Eric: Welcome to the GeriPal Podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And, Alex, who is our guest today?
Alex: Today we have Zaldy Tan, who we’re delighted to welcome to the GeriPal Podcast. Zaldy is a geriatrician and he’s director of the Memory and Aging Program at Cedars-Sinai. Welcome to the GeriPal Podcast, Zaldy.
Zaldy: Thank you for having me. I’m delighted to be here.
Eric: Zaldy, I’m super excited to talk to you. We’re going to be talking about caregiver support for those with dementia. But before we go into that topic, do you have a song request for Alex?
Zaldy: I do. My song request will be Remember Me.
Alex: And why this song? Beautiful song, by the way, from Coco. Love it. Loved learning it.
Zaldy: I agree. It’s beautiful in its simplicity. I think it captures this sometimes fragile relationships between caregivers and the person with dementia, especially the line that says, “I know I’m with you the only way I can be.” Caregiving, a lot of times, is a thankless task and I think this song captures that well.
Alex: Thank you. (singing)
Eric: Lovely, Alex.
Zaldy: So when are we going to hear the Spanish version, Alex? [laughter]
Eric: Is that the second half, Alex? You’re going to do the Spanish version?
Alex: Okay. I’ll look it up. We’ll see. I mean I could try. [laughter]
Zaldy: Just kidding.
Eric: Zaldy…caregivers, family members. They’re completely relied on by our healthcare system to deliver all the care to over five million adults with dementia. Aside from relying on them, we don’t really historically support them in any way or train them. How did you get interested in this as a subject?
Zaldy: Yeah, so that’s really an interesting question because I didn’t set out to really be involved in caregiver training. It came by accident when Dave Reuben and I started the UCLA Alzheimer’s and Dementia Care Program in 2012 and we got the CMMI Award.
Zaldy: We had originally planned to have a caregiving component to it, caregiver training component to it, but our plan was really to farm it out to our community-based organization, because, well, the UCLA Alzheimer’s and Dementia Care Program is truly health system-based. We reached out into the community, to the Alzheimer’s Association, to the Alzheimer’s Los Angeles, to adult daycare facilities, senior centers, because we really want to have that community-based aspect to it. Our plan was to have the caregiver trainings or interventions based in the committee.
Zaldy: But about a year into the program, I had, I think at that point, four NPs, four dementia care specialists. One thing that stood out was that the need for caregiver training was really quite significant. So we looked at existing caregiver training program, so there was the Ken Hepburn Savvy Caregiver Training. There were other homegrown caregiver training programs in the various senior centers and adult daycare facilities that we had a relationship with.
Zaldy: But somehow we felt that there was something missing in the sense that our caregivers, especially the ones that need it the most, really had very limited time, were very highly stressed, very short attention span, and their needs were very specific.
Zaldy: So here I was as the medical director of the program. I had the advantage of knowing what the needs are in terms of education and training that these caregivers have from just speaking weekly with my dementia care specialists, my NPs. And yet what’s out there, while they’re quite good and they fit a certain segment of our caregiver population, there was a segment of caregiver population where their needs are not being met. That’s how I got interested in addressing their needs.
Eric: What year was that?
Zaldy: So we started the Dementia Care Program 2012. So we started this caregiver training in about 2013, 2014.
Eric: Before you did that, so when you were actually getting your needs assessment, what kind of training were caregivers getting around dementia?
Zaldy: So the challenge was the connecting caregivers to what’s out there in the community. As I mentioned, Los Angeles being a relatively large city, there were some things out there. But we found that the primary care doctors, even the neurologists, even some geriatricians, were not really aware of what’s out there in the community. So making that connection between caregiver and what’s out there was not being made.
Zaldy: Then what’s out there, a lot of the things that were out there in the community were short of the multi-session spread out over weeks model, which, again, was very difficult for some of our caregivers to do.
Alex: I remember several people have used this quote before, but there’s this sense that when dementia is diagnosed, it’s diagnose and adios in that patients and caregivers are really left unprepared for what they have to face. I’m interested to hear from you, in addition to not being aware of the existing community resources, what are the other major needs of caregivers of people with dementia?
Zaldy: Yeah. So caregiver education and training, I think, is one of them. So a lack of education, lack of training, a lack of information or understanding about the prognosis, how the disease progresses, what community resources are out there, how to deal with their finances, et cetera. I think that’s a real source of stress. In fact, studies have shown that when behavioral problems start, that is actually one of the main predictors for premature institutionalization, heightened caregiver stress.
Zaldy: A lot of our caregivers, for example, do not anticipate that eventually they may need to provide physical caregiving, like dressing, bathing. None of them were trained for that. So it comes as a surprise and, therefore, heightens their stress. So I think that really speaks to the need for our health system to really address that.
Eric: What are the risks to caregivers? Are there risks like mental health risks, financial, others, that you’ve seen from the literature or you’ve seen yourself?
Zaldy: Yeah. Caregivers of persons with dementia, especially those who require more physical care and have more complex needs and potentially behavioral problems, are more likely to be depressed. They have poor self-efficacy. They are more likely to have physical problems themselves.
Zaldy: The interesting thing about that is that there is a positive aspect to caregiving that most of us don’t speak about. We think about caregiving us a burden, as a responsibility, but there is a positive aspect to caregiving. But not addressing the needs of the caregivers and, thereby, allowing their stress and burden to rise leaches away at that positive aspect of caregiving, unfortunately. So that’s the things that I think we need to be better at.
Eric: Can I ask from a healthcare system standpoint? So these caregivers aren’t necessarily the patients of our healthcare system. Does the healthcare system have an obligation … I mean I think this is an interesting ethics question … to these caregivers for all of these different risk factors that they’re actually exposed to?
Zaldy: Yeah, very interesting question because in our experience in our Dementia Care Program, that is one of the challenges, is that you might have a care specialist, a support system for the person with dementia and, therefore, some support for the caregiver as well. But if the caregiver is stressed, anxious, depressed, there’s very limited things we can do because they may not even be part of our health system. They might be getting their primary care elsewhere or may not be getting good primary care at all.
Zaldy: So the best we could do is really advise them and tell them or facilitate their getting help for this needs. But you’re right, ultimately the real patient is the person with dementia. But in reality the patient is really the dyad, the caregiver and the patient.
Zaldy: To your question, Eric, do we have an obligation, that’s an ethical issue that deserves its own podcast. But does the healthcare system have an interest? Absolutely. Why? Because characters are the one that drives cost, if you boil it down to utilization and cost and outcomes. They’re the ones who a lot of times fill out the POLST form and the advanced directives. So interest, absolutely.
Eric: Yeah, it was a little bit of a rhetorical question, too. I remember, God, I think it was almost a decade ago, me and Ken wrote an editorial on fulfilling our obligation to caregivers. We were talking about the REACH caregiver intervention in REACH II. I mean I think from a purely financial standpoint, from a healthcare system, focusing on the caregiver makes incredible sense because those are the people that we’re relying on to keep these people at home, away from really expensive interventions, whether it’d be ER visits, hospitalizations, nursing homes and the like.
Zaldy: Yeah, absolutely. There’s no question about it. The challenging thing is how do we then convince our employers, our health system to really invest in this, and ultimately the payers like Medicare to pay for this type of service.
Alex: Incredibly important. I also just want to highlight again what you said earlier about the positive aspects of caregiving, in that caregiving has certainly been characterized as a burden, medical, social, financial burden, but it’s also a gift. There are positive aspects of caregiving that largely go unrecognized, that we can support and bolster and encourage. I just wanted to give you an opportunity, if there’s anything more you wanted to say along those lines.
Zaldy: Yeah. So the research on that, that’s not my personal research, but the research on the positive aspects of caregiving is interesting and I think deserves more attention. It seems that people who provide care for others have a greater degree of what they call generativity, which is like caring for other people other than one’s self or immediate family. So this is this improved family relationships, improved sense of purpose. So there’s a lot of things that have been looked at as potential positive aspects of caregiving.
Zaldy: The challenge there is that, as I mentioned, when caregivers are not supported in their stress, that positive aspect of caregiving is wiped out. Then it becomes truly burdensome. Furthermore, we could look into that. So what are the things we can do as a health system, as providers to highlight the positive aspects and downplay the negative aspects?
Alex: Yeah, it reminds me of Maslow’s hierarchy of needs. If you’re so overwhelmed, emotionally exhausted, you don’t have the opportunity to experience those positive aspects of caregiving, that sense of generativity, of contribution, that sense of meaning and purpose. So we have to focus on making sure the basic needs of caregivers are met. As you were talking with Eric before, boy, it would be great if we had a system of universal healthcare where everybody was included in the at-risk pool, including the caregivers of the people with dementia, not just the people with dementia.
Zaldy: Yeah, absolutely. I think our society somehow have an over-reliance on caregivers, and yet providing support … I mean the expectation is that if your father or mother or spouse gets dementia, you’re on your own, good luck with that kind of thing, which is really not sustainable and it doesn’t serve the purpose in society in terms of our responsibility, but also practically.
Zaldy: That’s why the cost for dementia is super high, especially in the last few years of life, because if you never gave them information, never talked about goals of care, advanced directive, then guess what? They’re going to end up in our intensive care units intubated or in dialysis [inaudible 00:15:35] ever invested the time to educate them.
Alex: Yeah. I know we want to move on to talking about what you’ve done and the bootcamp, but just to briefly also importantly note that much of this burden falls on women, particularly adult daughters and spouses. There’s certainly a gender story here, isn’t there, as well, about unequal burden, not just on families but on women in particular. Reminded of this is the New York Times headline is talking about the burden of COVID falling unequally on women.
Zaldy: Yeah, yeah. Women, especially middle-aged women or older, in terms of demographics, they’re the primary caregivers of people with dementia. There’s also the sandwich caregivers who are taking care of their own children or other members of the family and then taking care of the generation above them. So that’s also an aspect.
Zaldy: An interesting thing, while more caregivers are women, I think the male caregivers are also a group that is in need, especially the generation of male caregivers that we have now, because of the gender roles in their generation is not the same now where the care for children and the household stuff is shared between partners.
Zaldy: But that gender roles were much more defined, well-defined, in that generation, where the husband worked and then do any of the housework or childcare and then that women, it’s the opposite. So now when it’s reversed and let’s say the female spouse needs help, and the male caregivers become extremely stressed because they never were prepared for it.
Eric: So can we talk a little bit about what you did? We’re going to have links also to … What I’m really interested in and what I was really excited to talk to you about was the research letter that you published in JAGS in 2019 about a Caregiver Bootcamp. Would you mind describing a little bit about how you approached this as far as providing caregiver training?
Zaldy: Of course. So as I mentioned earlier, once we figured out that our caregivers have a lot of caregiver training and education needs and what’s out there in our community didn’t exactly fit what was needed, we decided to put together a caregiver training program at UCLA.
Zaldy: So we reached out to the Archstone Foundation in 2014. Fortunately, Archstone was willing to support our efforts to enhance our caregiver training and support for the people who are enrolled in the Dementia Care Program. So we put together this caregiver intervention that involves not only the bootcamp, but also Caregiver 101 series, where we had a library of books and pamphlets and stuff that we gave out to caregivers. We even produced an app resource that we gave to caregivers who have access to technology.
Zaldy: Then this Caregiver Bootcamp, which you mentioned. So Caregiver Bootcamp, in a nutshell, is a one-day intensive caregiver training, held on a weekend and done in the community setting, so one of our adult daycare centers partners. We provided interactive, experiential training for caregivers who need it the most.
Zaldy: We also provided respite care. So they could bring their loved ones to the adult daycare and they can have that loved one taken care of in another part of the daycare center, where the caregivers are free to learn and concentrate on the things that they need to do and learn while their loved one is safe in another part of the center.
Alex: Oh, that’s so great. That’s so critical to making this a success. Can you tell us more about what the main content was and how you evaluated this?
Zaldy: Yeah. So the content was pretty much dictated by what we learned from the dementia care specialists, the NPs in our program. Again, the advantage is that they have intimate knowledge of what the needs are and reshape the program content based on that.
Zaldy: So some of the things we covered were very practical things like home safety, preventing falls. But we also covered things like what’s the differences between different care sites, like assisted living, how much do they cost, adult daycare centers, and the nursing home placement, nursing homes, and when it’s right to place people in a nursing home, at what point, how would they know if it’s the right time.
Zaldy: And things also that pertain to the caregiver themselves, like self-care, like meditation, like … We had an on-site support group, for example. A lot of our caregivers, especially those who’ve attended these programs, are so stressed and so time-strapped that they never even try the support group. So we had an on-site support group just for them to have a taste of it, and they came away saying, like, “Wow! I didn’t realize the support group is like this. I really want this to be part of my life.”
Zaldy: Yeah, and then we ended with an interesting … Putting on my educator hat, the standardized patient, SP, approach where we trained actors to act out a person with dementia, with agitation. Who’s wandering and who’s at risk for falling? Really, we put the caregivers in the hot seat, saying, “Okay. Now take care of this patient.” So it was a really fun and also I think a rewarding experience.
Eric: Wow! How did that role play turn out? Did people like it? I mean I think … Yeah, I mean we do it so much in med school nowadays. This is the first, I think, I’ve heard it around caregiver training.
Zaldy: Yeah. It’s interesting. Initially when I put it together, I thought that, “Oh, god. I hope that they don’t get stressed out.” So it’s how we did it at the end of the day.
Zaldy: One thing that was interesting, because it is a whole day experience and we provided … Thanks to Archstone, we provided their breakfast and lunch. They bonded. The caregivers will be like … In the back of the room, saying, “I don’t know anything. I’m just here to learn,” suddenly became their own experts, because there are different stages of caregiving. Some of them have been taking care of their spouse, for example, for five years or 10 years and there are newbies, people have just started. So they became experts.
Zaldy: Let’s say it was something about the dry mouth or daily care, they’d be like, “Costco, $5 a pack.” So they’re total experts and they bonded, interestingly.
Zaldy: But at the end of the day, they felt comfortable enough to be on the hot seat. There’s a lot of laughter, there’s a lot of coaching with each other. So, yeah, it was very interesting.
Alex: That’s great. I love that there was this community building aspect in some ways. I imagine they probably shared resources with each other, and stories, even outside of the support group, the formal support group mechanism. Can you tell us a little more about how you evaluated this program to decide if what you did was working?
Zaldy: Yeah. So this program, as I described, wasn’t set out to be a research project. It was really more to address the needs of our caregivers in our care management program. But we did want to see whether we moved the needle a bit on some of these measures.
Zaldy: So we did mostly a pre and post-model of the Berlin, we did the Zarit Caregiver Burden, we did knowledge tests, and certainly the satisfaction for time spent with the program. Fortunately, we found that they felt that they were more confident in their caregiving. So the Berlin improved, especially those whose burden was the highest based on the Zarit.
Zaldy: So it speaks to the fact that those who need it the most, you just need to find a way to get them to this program. As I mentioned, doing it on a weekend, doing it where there’s free parking, in the community, provide food, and all of that stuff-
Alex: Provide care for the person with dementia, yeah.
Zaldy: Exactly, because these are the ones who will not show up, because even on the weekend, they have no one who will cover for them. So it speaks to the fact that those who need it the most are the ones who benefited the most from this kind of a program. Of course, we’re gratified that they liked the program, they liked the structure. Yeah, so it’s been positive all around.
Alex: How are you funding this? Is it all Archstone? I mean what’s the sustainability model, I guess, is my question?
Zaldy: Yeah, so it’s a good question. So I was going to mention that we got refunded by Archstone in 2019 to reach out to the Spanish caregivers. But the English caregiver bootcamp is now sustained by its own by the medical center. So we’re no longer using foundation funding for the English version of the bootcamp, which is still ongoing. Then the Spanish bootcamp is the one that we are now testing out using the model.
Zaldy: Then making it more culturally sensitive, reaching out to people who are not part of the Dementia Care Program. These are people in the community who have dementia, primarily Spanish speakers, that we are partnering with their local senior centers, because, ultimately, sustainability is our key for the senior centers that serve the Spanish-speaking community to adopt this. We’ll give them all the tools that they need so that this is self-sustained.
Eric: Did you have to make a case for this for the med center to support this type of project?
Zaldy: Yeah. So it was folded into the Dementia Care Program, which is still ongoing. The UCLA Dementia Care Program is ongoing, even though we no longer have the CMMI Award or any grant funding. So, yeah, it has become part and parcel of the package of the Dementia Care Program is caregiver training because it does serve the needs of the caregivers. So we didn’t necessarily ask money from the health system itself to fund this, but it got folded into the operating costs of the Dementia Care Program.
Eric: And real quickly, what does it take as far staff to put together a bootcamp? How much time and who actually facilitates the bootcamp?
Zaldy: So it’s interesting that putting it together had costs attached to it because, obviously, we had to have people writing material and all that stuff. But now that we have our site sets, our scripts for the actors, and all of that stuff, it’s actually not that much, especially the venues are free. We do provide food, so there’s a certain cost to that, because we want the caregivers to be there for us for the entire day.
Zaldy: But the cost structure isn’t that much, especially now that it’s made and it’s available. So it just requires a facilitator. And the facilitator could be someone from the … It doesn’t have to be a physician or a nurse. It could be a social worker in adult day center or a senior center. So it could definitely be done in a relatively low-cost approach.
Alex: If you had to pitch this … I understand that in this case, it was folded into this whole package, comprehensive dementia care package. But if you had to pitch this to … Most of our listeners are overwhelmingly clinicians who may want to start a program like this. We’ll get into what resources you have for them online to start a program like this. But if you had to pitch this to a medical center, what would your pitch be?
Zaldy: So I think the pitch would be … And this is one of the things that I’m doing here at Cedars-Sinai, is looking at if I were to go into a health system like Cedars or any other system, I think we really need to know where their dementia patients are. So it’s what our health system’s pain points are. Then address what can we do with relatively little investment for this group of people.
Zaldy: So I’m looking at things like what percentage of patients with Alzheimer’s disease or related dementia who end up in the ER get admitted to the hospital? Are we okay with that, 80% of them who hit the ED get admitted to hospital, especially in this period where beds and resources are so scarce? Things like how many patients have an ICD-10 diagnosis of dementia who are discharged and how many of them are discharged to the SNF? What’s the readmission rates like? What’s their lengths of stay?
Zaldy: So if one were comfortable in reaching out to population health of their health system and getting hard numbers, I think our health system leadership will listen to them. If you say, “If you give these resources, I believe I can move the needle in these metrics that I know you care about as administrators.”
Zaldy: Certainly, I don’t claim that Caregiver Bootcamp will change all of this, but I think it’s part of the intervention. I think anything one can do to partner with their local senior center, adult day centers … Again, a lot of our adult day centers are already doing some sort of caregiver training. Savvy Caregiver is a very big good example.
Zaldy: But maybe look at your group and see if there is another model that will work better for a subset of your caregivers. I think that will be an effective way of talking to your stakeholders and finding resources for something like this.
Eric: Can we take a bigger, much bigger, step back? If you had a magic wand right now that could change any one thing around improving support for caregivers, what would you use that magic wand on? I’m just thinking like there’s some studies around what do caregivers really want from their clinicians. I think half of them just wanted some place in the medical record to add their names and their phone numbers, like how do you contact me, including, “Please contact me. Let me know when something is happening.”
Eric: So if I had to use it, I would probably say having some place in the EMR where the providing caregiver is named and their contact information. What would yours be?
Zaldy: No, it’s a challenging question because I think that part of me … Although you say a magic wand which will solve all problems, part of me is thinking about what’s actually within the realm of possibility. So I think that the models that the UCLA Alzheimer’s and Dementia Care Program, the UCSF Care Ecosystem, other programs like that, there is a large aspect of caregivers’ core training, et cetera, that’s involved.
Zaldy: I think that would be my wish is that somehow our reimbursement, our payment structure could be reorganized so that aspect of intervention that we could do from the health system could be reimbursed and sustained. That, I think, will be a more lasting change in the way that we support caregivers in our health systems.
Zaldy: But more specifically, not really [inaudible 00:33:04], I wish there was more opportunities for caregivers to get educated in whatever way. As educators, we talk about different learning styles. Some people learn by attending a live conference. We don’t do it right now because of the pandemic. But at some point, that will at some point recur. And using electronic resources, using whatever means possible to reach our caregivers would be, I think, just incredible.
Alex: Eric and I both unmuted at the exact same moment. Okay, he’s letting me go. Could you tell us more about what resources you have online and how people who are listening or reading about this and want to implement a Caregiver Bootcamp at their own institution could do that?
Zaldy: Yeah. We have a website, which I think I will be part of this podcast in terms of the links. That would be terrific for people to know what we’re doing and get a glimpse of the program. There’s also some media coverage there with some videos to show you how it goes. If they feel that maybe it’s right for their organization and they would like to use the material, then just feel free to reach out to us through the website and let us know. We’re happy to partner with anyone who feels that this might be helpful.
Eric: I swear this is my last question. I think I said that before. But my last question is if you’re talking to the busy clinician that’s out there in their office caring for somebody with dementia, any practical tips for them on what they can do to support caregivers?
Zaldy: One of my favorite questions when I encounter a caregiver for a person with dementia, I say, “I’ll need to just ask you a simple question. If something were to happen to you today,” I used to say, it’s a bit too graphic, but if you got hit by a truck, God forbid, “who will take care of your loved one tonight?” Maybe now it’s like if you got hit by COVID and you were isolated from your loved one.
Zaldy: I think that that is such an important question to ask, because if they say, “I’m not sure. Maybe my neighbor will drop by and help out,” I think that’s a sign that something needs to be done, because this is an accident just waiting to happen.
Zaldy: So that’s something that I would really want clinicians to ask is, “If something were to happen to you, you’re the caregiver, what’s going to happen to your loved one? Is he going to be safe? Is he going to have food? Is there going to be a risk of wandering?”
Zaldy: But aside from that, I think what we could do better at as clinicians is look in the corner of that room. That person who is trying to blend with the wallpaper while we take care of the patient, that is the person that’s equally important with the patient in your EMR, because that person is the one who can empower you as a clinician in carrying out the things that you want them to do to help their patient and, on the flip side, can also derail all of your fancy plans and your recommendations. So that will be my advice.
Eric: Yeah, it’s amazing how dependent we are for caregivers, yet we completely ignore them generally in our healthcare system.
Alex: Yeah. Here’s my last question. So you get a bunch of caregivers together for this bootcamp in a room indoors for a full day. You bring the people with dementia there and they’re cared for on-site by people who have not met them. Boy, this sounds so 2019. Let’s talk about COVID. What can we do now? What are you doing? What’s happening with these programs? What are the opportunities and potential of moving some of this material online and moving … As you have done with the website, with creating social connections and education and opportunities for training outside of in-person gatherings?
Zaldy: Yeah. So funny you ask because we have actually now shifted our Spanish Caregiver Bootcamp to entirely Zoom-based. Initially, we were hesitant because of certain things like access to technology and familiarity with how to zoom in and zoom out.
Zaldy: But we found that certainly, at least a subset, I firmly believe that because of the pandemic, there are caregivers that we could not reach because they don’t have reliable technology or wifi, et cetera. But at least for the Spanish Caregiver Bootcamps that we’ve had, we’ve trained over 50 Spanish caregivers here in Los Angeles just online.
Zaldy: And so, it can be done even during the pandemic. But I think, just like most things, it needs to be a blended approach. There are people who cannot really access technology so we need to have an in-person version. But there also has to be an aspect that can be done online for those who are able.
Eric: Well, Zaldy, I really want to thank you for joining us today. We’re going to have links to your JAGS article, website on our GeriPal show notes page for this episode. Also encourage folks, CAPC has a wonderful seven-module dementia educational products that you can actually go to. I think most people don’t know they’re CAPC members, but many are. So you can check that out as well.
Eric: Again, a very big thank you for joining us. But before we end, Alex, a little bit more Remember Me. Are you going to the Spanish version this time?
Alex: I looked up the Spanish version, and I don’t have the guitar chords next to the Spanish version. All right, I’ll give it a try.
Alex: So I’m just going to do the ending in English.
Eric: You sound like you have a backup singer behind you.
Alex: Oh, you didn’t see them? Oh, maybe they didn’t capture on video. [laughter]
Eric: They must be on the other side of the room. [laughter].
Alex: There’s been some fun purchases. [laughter]
Eric: COVID purchases.
Alex: Thanks to Archstone Foundation, while we’re speaking.
Eric: Zaldy, a very big thank you for joining us today.
Zaldy: Thank you very much. I appreciate it.
Eric: And a big thank you, as Alex said, to Archstone Foundation, who is a supporter of the GeriPal Podcast, in addition to Zaldy’s work. As always, a very big thank you to our listeners for support of the GeriPal Podcast.
Eric: Of note, we just made a big switch in our podcasting host from SoundCloud to Libsyn. So if you’re having any interruptions or issues with the migration, please send us an email and let us know so we can look into it. With that, goodnight, everybody.
Alex: Good night.