the both category. When I looked at fair and poor health, one in five receivers reported fair to poor health. And so care-receivers report three times poorer health than caregivers when we look at health overall. If we dig in and look at function, it turns out that one in five care-receivers need help with IADLs. Again, those activities such as shopping, preparing meals, cleaning up around the home. With ADLs, which are activities of daily living, things like personal grooming, assistance getting dressed. When we look at one to two ADLs, 14% of receivers needed help with one to two ADLs. 3% needed help with three to four ADLs. These are typically the higher, the activities that require more physical support, and where people have to, they're less discretionary, where someone needs to live with someone else. So it'll be interesting to look at this in relation to living arrangements. At three to four ADLs, people are often, if caregivers aren't available, people often end up needing to move into much higher supportive living situations because they're not able to live on their own without someone there to support them. Among caregivers, 97% report that no help is needed. And among caregivers, 63% report that no help is needed with IEDLs or ADLs. So it's other types of help that are needed, like transportation, help with medications. When we look at six chronic conditions, heart disease, COPD, cancer, diabetes, stroke, and depression, what we see is that among caregivers, the two chronic conditions that affect about one in four caregivers are depression and diabetes. But these rates are also high among caregivers. About 15% of caregivers report depression and diabetes. And if you look at cancer also, that was the third ranked chronic condition. One in three caregivers, I'm sorry, one in four caregivers, 23% report having cancer and 14% of caregivers also. So caregivers have significant health problems and this really points to the need for support for them also. In terms of heart disease, one in 10 caregivers report heart disease and one in five caregivers report heart disease. Okay. So let's look a little bit at quality of life and caregiving in relation to social activities and care receiving in terms of social activities. There is growing concern over loneliness and social isolation among caregivers and care recipients. A number of studies have come out recently showing that the impact of social isolation is as great as smoking 15 cigarettes a day as being overweight and as being sedentary. So a lack of social activities does point to some concerns and significant impacts on health. And as I mentioned, this measure was asked in terms of how often did you participate in family or friendship-based activities outside the household, a five-point Likert scale. So at least once a day, half of caregivers and those who are both in the both category report getting out at least once a week. But this rate is lower among care receivers. So the once a week category is promising. If we look at once a year, though, 11% of receivers report only getting out at least once a year. That's very concerning compared to 6% of caregivers and 8% of those in the both category. So it's that group at least once a year that we need to look a little more closely at and think about why it is that they're not getting out, that they're only getting out at least once a year. The highest rate of those who never get out with family or friends is found among care receivers. And all along the way, what these graphs show is that care receivers in particular are a particular concern. If we look at quality of life as measured by life satisfaction, again, this was a five-item scale. Some of the items included asking people to rate on a seven-point Likert scale items such as, in most ways, my life is close to my ideal, the conditions of my life are excellent, I'm satisfied with my life. So far, I've gotten the important things I want in life, and if I could live my life over, I would change almost nothing. So on a scale, a seven-point scale, answers could range from five to 35 and a score of 20 represented neutral. Most participants in the CLSA are satisfied with life. Most caregivers, 86% report being satisfied and three-quarters of care receivers report being satisfied. But twice as many care receivers, about one in five, 21%, and those in the both category, report being dissatisfied. And that's twice the rate of caregivers, which was about 10% when we look at the dissatisfied to extremely dissatisfied groups. And again, that's a bit of a concern. It shows that quality of life is really impacted. Okay, just to summarize, caregiving is highest among those ages 55 to 64 years of age, about one-third of our participants reported being involved in caregiving. And care receiving was highest among those aged 75 and over, about 32.8% reported being care receivers. Women are more likely to be caregivers, also to be care receivers, and to be in that both category. And the numbers, like this both category, again, about 3,000 of our CLSA participants is quite intriguing to see if the types of care they provide and receive might be different from the other groups. In terms of health, care receivers report poorer health in caregivers, which isn't too surprising because they do need support. And chronic conditions, care receivers and those in the both category had nearly doubled the rate of chronic conditions compared to caregivers. When we looked at social activities, care receivers had lower rates of getting out with family and friends. And life satisfaction is also impacted. Care receivers and those in the both category have twice the rate of dissatisfaction compared with caregivers. Now, these findings I should qualify are descriptive, and if we think about what's really needed, even on a descriptive level, we need to look more deeply in variations in types of assistance given and received, the intensity and duration of caregiving, to look at some of the relationships. We know that a lot of these are adult children and spouses looking forward to seeing some multivariate modeling and comparing differences in particular across provinces. These are going to be important analyses that can really inform public policy going forward. Those who are in the both category I mentioned, this is kind of the only study I know of which includes a group that report being both caregivers and care receivers. So that is a particular, and it's the only study I know of that has a large enough sample to really allow some interesting exploration of who are these folks that are both caregivers and care receivers. Another thing worth mentioning is that this is one of the only studies I know of that has a large enough sample of people aging with long-term disabilities such as spinal cord injury, post polio, rheumatoid arthritis, and these long-term disabilities will be able to look at the impact on caregiving and care receiving over time with this data. So these longitudinal analyses have not yet been done with this data, and so I'm also particularly, I think, a future direction that's key to address is looking at how caregiving and care receiving changes over time and what that means. Okay, this is the citation I mentioned, the CLSA report on health and aging in Canada, and you can find it on the CLSA website. So you can just go to the website and type in docs slash 2639, and you'll be able to download the entire report, which provides a number of chapters on the CLSA, looking at health, looking at a variety of social aspects of participants, et cetera. And I just put up my contact information. You're welcome to contact me if you'd like more information, and I welcome any questions at this point that we can talk about. Hi, Jennifer. I think you're just muted right now. You can unmute yourself. Okay, so I'll say that again. So thank you, Deborah. I appreciate the excellent presentation. I know that I learned a lot as I've been trying to myself come to speed up to CLSA and all the great work that's been done with the data that's been released so far. Just, I thought it was interesting. One of the things in my head, as you were speaking, was related to plans for using the CLSA's follow-up data, which is now available, and it sounds like that's something on your radar that you're keen to do as more data sets become available because the CLSA is doing a follow-up of the same participants every three years, so that will be very interesting to compare the longitudinal data over time. So I will turn it over to questions now, and we had a few posted. Thank you to those of you who are curious and willing to get the ball rolling. The first one was from, let me find it now, was from Susan, and she was actually interested in the caregiver and receiver category, and she was curious about both the caregiver and caregiver category. Any hints on the data about what is going on with this group? I'm sorry, the group that is both caregivers and caregivers? Yes. Yeah. It is an interesting group, and I suspect that these are some of the folks that are aging perhaps with some lifelong disabilities, but we haven't had a chance to tease it out yet. Wrote this chapter and haven't really been able to dig deeper into that, so all I can do is hint at that right now, but I promise more will be forthcoming. I guess from my perspective, it would be helpful, can you even give a couple of examples of who you think these people might be, different types of roles that they could be taking on? Yeah. I do think some of these might be spousal caregivers who both have their own health issues and may help with transportation or managing their finances from their children, but they also are providing care perhaps to their husband, their older husband. So these may be these quite very old people. I mean the longitudinal study on aging, we had people entering at age 85. Now they're 92. During the course of this time period, they were like 98 to 91 or so, and so I think we do have quite a few spousal caregivers who also need support themselves managing their own health conditions. Great. So now we have a question from Sarah, I believe. Were there any differences between quality of life and caregivers by chronic condition of care recipients? And for example, is quality of life different for those who care for someone with diabetes compared to those who care for someone with depression and or are there differences in those who care for someone with one condition versus multiple? Oh my gosh, that's such a great question, Sarah. Yeah, I'm sure there are differences in quality of life depending on if someone has comorbidities. I don't have anything to present on that specifically today, but we do know that as I mentioned, someone who's caring for someone with dementia, for example, it's much more difficult than someone than a care recipient who just needs support with ADLs or with IADLs in particular. So, yeah, the type of condition and how many conditions really, really has an impact on caregivers because of the complexity. And we know that so many people have complex chronic conditions these days that require quite close management. I mean, heart disease happens with adult onset diabetes and the combination definitely imposes more caregiver burden overall. So, thank you for that question. So, another question is from Salima and the question is, with 90% of study participants being white and highly educated, as you mentioned, wondering how participants were selected for the study and thinking about how these results would translate to other populations. Yeah, so the CLSA study was, the sample was pulled quite rigorously. It involved random calling and people wanted to participate. I had so many people in Victoria saying, I want to participate in the study and I had to tell them, no, you'll have to wait and see if you get a call. So, 30,000 of them lived within 25 kilometers of our data collection site and another 20,000 were selected randomly and only participated in telephone interviews. The 30,000 sample, which is called the comprehensive versus the 20,000 people sample, which is called the tracking sample. The tracking sample was included to make the study more representative and to capture, you know, the population that isn't living near one of the 11 data collection sites. Participants had to be able to come into our data collection sites because we were collecting data including included bone density scans, carotid ultrasounds, EKGs, vision, hearing, gait, we gathered urine and blood, like biospecimens for genetic analyses. So, it's not surprising, I think, that so many of our participants are white and highly educated. Although they were randomly selected, they were the ones that lived near more urban centers and are able to get into our data collection site the 30,000. So, the tracking cohort adds to the generalizability, but again, they are quite well educated. And indigenous populations weren't included in the study for some complex reasons. You can find out more about the study. If you'd like, there's a number of background papers on the Canadian Longitudinal Study on Aging Website that are excellent. Yes, and I encourage any of the participants to visit the CLSA website. There's lots of information about the study in terms of the sampling and the overall protocol there. Somebody also mentioned, and I think we mentioned it already, but I don't know if it came in before or after that. It was in terms of how often we will actually be collecting data, and it's every three years. So, we're now in the third wave of data collection. And here in Victoria, at every site, there's about 3,000 participants that come into each of the sites for the comprehensive. And then participants also get an in-home interview. So, quite a large amount of information data is collected. And the CLSA doesn't have any specific research questions. It's really meant to be a platform for research, but that said, the questions that they're asking about caregivers and care-receiving make it quite unique, and it's going to be amazing to have this longitudinal data as a resource. Okay, we have another question from Janet, and she asks, can you describe what was included in the social activity as a social activity? So, the CLSA actually has a lot of questions about social networks and all, but this was just one question that was asked, and the question was basically... Let me find it. It was something about how... Hang on one second. It was a question about how often do you get out? In the past 12 months, how often did you participate in family or friendship-based activities in the household using a five-point Likert scale? So, that Likert scale ranged from at least once a day, at least once a week, at least once a month, at least once a year, and never. And there were very few people in the never category, but it's kind of surprising that we had a number of people in the at least once a year category. So, they only get out at least once a year. That really raises some concerns. So, we'll move to Angus now who's from Caregivers, Nova Scotia. And the question is, the life satisfaction data do not match what we hear from our caregivers. Do you think there is a connection to their financial situation? And what additional... Oops, I lost myself there. Do you think there's a connection to their financial situation? And what additional data can you report regarding finances? Ultimately, the goal with the CLSA data is to link it to taxes, to educational records, and even to provincial health records, which will provide, which will really add to the data. But we aren't there yet. But we are asking about finances. I don't have that data on hand this morning. But life satisfaction, I think it's a complex kind of outcome that I think does reflect finances as well as social connections with others, and a lot of things that are going on in people's lives. So, that's where we really need to have more complex modeling and the data today is really just descriptive. But when you think about life satisfaction up to a certain point, finance is definitely impact on people if they have unmet need for care. And we do know that with care receivers there is quite a bit of unmet need. There was a Canadian let's see, hang on one second. I've got something here from the statistics Canada did a report and it looked at unmet need and the numbers were quite high. Just give me one minute here. Yeah, here we go. So, a study that was done by Statistics Canada in by Turcott called Canadians with Unmet Home Care Needs in 2014. That's available online. But about 8% of Canadians age 15 and older received home care. But about 1 in 8 had partially met needs, but 461,000 Canadians had unmet needs for home care. So the fact that the Canada Health Act doesn't provide home care even when it's medically necessary that's where older adults prefer to receive care in their homes. And so there's a lot of variability across and within provinces and territories as to in provision of home care services. And that can also definitely impact on finances and my satisfaction as well. Hopefully that answers your question Angus. Janet was also wondering if this work is connected to the CHI high burnout indicator that is being developed. Yeah. I think we do have a caregiver burden scale within the CLSA and we need to look at that and connect it in with, again, the amount and type of care being provided. I haven't looked at that work, Janet, and thank you. I will and see what we can do to develop these analyses further. Because this data is pretty fresh actually. And we're just getting underway with some of these analyses. And I think now that we have two data points looking at caregiver burnout over time among caregivers and how long this caregiving is going on will really address some gaps in the literature. Definitely. I also just wanted to clarify something that was said earlier that when we were talking about the population the sample for the study that indigenous populations on reserves weren't included, but indigenous people living off reserves were included. So it is somewhat representative of indigenous populations. Now we will go to, if I hope I pronounce the name right, and if it's interested in oldest old caregivers age 85 plus, are there any analyses specific to this population versus these oldest old caregivers being included in the 75 plus group? I know. We need to pull a sub-sample and look at that. I don't have any analyses specific to this population today. I really encourage you to go to the Canadian Longitudinal Study on Aging website and look under Stay Informed and there's a lot of publications that are coming out. And they address a number of aspects that I've kind of introduced today, not specifically in relation to caregiving also, but like looking at social isolation, looking at social, functional and mental well-being, social networks. And so it's quite nice to be able to just learn a bit more about the study over the last form. Particularly you'll see that like in the last in 2018, there's been like a plethora of papers being published. Are using this data set, looking at functional disability and social population, etc. And you may be able to find some additional information that expands on some of what I've done today. And I think that moving forward, you know, more papers and more analyses that will get done. And I think that relates a little bit to the last question in the list here. Is it possible to disaggregate the results by those who receive home care services and those who don't? Did you want to touch on that? Yeah, thank you. Yes, we do have, we do ask those questions and they weren't included, they weren't addressed in this chapter. And definitely home care is is a huge factor and has significant policy implications. So yeah, that will definitely be on the horizon. This is very kind of just a preliminary look at who was involved, who the caregivers were in the Canadian Longitudinal Study on Aging. Thank you though for that question. I can see that there's one more question including young caregivers 24 and younger. Well, the Canadian Longitudinal Study on Aging is only for people 45 and older. And so because it's not a caregiving study per se, it's a platform for research on aging. We can't include younger caregivers in that. Well, I think that was the last question. Let me just double check here. I see Janet has one. Oh, okay. The opportunity to look at what will predict the positive caregiver care receiver outcomes. And this is the analysis that still needs to happen. Some multivariate modeling so that we can really tease out these different relationships and the impacts they have. Thank you, Ludmilla. Machine learning. Interesting. Yeah, contact me. Let's talk further. That would be great. Great. All right. I just want to close any final questions. Any last questions before we start to close off? I think we've had some great discussions so far. And been a fairly solid 50 minutes. Did you have anything else that you wanted to note, Deborah, before I close it off? Yeah, I just want to thank everyone for joining us this morning and keep your eyes out. I plan to do some additional analyses here, but this chapter was really just kind of describing caregiving and care receiving. Although I couldn't answer some of your very interesting questions, I'm going to take them forth and plan to hopefully produce some additional analyses that will answer some of that. So do feel free to contact me and to stay in touch. Thank you. Thank you. Thank you. Thank you, Deborah. I would like to remind everyone before you go, if you can consider the analysis that we're initially running for this chapter. So thank you again for your interest and look forward to hearing from you. Thank you again very much, Deborah. I'd like to remind everyone whether the completing the survey located under the polling option. If you have any questions or concerns that we can help with, also feel free to write to us in the chat box and we can help on that as well. I'd also like to remind everyone that if you're interested in the CLSA data, that data access request applications are ongoing and the next deadline for applications is on February 21st 2019. You can visit the CLSA website under the data access tab to review what data is available for further information and details about that application process. What else do I need to tell you? The upcoming CLSA webinars, the next one will be on March 28 and it will be focused on disability associated multi morbidity including mental health conditions, a cross sectional analysis of Canadian population based data and that will be by Dr. Catherine Fisher. If you're interested in that, I encourage you to register for the next webinar series as soon as possible. You can also by following CLSA webinar on Twitter, you'll also stay up to date on the webinars that are underway as well as the webinars that are being planned. And I think that's all for today. I don't see any last minute reminders coming at me in the chat box. Again, thank you very much Deborah and I guess have a great day everyone. Thanks so much Jennifer. Take care everyone. Bye bye.