Navigating Difficult Conversations about Driving and Dementia

Transcript

Intro: I’m Dr. Nathaniel Chin, and you’re listening to Dementia Matters, a podcast about Alzheimer’s disease. Dementia Matters is a production of the Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners on the latest news in Alzheimer’s disease research and caregiver strategies. Thanks for joining us.

Dr. Nathaniel Chin: Welcome back to Dementia Matters. Driving is one of the many challenges that people with dementia and their caregivers face as a person experiences cognitive decline. Responsibility often falls to family members to assess a person's ability to drive and to make decisions that can greatly impact their lifestyle. Here to discuss family caregivers' involvement in driving with dementia is Dr. KJ Hansmann, a family medicine doctor at UW Health and an assistant professor in the Department of Family Medicine and Community Health at the UW School of Medicine and Public Health. Dr. Hansmann is also the principal investigator of the Driving Connections Lab and recently co-authored an article reviewing research related to family caregivers for dementia and driving. Dr. Hansmann, welcome to Dementia Matters.

Dr. KJ Hansmann: Thanks for having me.

Chin: Before we talk about the family side of this, can you help us understand the scope of the issue? How many people with dementia are still driving? And do we know whether dementia is associated with more crashes, driving errors or traffic violations?

Hansmann: It's a hard question to answer in some ways because it's hard to measure. I've been looking back to the data. I'm always looking for updated estimates. I still find the most thorough article that looks at population-level data is from the early 2000s, but it estimated that about one in five people with mild stage dementia—so people that are starting to have more difficulty with complex tasks like managing their finances or medications—one in five of those people may still be driving and as many as about half of people with mild cognitive impairment (MCI) may also still be driving even as they're progressing towards dementia. Now those estimates, why it's hard to measure this, what I've seen in my interviews is that people don't always acknowledge that there's a moment where they're never going to drive again and so it can be hard to say, “Are you still driving? Have you stopped driving?” Depending on who you ask, they may give you different answers. That is one factor of trying to put that in the scope. But people with dementia do drive, sometimes because they are still fully capable of driving and sometimes because this hasn't been appropriately discussed, which we'll talk about a little bit more. To your question then, does dementia affect driving safety? Again, the evidence, if you look at the research, can seem confusing because it looks a little mixed. Sometimes when people are diagnosed with dementia, they make changes in how they're driving. They only drive places they're familiar with. They avoid risky conditions. They have someone in the car with them. That all helps reduce the risk of crashes, but all things being equal, the cognitive or brain health changes that come with dementia do make driving less safe. There's less attention, less reaction time, less good judgment, and so we do see that people are more at risk for making driving errors or even having crashes.

Chin: And I'm sorry I started with such a hard question, but I wanted to really get at what you just said, which is, well, it would make sense to us that someone who's got cognitive change would have a harder time driving. It's important to know there is evidence for that, but also that that evidence is limited and for the reasons you just brought up. We know that not everyone with dementia gets a diagnosis and so there's plenty of people out there who could be getting into accidents or traffic violations that they don't even know they have this condition because they were never diagnosed with it. And yet it is such an important issue. You hinted to the difficulty in talking about it, not only as family, but even as clinicians, which is what we're going to get into. Conversations about driving are sensitive for everyone as they get older. How can care partners and families bring up concerns about a loved one with dementia who is driving?

Hansmann: So I'll start with the best case scenario, which is you've already been talking to your loved ones about driving even before you have concerns. It is always difficult to tell someone that you think that they're doing something less well than they used to. People feel like they're being overly critical. In interviews that I've done, people have described feeling really bad about watching people and keeping a list and keeping track of their driving, so it can be hard to start those conversations. I think one of the things that makes it easier is already having started to talk, looking ahead of if you're driving were to change, what would that mean for you? Would you need to live in a different environment that has more resources for getting around without you being the driver? Would you need more people in your social network to be helping with getting rides to places that matter to you? Those conversations can also be difficult to start, but I think they're easier than saying, “I've noticed that you're driving less well than you used to be.” And I think just starting with a place of compassion, acknowledging that you're maybe having concerns about the person's driving and you're worried about the risks that come with them continuing to drive, but acknowledging that there are risks to stopping driving too. When we focus only on the safety piece and not on what people are at risk to lose, I think we lose people in those conversations very quickly because we're not talking about all everything that matters to them in thinking about this decision.

Chin: I imagine it's even harder, though, if the person doesn't have the diagnosis of dementia, or they're not, I should say, even if they're not aware of their diagnosis, perhaps they've gone through the evaluation and the family's aware of it but they've lost insight. I bet that adds another layer of complexity.

Hansmann: Absolutely. I think once you're at that stage where the person no longer has insight into their driving ability, I focus a lot less on trying to convince someone that they're no longer a good driver. Again, I think there's a balance between are you safe enough to drive and do you need to drive? What does driving do for you? What does it mean for you? That is also a hard conversation. There aren't always good alternatives to driving. Driving can be really tied up with how someone sees themselves and something that they just genuinely enjoy doing for its own sake. So it's not a perfect one-to-one of, well, we'll just replace everything you like about driving, but focusing on how can we make stopping driving less painful. That might be simple conversations trip by trip saying, “That's okay, I'll drive this time. Just put your feet up, you can be the passenger.” It doesn't work for everyone, but sometimes those types of conversations where you focus less on convincing someone that they're not going to drive anymore and more on how can we get you to the library today or to visit your friends or whatever the trip is that matters for its own sake, how can we still make sure that happens?

Chin: You know, in a couple of your answers you've mentioned ‘during your interviews’, and so I think it's important for our listeners to recognize or to know, you're actually meeting with people. You are talking to individuals with changes and their families and learning from them and studying them as you're asking these questions. Is that right?

Hansmann: Yes. I've been in the process of conducting interviews with people with dementia and their family caregivers about this experience of stopping driving. I will also say that anytime I tell people what I do for my research, I hear stories (laughs) about what they've experienced with this transition so that is much more anecdotal but I have some thoughts and reflections on things people have shared with me from those stories too. It's fascinating and it's something that's really front of mind for a lot of people.

Chin: But it's so important that you, your work, actually talking to people with dementia, with MCI and their families to learn right from them what they're experiencing either before, during or after driving cessation. Now for our conversation today though, I do want to talk about your review of the paper you've authored. And so in that, caregivers often play this role of noticing and interpreting changes in driving. That's something you speak to. What are the earliest warning signs that families should pay attention to before there is a crash or near miss?

Hansmann: I think it's great to frame, rather than responding to the crash or that near miss where you think, “Gosh, we skated right by that one but that could have gone so differently,” thinking about what does it look like when someone's driving is changing. I find it helpful, as a clinician and a researcher but also as somebody just thinking logically about what should I look for, to think about, again, how is dementia affecting the brain health necessary to drive safely? A lot of the things that will come up are related to paying attention while you're driving, your reaction time while you're driving, making sense of what you're seeing on the road while you're driving and making good judgment about what you are taking in. Taking a step back from there, I also, I think it's helpful to think about how safe driving relies on the vehicle and road interaction. So is your car safe? Is the road in good condition? Is it a blizzard in March like we've had in Wisconsin many times and will again? What you're seeing on the road, your sensory inputs, how you're interpreting that, your cognition and your motor control of the car. Those are four buckets of things you need. But when we focus on dementia and the cognitive changes, I think you start to see people have slower reaction time. They may be having more difficulty with complex maneuvers. So we think about a left-hand turn—especially around here in Madison, we have a lot of tricky left-hand turns—making good judgment about is there enough space to turn the car. If you're the passenger in the car, you are going to get that jolt of feeling of, “Am I about to be T-boned?” if that person is just making the left-hand turn when there isn't necessarily enough space. The other thing that I heard people describing in the interviews that I was doing is noticing that the person with dementia was actually not looking both ways—so coming up to an intersection, just driving through and not getting in a crash because no one happened to be there but not because they were making good judgment or or going through all of the steps that are required for driving. So watching for someone being slower. Are they not looking for the things that you would expect for them to look for—looking both ways, checking their blind spot? And the other thing that you'll feel in the car is what we call hard braking events, which is where either because they, again, weren't paying adequate attention, their reaction time was slower, or they just weren't making good judgment, they're either following too close or they don't recognize that the person in front of them is stopped and so, when they actually go to stop, they slam on the brakes so you'll have that whiplash or jerking feeling in the car. Those are things that I think come up pretty commonly for people.

Chin: KJ, I'm hearing in your answer the importance of being able to focus, pay attention, process what's happening, problem solve as things are happening on the fly, and even your visual ability and scanning and looking. What I didn't hear in your answer was memory. And so I just want our listeners to appreciate that, because I see this in clinic a lot when someone says, “Oh, I'm forgetful. I guess that means I really shouldn't drive,” or a family member might say that, but I'm not hearing that as far as driving fitness from you.

Hansmann: It's a great point and I bring it up because I think you see those errors later, but memory is incredibly important for driving safely. Where that will start to come up is in remembering the rules of the road. People will describe someone as more prone to speeding than they used to be and, again, whether that's they're not paying attention to how this posted speed limit or they just don't remember what it is in an area where that's something that just used to be something innate. You don't think about it when you're driving through common places in town. You know where it's 25, you know where it's 40. I think the other place where memory comes up too is then how you find where you're going. The most common examples that I hear, again, from people telling me stories but also in the interviews that I've been conducting, is when something changes on a familiar route—there's some construction, something's different that day—somebody misses a turn and then a person with dementia will often just continue driving for a long period of time before they start to really understand that they're lost, be able to make those good decisions about how to find landmarks again and find their way back. Those episodes can be really distressing for, especially, caregivers but often everyone involved. So memory is also an important domain that you wouldn't want to miss. But when thinking about what are you going to see in someone, is someone a quote unquote “good driver”? There's a lot of other things beyond memory when we think about dementia that I always want to make sure people don't miss or that they're watching for early.

Chin: Yeah, thank you for summarizing that. I know many families struggle with the question of who gets to decide when driving should stop. How can care partners balance safety with respecting the autonomy and dignity of a loved one with dementia?

Hansmann: It's such a difficult question in dementia in general, but I think this is also a challenge with driving is that you're no longer talking about something that's going to impact the person with dementia and maybe their family caregivers as well—taking over driving for someone who stopped driving is a huge time burden for navigating that for people—but you're also dealing with the safety of everyone else on the road and that. It's hard to have those conversations and balancing, again, what is important to the person with dementia, their right to make choices for themselves, against what could happen to other people in their community if their driving is not safe enough to handle the situations that come up on the road day to day. I think it really does come down to focusing on having these conversations with compassion, talking about how do you support what is most important to that person and, again, I say that knowing there are some scenarios where driving is a hobby. It is something that people really love and enjoy so giving that up can be incredibly difficult, but there does come a point where it comes down to it's probably not the person with dementia's decision anymore when they don't have that insight or good judgment about their own driving safety. What I think can help for families in those settings is getting support from other people, so talking with the clinician to make sure that they agree about that assessment, potentially getting an occupational therapy assessment or the specialized type of OT or occupational therapist is a certified driving rehabilitation specialist. Those are occupational therapists who are trained to do very focused driving evaluations and maybe more of a behind the wheel evaluation as well. Again, in interviews caregivers describe having other family members ride with the person with dementia to also just, “Do you agree it's not safe for this person to drive?” so that they can have a little bit more support in making what feels like a difficult decision, particularly when the person with dementia disagrees.

Chin: And I know you and I have talked about this question before, but having the partner, the spouse, asking that person, “Would you let your grandchildren ride with our patient?” And seeing that initial response, that jolt, because as a family member, maybe you feel comfortable, but would you put your grandchildren in that spot? Now of course, that's all anecdotal, but I agree with you that it is not an easy conversation and certainly families are all going to be different. Some are going to be very conservative. Some are going to err on the side of letting their loved one go as far as possible with driving and having that support of a team and other specialists is certainly, certainly helpful in this conversation, but the conversation is difficult no matter what especially compared with other age-related health issues. Why do you feel like families—or what are you learning about why families so often delay the conversation beyond what we've just said?

Hansmann: There's a lot that makes this murky. One of the things is I don't think we do a good enough job preparing people for some of those things to watch for, what is going to change in terms of someone's driving ability as their dementia progresses. This is something I've heard from caregivers in interviews that they just felt uncertain about how unsafe was too unsafe. What were the changes that were happening? What should they be looking for? I think some guidance there can be really helpful. This is also a place where I'm seeing some burgeoning research looking at what we call in-vehicle kinematic data or naturalistic driving data, which is—I think the best real-world example that people are familiar with is insurance companies will give you a little tracker you put in your car and if you're a good driver, they'll make you pay less for your insurance, which is a much nicer outcome than we put a tracker in your car and, if you're a bad driver, we'll tell you that you have to stop driving. But the research does show that that type of day to day, in the car data—how hard are you hitting on the brake, what's your reaction time, how quickly are you starting at stoplights—can be really valuable for informing when someone's driving is actually objectively changing? So there's that need or desire for objective data that I think comes up here and makes this something that people push off and delay. There's also a lot that the caregiver is likely going to have to take on if they say this person can't drive. If it's their parent, they may have to take on an additional caregiving role of driving them more places. There may be disagreement among family members about whether or not someone is ready to stop driving or needs to stop driving. That can be difficult. We have stories that I hear of adult children who are not the one living with the person with dementia. It's the spouse or partner who lives with them. The adult child thinks they should stop driving and their spouse thinks they should keep driving. That's tough. And so, again, pushing off these conversations is a very natural reaction to this is difficult. It's difficult to talk about with the person with dementia and it can sometimes be difficult to talk about with other people too.

Chin: KJ, I remember putting in one of those insurance things in my car years ago and I never considered the fact that they could potentially study my skills and make a decision that—I mean I get it, objective data, but wow, that is that's a lot of monitoring right there. Are there ways clinicians can help families move from a crisis-driven decision after a scary incident to a more gradual, proactive plan for driving retirement?

Hansmann: I think there absolutely are. I think, underlying in your question is that clinicians also delay and avoid having these conversations in current practice. And I know, particularly in memory care settings, if this is something that you're in the habit of discussing it may be easier to start a more proactive conversation about this as a clinician, but that if you're a general family medicine doctor like myself—and I am now biased because I do research in this area—but a lot of my peers this isn't the conversation they have every day. So maybe we'll talk about it next visit, maybe we'll talk about it next visit. Oh, now the crashes happened or the near miss or getting lost so we have to talk about it today. There's still some work to be done to, I think, have clinicians be more proactive about this but one of the things that I think is so helpful is understanding where someone is starting from. That can take a couple of different shapes. That can look like taking a driving history and understanding what driving means to someone, how much experience do they have with driving and really understanding is this somebody who we're going to see maybe some of those driving errors come up right away because they weren't the main driver in their household. They were a passenger a lot of the time. They had a spouse or partner who did all the driving for them and now maybe that's the thing that we should just lean further into versus somebody who drove for their job and feels very confident as a driver. Those people can still experience driving errors with dementia, but they may have a different trajectory that we're talking about. I also think understanding how people feel about stopping driving early in this conversation can help tailor where we focus what we talk about. There are assessment tools, questionnaires, conversation guides that can help really get at people's emotions and attitudes about stopping driving. People that have a lot of readiness to stop driving, I think we can focus more on the logistics and start those conversations earlier of how would you like to get around? Does this mean that we have to make other changes? What's this going to mean for us from a planning perspective? Whereas someone who has low readiness from an emotions and attitudes perspective, we're probably going to have to talk about what this means to them in terms of the loss of something that matters to them in its own right, separate from the function that it gives them.

Chin: KJ, it seems to me that the driving history and the perceptions and readiness, these are things that could be done in a patient waiting room. We could collect this information and it would help us inform not only the conversation, when to have the conversation, and just being able to fit it into a busy primary care practice, or even as a reminder in a memory care practice. Any of these tools can be helpful and you've mentioned a couple, and so we'll try to post on our on this podcast in the show notes a link to some of those validated ones. I think it's really helpful to the clinicians that might be listening. Once a person stops driving, and you alluded to this, there is a challenge though. It's not just about safety, but also about mobility and independence and quality of life. What should families be thinking about to help a loved one stay connected to their community afterward?

Hansmann: It's a big challenge because in many of our communities driving is how people get around on most of the trips that they make. And so if someone is going to stop driving themselves, it means that someone else is going to have to start driving them if they're going to keep making all of the trips that matter. I think we have resources in place in communities that work variably well to get people to places like their doctor's appointments but there are so many other places that matter to people in terms of living a full life—getting to the grocery store, to social events, to places that they just go to for their own enjoyment. And so thinking about how is it going to be feasible to support that, that's harder for some than others. I think the other part of this that I see that often gets missed when thinking about dementia and stopping driving is that as dementia progresses, even getting ready for these types of trips, staying oriented during these types of trips, can become more difficult. And so acknowledging that it's not just about taking the time to drive someone to an appointment, an event, a place, and then drive them home, but that having somebody that can really support that person's orientation, their comfort, through that whole trip becomes really important.

Chin: Your work highlights that caregivers carry both logistical and emotional burdens during this transition of driving cessation. What kinds of supports do caregivers themselves need and where do you think the healthcare care system falls short?

Hansmann: Getting back to the time burden that I was just talking about, I mean, I think that's something that we have to acknowledge for people is that if you are going to take over driving someone to all of the places they used to drive themselves, it takes an incredible amount of time. From a clinical perspective, I think helping patients navigate options like paid caregiver status, FMLA or family medical leave, so that they actually have that time without losing what that means for them in terms of their workforce, their income. This can be a really big logistical change for people and an emotional one. I think supporting for caregivers that taking on things, the way that this changes the relationship dynamics, whether you're caring for a spouse or partner who now, as their dementia is progressing, feels maybe less and less like a partner because they're losing that ability to make decisions for themselves, you're having to make more decisions for them, that can be really emotionally challenging. It's also a huge relationship dynamic change when you're caring for a parent and you go from they used to tell you what to do when you were young and now you have to tell them what to do now that their insight and judgment is changing with their dementia. I think acknowledging, too, that there's a lot of emotional support that people need, whether that's through individual counseling and peer support groups and just thinking about navigating, beyond just the logistics, how are they going to navigate what these changes mean to them?

Chin: In your work in interviewing families and individuals with cognitive impairment, are there particular phrases, strategies, or approaches that make a driving conversation more productive and less confrontational for families?

Hansmann: I feel like I've said a little bit of this already, but I'll keep harping on it because I think it's such an important part of this. Starting the conversation early before it's even—saying, “I've noticed this change in your driving, but you have dementia now. Your driving may change. What do we want that to look like?” Starting early will always be a helpful way to have these conversations. I think starting early allows you to have a conversation too about, again, just because you have dementia doesn't mean that you categorically can't drive but we are trying to balance both your independence and your safety. One of the things that stood out to me in the interviews that I've been doing is that people really describe this process of essentially reaching a threshold where the way that they see the risks of driving suddenly or finally outweigh the risks of stopping driving but there are those real risks of stopping driving that I've mentioned. I think in your conversations, being honest about those and acknowledging those, acknowledging that some of those may not have easy solutions rather than trying to convince people that it's just not safe, it's just not safe. Acknowledging this is a big change for you—you may not get in a car crash every day that you go drive with dementia as your dementia progresses, but you are going to experience how difficult it is to not get around without your car every day if that's something that's been so important to you. I think empathic communication can be so helpful here and really focusing on acknowledging what people are up against as they're navigating this.

Chin: I think the things you've suggested are also very helpful for clinicians then too, because these again are difficult conversations in the clinic setting. Sometimes there's this fear of, “Ah, there's gonna be a fight. We're gonna get into a disagreement. They're gonna think I'm trying to take away their freedom.” And so approaching it from that empathetic, transparent and fully honest perspective, I think it can be very helpful.

Hansmann: Exactly. I mean, there's not a one size fits all. There's not one conversation trick that's going to work for everybody because everybody's coming at this from different places. Driving means different things to different people. What not driving is going to mean will also look different, what that risk is for people. For some people, there's only so far you can move the needle on what you can do to support what they're losing by stopping driving and so then you may need to lean a little bit more into some of the conversational techniques or strategies, I suppose, of reinforcing that there's a liability concern. You know, if you were to get into a crash, even if it wasn't your fault, insurance would likely still have concerns about the fact that you were driving with a dementia diagnosis. Or it's not, can you drive? I'm not saying you can't operate the vehicle out of the driveway, but we're talking about should you drive given all of these other concerns that we're talking about. Sometimes, again, having that objective data from an OT assessment or going to see your doctor can help. But there is this element, too, of once that memory decline, decline in insight or judgment has gotten to a certain point, there may never be a (conversation where) you're convincing that person that they can't drive, that they're not going to drive again, but just navigating the day to day of how are we getting where you need to go today with you not behind the wheel.

Chin: KJ, I've had some very interesting conversations with patients where the idea of community safety was important to them, but they still wanted to drive. Then I talked about the benefit of selling the car, having that income and not paying car insurance and that was what convinced them, fine, if I already can go where I need to go and now I don't have to pay this and I have that extra income and I can use it elsewhere. That was really quite rewarding to them. So you're right, it just takes multiple approaches, but I suppose lots of experience in talking about some of the benefits and downsides to these things.

Hansmann: Absolutely. And again, I think that's why it's so helpful to understand what driving means to someone and what stopping driving will mean to someone early in these conversations, because it will give you some more guidance of should I keep essentially harping on, “Well, it's just not safe. It's just not safe. What if a deer jumped in front of your car or another driver cut you off?” Or you could go for the emotional heartstrings and say the kid's basketball rolls into the road and they go running out after it—what are you going to do then? For some people, that's not the thing that you can make the most positive change with in terms of how they're thinking about this. You might be able to better say, “I would love to spend a little more time with you in driving you to these places that matter. I can make that work.” Again, that's more from the caregiver perspective, but really focusing on, I understand that it's going to be hard to not be in the driver's seat anymore and that you may need to backseat drive me from the passenger seat but let's do that together. I want to be there for you. I want to make these trips happen for you.

Chin: When you look ahead, what kind of tools, interventions, or community resources do you think could make driving transitions safer and less isolating for both people living with dementia and their care partners?

Hansmann: So I'm really interested in this question. It's a big part of where my research is going next and thinking about, in clinic, how can we support these conversations earlier and make them more tailored, again, to where people are coming from in terms of what driving means to them and what stopping driving will mean to them. I think looking at care pathways to help with conversation guides, getting the right resources at the right time, could be really valuable for taking some of the burden off of caregivers to be so responsible for knowing when to start the conversation, knowing what to say through all of these difficult conversations. There are some resources that, again, I'll happily share some of the links in the show notes that can help with that already. Getting those in front of people at the right time, I think, is the next step we can take. I also think it would be wrong to ignore that we need systemic changes in terms of the other ways that people can get around in their communities beyond driving themselves. We are a very car dependent society here in the United States right now and in many communities, and so whether that's investing in safer walking, more dense areas, public transit, that's great at some level and then also there's going to be times where public transit is not a good option for a person who can no longer drive. So thinking too about what does it look like to have safe rideshare services that are dementia friendly and opportunities for people, again, to make those trips in a way that is safe, convenient, comfortable and may not perfectly mirror what it looks like to drive themselves, but can give them some of that opportunity as well.

Chin: Well, to end today, I want to give you the opportunity to provide any other advice that you think would be helpful or meaningful for those living with dementia or their care partners about driving, about navigating these conversations, or if there are other organizations and resources you just think that they should hear exist.

Hansmann: Absolutely. Again, the biggest things I can say are start these conversations early. Start riding with the person with dementia as often as you can. It's hard to know how someone is driving when you're not in the car with them, but you really get that feeling in the passenger seat. Again, if they're hitting the brakes really hard, if they're making those left-hand turns that make you grip your seatbelt, that's really good information to have when you're thinking about how dementia is affecting this person's driving. And then tailoring how you're going to talk about driving to how either you as the caregiver know that person and what driving means to them and what stopping driving could mean to them or, as the clinician, gathering more information to help tailor how those conversations go. Some of the resources that I find really helpful that are geared towards family members, caregivers, are resources that focus on conversation guides, gathering some of this information and also just giving a little bit of a peek behind the curtain of what the different stages of this look like. One that I think does a really nice job of having videos that show sample conversations or even a detailed video about what a driving evaluation looks like with an occupational therapist is Plan for the Road Ahead, www.planfortheroadahead.com. And again, we can put that link in the show notes. I think the Alzheimer's Association has some really good videos on conversation guides, again, geared towards family members, caregivers, and that there's a number of other resources, again, that will give you conversation tips, resource tips, thinking about planning. In your local community, I would always recommend you reach out to your Aging and Disability Resource Center or Area Agency on Aging, depending on where you live, and talking about what are the resources that are local and specific to your community because having those at your fingertips early in this process will also help with, again, navigating how do you support what matters most to this person while they stop driving but still stay connected to the things that matter.

Chin: Well, that was a wealth of information. Thank you. And thank you for being on the podcast. So this is Dr. KJ Hansmann, and I certainly hope to have you on again after you have more to show us from your incredible research.

Hansmann: Thank you. Looking forward to it.

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