Eric: Welcome to the GeriPal podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, I see a couple of people in our studio office today.
Alex: We have a couple people here. We have a guest host today, Melissa Chubbuck who is a Palliative Care Fellow at UCSF. Welcome to the GeriPal podcast.
Melissa: Thank you. Hello.
Alex: And we have Krista Harrison who is Assistant Professor in the Division of Geriatrics here at UCSF, and a social scientist. Welcome to the GeriPal podcast Krista.
Krista: Thank you. Great to be here.
Eric: And we’re going to be talking about a paper you just had published in the Journal of American Geriatric Society, JAGS, on kind of the life of individuals with moderate dementia. Where do they live? What their life is a little bit like. But before we get into that, we always start off with a song request. Do you have a song request for Alex?
Krista: Well, given the topic, it seemed appropriate to attempt memory and with the new Cats revival coming out.
Eric: I heard about that.
Alex: There’s a Cats revival?
Alex: I didn’t hear about that.
Krista: There’s a movie.
Alex: There’s a movie?
Eric: Everybody and their cat is in the movie.
Eric: Like Taylor Swift is in it, right?
Alex: Are they going to have new songs?
Krista: I don’t think so.
Eric: I don’t think so.
Alex: No? Okay. It’s kind of like the Les Mis.
Eric: That is one weird music like-
Alex: Yeah it’s strange.
Eric: There’s no point in Cats. Is there? Like is there? There’s no plot.
Alex: I don’t remember enough.
Eric: Okay. Let’s try to figure out, listeners let’s try to figure out the plot of just this one verse.
Alex: Send us your thoughts.
Alex: Nice. Krista has, we should note, formal training in opera.
Eric: Get out of here.
Krista: Long time ago.
Eric: Oh my goodness.
Alex: At the end we’re going to hear some opera.
Eric: Can we?
Alex: We’re going to hear a little opera.
Krista: Just for you Eric.
Eric: That will be a GeriPal first.
Alex: That’ll be a first. That’s first. And we’re nearing our 100th episode.
Eric: No second.
Eric: Yeah. We had the operatic part on Queens, Bohemian Rhapsody.
Alex: A) we were not operatic during the operatic part. It was more like chanting. And B) that’s not an opera.
Eric: I still get comments about that GeriPal episode. And the exceptional-
Alex: The exceptional quality of the singing-
Eric: … Quality of the, singing yeah.
Alex: … In that particular episode, yeah.
Eric: Why did you pick memory?
Krista: Well, the study that we did is focused on identifying people with moderately severe dementia who live at home and comparing their clinical and demographic characteristics to those who live in residential care and nursing home settings.
Eric: Oh, that’s a lot to go over during this discussion. But before we do, how did you get interested in this?
Krista: Well, I was working in a community based hospice in between my PhD and coming to UCSF. And it’s a pretty neat model of care for people who are at the end of their life, but as I want to do, I looked around and said, “Who isn’t able to access this care?” And it’s typically the people with long trajectories of functional decline, and who are particularly difficult to guess when the end of their life will come.
Krista: And people with dementia and other neurodegenerative illnesses, specifically typically fall into that pattern. And when I thought about my own family’s experience and what I had heard from others, a lot of people said that people were mostly living in nursing home settings and much of the research on people with dementia and palliative care are in nursing home settings. And I said, “I think there are a lot of people who are living at home even when things get really hard. And is there a way to find out how big that population is?”
Alex: Should we talk about the article?
Eric: Let’s talk about the article.
Alex: How big that population is.
Alex: Right. How big is that population? And who specifically are we talking about in this article? I guess I’m the coauthor, so we should also acknowledged that.
Krista: Yeah. To get a sense of the size of a population, you have two choices. You can either do a study yourself to prospectively go out and ask people what they’re experiencing and recruit them to your study, and give them a neurocognitive battery of tests to assess what stage of dementia they’re at. Or you can use existing data sets. And the existing data set we used in the national health aging and trends study.
Krista: And so they have a series of questions that they asked to a nationally representative population of older adults, Medicare beneficiaries who are age 65 and older. And when they can’t talk to the person themselves, they talk to a proxy member. And they recruit these people and they interview them every year over time.
Krista: So to sort of get at a population of people who were experiencing probable dementia at a stage where things are probably getting a little bit hard, we developed a definition that’s based around activities of daily living. So you had to meet the criteria to be in the study, you had to newly meet criteria for having difficulty with eating, bathing, or dressing. And with one of the financially oriented instrumental activities of daily living, financial or medication.
Alex: So this population sort of approximates then fast stage-
Alex: … six. And just to put that in context, people become eligible for hospice at fast 7c. Which is have difficulty with, what is it? Three activities? I should know this.
Eric: Limited to six or less words.
Alex: Yeah per day.
Eric: Plus difficulty, you can’t independently walk around.
Alex: Walk around. Yeah.
Eric: Interestingly enough you have to meet 7a criteria on fast and have that 7c which is inability to independently walk around. But 7b kind of gets dropped. A little side note on hospice eligibility.
Alex: So why, I guess then the question is why people at that seven… What’d you say?
Krista: Six sort of A through C.
Eric: Yeah. Why moderately severe dementia?
Krista: Essentially, for one thing, we couldn’t measure 7c. The data isn’t there in this data set, so we couldn’t look at the people who were hospice eligible or might be hospice eligible. Second of all, because things are probably pretty hard when you have multiple limitations in activity of daily living and you have probable dementia.
Eric: Obviously everybody goes through it differently. Every stage is hard for different reasons, but this kind of the moderate stages of dementia where the behavioral issues come out. They’re having new changes as far as IDL and ADL function. So they’re starting to need a lot more care at home. That seems to be a really challenging part for caregivers that we don’t know a whole lot about.
Krista: That was our assumption as well.
Alex: And in fact this is, we were sort of thinking about this conceptually going into it as this is sort of around the time when a geriatric palliative care approach would be really helpful for patients in the course of dementia. Because sure everybody could benefit from geriatrics, everybody could benefit from palliative care. But you have to draw a line somewhere. And so people who have dementia who need assistance with activities of daily living in instrumental activities of daily living, that sort of seemed to be a place where people could come to agreement that that’s a time when geriatric palliative care approaches would be helpful.
Eric: How big of a population are we dealing with here?
Krista: So when you roll the estimates up, it’s something like 3.3 million people at a population level in the United States among Medicare beneficiaries who have newly progressed to the stage of having moderately severe dementia.
Eric: Wow. How’d you come up with that number? Like what’s the…
Krista: So NHATS has weights that you can apply to your analysis to sort of make your person level analysis represent the national characteristics.
Eric: 3.3 million people with moderately severe dementia.
Alex: Is that incident, moderately severe dementia over a time period.
Krista: Over five year period. Thank you.
Alex: Over a five year period. So that incident meaning people who newly developed and met newly met criteria.
Eric: Okay. So that 3.3 million people in the US living with moderately severe dementia. But 3.3 over a five year period developing moderately severe dementia. And how good are we at actually picking up like this moderately severe dementia? I can imagine if you’re looking at just ICD nine or 10 diagnoses, you’re just going to miss a whole lot ’cause a lot of people aren’t diagnosed with it.
Krista: That’s right. So the National Health Aging and Trends study does provide multiple different ways of identifying people with dementia. One of which is asking people themselves, putting them through a neurocognitive battery and then saying on the basis of this test, we think the probability is more likely than not that you meet criteria for having dementia, not clinical, but research.
Krista: Another way is asking the sample person or the proxy, “Have you been diagnosed with dementia by a clinician?” And the third way is by asking a proxy, a series of these tests that based on the algorithmic results says they probably have dementia.
Krista: So in the community it’s estimated that 50% of people with dementia actually get clinically diagnosed. So this helps a little bit towards remediating that. But there’s also some people that we’re probably missing. And for our diagnosis, we can’t tell the difference. For our paper, we can’t tell the difference between somebody who had been hit by a car and so was impaired in activities of daily living because they had been hit by a car but have very mild dementia. And the person who’s all their activities of daily living are impaired by the degree of dementia. Or the progression of the disease itself.
Eric: So some of these people may have had functional impairments from some other disease, but we’re thinking of that as moderate dementia. So maybe inappropriately.
Krista: Well, we’re not sure. Bottom line is if you have probable dementia and you have a number of impairments, it’s probably tricky. And there’s probably some particular care needs that could be best met wherever you are living by geriatric palliative care approaches perhaps.
Eric: So is there anything surprising that you found about these 3.3 million people with moderately severe dementia?
Krista: A large number are living at home with dementia and of that population, they are more likely to be members of disadvantaged populations. So they were more likely to be members of black or Latinx communities they … or who have identified as such, more likely to have only a high school or less level of educational attainment. They were more likely to be…
Eric: Lower socioeconomic status. Right?
Krista: In other words, yes, More likely to be born outside of the United States. So presumably a lot of those people are immigrants.
Melissa: Were those the primary questions you are asking when you started the study?
Krista: I had gotten a couple different responses when I started this study. Some people said “Well, they’re more likely to be higher levels of people from historically disadvantaged populations.” And other people said, “These are all going to be white, well-resourced people.” And it was an open question.
Eric: So why do you think that is? Why do you think that these historically disadvantaged populations are at home and is that a good thing or a bad thing? Cause we always hear over and over again that people want to stay in their homes. Is this one of those disparities where it’s actually bad to be wealthy and white?
Krista: We fundamentally don’t know the answer to that question from this study. That’s one of the studies we’d like to do in the future. I am also doing a qualitative study, actually talking to people with dementia and their caregivers to actually ask about their experiences to start teasing apart some of these questions. What we do know from this study is that … .
Eric: Alex’s mic-
Alex: Sorry, my microphone just dropped like two inches mysteriously. There’s a ghost in the room.
Eric: We got new microphones in. They’re really heavy.
Krista: So what would be great is if the people in this study are living at home and they are receiving optimal care in accordance with their values and wishes, and with adequate social support, and with adequate medical attention according to they actually want.
Eric: Do you think that’s the case?
Krista: Well, unfortunately when we looked at their medical characteristics, they have higher rates of bothersome pain, high rates of hospitalizations, of falls and other worrisome things that make me concerned that maybe the people living at home aren’t getting the care they need. And in some ways that’s unsurprising because we don’t currently have great financial support for home-based models of care in the United States.
Alex: Particularly for people who don’t fall into one of those specific buckets, like hospice eligible, or nursing home eligible, and have Medicaid insurance to pay for nursing home. There are huge numbers of people who have prognoses that are longer than six months who have geriatric palliative care needs and might not meet nursing home eligibility requirements or might not have Medicaid.
Krista: And there’s increasing attention to preventing caregiver burnout, particularly at end of life. But if you’re talking about somebody with dementia who has maybe been experiencing symptoms of this illness for 10 or more years, trying to do something about caregiver burnout in the last six months is unlikely to have a great deal of impact as opposed to making sure that you get ahead of the curve and start providing care in the home, or wherever the person prefers to receive care early in the process, and supports both the caregiver and probably more likely multiple caregivers who are involved in this.
Eric: Do we have any idea who these caregivers are of these people with moderately severe dementia? They have an ADL, the deficiency, so it’s likely they’re getting some help from a caregiver.
Eric: How much do we know about these folks? Are they family caregivers? Is that why there’s this difference between the groups is that there’s more familial structure that’s keeping them at home? Or what do you know about them?
Krista: That’s a great hypothesis. We haven’t looked at that in this study yet. We do know that the people living at home in this study are more likely to have multiple people in their household as opposed to living alone. Although surprisingly 15% of people were living at home alone with moderately severe dementia. But from some other work I’ve been doing in using some palliative care registry data, it does look like it’s more likely to be people living at home with family members, multiple family members.
Alex: And what would you say surprised you most about these findings?
Krista: I mean in some ways what is most surprising is how unsurprising they are. You worry that people are staying in their homes according to their preferences, but they are not able to get the care that they want without leaving the home so that they have to go to ambulatory settings. And the result of that is that they are having symptoms, they’re having clinical concerns that are not being addressed.
Alex: And the implications of this study I’m trying to think, are there clinical implications? It seems like most of the implications are more in the health policy arena. Is that right?
Krista: That is correct.
Alex: And what are the major sort of directions that we need to go on the basis of these data in terms of health policy?
Krista: Well first of all it tells us that we need to start developing better models of care, financial models of care to support people receiving care in the home, particularly those with, again these long trajectories of functional decline as is the case with people with dementia.
Krista: So ideally, wouldn’t it be nice if we had a Medicare dementia benefit that supported not only the people with dementia, but whoever is involved in their care, which probably varies over time and really supports them and allows them to receive care from physicians, nurse practitioners, physician assistants, social workers, chaplains, OT, PT, all the different members of the interdisciplinary team in their homes where it is least disruptive for them, so that they are not dealing with a caregiver taking their loved one to an ambulatory doctor’s visit, and telling us about how the patient was trying to get out of the car door and so that ended the trips to coming into clinic. And instead were able to receive care at home.
Alex: Yeah, that’s a terrific proposal and we’ve had some podcasts about home-based care models and we’ll have more in the future. One nice feature of that that comes out of your work here is that those type of resources for people living at home have the potential to disproportionately support historically vulnerable populations.
Alex: And unlike some of the other topics we discussed on this podcast. For example, we just had a podcast on physician aid and dying, which are laws that several states have passed that typically privileged and support wealthy white, highly educated individuals. Home based care programs for people with dementia have the potential if they’re rolled out correctly to support some of the most vulnerable members of our society. Is that right?
Krista: That’s right.
Eric: How does hospice play into this? Or does it?
Krista: Hospice has increasingly caring for people is increasingly caring for people with dementia, but there has been increasing pressure, regulatory pressure on hospice that has affected the ability to care for people with dementia. So, in a study I did that talked to hospice professionals, they talked about how the change in diagnostic criteria and how precise you had to be about the dementia criteria has impacted their ability to admit people. The pressure to only keep people on for six months or less has meant that they start to dis enroll people alive, which is incredibly disruptive to the care process. And often leaves people scrambling to assemble different sources of support just when they’ve started to get accustomed to the hospice model of care.
Krista: They also aren’t typically well-trained. It depends on where, but they typically don’t have additional training in the specific needs of people with dementia and supporting their caregivers. That’s a very different set of symptoms and needs compared to say people with cancer, who were the more typical people served by the hospice model of care historically.
Eric: Well, I’m going to open it up to all three of you. Like where do you, I think it’s clearly defined where the geriatrician falls into this like hopefully early on in the course of the cognitive disorder, whether it be Alzheimer’s disease or something else. Where does the palliative care team fit in? Alex, you mentioned maybe around six, but what are your thoughts? Where does specialized palliative care outside of hospice care fit in, in the clinical course of dementia?
Alex: I’ll take a stab at that one.
Eric: Since she’s moderately severe patients cause now they’re starting to have-
Alex: I actually don’t think it matters what the term is and this is something that sort of came out through the review process I think. Right in the original versions of this paper, you talked quite a bit about geriatric palliative care, geriatric palliative care, and the reviewers and the editors said, “Why do we have to label it that? Why is it a palliative care intervention? Why isn’t it just an intervention?”
Alex: You know, no matter what you call it, it certainly has elements of primary palliative care. Does it need to be owned by the profession or the field of professional palliate medicine or the field of palliative care? I don’t think so. I think it’s more important that we design services that meet their needs, and that they will be deeply informed by geriatric care principles and by palliative care principles and probably by bioethics principles.
Eric: But I’m going to push you on this. Does palliative care specialty teams have a role to play in like mild or moderate dementia?
Krista: I think any time that there are particularly complex dynamics that it is helpful to have experts to call in to provide an additional layer of support. But I sort of think that if you see something, say something is a useful phrase in this context because people with dementia get seen by all manner of clinicians and everybody’s got to see a little piece of need here. And people should take ownership of whatever piece that they see, so that together we are all helping people move towards identifying where is the likely course of this disease headed? What are the things you’re going to need to think about, what anticipatory guidance clinicians provide? Can they keep prodding people to think about what’s coming, and have these discussions, and plan ahead, and think about what’s the contingency plan when the first caregiver is overwhelmed or a new care comes up.
Krista: Maybe they have to care for their own child who has a need come up or another family member gets ill. We need number of contingency plans. And to that end, palliative care specialists get advanced training in communication and really helping provide this anticipatory guidance. And so when things are particularly complex, I think that’s when it’s a great time to call in the experts.
Melissa: I think this is definitely a situation too where the primary palliative care and moving palliative care earlier in the illness course becomes incredibly important for this population in particular with populations that might either have less familiarity with the healthcare system or historically distrust the healthcare system.
Melissa: I think it becomes really important that they are not avoiding a hospice model out of fear of what that means. And so if a palliative care team can wrap around that family earlier on and build trust earlier on, I think for these folks especially, it becomes really powerful to have palliative care on board.
Eric: And there was a great editorial attached to your paper too.
Krista: Yes, indeed. Joanne Lynn.
Eric: Joanne Lynn. And the one thing that I remember from it, she thought of a care pathway similar to a care pathway that is used in obstetrics. Like a birthing plan that you can follow, but you also can kind of take different paths away from it. What are your thoughts? Should there be a birthing plan for dementia patients? Kind of like a care pathway or multiple care pathways that help people through going through these stages from diagnosis, mild disease, moderate, severe, end stage?
Krista: Well, one of the things that we hear in some of our qualitative work is the amount of guilt that proxies and caregivers feel about whatever decisions they make, particularly when the decisions they need to make go beyond what their loved one communicated to them or that the person with dementia communicated to them.
Krista: And so this nice simplicity of a recommended care path is you can say, “Here’s what the evidence says is likely to be the most recommended way forward.” And then people are allowed to deviate and can make different choices, but they have a default that makes sense for the disease and for many people. And that could be something that you could actually … developing that care pathway could incorporate the expertise of clinicians of all types, and as well could take into account the perspectives of caregivers of people with dementia and people with dementia themselves. So that it accords with both professional recommendations and the lived experiences of people going through the process.
Alex: Not to what Krista said, but to the idea of the birthing plan and everything. I don’t know, this is going to be controversial, but I’ll just say so my wife’s an anesthesiologist is she would get frustrated when she was doing more OB. She doesn’t do as much OB anymore. When women would come in and they’d have this, “This is how I want my birth to go. Okay, I want to be in labor for two hours and then give birth. I don’t want any pain and I want Enya playing the whole time, and we should be on the peak verse of Orinoco flow at the time that the baby emerges.”
Eric: I haven’t heard that name Enya in a while.
Alex: It’s just like, “No it’s actually pretty unpredictable. It doesn’t really work that way. We will try and help you but, setting up expectations that we can predict what will happen is unrealistic.”
Alex: That said, sure there are … like we interviewed Barak Gaster about the advanced directive specific or the dementia specific advanced directive. And the whole idea there was sort of predicated on there are specific sort of sequences of events that predictably happen for people with dementia and we can help them prepare for it.
Alex: Joanne’s right in the sense that we can help prepare people for what’s likely to come, and we can engage them in advanced care planning about what’s likely to happen. But sometimes the unintended consequence of that is that people sort of have in mind that they can control every little aspect of what happens. And those who have more controlling personalities then become much more challenging patients.
Krista: Well, let me push back on you for a second. Although I will say my birth plan was to leave alive, preferably with a live baby.
Eric: That’s good. Yeah.
Eric: Was Enya playing in the background thought?
Krista: Not, not relevant. But think about Joan Teno’s work on tube feedings and Susan Mitchell’s. The research says that tube feedings neither extend life nor improve quality of life with people with advanced dementia. Couldn’t guidelines say we recommend against tube feedings when you have advanced dementia?
Eric: Don’t they? I mean, we got-
Alex: They do. Yeah. Yeah.
Krista: Wouldn’t that be part of a standard pathway?
Eric: Well, the way I think of the pathway … tell me if you disagree with this, Alex. The way I pictured it as I read the editorial was there are so many things that can help caregivers and patients with dementia from the time of diagnosis through mild disease, to moderate disease. Even making sure that part of the pathway is, has somebody talked to them about what to expect? Has somebody talked to them about their … and I think there is certainty that their disease will progress. It’s part of the diagnosis of dementia. As far as who do they want to make medical decisions and financial decisions as this disease progresses while they still have capacity? Not just thinking about like code status but all of these more difficult decisions. Like when you talk to family members, it’s not just code statuses like around placement.
Eric: She never talked to me about where she wanted to live. Or, she had very fixed beliefs of where she wanted to live and I feel terrible because I can’t make that happen. Actually having those discussions, the amount of people who never get referred to Alzheimer’s Association or their caregivers never get referred to it. The amount of people who never get any training. And part of it is that there is oftentimes not limited access to training rank caregivers, but like the Alzheimer’s Association, great resource and very … I don’t know. I wouldn’t say very few, but historically underused resource, great connection to the community. I think those are the things that I think about with a care pathway. It’s not just what it looks like at the very, very end, but just the idea of a general sense of where we’re going.
Alex: Yeah. I think that that has a tremendous potential to be productive. I mean, if you think about in this study, as Krista said, like half people with dementia go undiagnosed. Like there are huge issues with making sure we recognize dementia or call it for what it is but don’t just abandon patients. It’s not diagnose and adios as I read in one grant. It’s got to be, here are the supportive services that are going to help you. Here’s some information. Here are systems that are in place to help you navigate this illness.
Eric: So the other question I have from your paper is two-thirds were living in the community, these moderately severe dementia patients. I think one in five lived in a residential care facility, not a nursing home. What is a residential care facility and did they differ at all from those in a nursing home?
Krista: So these residential care facilities are assisted living board and care group homes. They’re somewhere where you can purchase additional supports and services, but aren’t staffed with nursing staff, medical professionals, as a skilled nursing facility is. And so these are a large and growing segment of the long term care population. It’s not well-regulated. There have been a number of New York Times articles about this recently, about how they’ll have memory care units, but in fact that the care that they provide often isn’t what is needed by people with dementia or can’t really progress with them.
Krista: So then you may be looking at even if you’ve moved them into a residential care facility, they then need to move again over time as their medical needs escalate. So this is unsurprising that the people who lived in residential care facilities in this study looked generally more like people in nursing home settings than they did like people in home settings.
Eric: And I always think about assisted living facilities as the nursing home, if you have money. Is that what you saw as it was there? Did you look at income status, socioeconomic status?
Krista: We did, but everyone we looked at in this study, such a small number of people have income and assets that are more than $25,000 a year. We didn’t look at small increments above that. We just looked at increments below that. So we looked at people who had $10,000 a year or less, and this is in 2011 dollars. And people between $10,000 and $25,000 a year in assets. And we did see more people with the very lowest incomes living in nursing home facilities presumably because they were in Medicare, Medicaid eligible.
Alex: Medicaid eligible. Yeah, the dominant payer, for nursing homes.
Eric: Yeah, versus assisted living. It’s out of pocket money and you’re looking at $6,000 to $8,000 a month depending on your needs.
Eric: And I do think that there is something also, you know, the birth of the assisted living facility was also pushed back against some of the regulations, to make it a little bit more like the community versus this highly regulated institutional structure that’s a nursing home.
Alex: The most popular article in the New York Times, I think for the fourth day running, it’s titled How Not To Grow Old In America. The assisted living industry is booming by tapping into the fantasy that we can all be self sufficient until we die, by Geeta Anand. Yeah. Fascinating article by the way.
Alex: It talks about how there’s this whole assisted living industrial complex, almost that’s making money by tapping into this fantasy and then the quality, as you said, is highly variable. The level of support they provide is highly variable and there’s very little regulation around these assisted living facility.
Eric: Yeah. I always think of it as pay to play. You got to put up money to get more out of it. And I mean one side you can think of as a downside to these assisted living facilities, but it’s also a reaction potentially towards some of the negative consequences of a highly regulated institutionalized structure like nursing homes are.
Eric: And you ask people where do they want to die? Nobody says in a nursing home. Well I won’t say nobody, but people mostly-
Alex: Pretty much nobody.
Eric: Yeah. So I think it’s re-imagining or reshaping how we think about long term care services for older adults. Especially like you said, when two thirds are living in the community with ADL deficiencies and IADL deficiency and moderately severe dementia.
Alex: Yeah. The challenge is, is the assisted living facility prepared to meet the needs of those patients?
Alex: Or is it saying, “Yes, we’ll take care of you.” And then have images of older adults who are playing golf and that’s who they want to take care of it. But those people get sicker too. They develop incident, moderately severe dementia. And then what happens to them as they stay in there over time, over time and they can’t meet the needs of those patients.
Alex: Well, Krista, I really want to thank you for joining us today. I’m wondering if you can give us a little special treat. Let’s hear some of the classical training that you’ve received maybe a little Opera.
Krista: All right, well thank you for having me.
Alex: Yeah, I’ve had classical training too. My music teacher was Jim Classic and he trained me. I was terrible.
Krista: All right.
Krista: Good enough?
Alex: That was terrific. That’s awesome. Thank you Krista. That’s the first time we’ve had Opera. That was-
Eric: Second time Alex. Bohemian Rhapsody!.
Alex: It doesn’t count.
Eric: There’s an Operatic section that we did.
Alex: Mamma Mia. Thank you Krista. That was wonderful.
Eric: Thank you Krista. Thank you to all our listeners for joining us this week. If you have a moment, please share our podcast with your friends, and family, and rate us on your favorite iTunes or other podcasting app, and join us next week.
Alex: Thanks folks, bye.