OTTAWA, Wednesday, April 20, 2016

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:17 p.m. to study the issue of dementia in our society.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.

The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.

I am Kelvin Ogilvie from Nova Scotia, chair of the committee. I will invite my colleagues to introduce themselves, starting on the left.

Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.

Senator Merchant: Pana Merchant, senator from Saskatchewan.

Senator Nancy Ruth: Nancy Ruth from Ontario.

Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.

The Chair: Thank you very much.

I would remind everyone that today our committee continues its study on the issue of dementia in our society.

We are pleased to have three sets of witnesses with us today. I will invite them to present in order from my right to my left. I gather that has been deemed satisfactory.

I am pleased to invite Dr. Andrew Kirk to begin, Professor and Head of the Division of Neurology at the University of Saskatchewan. He is here from the Rural Dementia Action Research, or RaDAR.

Dr. Andrew Kirk, Professor and Head, Division of Neurology, University of Saskatchewan, as an individual: Thank you very much, senator, and thank you all for inviting me here today.

I would like to tell you about what we do in our Rural and Remote Memory Clinic, and then I have recommendations to go through.

There is a big problem. We know the prevalence of dementia is increasing as the population ages, and we have a large rural population, particularly in Saskatchewan. We also have a large older population which is growing quickly. Seniors are more likely to live in rural areas than younger people are, and we have a large geographic area.

Saskatchewan, for example, is almost the same size as Texas, yet Texas has 27 million people; we have 1 million people. We have a lot of big, open spaces.

"It was like climbing a mountain to get a diagnosis.'' That was a comment of a focus group member in an Alzheimer Society session in the early 2000s. We came together as a group to try to make that climb a bit easier.

Our goal was to develop and evaluate a streamlined, interdisciplinary, one-stop shopping clinic for patients from rural and remote Saskatchewan for diagnosis and management of dementia and to evaluate Telehealth as a means of delivering follow-up care to patients and their families. This was very much community-based, participatory research. As we were designing the clinic, we visited every Telehealth site in the province at the time. There are a lot more now, and that would be a hard task to do today.

Patients are referred by their family doctor or nurse practitioner, and the patient and his or her family come once to Saskatoon. They have joint and individual assessments by a neurologist, neuropsychologist, physiotherapist and dietitian. They get their neuro-imaging and have already had their blood work done. That is all done in one day.

As we started, we found that some adaptations were needed. Some of the neuropsychological tests, for example, are not friendly to our Prairie environment. For example, there is a test called Pyramids and Palm Trees. You get a picture of one thing, and you have to match which of the two pictures below it goes with. One example has a clown, then a lion and a giraffe. You are supposed to say the lion goes with the clown, because they are both in the circus. We found that some people would say it was the giraffe because they are both funny-looking. We don't have a lot of circuses in Saskatchewan; we don't have any lions or giraffes. I suppose we have as many clowns as most places.

But Dr. Margaret Crossley, one of our neuropsychologists, came up with a new test. She called it Grasshoppers and Geese. One of the items there, for example, would be a snow-covered trail in the forest, then you have a motorcycle and a snowmobile. That was friendlier to a Saskatchewan environment, particularly to a northern First Nations environment. She has adapted several tests that way.

At the end of the clinic day, we have a meeting of all the professionals involved. The family doctor can phone in on the telephone while we're discussing, and then we meet with the patient and family to discuss diagnosis and management plan.

Then we follow up with people. When we first started, there was no clinic like this anywhere in the world. We didn't know if Telehealth was a valid way of following people. Originally, we randomized people for their first follow-up visit, either to be in person in Saskatoon or over Telehealth from their home community. Then they alternated after that.

You will see in a moment why we only do Telehealth follow-ups now. We see people with all different sorts of dementia — generally types of dementia that are harder for the family doctor to diagnose. Almost half turn out to have Alzheimer's disease and the rest are various other types of dementia. At the same time, we can reassure about 15 per cent of people that they do not have dementia.

So did it work?

Let us look at the practical aspect of travel. The round-trip distance from home to a Telehealth site is, on average, 71 kilometres for our parents. Even that is not trivial. The round-trip distance to Saskatoon and back is, on average, 529 kilometres. We are saving our patients 458 kilometres on each visit, which is fairly impressive.

When we asked family and patients to rate their satisfaction with the appointments, there was no difference between Telehealth and in-person. They were equally dissatisfied with me, whether they saw me in person or over Telehealth. But when asked to rank the convenience of the appointments, Telehealth was significantly more convenient, as you might imagine.

Could we really follow cognition over Telehealth? We were not sure we could. Would people with dementia really understand that this guy on the TV is talking to them?

When we looked at, the mini-mental state examination is a simple neuropsychological screening test. On our first 71 patients, we compared in-person versus Telehealth mini-mentals and, again, found there was no significant difference. So it is quite valid to see people over Telehealth.

Initially, we were a CIHR-funded research project. Now we are funded directly by the provincial government. It was a circuitous route to get there. We get a fairly low level of funding, which we're grateful for, but can only operate one day a week with the funding we have.

We recognize that specialized clinics can't and don't have to see everyone with dementia. We are now working with the rural health region trying to improve primary care diagnosis and management of dementia.

A one-stop multidisciplinary rural and remote memory clinic with Telehealth follow-up is a convenient, valid, effective and transferable way to improve the care of those with dementia and their families.

Here are a few recommendations, as I promised. One is transportation. If you live in downtown Toronto and have dementia and therefore can't drive, it's not that hard to take a taxi or bus. But those options don't exist in rural Saskatchewan and Newfoundland. We need to look at better ways of getting people around.

Caregiver support: Again, if you live in Toronto, if your spouse has frontotemporal dementia, it's easy enough to find a support group where you can talk to other people dealing with the same thing, but if you live in La Ronge, Saskatchewan, the nearest person dealing with that may be hundreds of kilometres away. So Megan O'Connell, a neuropsychologist with our team, has developed a Telehealth support group where people from all over the province with spouses with less common forms of dementia can meet monthly and discuss their issues.

Home care: We need more staff to help keep people at home and more hours. As I was preparing the other day for this meeting, I had a call from La Ronge about a patient who would be much better managed with a medication she could take twice a day, but she could only get home care once a day to give her the medication; they wouldn't come in the evening. So we had to go with a second-best medication that we could try once a day. We'll see how that goes.

Culturally relevant assessment tools — I've made that point.

Chronic disease management plans. Family doctors have an incentive to use some of these plans for things like diabetes or hypertension, but those don't exist for dementia. It is one of the things we are looking at trying to help develop.

Better primary care education. We have done several surveys that show that rural family physicians, at least in Saskatchewan, rate themselves as not very confident in making a diagnosis of dementia or in having some of those difficult conversations around things like driving, which are problematic.

It doesn't look like a cure is imminent, so research on better ways of delivering dementia care is important. We need to track quality indicators. We don't know if we are delivering good care if we don't measure how it's being delivered now.

Greater use of Telehealth — that point has been made.

Investment and better control of diabetes and other risk factors, especially in the Aboriginal population — we will hear more about that. We know that diabetes, for example, is rampant in First Nations populations. This is a relatively young population but is getting older, so we will see dementia but also heart disease, stroke — all the other things that these are risk factors for.

A national dementia strategy — that goes without saying.

We need better funding for innovative programs with proven effectiveness, such as — I would humbly submit — ours. If we had funding, for example, for a neuropsychologist, there would be nothing to stop us from operating five days a week instead of one.

Those are my thoughts, and I am happy to answer any questions later on.

The Chair: Thank you very much, Dr. Kirk.

I will turn to Dr. Wayne Warry, professor and director of the Centre for Rural and Northern Health Research of Laurentian University.

Wayne Warry, Director, Centre for Rural and Northern Health Research, Laurentian University, as an individual: Thank you to the committee for this opportunity.

I am here on behalf of the International Indigenous Dementia Network which was established by Dr. Kristen Jacklin in 2009. We began as a national network with 16 members and have grown to 53 members in 6 countries. Our goal is to bring researchers together who have an interest in Alzheimer's and dementia in Aboriginal peoples to facilitate the sharing of knowledge and experience with research in this area and to encourage collaboration between researchers, government and communities.

There is an imminent need for more research focused on all aspects of dementia in indigenous populations. Many of our members belong to the Canadian Consortium on Neurodegeneration in Aging. This has been a vital resource to supporting our collective efforts in this area.

However, the needs in this area are disproportionate to the funding available. There are too few researchers invested in this field. There is a lack of money for graduate students or career scientists to move into the field. There is also a lack of funding to initiate large-scale, Canada-wide, multi-sectoral studies to better understand the complexity of dementia in indigenous populations.

I would like to share with you what we currently know about dementia in the indigenous population in Canada.

First, our research shows that the rates of dementia in First Nations have been steadily increasing for the last 7 to 10 years. They are now approximately 34 per cent higher than in non-First Nations. What is more, the age of onset is typically 10 years younger than in non-indigenous communities. This is a recent change from historically lower rates of dementia in First Nations.

The study also showed that the increase couldn't be attributed to aging alone: there are other factors pushing the rates higher. These factors include high rates of diseases that are linked to dementia, such as diabetes, as was mentioned, and heart disease and greater exposure to risk factors such as smoking and head injuries.

These rates of dementia are even more significant when placed within the broad context. Because these communities typically experience delays in diagnosis and sometimes do not seek diagnosis, the actual number of people living with dementia is likely much higher. Failure to diagnose also means that patients and their families are unable to fully benefit from local care and support services where they are available. It is worth pointing out that these services are often not tailored to indigenous people. Mainstream approaches are not working.

We found that unique cultural understanding concerning dementia and culturally based approaches to caring for someone with dementia exists in indigenous communities and families. Our research shows that the symptoms, experiences and disease trajectory of dementia are consistent with indigenous culture, world view and of the circle of life which understands dementia as a natural part of many people's life course.

Our work shows how this world view can and does facilitate a natural understanding of dementia which is different from a disease-based view. Indigenous family caregiving models also support people with dementia, and indigenous beliefs produce less stigma in the community about what happens in the final stages of dementia.

A unique challenge for the health care community is to create policies and practices that respect this cultural view while ensuring that indigenous people have access to early diagnosis, good information and care support in culturally relevant ways.

Like many others, we have also found that the legacy of residential schooling, TB sanatoriums, forced removal from communities for medical treatment and inequitable and discriminatory policies affecting indigenous peoples in Canada are barriers to care for the older adult population. Many of the issues captured in the Health Council of Canada's 2012 report on cultural safety for Aboriginal people, entitled Empathy, dignity, and respect, also resonate with rural and remote communities.

Remote communities face incredible challenges when caring for older adults. These include high rates of youth out- migration; woefully underfunded basic primary health and home care services; a lack of access to non-governmental support; an absence of long-term care facilities, hospitals and elder centres; long-distance travel for specialist services and imaging; a lack of dementia-specific training for Aboriginal health care staff; and a lack of cultural safety training for non-Aboriginal providers.

Despite recent collaborations between the federal and provincial governments in response to specific health crises in First Nations, we also note that interjurisdictional issues continue to create barriers to adequate health care. We can also say that some basic health needs are widespread, such as physician services, while others are specific to communities and influenced by geography, language, culture and history.

Dr. Kirk mentioned the role of technology. Our preliminary work in this area has just pointed to large differences in broadband and mobile technologies between and within provinces — huge differences, for example, within Ontario in terms of access to broadband services. Limited connectivity makes telemedicine and other kinds of technological consults difficult.

I would agree with Dr. Kirk: We have had preliminary consultations with geriatricians, and they believe that early consultations with indigenous patients should occur face-to-face but that telemedicine could be huge in terms of following up with patients.

There is, then, a need for culturally grounded and strength-based approaches to dementia care in Aboriginal communities to support existing family and community caregivers. Keeping Aboriginal seniors in their communities as they age, with or without dementia, needs to be a priority.

Chronic disease is complex to manage in Aboriginal communities. There are high rates of people with multiple morbidities and high rates of polypharmacy, which places even greater onus on practitioners to fully investigate symptoms, yet there is no easy access to tests, including the routine imaging that occurs in urban centres. I can talk more about this. We need appropriate clinical assessments, including culturally safe and sensitive approaches to conversations about dementia with patients and their families, and significantly appropriate cognitive screening tools adapted to the Aboriginal community context.

We conclude by stating the obvious: health equity, in many ways, is about access to resources, both material and human. We hope that indigenous peoples are meaningfully engaged in the development of any national strategy, policy or initiative focused on dementia, and that adequate resources for research, intervention studies or innovative programs be population-based. By that we mean equal to indigenous population levels or 4 to 5 per cent of whatever funding is provided. Such equity or population funding is found in Australia, for example, but has never been guaranteed as part of Canada's Tri-Council research environment. Thank you.

The Chair: Thank you, Dr. Warry.

I am now pleased to welcome, from the Assembly of First Nations, Chief Isadore Day, the National Health Portfolio Holder and AFN Regional Chief for Ontario; and Norma Rabbitskin, Senior Health Nurse, Sturgeon Lake First Nation Health Centre.

Chief Day, I understand you will be making the presentation.

Isadore Day, National Health Portfolio Holder, AFN Regional Chief, Ontario, Assembly of First Nations: Yes. First, I want to thank Senate committee for allowing us to be here. Mr. Chair, thank you for convening this important exercise and allowing the AFN to make this important submission. I want to also acknowledge my fellow presenters here.

I want to provide this evidence in the spirit of respect and reverence that First Nations have for those that we don't often refer to as seniors but as our elders. There is a much personal and deeper sense of who we are connected to the community and the responsibilities that we have in the area of health jurisdiction in that sense.

To begin, I would like to thank the Algonquin people, on whose territory we are meeting.

It is an honour to appear before you and to speak to the increasing incidence of dementia in Canada, the causes, consequences and the way forward for the First Nations. The AFN considers engagement with government on First Nation seniors' issues and increasing incidence of dementia in Canada from a First Nations perspective to be a top priority.

Prior to our full presentation, I wish to outline a number of key recommendations. We require increased research that is respectful of First Nations governance, processes and OCAP to fully understand dementia and its impact on First Nations.

We require the federal government to commit to the full implementation of the First Nations Mental Wellness Continuum Framework. The framework recognizes that culture plays a central role in improving the mental wellness of First Nations while also seeing the importance of evidence-based best practices. We call upon the federal government to use population statistics from current population figures when allocating funding for the home and community care program.

First Nations require supports and caregiver training and preparedness to meet the complex challenges in caring for someone diagnosed with dementia. Support is required for urgent respite care and structured day programming funded as a preventive measure to provide families with enough support to be able to keep seniors home as long as possible. Interested First Nation communities in remote and isolated regions may meaningfully benefit from key government supports and investments in e-health.

Finally, we welcome continued engagement and encourage continued collaboration to address the increasing incidence of dementia in Canada, the root causes, the consequences of inaction and apathy and the way forward in a manner whereby First Nations communities can adapt, reform and realign wellness programs and services according to First Nation priorities.

I would like to speak to the United Nations Declaration on the Rights of Indigenous Peoples, Article 23:

Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions.

Article 24 (2) of the declaration states:

Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right.

It has long been the goal of the Assembly of First Nations to close the health gap outcomes between First Nations and the general Canadian population, as noted by my colleague.

While we clearly share similar objectives, the fact remains that First Nations people continue to suffer disproportionately with poor health, both mentally and physically. The government's role in examining and reporting on the increasing incidence and deficits in care of those with dementia needs to include First Nations and our history, with an understanding of both the history and impacts on our cultures.

There is a growing awareness on the health crisis faced among other communities, and this crisis implicates our senior populations.

I want to note that just over the last few weeks, with respect to Attawapiskat and other First Nation communities that have been in the media, it's interesting that we're focusing on various demographics. We saw the babies in Kashechewan. We heard about the families and the three generations that lost their lives in the fire. In Attawapiskat we're predominantly now talking about the youth, and here today we're talking about the seniors demographic, those we call our elders.

When considering seniors, then, we must look not only at the social determinants that seniors are experiencing in the present but also the determinants they have been exposed to from birth or even conception onwards that have all acted to shape the person's life and health, according to researchers Charlotte Loppie Reading and Fred Wein in 2009.

Following is a brief snapshot of First Nations seniors issues. In 2007, the Assembly of First Nations shared with the Special Senate Committee on Aging a comprehensive report, Sustaining the Caregiving Cycle: First Nations People and Aging, regarding the status of seniors, including key data and recommendations. Subsequently, the special Senate committee outlined key points and direction for further work as with regard to First Nations and seniors in its report.

Researchers note that population projections show the number of First Nations people in Canada is expected to increase by 40 per cent between 2006 and 2031, and a disproportionate amount of growth will be among those aged 60 and older who are expected to more than triple in number to 184,334 in 2031. Just to note, Mr. Chair, that there is a very distinct difference in the demographic bubble between the mainstream aging population and First Nations that clearly gives rise to a need to look at First Nations-specific models.

Many researchers are making the connection that people with diabetes, especially type 2, may be at higher risk of developing dementia; however, more research is required to better understand that link. There are many more reasons why this population is seeing an increase in dementia. Again, note that we're also seeing even younger people experience type 2 diabetes. Children are getting this in First Nations at an alarming rate.

First Nations people are already dealing with the lasting effects of colonization and residential schools and suffer from what is described as a form of post-traumatic stress disorder, or PTSD. I want to note that in the media recently I've been highlighting this very strange phenomenon of potential collective post-traumatic stress in First Nations communities because of the confines that the Indian Act imposes on a group of people. That also gives rise to the fact that this should be a specific area of study.

Added to this, many seniors find themselves socially isolated, and families are less able to care for seniors because of their own challenges, including mental health issues, addictions, poverty and family violence.

The First Nations and Inuit Home and Community Care program is intended to enable people with disabilities, chronic or acute illnesses and the elderly to receive the care they need in their home communities. Care provided in these familiar settings allows First Nations people to be close to their loved ones for as long as possible and to keep their independence. I just note that this a model of customary care that, again, is not something that the mainstream understands very well, and I think it's an important aspect that should be further explored.

Unfortunately, the home and community care program still administers funding based on population statistics from 1997. Home care nurses are seeing first-hand the growing number of clients and the growing rates of dementia, with no additional funding or supports to assist them in addressing the growing epidemic. Some communities decline to administer the program because there is simply not enough funding. Some provinces will not assist with home care on reserve, citing federal jurisdiction.

Regarding some of the risk factors, there are many modifiable risk factors of dementia, including type 2 diabetes, head injury, strokes and mini-strokes, high cholesterol, high blood pressure, mild cognitive impairment, chronic inflammatory conditions, a history of clinical depression, lack of cognitive stimulation and obesity. Other factors that have been linked to possible increased risk for developing dementia include a lack of formal education, low socioeconomic status, smoking and alcohol abuse.

Once again, important considerations must be given to First Nations peoples and the long-term care effects of colonization, intergenerational trauma and how the compounded layers of historical trauma may have detrimental impacts on First Nations people when attempting to understand the full spectrum and symptoms of dementia.

Regarding the consequences, we cannot state this any more clearly. Every year that the home and community care funding uses population figures from 1997, it results in increased pressure on the home and community care program, nurses, the clients and community budgets. As a result, there is no additional funding to meet the growing demands of clients with dementia, and this must change. Where traditionally families step in to care for seniors, in too many circumstances we are seeing families struggling with poverty and addictions and they are unable to do so, leaving the care of seniors with much uncertainty.

As for the way forward, while researchers note that dementia is a condition of the brain and is not a mental illness or disease, we recognize the strong links between dementia and mental wellness and wish to note our wellness plan called the First Nations Mental Wellness Continuum Framework. This framework, Mr. Chair, may serve as a model to guide and support conversations with major health care professoinals, other service providers and jurisdictional partners to enhance collaboration and build partnerships to ensure the needs of First Nations people are met on dementia. The First Nations Information Governance Centre's regional health survey is currently in the field asking key questions on dementia. The survey report will assist in supporting necessary evidence from First Nations' perspectives, and the survey final report is due in 2018.

The World Health Organization is currently developing iSupport, which is an e-health solution that provides evidence-based education, skills training and social supports for caregivers of people living with dementia. First Nations communities in remote and isolated regions may meaningfully benefit from investments in e-health. A vital component of any effort to improve health outcomes for older First Nations people and to plan for the future is the use of high quality, relevant and accessible research and data.

First Nations also require culturally appropriate diagnosis, assessment and treatment for dementia in their home communities.

Thank you for this opportunity to present to the committee.

The Chair: Thank you very much. I will open up the floor to questions, and I will begin with Senator Eggleton.

Senator Eggleton: Thank you very much for your presentations. This should not be a surprise to us. You've outlined a great many needs in the First Nations communities.

Is there any particular program, or two or three programs, that either exist or don't exist that you would think should be given some priority, should move early on to bring about the maximum amount of impact in terms of coping with dementia?

Mr. Day: I think noted in here is the First Nations Mental Wellness Continuum Framework. The fact that there is differentiation between the medical and disease model and mental health, it goes without saying that being that First Nations are communal in nature and that we've got so many other issues affecting the wellness of the community, as a whole and as a collective, the mental wellness continuum framework is engaging all community supports and agencies, and it's engaging the leadership, youth and seniors.

Stimulating a move-forward basis in a mental health continuum framework is one of the strongest things we have going for us right now. What I would offer is it's ready to develop, we've got shovel-ready projects and it's a huge positive step forward that will be of interest to the committee.

Mr. Warry: I also want to emphasize the significance of home and community care programs. We're working with Health Canada and the First Nations and Inuit Home and Community Care Program to develop dementia fact sheets and training programs for home and community care workers so that community-based workers have a better understanding of dementia and the early warning symptoms. I think that's a really important program.

The other thing I would highlight that we're also doing is the need for culturally appropriate early screening that can be done not by physicians but in the community by caregivers and others. We're just in the starting point of adapting the KICA, the Kimberley Indigenous Cognitive Assessment, from Australia. It's a simple prescreen for dementia developed in Australia, known worldwide as the first true cognitive screening for indigenous populations.

We're working with language groups on Manitoulin Island at the moment to adapt that tool, but again that's something that really requires additional supports.

Senator Eggleton: That's from Australia?

Mr. Warry: It has been adopted from Australia.

Senator Eggleton: I would like to get a sense of what the traditional perceptions of dementia are for First Nations people and the types of care in the communities that would be different from the other communities in Canada. How do First Nations people look upon dementia and the types of care that they think are necessary?

Norma Rabbitskin, Senior Health Nurse, Sturgeon Lake First Nation Health Centre, Assembly of First Nations: I am a senior health nurse in Sturgeon Lake, and I oversee community health and the home and community care program.

Traditionally we value our elders. They're our wisdom keepers, so they provided direction. In regard to how our history has evolved, over the years that role has been taken away from our elders. What we're left with is the symptoms now in our communities. We need to understand the indigenous views of dementia.

The circle of life is celebrated, when our people get prepared to leave, or to transcend. We're born as an infant, and through the life cycle we go back to the infancy state — I guess the mainstream would say dementia. It's a celebration. This is where we need to give that ownership to the individual indigenous culture to tell that story and how it's a celebration.

A lot of predisposing factors come into play where we have early onset of dementia. We have to look after the mind. There is a normal process that is interrupted. As our colleagues say, there are many causes. In our communities, it's not necessarily being diagnosed at the onset. We need to link those services with an assessment.

To try to describe dementia to my people, we have to use the indigenous world view of understanding our culture and how everything has been interrupted. It has to be led by our people to really understand what happened. When our people talk about mental health wellness, we can't really separate mental health and all of that. We have to look at the whole person.

Senator Eggleton: What are the types of care? Does this home and community care program meet your needs culturally?

Ms. Rabbitskin: The home and community care program has been in place for over 10 years. You have to understand the uniqueness of how the service is delivered across Canada. In Saskatchewan, it's either delivered at the community level or by tribal council. If it's delivered by tribal council, you only get home nursing. In my community, we deliver home care. We're able to provide home nursing assessment, case management and personal care. We hire personal care aides, but the challenge we have is the lack of funding to provide appropriate care.

Mr. Day: Thank you, Norma. In Serpent River, where I was a chief for 10 years, one of the programs we had was built on the life-long learning continuum. We know that dementia affects cognitive issues and learning abilities. What we have done in Serpent River has been successful. We built the JOY program, joining old and young.

In our community, the elders spend time in the daycare community. Basically, they have structured programming and the types of exercises and the art, for example, bode well with keeping elevated skills for seniors and the issues around dementia. Also, there is social cohesion. The building with the children and daycare service is one of the premier programs we have in Serpent River, and we're proud of it. I think this should be explored because it uses community resources, looks at the life-long learning continuum, and it's a culturally based model and it works.

Mr. Warry: There is so much to say. Mainstream people can learn a lot from how Aboriginal people think about old age and dementia. It's true that it's a much more positive outlook on the aging process.

I'll give you one example. If you have a person with dementia in mainstream society, we say they hallucinate. If an Aboriginal person is going through some sort of auditory or visual hallucination, it's often taken as a positive sign that the person is in much closer contact with the spiritual world and is trying to convey information back to this world. It is a completely different world view about aging and dementia, which reduces the stigma around the disease. I think mainstream people can learn a lot from that.

There are a lot of really good models out there of community-based family care giving. Chief Day mentioned the need for respite. Aboriginal people want to care for their family members and keep them in the home for as long as possible. They do not like old-age homes or institutional care for lots of reasons.

Keeping older people in the home is the preference, but that requires resources for things like respite.

Dr. Kirk: I'm sure you've heard the term "dementia-friendly communities.'' In my experience, I find it's often the Aboriginal communities that are the most dementia friendly in rural Saskatchewan. People know that a person wanders and they take them or send them home. People like to have family members at home as long as possible and, in my experience, more so than in the rest of the population. I think we can learn a lot about dementia-friendly communities from First Nations.

Senator Stewart Olsen: Thank you all for really thoughtful presentations. I am learning a lot about especially the indigenous way of looking at aging and the circle of life. I'm fascinated, Dr. Kirk, with your rural approach, because I'm from New Brunswick and we certainly need something along those lines. You started it in the early 2000s. Was it a big group of people who got together? How did you get going?

Dr. Kirk: There is a photograph of our early group in one of the PowerPoints that has been circulated, so you can actually see the people.

A group of us at the University of Saskatchewan, who were working in dementia but not necessarily working together, got together. It was really Dr. Debra Morgan who brought us together and said there is this new emerging team grant we could apply for from CIHR; let's do something around dementia. A bunch of us got together — I think there were about eight of us on the original team. Not all of us were clinicians. We had a human geographer, a sociologist; various types of people. We visited all the sites around Saskatchewan — some in the north, some in the south — and we talked to the communities and asked them what they needed around dementia.

Interestingly, in a lot of the First Nations communities, we heard, "Why are you doing dementia? Our big problem is around young people.'' We are seeing that in the news these days, but these are all problems. As we heard, dementia is growing in the Aboriginal community. I don't think we would hear, "Why are you focusing on dementia?'' if we went to First Nations today.

A group of us got together and designed it with a lot of feedback from the communities and it has grown over the years.

Senator Stewart Olsen: You see patients for their initial assessment one day a week. How many are you able to assess?

Dr. Kirk: In that day we see two new patients in the morning. I see them in the morning with the group, and then they go through various assessments — neuropsychology, dietitian, physiotherapy, neuroimaging and CT scan — and I then see them at the end of the day. For the rest of the day I am seeing people over Telehealth in follow-up all over the province.

Senator Stewart Olsen: On your Telehealth, are those individual or group sessions?

Dr. Kirk: They are individual sessions with me. Sometimes we will have one of the other health care providers involved if there is a special need. Usually it is just me, and then the patient and, perhaps more importantly, their family can be present. It is a lot easier for someone to bring in their extended family to a local Telehealth visit than to drag them all the way to Saskatoon, or to Moncton if it were in New Brunswick.

Senator Stewart Olsen: One of the interesting comments you made, Mr. Warry, was the lack of broadband. That is a huge problem everywhere in Canada.

Ms. Rabbitskin, I am interested in your perception. Do people come to you and say, "There is something wrong with my mother or my grandmother?'' Is everyone up to date on the incidence of dementia? I understand they don't look at it in the same way that other communities would, but how do they go about getting help in the initial stages?

Ms. Rabbitskin: We have tools, the same thing as mini-mentals that we do. We try to refer them back to their family physicians, but they don't want to diagnose dementia. That is where we struggle with disjointed care.

It is something that is on the horizon. We don't really have a good handle on it because we are not tracking it well. The home and care community program is only 10 years old, and we have our own way of tracking. We don't have an assessment tool. We have an assessment tool that was developed within our region. I know that they use interRAI as an assessment tool, but it is something that is being looked at as one of the ways to assess people and link them with the province.

Basically, the challenge is how to link the services outside the community. The service delivery is unique. I am still trying to link the services. I didn't know that you had that study in Saskatchewan. I could be learning more about your service delivery and how we could improve our program.

It is a lot about training our people, our nurses and support staff, and also enhancing our programs. We have a ways to go.

Senator Stewart Olsen: One of the things we have seen is that there is knowledge and there are programs all over. There is a real need to have a central area where you can go and say that this might work in my community.

Dr. Kirk: Home care is tremendously important. I estimate that with maybe 10 per cent of the patients we see it is the home care nurse seeing the patient about something else who says to the family doctor, "I think you need to refer this person for a cognitive assessment.''

In answer to one of Norma's comments, we try to keep our clinic quiet. We don't publicize it, because we are overwhelmed enough for our one day a week. I cannot overemphasize how important home care assessments are.

Senator Merchant: Thank you to all the people here from Saskatchewan; it is great. You answered my question, Dr. Kirk; you have a long waiting list. How do you get referrals? You said if you had more neurologists you could operate the clinic every day.

Dr. Kirk: The referrals are from family doctors and nurse practitioners. We encourage them to refer people who have difficult-to-diagnose issues or difficult management issues. Nonetheless, that's hard to police. Sometimes we see people who, in my opinion, the family doctor could have diagnosed. As I said earlier, we need to support family doctors in making those diagnoses. Our waiting list is long.

If we had funding for a nurse psychologist full time, we could do our clinic every day, but we don't. Megan O'Connell, our neuropsychologist, does this free as part of her academic mission, but we could certainly use more.

It wasn't easy to get the funding that we have, as you might imagine. You know what these things are like.

Senator Merchant: You have people from all over the province of Saskatchewan coming to you?

Dr. Kirk: Yes, they come from Eastend down in the south to places as far north as you can get, up to Black Lake near the Northwest Territories border.

Senator Merchant: How many kilometres would be the furthest?

Dr. Kirk: The furthest would be from way up north, and that must be maybe 1,000 kilometers. I am guessing.

Senator Merchant: And they are on a waiting list to make the journey?

Dr. Kirk: Yes. They can't drive, so often they have to fly down and stay for a couple of days before flying back.

Everyone is at least 100 kilometres away from Saskatoon or Regina. On average, they are a few hundred kilometres away.

Senator Merchant: I would like to speak to the different cultural ways that the First Nations have. That is, the cultural sensitivities you spoke about.

We have learned that women are more prone to dementia than men. Women elders play a significant role in the family unit, don't they? I have known grandmothers who are looking after the grandchildren because, in the interim, the other generations are either in the cities or elsewhere.

Perhaps you could tell us how it is so different because of the family units. How does that work when a woman elder perhaps has all kinds of responsibilities looking after other generations?

Ms. Rabbitskin: The grandmothers and women are pillars in the community. Grandmothers are matriarchs in our communities. When they are affected, that's a great loss.

The expectation is the community, and also historically the family, looks after one another. Kinship is crucial. When one of our family members gets sick, the family comes together and supports one another. That is where it is hard. It's not the traditional way to place a family member in a nursing home. It's not something that was taught to us. It is a crossroads for families, and placing their loved one in a care home brings a lot of stress if the family is burnt out.

This is where home care is able to provide that temporary support until they are able to deal with it. That is not available 24 hours a day. It may not be available in a community. So that is where we need to link up to services outside or support the community to bring home care into the community. Not every community has or is ready for that choice. It is like a lot of the funding issues and access.

Mr. Warry: This is not to say anything against what has just been said. The role of women in First Nations is absolutely critical when it comes to health and so on, but I have one small correction.

You have heard that the rates of dementia are higher in the mainstream amongst women, but one of the interesting things about dementia that we have discovered is that in Aboriginal communities dementia rates are actually higher in men. There is a reverse there between mainstream and First Nations. I'm not particularly sure why. It may have something to do with rates of vascular dementia as opposed to other kinds of dementia. Nonetheless, the rates are more balanced in First Nations than they are in the mainstream.

Mr. Day: That is a very good question and clarification.

One of the reasons — and this goes without saying — is that the women in our families are the multi-taskers. They can do so many things and use their left and right brain at the same time because they are caring for their kids, their grandkids, nieces and nephews. Basically, it is a way of life. I understand that dementia can be combatted by activity: simple repetition. I'll say it: the woman's mind is stronger than the man's in that sense.

The other thing to note is one of the reasons there may be higher incidences of dementia in men is because of the welfare system and colonial issues and impacts. Our men were hunters, gatherers, fishers and they travelled. The welfare system and the confines of the Indian Act oppressing the people, the land and their activity simply has created an "ethnostress" that certainly correlates to the impact on our men having a higher incidence of dementia.

I'm not sure if that is founded in a study, but it is quite obvious that our people were closely connected to the land, and that is as a result of us not having access to the land via the Indian Act. It's now creating a number of other issues and socially impacting our people.

The Chair: That would fall into the category of a major stressor, the concept of a significant cultural change.

Dr. Kirk: I want to echo the importance of the grandmothers. I didn't have time to say it in my introduction, but I mentioned how Margaret Crossley, our original neuropsychologist, adapted a lot of neuropsychological tests. That came about because she sought out a grandmothers' group of Aboriginal elders in Saskatoon and met with them and asked for their advice. She showed them some of the neuropsychological tests she was using, and they laughed at some of them and said, "This isn't good for our people. You need to adapt this.'' That is how it came about.

To be clear, about 20 per cent of the patients I see in the rural and remote clinic are Aboriginal and the rest are from the majority culture.

Senator Merchant: Is it culturally acceptable to depend wholly on medications? I have sometimes heard that people with dementia don't like to take their medicines no matter what their culture is. In the Aboriginal culture is there a stress between the medicinal ways of healing and other ways of healing that are appropriate to you culturally related to dementia?

Ms. Rabbitskin: To be truthful, it's usually the women who seek help right away. In our community, we offer traditional healing and they are the ones that come and ask for that help. They utilize both. That is one of the things that the healers say: you use both and integrate them. When you are taking traditional medicine you will eventually taper off the medicine, because it is about taking ownership of your health. When you take ownership of your health, that is what empowers the individual.

Traditional healing is looking after mind, body and spirit. If the woman asking for help takes ownership of her health, she will find that she doesn't need medicine anymore. It is like taking your spirit.

One thing about the biomedical model is that it doesn't address the spiritual and emotional side. We are finding that post-traumatic stress has impacted our communities, and our women are taking on a lot of the roles and responsibilities. There are many things that are compounded. They are seeking traditional healing, and we offer whichever will help them.

Mr. Day: If you look at the health testing of placebos and the role they play in determining the best approach, pill and practice is key with our people.

I agree that a lot of times our people just need to have repetition of smudging and using various activities to ensure that they have a fighting chance against dementia. We see in our communities that if you put someone into a job, even if it is just to perform sweeping duty in front of the band office, it often helps to provide an opportunity to combat issues like dementia. Those are my two cents.

Senator Nancy Ruth: Dr. Kirk, it sounds like you are doing some statistical analysis on race and gender; is that correct?

Dr. Kirk: We are looking at that now. I have a student working with me, as we speak, on comparing the differences between the men and women we see in our clinic. I have another student who is interested at looking at Aboriginal versus non-Aboriginal and looking at some of the data. I hope to have more to report on that fairly soon.

Senator Nancy Ruth: So there are no conclusions on that yet.

Your model of rural health is exciting to listen to. Are there other countries that have comparative or good models that we could learn from?

Dr. Kirk: We have had people visit from Australia. Obviously, they have big, wide open spaces as well. We also have had people visit from Scotland, which you wouldn't immediately think of a place that needs something like Telehealth. If you look at a place like the Shetland Islands, they are way up north and it is a long trip by ferry to get to the mainland to be seen. So it's being used in other places, and we have interacted with people in other countries. It is used somewhat in the United States as well. They have some big distances to cover. I think Canada is the leader in big distances being covered.

The Chair: Before I go to the second round, I have some questions that I would like to ask you.

First I want to start with your last comment about the placebo effect, chief. It is a very real phenomenon in terms of one has to believe in the placebo concept, whether it is an activity, a fake pill or whatever. One has to have confidence that it is there. What it illustrates is that the individual, as Ms. Rabbitskin said, if they take personal control of their health and are convinced that an activity, behaviour, practice or cultural event will help them, it is entirely possible.

In other words, we are recognizing that behaviour has a clear impact and it can be a very positive one. We usually think of behaviour as having a negative impact, but in actual fact community involvement can have a positive impact on health. We know people heal much better in their home environment than in a hospital setting. We are just not learning fast enough from them in terms of how to implement them.

In that regard, Norma, you referred to the bringing of the elder with the young people and medical involvement. I want to take that a step further in the way you handle persons, let's say elders, who we might say have dementia symptoms. Are they much more free-roaming within the community than would likely be found in a typical town or city where there tends to be a high degree of institutionalization?

Could you comment a bit about whether there is more freedom of movement for elders in your community and if, in fact, you have observational indication that they tend to be happier in that kind of situation as opposed to those who tend to be confined more to a single location?

Ms. Rabbitskin: We just had one of our community members who progressed to dementia over the past few years, and he was one of our elder advisory board members. His family tried to provide that support. The home care program approached his wife and she said, "No.'' You have to respect their wishes; you don't want to overstep your boundaries. We provided that support. We helped her with accessing equipment and whatever supplies they needed to make their home safe.

Generally, we don't try to interfere because as a cultural norm it is all about non-interference and we have to be mindful of our culture as well in respecting our individual families. She did come and ask us for support whenever we were linking services outside. It is about allowing them to be at home and providing the family what we call wraparound support. That is the mandate of home and community care, to provide that support and to help them remain independent. It is about allowing them to remain at home where they thrive better.

He was able to come with his wife and attend meetings. He would sit there and just listen.

The Chair: Thank you.

Dr. Kirk, I want to come back to your model, which was very interesting. I want to be sure that I have understood it. At the present time, the first assessment is done at your clinic, so people have to travel to that.

Dr. Kirk: That's right.

The Chair: It is subsequent to that, where possible, that you are able to introduce some telemedicine, shall we say?

Dr. Kirk: Originally we alternated between Telehealth and in person because we were trying to show whether it was valid, but now we do them all over Telehealth, except in some special circumstances. Last summer when there were fires up North, I saw some of my patients from the North in person because they were stuck down in Saskatoon.

The Chair: We'll understand acts of nature as separate. I am trying to get to the core of your plan.

I also heard you clearly say that if you had a full-time neuropsychologist, you could extend your clinical work to five days a week. That would have a significant impact, I would think, in terms of reducing the wait times for people to get first assessment and so on.

Dr. Kirk: I would hope it would.

The Chair: It seems to me to be a relatively small social investment for a big return.

Dr. Kirk: Me, too.

The Chair: I have a couple of questions with regard to the distance follow-up. I was impressed by your analysis and the tests you did to try to see the comparison between using — can I call it telemedicine or do you have a better term for it?

Dr. Kirk: In Saskatchewan it's called Telehealth. Many people call it telemedicine as well.

The Chair: Okay. You're using Telehealth. The Telehealth model versus the in-situ model, you saw no significant differences, and therefore it would be nice to apply it on a larger scale. I understand the difficulties of getting broadband across the country, so that will not be my question. That is an easy one for us to deal with.

My question relates again to the question I asked in a different way to Norma. We are hearing that when people can communicate freely with other people, if you have an institutional setting but a large social area within the institution where people can be free-moving throughout it, the individual seems much happier and more content. The implication was they are seeing slower progression of some aspects of dementia.

Do you think there would be a possibility of setting up one of these memory cafes that are now spreading? They started in the Netherlands, spread to the United States and are now spreading across this country. They are in New Brunswick and other parts of Canada at the moment.

Do you think it would be possible to have a Telehealth model of one of these cafes to be able to have people in disparate areas come together and socialize over a Telehealth model?

Dr. Kirk: It's not something we have looked at. As I say, we have had a Telehealth support group for caregivers, spouses of people with frontotemporal dementia. We haven't looked at something like that for people with dementia themselves, but it is certainly something that would be interesting to look at.

The Chair: Yes, I gathered you hadn't done that. If you had the ability to actually interface with an individual and do significant and comparatively accurate diagnosis via Telehealth, then it would seem to me there would be a real possibility because with modern technology you can have people in virtual reality communicating together.

From what we have been told, these cafes have a positive impact on the social attitude of the individuals involved. I appreciate the frankness of your answer. Do you think it might be a possibility, at least conceptually?

Dr. Kirk: I think it's worth examining, yes.

Mr. Day: As a supplement to that, I think it's a great idea. In many of our remote First Nation communities that are currently, for the most part, living in Third World conditions, we are finding that being able to hard wire everyone to the 21st century through the Internet is certainly proving to be a valuable tool. We are finding that our young people and those who embrace this technology are doing awesome things with it.

With respect to First Nations being so disadvantaged and underdeveloped, with the Internet we have Telehealth in the North and it seems to be helpful.

This concept of joining these populations together and employing strategies of that nature, I can tell you that I've found people from the older population of our communities on social media. I am surprised that they are so vibrant on social media. I think there is a huge opportunity there. For the most part, I think this is something that should be explored with First Nations as well.

The Chair: Chief, that is excellent. I was thinking as we were discussing it that the issue of youth involvement, activity and motivation, the interaction of youth across different areas with regard to socially interactive programs — which are now becoming part of skill sets and interactive group benefits and using technology — if this kind of concept could develop it might be a significant motivational possibility. It would cover those areas as well.

Mr. Day: Yes. I want to also comment that I think there is another alarming factor that we need to ensure is noted for the committee. Climate change in the North is having an acute impact on the social fabric of our First Nation communities. It is elevating the level of anxiety and stress. It's probably one of the reasons there has been increased suicide ideation. I certainly think it must have an impact on the aging population as well as dementia. I think we need to do something soon.

The Chair: Thank you.

Senator Eggleton: Dr. Kirk, the Rural Dementia Action Research, or RaDAR, you say started in the early 2000s. The memory clinic is a flagship project.

When did the memory clinic start?

Dr. Kirk: In March 2004 we saw our first patient.

Senator Eggleton: Have there been evaluations done?

Dr. Kirk: We've done plenty of evaluations.

Senator Eggleton: Third-party evaluations?

Dr. Kirk: Third-party evaluations, not that I can think of. You can see in the further reading that I put together that there are lots of references to things we've published over the years.

Senator Eggleton: You've said twice now that you can only operate one day a week because it's tough to get the money. If this program is working so well, why should it be tough? Where does your money come from? Is it from the Saskatchewan government?

Dr. Kirk: It comes from the Saskatchewan government, yes. It's a mystery to us as well. When we started doing this, after a few years, our health region didn't know we were doing this. As I said, we didn't call attention to it; we knew we'd be busy enough.

There was an accreditation of our health region, and the accreditor picked up on this. At his final speech at the accreditation, he mentioned our project as something that was very valuable. Then all of a sudden our health region started paying attention. They put things in the paper about it and publicized it. It was all nice until our funding was running out from our research project and we asked them for money.

For a while they were calling it Saskatoon Health Region's memory clinic, which it wasn't. But when we asked them for money, it was "No.'' We applied to the provincial government and got a little bit of money, but it's hard to get money for projects in this climate.

Mr. Warry: I probably shouldn't say this, but there is a huge institutional gap between research and then programmatic intervention. So much happens in the world of research where you demonstrate the viability of something, but then finding money for sustainability of that is really hard.

Senator Eggleton: Yes, it's an old story.

The Chair: We found in so many of our studies — and it's a term used among the medical profession a lot — that Canada is a country of pilot projects. It's true.

I wanted to pick up on the question Senator Eggleton put to you with regard to the funding in this aspect. I wanted to be clear: Are you aware of any other example of this in the Western provinces?

Dr. Kirk: There are some geriatricians and neurologists who see people over Telehealth — not in such an organized fashion as ours, but there are examples of people being seen over Telehealth. I know of some people who see people with MS over Telehealth, for example.

It's bit of a leap for a physician to start using Telehealth. Once you've done it, it becomes second nature and it's easy. But it's sometimes a bit of a leap to get started.

The Chair: There is a major difference between a "one of'' and a delivered program. We think you should go and pound on the door of the deputy minister.

Dr. Kirk: We're meeting with the assistant deputy minister next week about something else.

Senator Eggleton: Brad Wall was just re-elected, so go get his money.

Senator Stewart Olsen: I want to ask your opinion. Do you think that perhaps it's less stressful for someone with developing Alzheimer's or dementia if you are in an indigenous community because of the way they are regarded? I'm saying for the patient themselves. I've seen people who are absolutely terrified because they know that they are losing their abilities. If you had a society that maybe made it less terrifying, would that not contribute a lot to the progression of the disease?

I'm asking for your opinion on that. I think people get very stressed when they find they're losing their cognitive abilities.

It sounded to me when you described the Aboriginal way that it's a normal part of life; it's a progression. "If that's happening, we'll be with you; we'll look after it.''

I'm wondering what you think of that kind of outlook?

Dr. Kirk: I will go first, as someone non-indigenous. Wayne mentioned hallucinations, and I've also found that people with Lewy body dementia often hallucinate. Aboriginal patients with that are less bothered by their hallucinations because they see it as relatives coming to visit them. Culturally, it seems to be more acceptable.

Mr. Day: I believe there are a couple things going on here. In a community that is well, a community that has the parts and pieces in the social determinants of health, there is generally a more positive outcome. You will see an uncle wandering down the street, and somebody is actually taking care of that. They know where he is all the time, and there are various scheduled programs in the community. In that respect the answer is "yes.''

But you have to understand that maybe the communities that are not living in the 21st century — those in Third World conditions right now — do not have the social determinants of health. The systems are dysfunctional. The young people are experiencing upheaval and social issues in the North, for example. Once you see one part of the family unit shaken by an attempted suicide, that increases the stress and pressure in the community.

We're in a First Nation health crisis in this country right now, and one of the things I'll be doing as the Chair of the Chiefs Committee on Health at the Assembly of First Nations is we'll be looking at the World Health Organization's social determinants of health framework, because that's one of the things we will need to ensure is in place.

With patients who are predisposed to dementia or have advanced stages, these people are in vulnerable situations and we'll have to look at the comprehensive approach to dementia. This is why the AFN has a special task force on dementia and why we're moving forward that way.

Senator Stewart Olsen: I'm taking that, but I'm saying there's maybe more we can learn from indigenous communities and how you're approaching it. We tend to warehouse people, or in New Brunswick we try to keep them in the family.

I learned a lot today, and I'm wondering if that would alleviate some of the stress of people newly diagnosed or suspecting. They are terrified, and people around them are not as supportive as maybe they are in your communities because of your way of looking at the circle of life.

Mr. Warry: I would agree with that. There is no specific word for dementia in Aboriginal languages, and I think words are important. So when people quite naturally use their language to talk about memory loss or forgetfulness, these are words that Aboriginal people use instead of using the label of dementia.

The diagnosis does bring stress with it, so I think reframing dementia for the patient and family caregivers is an important aspect of what people can learn from Aboriginal peoples.

Senator Stewart Olsen: Thank you. I'm not saying it's a panacea.

Ms. Rabbitskin: Yes, you'll see different communities are at different stages in supporting a multitude of clients who are suffering through chronic diseases.

One of the things that I struggle with is that, yes, we do have federally funded home and community care programs in the community. We also have public health, which is supposed to also look after chronic diseases in the community, but it was one of those programs not funded in the First Nations community.

So who does all the work? Home care. They're expected to do catch-all, and we're overworked in that area already. This is why we feel that we need to bring back culture and celebrate the strength in the community.

I worked in a community where we're doing primary care, only band-aid solutions. I'm in this community where the culture is still very much alive with their ceremonies and the healing methodologies that are available, and the community is utilizing their full capacity. That's why I stay there, because I see the positive when the community takes ownership and thrives. But we still have a lot of the chronic diseases that we're struggling with, and funding is a big thing.

The epidemic that we're seeing in First Nations in our region is that HIV is on the rise, and that also has dementia attached to it. I had to look after a client who had acute stages, and we had to provide that support. When you don't have palliative care, when you're supposed to align the service and link with the provincial services and it's not there, we're standing alone. So we need to align those services as well and work together.

Senator Stewart Olsen: Thank you very much.

The Chair: This has been quite a remarkable session, and I think we've gleaned some really useful insights today.

Some are clearly at the early pilot stage, as we are in Canada in a lot of things, but I think you've helped us a great deal with some concepts, ideas and actual experience, very real experience. I encourage you to take the bus to state house and get that extra neuropsychologist. It could have such a tremendous impact on the rate of dealing with people who are in desperate need.

I want to thank you all for being here, and my colleagues for their questions. With that, I declare the meeting adjourned.

(The committee adjourned.)