for the memory of rainy afternoons swingy Harlan tools motor trips and burning lips and burning toast a memory of candlelight just let anything make sure that is in time has many times okay way too fast hey our next speaker is dr oh come on he is an assistant professor of neurology at the university of texas health science center and you think is speaking about near-normal disorders in part of disease so please give them a run applause thank you all right thank you so much everybody can hear me okay alright so what I am going to do today is I’m going to have a slightly different approach you’ve heard a lot about dementia and that’s certainly fall in the category of disorders that are going to discuss but I’m going to take the time to approach other common neurodegenerative disorders that you’re going to see in a clinic that effect in aging population I have no conflicts of interest to disclose so the objectives of this lecture is to describe this company most common neurodegenerative disorders and I’m gonna stay away from dementia you hear a lot about it so far and you cannot keep giving lectures about it later on I’ll review the classification of these disorders compare the similarities and differences between them and also discuss a palliative management of patients with advanced knowledge episode so what are those what is a neurodegenerative disorder know the jetty disease basically we use it as an umbrella or arrangement conditions and the basic pathological problem in that Texas ignorance ah all of them so far are incurable we had three minutes to alleviate symptoms how to match comorbidities but none of them as specific year yet and all of them are progressive and debilitating and their director eyes by progressive degeneration of the nerves and depending where they are located you can have different manifestations for example if you have a loss of neurons in the substantia you got parking services he had lots of neurons in the cerebellum is called as fine a circular in taxes we had lots of motor neurons we have ALS just to be with something so far by far dimensions are responsible for various version of this is beyond samer representing more than 50 cent per scott cases so what are the most common origin they’re only genetic disorders Alzheimer and associated dimensions Parkinson privacy’s falls into this category motor neuron disease Huntington spinocerebellar ataxia since Panama score a dream just to mention a few so as a group they shared different similarities one the interest are affecting specific subsets of neurons they tend to arise without any clear explanation without any clear trigger factor they are progressive they are age-related so by far they tend to be Seymour and other population and they are associated by pathological changes if you look at the brains of these patients that includes that there’s neuronal pathology in the runoffs out there that leads to the loss of disappearance of the rocks and valleys and it’s going to be replaced but we are proliferation basically scar tissue there’s a lot of kind of tipping variability between these disorders community environment and dimension are common for a lot of them but it’s not mandatory the major risk factor for all of them is advancing age and it’s not uncommon to see that they can share features with each other for example there are some types of frontotemporal dementia that can be associated with ALS and actually there are genetic markers

providers so you can have some overlap so this is how to classify them other disorders you have predominantly cognitive symptoms you establish Ibiza mestic so memory problems most likely Alzheimer disease it is it said to be dysfunction is probably a non on summer dementia and this you can subversive fly us to temporal dementia complex or their c-note apiece from the grant of the pinch dementia can be also differentiated from a psychological standpoint if they have positive tau protein capture and that includes ecstasy political base of the generation and progressive supranuclear palsy it is ubiquitin positive and negative you can have a typical frontotemporal dementia of the form of dementia air and see the similarities include Louis Ala convention dementia so silly with autism optical system absolutely now you have to know me asleep modern symptoms it is a movement disorder Parkinson disease is the most common we have three new photography disorders that includes for example parish ataxia Huntington disease in defined cerebellar ataxia and it is purely model and we fall into the category of motor neuron disease like primary lateral sclerosis progressive was for a trophy for ALS so what I’ll do is I’ll talk about the three of the most common errors in neurodegenerative disorders associated with dementia and the first one was compound all of them by pirates Parkinson disease and the reason it should this cartoon is there actually studies showing that caffeine intake and smoking is a protective factor of Parkinson know that I encourage you to start smoking but I Lisa gave me a justification to bring more coffee so Parkinson disease as prevalence is about 1% in older than 60 in about four percent while eh eh the mean points that is age 65 but you can range a lot there’s and young onset Parkinson’s disease the ratio of media powdery versus hereditary is 91 to mention there are some protective factor that caffeine smoky and there are some risk factor that have been associated there’s family histories of certainly a genetic component pesticide exposure of the associated with parties and repetitive editorial Parkinson’s so in this particular neurodegenerative disorder the primary pathologies in the substantia and these communications with the striatum and the brain stem so just to review the basic clinical features of Parkinson there are four basic components for the dinosaur Parkinson is for Bradley Kenisha which means a slow learner and I’ll show you a video but it like that rigidity that is something that you can elicit under a physical examination resting tremor which is very characteristic of Parkinson of artisans parkinsonian disorders and postural instability so we have four of those it’s very likely have parking now there are some other features that are helpful responsiveness to levodopa is also very suggestive of the classical Parkinson my program yet which means when you start writing it’s very small and salsa very how many Parkinson and asymmetry at onset is also very common so for a participation they usually say they starting on the right side professor ER transfers to the other if you have a patient at party center from the beginning is but pilot from it’s usually something else so sometimes you can make the diagnosis just by looking at the patient coming to your room shaking their hands you see the classical posture they can have resting tremor and you can see what they’re walking they tend to have this forward shields reduce on screen when the moon at the shocking game which is very characteristic so again this is just to review some of the basic findings in parkinson disease of basically they’re asking this patient to do prepare your movements like foot tapping this is on the web and compared to talk is gonna do it in the right so look slower product Asia in its AC method if you look how he’s walking you see that the right arm doesn’t move as

much as the left right this is a classical resting tremor or P warming it’s a little bit mark your money okay don’t worry about that that way we can shake I don’t like it but ever we can see how it okay according here so this one is from dyskinesias you see that he’s being asked to move his hand and he hung over his head in his legs this is a voluntary movement and these are dyskinesias it was by both mine the same here is us being asked to move his hands using on his legs open so when you have advanced Parkinson you go to is on and off symptoms and basically doesn’t stop basically any patients are very rigid very slow to move you see since I’ve been asked to just walk you see how stupid is that some freezing of the game it’s a short length is pretty much no arm swing and you can see the same vision welcome doing am on period so let’s itself in the same patients but this is an context age and you see that on and off typically in advanced stages of the disease when they’ve been receiving so in terms of the progression of parties and we know that there’s some preclinical changes usually patients are developing symptoms when you’ve lost about fifty percent of their neurons in the substantia then you get diagnosed hopefully and nobody’s called a honeymoon period which means you get symptoms you start medication you feel great sometimes they completely go away or of this ninety-eight percent but then d vinegar to be a time of war enough which means the medications are not as effective as they used to be so you start requiring more medications or higher frequent and increased frequency of higher doses and then you get into device called the motor complications which include the word enough they found out this condition on this occasion when the one that I show you the video they have some point ubaldo Park which is amazing stop being effective and open at the end currently define or dimensions to see which markets on can do so where are the some of the main differential diagnosis for parkinson essential tremors for about the most common this is a postural and action trailer so instead of the artisan which is at rest this montebello’s so you are sufficient to either montina posture always need to do something essential tremors doesn’t have any other neurological findings so there’s no rigidity that now interestingly intend to respond to alcohol again other encourage drinking but they feel better and frequently fifty percent of patient a family history of essential tremor so that’s also help vascular parkinsonism so we get into the parkinsonism which means they look like Parkinson but it’s not the classical form so if you have multiple strokes either major ones or small strokes in the brain you can develop faster parkinsonism it lets them have a more stepwise progression and you get to see focal neurological kindness related to the location of the scrotums an important one now that everybody is taking psychotropic medications parkinsonism we see that a lot and basically patient are taking the robotics and they look fly Parkinson their skiff of reaching the cuttlebug the tremors and basically you take them off and do the way asa e yes another one is the dementia with Lewy body see the key here is that the opposite of cognitive symptoms is very closely related to the bar symptoms usually within a year and they also have frequently visual hallucinations or later on they have prominent fluctuations and in a pension and commissioned in something that also taught you that so these are tell the red flags to tell

you this probably is not partisan if you have early hominin gaiden speech disturbances is probably not the classical Parkinson at the end of sleep disorder you have a lot of postural instability what that means is that they fall variously from the beginning in their rigidity is more the axial muscle than the lean muscles that’s also a typical for parkinson if you have fun in autonomic dysfunction which means bladder bowel sweating salivation erectile dysfunctional that it is very prominent very early that may suggest something like multiple system atrophy and whenever you see a patient that at the beginning doesn’t response to levodopa is probably not parties it’s probably something else so in terms of what kind of diagnostic evaluation you can do in these patients this is a review the common tests perform really the diagnosis of parkinsonian is a clinical diagnosis you quickly do an MRI to store all the things like vascular parkinsonism but again classical history the dark studies with PET scan our specs this is mainly used for research the spec can be useful sometimes to appreciate those cases of essential framework that may look very similar to parties and sometimes it’s hard to appreciate the spell can help you in we’re getting close to having several stories publish of looking to skin biopsies and you can measure their protein so you can measure opposite of lean protein in skin biopsy and although this is not clinical standards there are several reports showing that it can be an effective tool in the future for diagnosis of parties so in terms of treatment that you can use the first question that you have to ask is to boost our medications if a patient has very miles into the Parkinson you may not need to so the American Academy neurology recommences the treatment once there’s some type of functional disability and it can be something simple and patient have difficulty writing for example maybe not a lot of symptoms but is effectively Simone lifestyle and there are a lot of studies going to look for neuroprotective agents and patient sometimes ask you about that and the reality is now component has been established as your protected so what are the options one can occasionally use for parkinson the main stander easily was open are always dealing with a lead over the familiar avenues can be used or nao being inhibited so we’ll go over those so cowardly dog poly modify the gold standard for management of our concern is the most effective it improves his ability Valley has problems especially over time so long term use of levodopa and his patients is going to need situations which means destinations when they’re on when they’re very shaky or wearing out for the exterior region in the concomitant with all their non modern complications of the bow dr hypertension hallucinations can impart so the idea is into a patient is over 65 this is kind of an arbitrary number we tend to start with levodopa because the life expectancy and the time of onset of long-term complications is terrible favorable but if you have a young patient meaning 1555 you probably want to start with something up before food so the dopamine agonists that we have available pramipexole rope enroll the most widely used they can be as a monotherapy or as add-on therapy they can be combined with the others he has less risk of motor complication so that’s a big advantage disadvantage isn’t that it has affected he helps by not as powerful as keyboard over they can also have dominated symptoms nausea vomiting noticed a typo education neuropsychiatric symptoms can occur and those are interesting sometime they have compulsive behaviors impulsive gunman you described somnolence destination Lars effectiveness and the third group of vacation that you can use as a monotherapy will be the mao inhibitors selecting and recycling are the most commonly use if you can use it as monotherapy it has to be very massive mr. Parkinson it has a lot of interactions with other medications you gotta be very careful in Sipan in treat a possibility of service direct and as a measure they’re not as strong but you can use it as a pledge about medications

or something that you can a dimension now this Co empty hitters can be using combination valuable Appa only and the most common form of the point where we use anymore and the idea is when you’re starting to have modern fluctuation is on and off periods you can add one of these so you can reduce the amount of developing and giving and hopefully decrease that positively those motivations they can tell nonconformity are to study hypertension and giving discoloration now for certain simple you can use the specific medications like for this cognition you can use a method which is a three hitter for tremor just for the tremor it is a major problem you can use some tackle in your cheeks like best hope in your area the problem is they has a lot of poverty side effects so I can get issue in elderly patients but you have a young patient has a lot of tremor this would be a good option free see no day is a problem and videos showing you the person that a lot of difficulty starting to move there are centers strategies or physical therapists are very good at it and teaching patients certain tips to facilitate starting to moon so imagine you stand up in a star walking cane get the first step so that we can you can teach the patient to alter his distribution of body weight tries to kind of lean back and forth there are kings for example that have our laser point to the poor and just to have that visual stimulation to facilitate getting the next step they can use verbal or uninteresting like marching to a command like a soldier walking to music so there are interested in the therapist and teach patients of facilitating this prison of data can be very nice am in a in a lot of car keys of patients have non-motor symptoms that need to be addressed and that’s also very important fatigue a lot of patients complain about it until finally can be used now you have to be careful with the potential side effects of any day but it’s an option management of depression again very how many Parkinson there are studies with SSRIs and on SR eyes hopefully that’s a good evidence but you also have to worry about it the Connecticut and cognitive effects now patients that develop dementia so say with parkinson disease rivastigmine is FDA approved for this invitation and there are also stories with one episode or two study can potentially can be primary to the disease and impression with Parkinson can have it or can be caused by the medication that we used to treat it so if you think there is more a side effect of Education you can try to adjust it first other thing that you can use is compression stockings is water intake as long as you say and we have abilities yeah sure medication that you can use for symptomatic or just I have a pension in the green or to the courtesan and it can happen very Buster starvation hallucinations in parkinson so the same principle applies first think about it in CID medication-related not there are only two medications that I will use some patients with Parkinsons and hallucinations I remember you don’t need to treat all hallucinations and in those that are refractory for the treatment especially to be very aggressive behavior so gossiping is the most effective of all these medications the problem is there’s a FD a black box warning the use of Josephine associated with severe agranulocytosis and liver failure so in quite that you have to get CBC and our keys every week for the duration of finding which educating ideas are you thankful to do so the alternative is quetiapine and again is not as effective there’s a cause more somber less and but is there because it’s just easier to manage so don’t think of it you don’t use any of the others you will never use how the whisper down or any of those olanzapine because they’re going to activate the symptoms of parties so they on all of your photography if you are give you started the low dose and go up slowly do you have this problem into some woods we only start that way somewhere very low and graduate some patients with a very low though they’re right so you have to titrate but yes

that’s probably all of those and there’s no rush to go to her house and they kind of connects to this so non-motor symptoms also sexual dysfunction so they’re not happy news insomnia again going to be careful in terms of some of the side effects of sleep medications but there are studies with salted install opponents of melatonin is purely use just because you say there was a one more people study showing if he was effectively partisan they show our benefit you are in general monotony effect is stronger so there are medications vice are these safer to do ray behavior disorders commonly seen Parkinson Randy liver disorder means that the patient basically adds their dreams and basically you know during sleep when you’re dreaming you’re paralyzed so you can do and move on the Google your vines your breathing muscles but we ran behavior disorder you lose that ability to be paralyzed into means asleep and basically these patients that you have nightmares and they start kicking and fighting and jump video and usually the patient person the complaints about it is that why or the spouse because they are being attacked so for that type of behavior is pronounced upon monocular can use non-shared can be associated with a lot of the medication that we use for for parkinson’s that you can you compare them they tend some balance most commonly caused by medications they are some studies with balcony for this particular indication and then we get the surgery if I hear more and more deep brain stimulation being used for management of Parkinson disease so the idea of using the brain stimulation is to improve ops time in the average in the studies is four to six hours of improving on time so it may not see as much but having six hours of other day and you can actually move and is a huge difference for patients so who is a candidate for it and so far the indication is patients who still respond to little oppan so that’s important if a patient doesn’t respond at all even for 30 minutes or an hour to the device culinary academy then they have on and on filtration so they go through these periods of time or so much movement or not moving at all the dyskinesia this involuntary movements are affecting the quality of life that the tremor in persistent to medications and they have a good cognitive function so those are very indications consider different stimulation and it’s very effective in more or ears nowadays and then you get you all right what patients with Parkinson for which a state that none of these therapies are good option they had to think about palliative care and the principles of politic very patient with our concern are pretty much the same that in other conditions they want to relieve pain and other distressing symptoms is intended to facilitate here and some can be reserving a part of filter support system is not each team approaching the very psychological and spiritual aspect liberation so when you consider palliative care valuation officially Parkinson so there’s a classification that we use in Parkinson’s called upon a new year stage and because from one to four and the stage 3 which is advanced party some of the significant issues and ability played by after fifty both sides of the body so that will be a consideration patient our dimension associated or psychosis well then you see that the caregivers are going to a very significant difficulty managing patients so many difficulties referent infections weight loss of what they have multiple comorbid condition that I get very difficult to obtain so those are considerations to consider product and so in provided the politic especially provide emotional support caregivers support calculate communication difficulties manage the terminal symptoms in our swinging American so how predicting there is hard in any condition in Parkinson’s particular so the most common cause of the restoration amalia other frequenting comorbidities United fragrant urinary infections Falls delirium the only good predictor for death Parkinson is food refusal or needy seem excited context of delivery protection so if you’re going to manage in terms of

palliative care of this patient it will dress musculoskeletal pain which is common remember the species are very rigid so that they can develop contractures and those you can manage with therapies with a medication for pain so that’s what contraction opinions both laugh detoxic constipation common complain or six columns so you try to address all these symptoms that family the series buddy make a huge impact in topology apply yeah do they respond advances came back case it depends on we’re talking about palliative care yeah well it with into this dark early preventing some structures Estonia better idea than waiting for a person to happen but you know you very sick patients at any stage so at least I get an initial physical therapy evaluation acidic and impress some of these problems and I also i use therapy a lot in a different stages of the disease because our therapies are very good at addressing some of the fall prevention giving them strategies for managing that the freezing of gait for example dementia so I tend to incorporate therapy and during different stages of the disease which one viral etiology well it has been many different process of being addressed but there’s decided genetic factors and environmental factor that increase the risk of Parkinson no particular bars of being racist awesome all right so I’m going to jump two totally different neurodegenerative disorder and this is ALS and ALS as a neurodegenerative disorder and as I mentioned before affected and modern nerves so it’s probably causing muscle weakness in the basic mechanism is dysfunction of the upper and lower motor neuron so when I say upper motor neuron is the wonders of the brain that communicates with a lower corner of the spinal cord level and the combination of findings both upper and lower words what makes the diagnosis they have the capability to possess sensory function because the muscles of that can be the bulb or muscles this failure gazzara are very common and the different stages of in the initial presentation some others is later on weight loss is very common and they can also have symptoms of chronic type of installation because these patients have weaknesses or respiratory muscles they can / send me the morning headaches fatigue and some Lawrence’s so there’s some examples of one of the lower motor neuron finding is a trophy the loss of muscle sinew compared is a significant atrophy of the crystal in this comparison compared with it and you can see this a trophy in different parts of the body yokohama situations so one play that you always look at the time this son is a trophy is used to be a meanie of that basically you can see how it moves spontaneously so those populations are very suggestible kappa sig relations in wearing your body and depending on what modern iran is affected you can have different spectrum of the disease please mention classico ALS is upper and lower Bollinger but you have purely upper monitor of violence is both pls of family lateral sclerosis and that is the hell is slightly better prognosis compared to the classical a less attention survival no one motor neuron is fuel or more nervous for progressive muscular atrophy and it is purely Volvo equally progressive bulbar palsy again a lot of these two continues to progress the classic ALS so it’s just as easy starts away and sufficiently clear also a mess so how do we manage patients with ALS we we have multi-disciplinary and ALS clinics and that person has been shown to improve the care quality of life of patients and instances the incorporates neurologists whom our doctors therapies nutrition and psychological support social workers and

so the a the American Academy of Neurology recommends the use of the specialized multidisciplinary clinics for management of his patients has different studies have shown including health care delivery and prolong survival a lot of what we do in ALS is symptom management so patients can have is called pseudobulbar affect or PDA and basically is Colin emotional incontinence it’s patients who start laughing or crying without any particular trigger so we’re very minor triggers and it is crying a lot of times they probably think that they’re depressed and that’s why they crying so much but it’s just an involuntary release of emotions and there are specific treatments for that the combination has been effective in Salinas also salary is also very common because of the weakness of their former angel muscles so we can use some techno geeks scopolamine patch but Latin toxic injections to the salivary glands or for extreme cases radiation therapy no is prime so like yeah you see them I using like yawning yeah this is a crime and emotional and it looks like it’s a very intense emotion but the trigger is basically nothing but the very common in ALS he can be related to the deceased it can be a sign of chronic hep of information so you know this trick the ventilatory studies because that meanie a market to say that this patient is for a dog sitting area well at nine and they need some type of supported device you have to address other symptoms depression and anxiety pain cramps just the warm up ramps which I everything and not really helps much 20 water is something that you can recommend has a little planning on it there are studies with galloping in ruidoso Bimini specifically for cramps in ALS not been shown being affected in the publicity of quinidine for France but the FDA the salad is too risky because of the calculus corazon is not authorized is used oxide catalyst going specifically any provocation mms so you can use back open by sanity or vegetable settings or management of apostasy decreased mobility so that’s what we have therapists we use simple devices regulation or products we address the sergeant communication problems early on we are ok the use of voice fun so basically while the patient still has a complete communication reconsider voice and death can be use for future communication devices targeting permanent dimension can happen in any less not all patients but I mentioned before the association between certain types of and also patient without a particular pattern can also have fun there’s only one medication that it’s FDA approved for the treatment of ALS and it’s called realism the study shows you that improves our kissimmee free survival within two to three months so a very modest effect and there is no signal symptomatic improvement by the communication the two main things that you have to address impatient with ALS is nutrition and respiratory management so one of the most common question is when you can affect you number one if the patient is willing to wait on the scene for the nice art area is very prominent whether it is Rangers program now I really you want to put the paddock when you’re forced vital capacity still fifty percent or higher that decrease the risk of complications now that doesn’t mean that you have a qualified person or articles in the end up doing buddy hustle here is more risk of complications and I know there’s a lot of controversy if you have a pedicure with a terminal condition but really improves of quality of lab and caregiver in terms of management of this patient so we are advocating for the use of peaches when it’s necessary and the other is ventilation so you can have invasive ventilation I can suggest amine

or non-invasive ventilation and / non-invasive inflation is possibly affected in racing quality of life in patients with ALS you have signs of respiratory insufficiency in the use of our destiny is more controversial it depends on the wishes of the patient what I’ve seen is younger patients tend to go more to rest and all donations different and here is appointed wishes and at some point and patients are gonna require hospice care basically the star must be skating in to establish order for dnr you make up scene for patients who have progressive this page and then they don’t want to pick tubes when i start the velocities the hell progressives grand compromise even when ventilatory support those who have severe chronic pain and remember illness percent us in hurts but because of the lack of mobility they had frequently have problems with contractures joint pain common so you have to address that in the family is an able to care of the patients of their other medical problems are contributing to the status of the patient may not consider hospice to now medicare has very specific guidelines or hospice criteria for ALS so you have to have at least one of these critically for reading capacity as demonstrated by one of the following a false idol capacity has a ten percent is an arrest and also they can make mechanical ventilation number to a rapid progression and clinical nutrition in Carmen’s so a rapid progression means visions are quickly are joined from independent to will share it background and how fast is rapid that’s a little bit more adjustment period as a specific months progression from Norma to barley until she was age progression from normal for a diet or mean the major assistive or ideals of clinical nutrition environment is demonstrated by all of the following oral intake is sufficient amount in life from being weight loss dehydration or absence artificial feeding at the zoo and the third criteria is both rapid progression in Moodle life-threatening complications and vanity sort of registration in one year the kibbutz’s ulcers recurrent fever sometimes politics or inability to maintain sufficient fluid or anything so those are the criteria for Medicare in administration of the third normal geography circle huntington / here I better give you a little bit of so let me show you a fish in Korea so viciously huntington korea has three basic syndromes they have a dementia they have behavioral problems and they have the movement disorder which the most common manifestation is in Korea in Korea basically this involuntary about this Canadian movements that the patient can really control so that’s what they do is they try to incorporate for actual movement so for example if the hand starts moving they try to do something in the end just to kind of company you can have to rehab the face facial muscles that are so so Huntington disease is an autosomal dominant condition prevalence is 45 47 per hundred thousand the diagnosis is confirmed with DNA testing it’s pretty but remember ten percent have a previous family history you can have this for transportation and in the lucky ones so you have to have a family history to say that is high and the movement disorder area is the most by far the most common manifestation but they can have also been about other movement disorders like dystonia I applaud prime opportunity and actually in the younger John Kahn said Huntington and representing the friends they tend to have more than rigidity so they look more like parties and actual

for you psychiatric manifestations are very common the pressure is the most common but aggressiveness can develop in about fifty percent of patients at some point of the disease obsessive-compulsive behavior again very common and study and psychosis and the third element in the dimension memory loss slowly sponsors interestingly language tends to be preserve until later on of disease and they have early loss of executive function so that ye are the three min of Huntington in terms of a little carries the gradation or number they not severe ones and treat moderate sector to Monica stations and you make sure that the environment is safe this vision higher higher risk of suicide high risk of injuring themselves they have to be careful about that so nutrition is a big problem they had to spend about four to five thousand calories per day so you had bring a lot to compensate that kind of power it flows in often they help to remain a swallow difficulties so that makes it even more complicated now here you feeling to be much more controversial it depends on what stage of the disease the patient is what are the spectators of the fish finally sleep is a big issue Olson a pair of these patients you have to establish a very detailed feel at time 13 remember they have a lot of times obsessive compulsive behaviors so you have to work on that benzodiazepines may help with a sleeper inside for the movement disorder percent for the Korea tetrabenazine is a clear blue for this indication this is how you start orb of those in gradual increase side effects worsening depression and suicide ideation all the medications that have used for Korea Samantha psychosis as you mentioned the psychiatric symptoms are common the medication has been studied the mostest or not something that you can use the others parkinsonism if they have parties sometimes symptoms you can use the pub energy categories of levodopa or remember that can increase also your risk of hallucinations management depression with SSRIs or any specifics or books are wiser a lot of therapy shins in Japanese institution because of the significant dementia and psychiatric system the most common cause of it is the one has pneumonia infections and a lot of times patients have seen their parents died of the disease and you can imagine if you saw your mom or you’re going through this process of getting the methods it’s a county manifestation of the career and the other have their symptoms is extremely hard and also you have to admit any be a potential in the next generation can be affected most patients none sir I’m symptoms by age 40 that’s the most common age of onset so by that time you already have kids basis so we had to address those issues common signs of that the end is near weight loss despite high caloric intake repeat infectious or excessive sometimes so I think that’s it for today I’ll be happy to take any questions again there’s a lot of research being in all these conditions and if you should have more or understanding about what’s the cause of these disorders how they can thank you I just have a question about the I guess to clarify the main determining factor the difference between the ALS and Huntington ok als is purely a motor disorder which means is characterized by weakness in weakness of the eponymous elect muscle discovery muscles of Obama’s Huntington is a combination of a movement disorder when a simple men disorder is not witness is that they have this Korea brand Mars estonia they have dementia and they have the psychiatric symptoms and you happen to see those with my details so in terms of how you make the diagnosis any other

questions motor trips burning lips burning toast thanks father memory of candlelight wine castles on the right