Understanding Hallucinations and Delusions in Parkinson’s Disease: Causes, Early Signs, and Caregiver Guidance

[00:00:00] Hallucinations can be misinterpretations that are visual, auditory, tactile. It does not mean someone's losing their mind. Visual hallucinations are the most common by the way. We see these visual hallucinations in minor hallucinations where someone sees a shadow or an animal move in the corner of the eye. Some patients may experience the form of hallucinations called presence. Hallucinations where they have a feeling someone's standing right next to them. But as time goes on, maybe there's more formed hallucinations which can be more vivid.

[00:00:47] Welcome back to The Caring Neurologist. Today's conversation is an important one and often a quiet one. Many patients with Parkinson's disease and their family members notice changes that are hard to talk about, seeing things that aren't there or misinterpreting reality or developing suspicious thoughts. These experiences can be frightening, not just for the patients, but for loved ones as well. I'm Dr. Sandeep Thakar and I'm here to explain why this happens in Parkinson's disease.

[00:01:16] What's normal and what's normal and what's not and how these symptoms can be managed with the care and dignity as we would want. Let's dive in. Dr. Thakar, some patients with Parkinson's may experience hallucinations. Can you explain what these are?

[00:01:37] Yeah, so patients with Parkinson's disease may develop dementia and the term of dementia is usually associated with hallucinations and delusions. So we'll start first with hallucinations. Hallucinations are usually sensory experiences that are not real. They are a core component to the term of Parkinson's disease psychosis.

[00:01:56] And you may come across the nomenclature of PDP, Parkinson's disease psychosis. It can affect roughly 20 to 50% of people in their lifetime if they have Parkinson's. But typically occurs in later stages of the disease. Hallucinations can be misinterpretations that are visual, auditory, tactile.

[00:02:17] They can be even hallucinations of taste and smell, which we call gustatory or olfaction. It does not mean someone's losing their mind. Visual hallucinations are the most common, by the way. And we see these visual hallucinations in minor hallucinations where maybe someone sees a shadow or an animal move in the corner of the eye. Some patients may experience the form of hallucinations called presence hallucinations where they have a feeling someone's standing right next to them or behind them.

[00:02:47] But as time goes on, maybe there's more formed hallucinations, which can be more vivid. They could be detailed images of people or children or loved ones that have been deceased. They could also be visual hallucinations of animals or insects, but they're typically not threatening. And they can also be silent. For instance, figures do not have to speak to patients. Now, some of the visual hallucinations or illusions can also be patterns that you can see on the ground or on the walls.

[00:03:16] And most patients don't find these such threatening, so they don't really bring it up. But sometimes we have to ask and we may come across patients saying that they see things that are not there. When we go into the auditory hallucinations, they're less common, but they could occur. And they could occur alongside visual ones as well. But they're usually muffled sounds, music or nonverbal voices.

[00:03:40] The senses, when we talk about tactile hallucinations, patients may experience bugs or crawly sensations. Smelling smoke can be an olfactory hallucination or involuntary kind of sense of taste. Someone may feel like they're tasting something that's unusual or kind of dirty or kind of grimy. And then there's also these that are, again, are typically quite rare.

[00:04:09] But those are, again, the different paradigm that we think about when we think about Parkinson's-related hallucinations. And you also mentioned delusions. Can you explain these as well? In Parkinson's disease, the delusions are also part of the dementia or psychosis, the PDP, so to speak. And the delusions are usually fixed or false beliefs that are not based on reality.

[00:04:36] So unlike hallucinations, which involve seeing or hearing things that are not there, delusions are more about the irrational thoughts. They're about what a person firmly believes, even when presented with the proof that they're not true. And delusions affect approximately about 8% of patients with Parkinson's in their lifetime. They're considered a little bit more complex and difficult to treat than the hallucinations that are more commonly seen in Parkinson's dementia.

[00:05:03] The common types of delusions in Parkinson's disease would be centered around certain themes. And there can be a little bit more paranoid in nature. So some of them are delusional jealousy. We call them Orthello syndrome. And this Orthello syndrome can be more common than not. It's where a patient irrationally is convinced that their spouse or partner is being unfaithful.

[00:05:28] There can be also persecutory delusions where believing that a patient's being followed or spied on or plotted against and that patients are stealing even, or sorry, people are stealing money from the patients or the person dealing with Parkinson's. There's also somatic delusions where it's an irrational obsession that something is physically wrong with their body. Such as believing maybe there's a hidden injury or severe internal illness.

[00:05:57] And the last type of delusion that someone with Parkinson's may experience is called Capgras syndrome. It's a specific type of delusion where a person believes their loved one has been replaced by an identical imposter. And these are things that we have come across. There are different spectrums, obviously, of severity.

[00:06:18] But I do want to make sure it's understood that these symptoms are part of the disease process, not like some personal failure or psychosis from schizophrenia. And you mentioned these happen when, if dementia develops, right? They're part of what you would call dementia. Yeah, and it's dementia associated with Parkinson's.

[00:06:44] So when someone's having some mild cognitive impairment, maybe they're having word finding issues. That's not dementia. You know, sometimes we forget things. We place things around the house and we're like, oh, shoot. Or maybe you feel overwhelmed and stressed. That can be some cognitive impairment. It can be something associated with aging. But it may lead to something like a dementia. When we think about Alzheimer's, dementia is definitely forgetting names and places and people and what we do for a living.

[00:07:11] But Parkinson's dementia is this Parkinson's hallucinations and delusions. And what's happening in the brain that leads to hallucinations or delusions in Parkinson's? Well, I'm sure there's a lot to be learned. And the things that we have, our understanding is there are neurotransmitter imbalances. And we can talk about that. But hallucinations and delusions in Parkinson's are caused by a combination of chemical imbalances, the structural changes that happen in the brain.

[00:07:39] And they can be triggered or worsened by the very medications we use to treat the disease. So the first part is a neurotransmitter imbalance. The brain relies on delicate balance of chemicals to process information. And those are the neurotransmitters. And that's what we focus on in trying to manage with Parkinson's is giving patients dopamine to maintain their motor control so they don't tremor and they're not stiff and not too rigid. But then there's this problem where we create a dopamine overload.

[00:08:07] And the Parkinson's treatment that we use to help increase the dopamine with the movement, it creates an overstimulation in the limbic system, areas of the brain for the emotional center. And that can add or aggravate the hallucinations for delusions. So we really want to balance out how we're giving medicines. There's also changes in serotonin, which is another neurotransmitter. And those serotonin changes are very unique.

[00:08:29] The research suggests that a specific type of serotonin receptor, which is a specific what we call subtype 5-HT2A, becomes very hypersensitive, overreacts. And it works actually in pathways in the deep structures of the brain that go and signal to the visual cortex, which is the occipital lobe. And the brain processes those visual stimuli differently. And that's why visual hallucinations are more common.

[00:08:57] And one of the other neurotransmitters is acetylcholine. So we see a diminished or acetylcholine loss. And that decline in acetylcholine is a chemical that's very critical for attention and for memory. So it makes it harder for the brain to realize or distinguish what's real from a sensory import and from the internal thoughts. Now, those are the chemicals. Now, there's also the issue of network miscommunication. So we're sending signals.

[00:09:26] And the recent neuroscience suggests that the hallucinations occur within different networks within the brain. And the brain should be communicating properly, but between one network and another network. So the default mode network, DMN, is overactive. That's a part of the brain that's active during daydreaming. So that network in patients with Parkinson's, that network of the DMN, is maybe overactive and it intrudes into reality.

[00:09:55] So we're daydreaming while we should be in reality. And that creates the brain to have maybe or project the internal images into the outside world. So it's kind of having like one screen and another screen, and then you're projecting one screen into the other visual pathway. So there's the attention breakdown, these networks that are responsible for focus on the real world, like one part of the brain called the dorsal attention network. That may weaken, making the brain more likely to misinterpret shadows or ambiguous objects.

[00:10:24] And then there's also the changes of the physical brain size, the changes within. We do see that the visual cortex, if someone had a stroke there, then our brain can fix or replace that area of loss of vision with some other reality. And so there is what's called cortical atrophy, thinning of the gray matter loss in the occipital lobe. There's also the hippocampus, which is for memory.

[00:10:51] And that's frequently seen that with the psychosis or delusion, that's atrophied as well. And again, these are all potentially parts of the Lewy body proteins that are spreading or the alpha synuclein that's spreading to the cortex. So the brain chemistry is a big issue. It is not an imagination or intention that someone has hallucinations or delusions.

[00:11:15] And I can imagine people, when they start having hallucinations, it's hard to spot. What would be the early signs that hallucinations may be starting? Yeah, they're very subtle. And the early signs of hallucinations and Parkinson's dementia can be mistaken as normal aging. They can be vision problems or vivid dreams.

[00:11:40] A neurologist often categorizes this as minor phenomenon or isolated minor symptoms. So the early sensory signs, minor hallucinations, can be a form of passage hallucinations. Like feeling that someone is seeing a fleeting shadow or a shape or in a small insect or animal. Sometimes patients will say that they saw a cat or dog dart across the house or sitting in the corner and then they look back and it's not there.

[00:12:10] They usually again disappear early on. Now their sense of presence is when there's a distinct strong feeling that someone's standing behind them or around them or in the same room. And those are, again, without any sort of obvious sensory trouble on the patient. But patients may not bring this up. And so these again, early, early on. And then there's the illusions that are misperceptions and you misinterpret a real object for something else.

[00:12:40] So for instance, a pile of clothes may look like an animal or a floor lamp may look like a person. Many patients may tell us like a sock on the floor may look like a rat or a mouse. So this is, again, the misinterpretation early on. The other changes that we may see along that time period is vivid dreams. Patients may talk or act out their dreams. And then when they wake up from sleep, they're kind of like still in that vivid dream state. They're like, no, this was real.

[00:13:06] Or they wake up and they may misinterpret what they saw right when they woke up. I've had some patients who like they have their CPAP machine and the hose for the CPAP machine is mistaken as a snake. Initially, that can seem scary, but then they kind of readjust and like they realize that's not what it is. And then patients who are more likely to develop these visual hallucinations and delusions may have a history of what's called REM behavior disorder. They act out their dreams. They're talking in their sleep.

[00:13:34] And that precedes the typical hallucinations when they get woken up. Rarely in the early stages, patients may hear things. They may hear indistinct nonverbal sounds, radio playing, muffled voices in the hallway. And then they misinterpret. They realize, oh, that's not real. Maybe it's just something else going on. And then they brush it aside. And that's usually, again, early on. But these patients typically retain insight. They know things aren't real. They may think that the brain is playing a trick on them.

[00:14:03] And then they just realize, oh, it's not a big deal. But they don't necessarily communicate this with patients' loved ones. What ends up happening, though, the disease progresses. And then there's more confusion. And typically, there's a sundowning that develops. And you mentioned that sometimes the medication that's given to the patient, that it's enhancing dopamine.

[00:14:32] If it's given in higher doses than it's needed, then it can cause overstimulation. And that may result in these hallucinations or dilutions. Did I get that right? You totally got it right. Yeah. So most of our Parkinson's medicines can contribute to hallucinations. They don't have to. Because even 50% of patients who have hallucinations may not be on Parkinson's medicines.

[00:14:59] So we've seen that when there are the sensitivities to medications that we're giving and we're increasing in dopamine levels in the brain, maybe that can contribute to the brain being overstimulated in the non-motor symptoms of the brain. And that can lead to the psychiatric side effects of the meds aggravating the disease state. So there are different classes of Parkinson's drugs that vary. And that could also induce the hallucinations.

[00:15:28] The dopamine agonist, which are Primapexol, Ropinorol, Rotigatine, these can significantly trigger more hallucinations than typically levodopa. There are other medicines called anticholinergics. And we use them for tremor. They're also known as trihexifenadil or venetropine. And they have a high predisposition for potentially causing confusion and hallucinations, especially in older patients. And then there's a medicine called amantadine.

[00:15:56] That's an old flu medicine that we have used for tremor and also dyskinesia. But that could also trigger hallucinations. And once we reduce those medicines or stop them, maybe you would see lessening of those visual or auditory hallucinations. However, levodopa can create hallucinations, typically a lower risk, but it can.

[00:16:16] And especially even if we don't change the medicine amount, but it's the brain is changing or the chemicals in the brain are changing, then we may see that hallucinations can still occur. But they're triggered by the disease progression. And each patient has their own fingerprint or progression that's unique to them. And so they may be more sensitive to certain medicines that they're on. Maybe the combination of medicines may be too much at one time. And we also see that there's what's called polypharmacy.

[00:16:45] They're on multiple medicines, maybe for their blood pressure or for maybe their diabetes or maybe for their heart. And maybe there's some drug interactions that's affecting them or affecting their cognition in general that may make them more vulnerable. And what non-surgical, sorry, what non-neurological factors can suddenly worsen hallucinations? Since you brought it up, I think it was a Freudian slip, but it made sense in surgeries.

[00:17:13] So even if they're exposed to anesthesia, potentially that could be problematic. But the more common things that we see, and again, I have a lot of patients who've been watching this podcast and they come in and they're like, I didn't realize that infections and a urinary tract infection can cause such problems. But infections are the common cause for hallucinations. And what we need to make sure is when they come up abruptly.

[00:17:39] So UTIs are the most common that we see with Parkinson's that create hallucinations. They're much more rapid onset of memory changes. We see that respiratory infections, especially like a pneumonia or COVID-19 can aggravate the system, especially if it becomes systemic. There are also metabolic stressors. This is a systemic issue. So for instance, someone is very dehydrated. Someone's having very low sodium levels. That affects the brain. So we call that electrolyte imbalance.

[00:18:08] We see that sometimes very extreme calcium and potassium can lead to delirium. And that's a sense of confusion. Or sugar levels being extremely high or extremely low. Those can aggravate the cognitive clarity of one's thinking and processing. And again, we've also seen vitamin deficiency. So vitamin B12 deficiency can also aggravate confusion, create a pseudodementia, and aggravate one's hallucinations.

[00:18:38] The non-Parkinson's medicines also can be a problem. And so what we end up talking with patients is if there's been an abrupt decline, are they on Benadryl? Are they taking something for their bladder? We see that these medicines can also aggravate hallucinations. Pain medicines, Ebre, can be quite problematic for patients.

[00:19:01] Narcotics, opioids, muscle relaxers, sedatives that we take like Valium or Adivant for anxiety can also cause confusion and aggravate the hallucinations. And in one's environment, the lifestyles that we go by, right? So sleep deprivation, chronic insomnia, disrupted sleep cycles, the actual things that are meant to rest our brain will aggravate the sensitive areas of the brain that will make and put us at more risk for hallucinations.

[00:19:30] And a lot of patients who are hospitalized, it's an unfamiliar environment. It creates a lot of stress. Maybe they had to have surgery. Maybe they're getting out of anesthesia. Maybe they're on pain medicines. All of this creates this sudden worsening of symptoms. And we see a lot of patients get confusion and agitation. And we call it delirium when in the hospital. So the first thing we try to do is rule out a UTI or see if there's any other infection that's being aggravated.

[00:19:57] Just to clarify, a delirium would be a dilution? Not necessarily, but delirium is a term that we use medically that is a confusional state. Okay. And when a hallucination or a dilution happens, how should caregivers respond? There are many ways that we can respond.

[00:20:19] You want to handle the hallucinations or delusions that require a sense of calmness, a sense of validation for the patient, and make sure that the patient's safe. So early on, one can reason that their loved one is not having a hallucination. But when we start seeing more advancing circumstances, then, you know, maybe physically the patient can be a little bit more irritated and say like, no, like this is real.

[00:20:49] And they can't assess the difference between reality and the hallucination. So we need to address and assess the safety and distress of a patient. First, the patient could be upset. They may see a visitor. They may say like, hey, no, someone's right here. And they could, again, be aggravated that we are not talking to the visitor. So we want to talk about this calmly. We want to make sure and understand that the hallucinations are not typically frightening for the patient.

[00:21:19] But we also want to make sure that we are, you know, not having the patient get up and try to serve the person that's there that's not real. Or, for instance, maybe a patient may be seeing a dog or an insect and trying to clean after the pet or get rid of ants that are being on the floor or behind the toilet. And we've seen injuries and falls happen.

[00:21:44] And there are situations, unfortunately, that, you know, someone really believes in seeing something. And they'll argue back and they'll fight back verbally with the caregiver or the loved one. So we try to say let's not argue with the patient. Let's avoid the contradicting. We don't need to necessarily say there's no cat on the table. We don't need to create a sense of frustration because it does create a sense of loss of trust as well. But we want to maybe validate the emotion.

[00:22:13] So focus on how they feel. I can see that you're seeing something that's making you nervous or offer reassurance. Like, I'm right here with you. You're safe. Everything's fine. But, you know, these are the type of things that we would counsel about. So we would also want to maybe gently redirect the patient. For instance, once you've acknowledged that their reality, just shift them to a different attention. So change the environment. Maybe move them to a room that's with brighter lights.

[00:22:42] Or maybe that visual hallucination may vanish itself. Engage them with simple tasks. Offer them a snack. Maybe start a conversation. Maybe reset the brain's focus. And I like to have people drink water. Maybe change in temperature, colder water. Maybe have them again walk around, get to more sunlight. And then offer them, like, reality checks. So if the patient's still having retained insight, you know, they would, you know, you could say, like, Hey, you know, like, do you actually feel the person there?

[00:23:11] Like, once you feel the chair, maybe you don't see the patient. The patient may not misinterpret the chair with someone sitting on it. If they touch the chair and there's no one else there, right? Turn on the better lighting. Maybe get rid of the shadows that are there. So, again, those are different ways you can go about it. I think what's harder when you're trying to manage the delusions. Because there may be a sense of paranoia. And the delusions are definitely harder because they're more beliefs than visions.

[00:23:40] So we want to avoid being defensive. We don't want to accuse anyone of anything. But what happens is when the patient's accusing the caregiver or the loved one that they're stealing or there's infidelity, again, we ourselves get defensive. So we want to be mindful that try to understand that they're not doing it on purpose, that there's a sense of confusion at that moment. And then we want to redirect or explain, like, how could I be doing this?

[00:24:09] Why would I be doing this? I've been with you this whole time. I haven't left to go out of the house, whatever it may be. And try to agree to disagree, so to speak. So, you know, you may say something like, I understand how you feel that way. I'm sorry you're upset. But let's get some tea. Let's talk about something else. Let's, you know, redirect. So it's typically better to reassure the patient that things are safe and stable.

[00:24:35] I can see how that can be difficult and require a lot of patience. But like you mentioned, reassuring rather than conflicting with someone might just ease their nervous system to not react. Exactly. And I think, look, we all react and we have a sense of natural reaction. Being a caregiver, being a loved one with someone with Parkinson's, that's developing hallucinations or delusions.

[00:25:04] It can be really difficult. And it can be hard at that moment, especially when the day's been going great, everything's fine. And then maybe there's some sundowning and then it's the evening time and we're all tired. And maybe that's when the brain's getting tricks being played on it. However, you know, if there's progression and more advancing stages of the hallucinations and delusions, it's hard to keep one's nerve, right? It's hard to keep our, like, calmness and collectiveness.

[00:25:31] So there are different tricks, but sometimes also having other family members and friends involved. But in our normal routine, we have a lot of caregivers that come in and take care of patients. And when you start seeing new caregivers, then it also may add to the confusion. So it's better to keep everyone very close that they're unfamiliar. And what treatment options exist today for Parkinson's-related hallucinations?

[00:26:01] So the treatments that we typically have for managing Parkinson's disease psychosis, it's a multi-step clinical approach. And doctors like myself, movement disorder specialists, we'd try to, again, first rule out the infections. We want to make sure there's no pneumonia or dehydration. We want to make sure that we peel away the drugs that are being given that are aggravating the brain.

[00:26:25] So, again, if there's anticholinergics like artane, if there's amantadine, these medicines that are highly contributing to confusion, we want to get those out of the system first. And we would also then look at dopamine agonists, which are used to help motor symptoms, but maybe lower the dose slowly. And then maybe get rid of the boosters for levodopa. So there's something called Compton inhibitors. There's MAOB inhibitors. We try to get peel away from those.

[00:26:54] And then eventually we'll get to levodopa by slowly reducing if we need to. But if the hallucinations are still bothering a patient, we may actually have to use certain pharmacological therapies. There are FDA-approved therapies. One of the main ones that we like to use is called Pimavanserin, or also known as brand name Nuplazid. And it is approved for Parkinson's-related dementia and psychosis. And this is for the hallucinations and delusions that develop.

[00:27:23] So unlike standard antipsychotics that target dopamine, Nuplazid, also known as Pimavanserin, is really focused on serotonin. And that works on that 5-HT2A pathway, which is the pathway of the deep part of the brain that sends signals to the visual cortex. So it does not worsen motor symptoms. Now, Clozaryl is another medication. It's an antipsychotic that's been highly effective for patients for hallucinations and delusions and Parkinson's.

[00:27:52] And it may worsen the motor symptoms, but not significantly like some of the typical antipsychotics that we've had in the past. However, Clozaryl or Clozapine does have to have frequent blood testing because there's concerns of low white blood cell count. And we don't want to create a weakened immune response for other infections.

[00:28:15] Other medicines like Seroquel, also known as Quetiapine, are frequently used for patients who have dementia associated with hallucinations and Parkinson's. But it could make someone very sleepy or tired, and it could potentially at certain dosage create worsening tremors or rigidity.

[00:28:34] Now, some of our colleagues from the dementia world, our Alzheimer's world, for instance, we may bring medicines from there to think better, clearer, focus a little bit, bring more attention. So, donepazil, rivastigmine, also known as Exelon patch, we may utilize that to help patients think a little bit more clearer. And so, those are type of things that are medication-wise that we would introduce. But first and foremost is let's get rid of offending agents.

[00:29:04] And can the Parkinson's-related dementia be a momentary reaction to infections? So, it hasn't developed for long term, but it's just because they're having an infection at that moment that they're having these hallucinations and delusions. Exactly. Exactly. And so, we see that it aggravates the system. The infection is very troublesome when it gets into the bloodstream or affects the brain.

[00:29:35] You know, it's actually more common than we realize, but those are the kinks in the armor for the Parkinson's patient. And when that area of the brain has been irritated, they were more sensitive to such infections. But once you treat it with antibiotics, all of a sudden, patients are better. Okay. All of a sudden, but I mean over like a week or two. And how do you help patients preserve dignity when these symptoms appear?

[00:30:01] Yeah, you know, I think this is the whole purpose of these podcasts, right? It's like we want to promote education. We want to understand and counsel family members, patients. We want to continue to preserve dignity in general about the disease state. There are a lot of patients that come out and they tell people, like they're celebrities that have come out. This is April and April is Parkinson's Disease Awareness Month.

[00:30:27] And so with April coming out, we've already seen so many celebrities have come out saying, hey, you know, I want to just share my health and let you know that I've been diagnosed with Parkinson's. And we're seeing this like on different social media platforms. Well, patients want to also share that they're doing well because they want to preserve their dignity. They want to show that I can still play music or I can still act or I'm still playing sports. And despite being diagnosed, I can still do the things we need to.

[00:30:55] So when we now start talking about preserving dignity with Parkinson's dementia or Parkinson's psychosis and hallucinations, it really kind of hits home where people feel like I'm causing more trouble or now I'm needing much more support. And we want to make sure that we understand there are ways of managing it. There's ways of treating this, but we want to quietly correct the issues at home. We want to make sure that we approach a patient's overall health properly,

[00:31:23] whether it's proper lighting at night, maybe it's also getting to sleep early, maybe avoiding medicines like Benadryl, avoiding pain medicines at the wrong time. Because patients can look well during the day, but even at night, they're taking out other medicines. Now the brain's more vulnerable. So the dignity part of it is we want to validate. We don't want to infantilize this. We don't want to argue with someone.

[00:31:48] We don't want to make someone in a confused state already feel more frustrated. So talk to them like an adult. Speak to them with much more directness. Don't want to make it so confusing as well. And talk to them one-on-one, not necessarily in front of other people when this is bothering them. And also, you know, we want to bring this up with the doctor, but don't bring it up right away in the doctor.

[00:32:14] Make sure it's discussed with the patient well before the doctor's visit. Say, hey, you know, remember you were having some visual disturbances, seeing some animals or insects. I want to make sure that this isn't a specific problem related to some other medicines or anything else that's going on. So we want to maintain our privacy, respect the situation, but then also bring it up so that it's going to be discussed properly.

[00:32:40] Patients don't want to be told from the doctor that, oh, your family brought this up. It's a shock. And then that can create a rift as well. So we want to also give choices. We want to make sure that the patient feels like they've not lost control of their mind. Give them an approach about that. This is manageable. Let's do small steps to get into the right way of thinking. And again, normalize the symptoms.

[00:33:07] These symptoms are not because someone's schizophrenic and going crazy. This is actually part of the disease state that can be managed or adjusted. Hallucinations and delusions can be some of the most distressing Parkinson's symptoms. Not because they're rare, but because they're rarely discussed. If today's episode gave you clarity or comfort, please share it with someone who may be struggling in silence.

[00:33:36] Early understanding leads to better outcomes and no one should face this alone. Thank you for listening to The Caring Neurologist.