Mental Wellness & Connection for Veterans with Parkinson's

Crista Ellis 00:00:02
Hello and welcome to the Parkinson's Foundation's webinar on Breaking the Silence on Mental Wellness for Veterans with Parkinson's. I'm Crista Ellis, your host for today's webinar, and helping me behind the scenes are my colleagues Danielle Agpilo and Laura Cameron. Today's program brings awareness to the symptoms that are often unspoken among veterans with Parkinson's. We will address the real impact of loneliness and isolation, offer strategies for managing post-traumatic stress disorder, and provide guidance on overcoming fears associated with symptoms. We'll also share resources and support options designed to relieve isolation and nurture meaningful connections.

Today's webinar and the entire veterans webinar series is presented with support from the Don and Lorraine Freberg Foundation. We want to take this moment to thank the Freberg Foundation for helping to make these programs possible.

The mission of the Foundation is to make lives better for people with Parkinson's, whether you are living with Parkinson's, caring for someone with Parkinson's, or working to end the disease. We are here to support you. To achieve our mission, we pursue three goals: improve care for everyone with Parkinson's, advance research toward a cure, and empower and educate our global Parkinson's community. Today's program is a great example of one of the things we are doing to help us meet these goals.

The Parkinson's Foundation hosts weekly education and wellness programs through its PD Health at Home virtual programming. Join us for Mindfulness Mondays, Wellness Wednesdays, and Fitness Fridays. Most of the PD Health at Home programs are recorded and posted on the Parkinson's Foundation's YouTube channel. You can scan the QR code on the screen to connect to that YouTube channel, or find out more and register to attend our live PD Health at Home programs at Parkinson.org/PDHealth.

Part of the Foundation's commitment is to reach every person living with PD. A critical way we do that is through our partnerships. With more than 110,000 veterans living with Parkinson's disease, the Foundation is proud to have established a formal partnership with the Veterans Administration. This partnership has the overarching goal to improve the quality of life for veterans living with Parkinson's disease and their care partners through greater access to education, resources, and support.

I'd like to invite you to visit our webpage and explore the resources offered by the Parkinson's Foundation that can support your navigation of living well with Parkinson's as a veteran. That website is Parkinson.org/Veterans.

I'm happy to kick things off by welcoming Dr. Ellen Bradley.

Dr. Bradley is an assistant professor of psychiatry at UCSF Weill Institute for Neurosciences at the University of California, San Francisco. Dr. Bradley, thank you for sharing your time and knowledge with us today.

Dr. Ellen Bradley 00:03:00
Of course. Thank you so much for that, Crista. Really kind introduction, and thank you so much for inviting me to be here. I really appreciate the chance to talk with you all today. Like Crista said, I'm a medical doctor trained in psychiatry at UCSF, and I split my time doing research and then working with patients who have PD in our clinic. It's great to be able to be here speaking about this topic, about mental wellness and connections, especially for veterans, who I work with quite a bit. As a psychiatrist who's working in movement disorders, I think about this a lot: How can we help to promote wellness? How can we help folks strengthen connections when they're living with PD?

Today, we'd like to have two parts. First, I want to talk a bit with you about what the problem is, how PD can lead to isolation and can create this disconnection, especially for veterans, and the additional challenges that can come with being a veteran. Then we'll have a brief break, and when we come back, I'd like to jump into what we can do about this problem. What are potential solutions? Then I'd love to hear questions from this group, especially folks who are actually walking this walk, living with PD and trying to navigate these challenges.

All right. Before we get started, I do not have anything to disclose.

Okay. Why are we even so worried about this problem of isolation and disconnection from other people? Why is it such a big deal? Why are we having a whole session about it today with you all? The bottom line is, and this is true not just in PD but actually for all of us, we know that isolation and the feeling of social disconnection are really bad for our health. Feeling more isolated and lonely actually has these real negative consequences. In PD in particular, we know that it can make people's symptoms worse.

It's also associated with faster cognitive decline, and it can put people at risk for developing even more medical problems on top of PD. Problems with their cardiovascular system and with their mobility, just to name a couple. We don't know exactly how the problem of isolation negatively affects health, but there are some theories that possibly it's because it can really disrupt our sleep. It can also disrupt our body's natural stress response, and it also may even impact the way our immune systems function.

Feeling isolated is really not good for anyone.

Dr. Ellen Bradley 00:06:14
A challenge for people living with PD is that the symptoms of PD can do a lot to really feed isolation. I'm sure that folks here are already familiar with this analogy that PD can often be kind of like an iceberg. There's this big chunk above the water that is kind of what we all think of most readily when we think of PD: the motor symptoms, the slow movements, the tremor, the rigidity. But then there's this bigger part that is kind of hidden under the water that is harder to see, and a lot of people don't even know about. Things like sleep problems, fatigue, pain, cognitive issues, autonomic problems like changes in blood pressure, hallucinations, and then anxiety and depression.

This is because, as you all know, the degenerative process in PD impacts a lot of circuitry in the brain, not just the circuitry that is responsible for our movements. More and more, we think of PD as really not only a movement disorder, but a complex neuropsychiatric disorder because of all of these things.

I think we can all agree that each of these different symptoms of PD can contribute to folks feeling isolated and disconnected, right? Physical limitations from the motor symptoms, having trouble speaking loudly and clearly, being distracted because your phone is beeping, reminding you that it's time to take levodopa, a tremor that's interfering with eating when you're trying to have a meal with your friends, feeling self-conscious about shuffling when you walk. All of these things can really mean that it's not surprising to us that a lot of people with Parkinson's can become isolated.

Sometimes we feel that if we limit our contact with the outside world, then we'll have less to worry about, less explaining to do. That feels a lot easier in the moment: the ability to just avoid situations that can make you feel different from other people.

Even though all of these issues that people experience with PD can contribute to isolation, so really they'd all be relevant to what we're talking about today, I want to focus in a bit more on these mood changes, on the depression and the anxiety, because these can often be the hardest to see. They're like the deepest underwater. Sometimes they're the last thing we doctors and other providers even ask you all about. But that really shouldn't be the case, because these are so common in PD.

We think that it's probably well over half of people with PD that are dealing with anxiety or depression. Many are dealing with both. It's really, really impactful. These mood changes are associated with having a faster cognitive decline and a faster physical decline, and they're actually even stronger predictors of quality of life with PD than how severe your motor symptoms are.

Dr. Ellen Bradley 00:09:47
Even though they're so important, they're so often under-recognized and therefore undertreated. Like I said, that's why I really want to talk about them today. Why do we think that mood is so important? Mood can color our view of everything on this list, of the whole experience of having PD. I think that's how depression and anxiety can end up keeping people from living well with PD, and can contribute to that isolation, that lack of social connection.

I was working with a patient a couple of years ago with PD, and he was telling me that he was really bummed that he wasn't going to church anymore. Church had been a huge part of his life, and he had a social community there. He really loved going regularly, but he stopped going. He told me a few times that he'd stopped going because of his tremor. He said, "It's really the tremor. That's the reason why I can't go to church."

I started to ask him more about this. I was like, well, what do you mean? How exactly does the tremor interfere with you going to church? Then he said to me, well, I think about what other people around me in the pews would think. That they might get freaked out. They might not know what was going on, they might think something was wrong with me, and they would stare at me, and then I would feel self-conscious and it wouldn't be enjoyable at all.

We talked about this for a while, and what we really came to was that it wasn't exactly that tremor was standing in the way of him going to church and enjoying himself. It was really anxiety about that whole experience. He was really able to focus on tackling the anxiety in order to get back to doing something that he liked to do. Just an example of how mood really does influence our whole view of our experience.

We used to think of mood changes in PD as, I think, purely a psychological reaction to having this very difficult disease. There's a lot of appeal to that view because, of course, it's very intuitive. It's very hard to have PD. It is stressful and challenging, and so it makes sense that people would feel anxious and depressed.

But we know now from a lot of research that that is probably not the whole story of these mood changes. We think that the mood changes may actually be part of PD itself. There are several changes that are happening in PD that also are related to our mood. I'll just quickly go over some of them here.

Dr. Ellen Bradley 00:12:29
One thing is imbalanced monoamines. Monoamines, of course, are these chemical compounds that act as neurotransmitters in our brains. The monoamine that we think about most in PD is dopamine, but PD doesn't just impact dopamine. It also is impacting other monoamines like serotonin and norepinephrine. All of these are really important for maintaining a healthy mood.

Another thing is what we call decreased trophic support. Trophic factors are these proteins that are super important for stimulating the growth and survival of our cells. They're really important for brain health. We know that these are reduced in PD, and we also know that they're very important for mood as well.

Another thing is dysregulation in what we call the hypothalamic-pituitary-adrenal axis. This is this hormonal communication system that's responsible for regulating our body's response to stress. This is also struggling more in PD, and we know that regulating a stress response in a healthy way is important for our mood.

Inflammation in the brain: we also think that this is something that plays a role in depression and anxiety, and we know that it is a huge part of what's going on under the hood in PD.

Lastly, this idea of oxidative stress. That's the imbalance between these unstable molecules in our bodies called free radicals that can harm cells and protective antioxidants. When we have that imbalance, that oxidative stress, that leads to our mitochondria, pictured here. Mitochondria are these little organelles that live in our cells, and they're the energy powerhouses of our cells. This oxidative stress makes the mitochondria less effective at meeting our energy needs.

This is something that's happening in PD, and we also think it could be related to mood changes. We don't know yet if one of these mechanisms or all of these mechanisms might be a contributor to mood changes, but these things might explain why it's so common that we see the mood changes that we do in PD. We're hoping that research in the next several years can shed more light on this issue.

Dr. Ellen Bradley 00:15:41
Really important for our focus today, something that we have learned from research in the past few years is that dealing with PTSD or having a traumatic brain injury, a TBI, actually raises people's risk of developing Parkinson's years later. There's research that has looked at hundreds of thousands of veteran records to understand this. We don't exactly know how this link might work, but it's possible that these war-related illnesses like PTSD and TBI could kick off changes in the body and the brain that drive the development of Parkinson's disease later. It's possible that this is related to our system for managing stress in the body, as well as levels of inflammation in both the body and the brain.

Regardless of what the mechanism underlying this relationship is, this finding, this research tells us that the veterans who have experienced PTSD and TBI are more likely to develop PD. We really want to think about their particular challenges.

As you may know, there's quite a bit of overlap between PTSD and TBI symptoms. With PTSD, of course, the things that we think of as being quite common are hyperarousal, or feeling on edge all the time; having re-experiencing of traumatic events, either in nightmares or flashbacks; and social avoidance, kind of steering clear of situations that might feel triggering.

With TBI, people may often have headaches, dizziness or balance problems, and can also have impulsive, kind of uncharacteristic impulsive behavior.

Symptoms that are found in both PTSD and TBI that I want to highlight are, again, depression and anxiety, so these mood changes; irritability; difficulty with concentration; and insomnia, as well as fatigue. This disrupted sleep often leads to insomnia and fatigue.

I highlight this because many veterans, if they are dealing with PTSD or TBI or both, may already be dealing with some or all of these symptoms, often for years before they're even diagnosed with PD. If we look at this list, I think we can all imagine how a lot of these problems here can contribute to making people feel more isolated.

Dr. Ellen Bradley 00:18:39
I think that the reality is that many veterans have been dealing with the consequences of these symptoms, and one of them is isolation, for a long time, even before they're diagnosed. We don't always do a good job of recognizing this, right? Sometimes people, humans, can be so good at adapting to symptoms over time, adapting their lives around the symptoms, that we don't even catch that these things were going on before someone was diagnosed with PD.

I worked with a veteran a while back who had PTSD for many, many decades, but he told me that actually the PTSD wasn't really a problem for him anymore. I was like, wow, that's great, it's not bothering him. Then we got to talking about stuff he liked to do, and he told me that his favorite thing in the world was watching baseball games.

I asked him what was the last game he went to, and he told me, "Oh, I haven't been to a baseball game in over 30 years. I can't go to a baseball game. It would be too triggering. I would have PTSD." It's interesting. In his mind, he was like, PTSD isn't an issue for me, but he had been taking these steps so long to avoid the symptoms that he'd ended up distancing himself from things that he really, really loved, like going to baseball games.

Just some quick points here before we go into taking a break. The things that I really want to highlight today are, first of all, that mood changes are so common in PD, and they are so important because they're linked to lower quality of life. We often don't recognize them, so they go untreated for too long. This is really important because we know that these mood changes, one of the ways that they negatively impact people's quality of life is that they contribute to isolation. They reduce social connection.

We also know that these mood changes are not something that folks with PD can just shake off. We think that they may actually be part of PD itself. They could be related to changes that are happening in the brain. We really want to treat them just like we treat other symptoms of PD, trying our best to improve them because we think that is going to help people live better with PD. We'll talk more about that after we take a break.

Dr. Ellen Bradley 00:21:36
Lastly, symptoms of both PTSD and TBI, which are very common in veterans, can make it harder to manage PD because if you've been living with PTSD or TBI already, you may already be feeling isolated. You may already have stepped back from social connections even before receiving a PD diagnosis. Then PD can come with its own mood changes, and that can make it more challenging for folks to feel resilient and to be proactive about living well with PD, about taking good care of themselves.

Okay. I'm going to go ahead, and if it's okay, we'll go to the break now. Take five minutes, and then when we come back, we'll talk about what we can do about this problem. I'm hoping to be able to leave some additional time for questions at the end.

Crista Ellis 00:22:37
Thank you, Dr. Bradley. Now we're going to offer a quick five-minute stretch and movement break led by Sydney Boggs from Beaufort Memorial's Delay the Disease Program. Feel free to step away from your computer or stay and participate. We'll see you back here for the second session with Dr. Bradley in about five minutes.

Sydney Boggs 00:23:15
Today, what I'm going to do is show you a glimpse of what we do in Delay the Disease. I'm going to start by getting you guys warmed up. We're going to do a few balance exercises, and then after that, we should do a few stretches. All right?

To start, what we're going to do, you can either do these in a chair or you can do them standing. We're going to do some high knees. If you're in a chair, you can kind of scoot to the edge of your chair and just lift your knees up. If you are standing up, you can get beside your chair, hold on to it if you need to, and you're going to lift those legs up as high as you can, keeping your core nice and tight.

We're going to do this about 20 times, and I think I'm about on six. We're going to go seven, eight, nine, ten, eleven, twelve, thirteen, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, twenty. Good.

Next, what we're going to do is have a seat, and we're going to do sitting jumping jacks. Just like you did in gym class, you're going to start by your side. When your arms go out, your feet go out. All right, same here. You're going to do about 15 of these too. Three, four, five, six, seven, eight, nine, ten, eleven, twelve, fourteen, and fifteen. Good.

Again, you can either do these next exercises sitting or standing. We're going to get our smaller joints warmed up. We're going to start with our wrists. We're going to hold our wrists out just like this, and we're going to turn them in a circle. Try to keep your wrist, not your whole arms. We're going to do a few rotations one way, and then we'll switch opposite directions and do them the other way. Same thing, about 10 or 12 on each side.

All right, good. Shake those arms out a little bit. Next, we're going to do big arm circles. You're going to go big arm circles forward. Try to get a full range of motion. Make big circles with your arms.

We're going to go backwards doing the same thing. Three, two, and relax.

All right, if you're already seated, great. If you're not, go ahead and have a seat because we're going to warm up the ankles next. What you're going to do is put one foot out, and just like we did with the wrist, we're going to go with the ankle. We're going to start by going to the right, doing about 10 each side. Four, five, six, seven, eight, nine, ten. Then we'll switch to the left foot, same thing, going to the right. Try to make an O with your toe. Four, five, six, seven, eight, nine, ten.

Sydney Boggs 00:26:17
All right, from here, you're going to extend your leg. We're going to work from the hip. We're going to try to make big circles with our legs, trying to get as much as we can. Going to the right, four, five, six, seven, eight, nine, and ten. Good. Switching legs, same thing: one, two, three, four, five, six, seven, eight, nine, and ten. All right.

For the next exercises, we're going to be focusing on balance. What I'm going to have you guys do, you're going to stand to the right of a chair, and if you need help with your balance, it's fine. You can just hold on to the chair. If you don't, that's fine too. But the goal here is we're going to go into a staggered stance. You're going to start with your right foot forward, your left foot behind. Have your feet about six to eight inches apart, okay? I don't know if you can see, but they are kind of diagonal from each other. My left foot's behind me.

What you're going to start doing is you're going to rock, come forward on your toes, and then rock back on your heels. We're going to do this about 10 times, coming all the way up and then all the way back. Four, five, six, seven, eight, nine, and one more. Ten. Good.

Now we're going to do the same thing, but we're going to lead with our left. All right? Our left foot's in front, our right foot's behind us. Same thing, six to eight inches apart, staggered stance. Coming up on our toes and back on our heels for one, two, three, four, five, six, seven. Good.

All right, shake those legs out a little bit. All right, guys, that is all I have for y'all today. I hope you enjoyed it, and thank you guys for having me.

Crista Ellis 00:28:35
Thank you, Sydney, for guiding us through movement just to get our bones and joints and muscles moving around a little bit before moving into our second session with Dr. Bradley.

Dr. Bradley, thank you again for joining us today, and I look forward to learning more from you as we continue this webinar.

Dr. Ellen Bradley 00:28:59
Thanks, Crista. All right.

Okay, thanks. Can you hear me now?

Crista Ellis 00:29:10
Yep, I can hear you. Great.

Dr. Ellen Bradley 00:29:12
All right, great. Thanks, and thanks for that great break. That was really nice. We should do that in all of our long meetings and presentations.

What can veterans with PD do to improve their mood? I want to talk about this because we just talked a few minutes ago about the problem of isolation and the fact that depression and anxiety are really big contributors to that problem. That, I would say, is the bad news: that those problems are quite common in PD and that many veterans were already dealing with those problems even before they had PD.

The good news, however, is that mood can change. We have a lot of great ways to help people improve mood and tackle depression and anxiety. I really encourage people to think about which strategies we talk about today speak to them, and consider trying some of them out. We don't have a cure for PD right now, but that doesn't mean it isn't hugely important for folks to be doing everything they can to, I think of it as kind of putting money in the bank.

It's easy for us to, we don't always think of tackling depression and anxiety this way, but often it's easier to think about the example of physical therapy, right? I think we all know physical therapy is so, so important. And PT, why? Because even though it's not curing PD, it is doing a ton to help people build physical strength and build resilience. It doesn't mean the PD goes away, but of course it can mean that living with PD will be a lot better. People can fall less, and they can be less likely to get injured if they do fall.

Same with our strategies to improve mental health and reduce isolation. I think of them the same way. It's like if you can put this money in the bank as early as possible when you have PD, that's fantastic to really build your resilience to the challenges of living with the illness. People who are able to do this, to invest in getting more connected socially, tend to have better access to information about best practices and things that work for other people in their community. That can really help people dial in their own treatment. They also tend to get much more emotional support, which we know is really hugely helpful as people are dealing with different challenges. The disease is always changing, it's always throwing a new curveball, and it's really great to have that support from others.

Folks who get more socially connected also tend to be able to manage stress, change, and loss of function in healthier ways, and to bounce back faster when they deal with a physical setback. Also, being more connected often leads people to be able to seek out opportunities to help others. They tend to think more about what it's like in the shoes of others. We know that taking the opportunity to help other people can often offer physical and mental health benefits to ourselves. It feels good to help other people, to be useful in our community. All of these are potential benefits to think about when we're thinking about why we want to reduce isolation as much as possible.

I wanted to talk about a few of the key strategies that we use to support mood in PD. This first one is what we call behavioral activation. This is a technique that is really grounded in the idea that there is a vicious cycle of inactivity, withdrawal, and isolation that contributes to mood problems. Here we're showing depression, but the same is true with anxiety. If we can break that cycle by gradually helping people increase their level of activity, people tend to feel better about themselves and have a brighter outlook on life. It tends to create this virtuous cycle, and then people tend to want to do more of the things that are important to them.

This all, of course, sounds good and looks really intuitive. We all want to go from a vicious cycle to a virtuous one, but we know it's easier said than done. This behavioral activation can be really, really effortful to begin with. It can be really hard to get started and to break out of that bad cycle.

I like to think about it in a few clear steps, just to break it down, and I think really everyone can do this. Everyone can find a way to make this work for them. The first thing that we do is identify a pleasant activity. This doesn't have to be something that feels like it's going to be a mountain to climb. I always recommend that folks start small. Just think about something that is pleasant for you to do these days. That's it. Keep the bar pretty low to start.

Dr. Ellen Bradley 00:35:16
This is a really important step. Then you schedule the activity. This is so important because we know that PD really does a number on motivation, right? That's one of the primary issues in PD. Our motivation diminishes, and that's because of the loss of dopamine in the brain, right? We know that it's really critical to create this scaffolding that can support activity. It's very common that folks feel in the moment like they don't want to do anything, that they don't have that motivation. This is why we really encourage people to schedule the activity. The idea is you're going to put it on the calendar, and you're going to just do it, regardless of whether you feel like doing it in that moment when that time comes. Kind of like taking medications.

I don't think that when we think about taking regular medications, we decide every time it's time to take a pill, 'Do I want to take this pill or not?' We usually just make the decision that I'm always going to take this pill at noon every day because I know it's going to make me feel better. I'm just going to do it. We try to treat activities the same way.

Okay, the third step is doing the activity. Again, even if you don't feel like it in the moment, it's time to do that. Here is a Tai Chi class, and you're just going to go do it.

Then the last step is just to notice. Just start noticing your mood after you do the activity. We've found through a lot of research that even though PD can really reduce our motivation to get up and do the thing, almost always, once people have gotten up and done the thing, they do feel better. That has huge benefits for getting into that virtuous cycle of doing more things that you enjoy and feeling better about yourself.

Just to highlight some options for ideas for these behavioral activation techniques, like I said, we want to start small. We want to keep the bar low. Of course, exercise, any form of exercise, and any kind of movement are always great. We want to support it, but these are a few ideas for pleasant activities that patients I've worked with have come up with in the past. As you can see, a lot of them are really simple: taking a bath, listening to a song you like, playing with your pet, talking to a friend, looking up at the night sky, or watching a funny YouTube clip. I had a patient who loved to watch cat videos on YouTube.

Those are the kinds of activities to start with. Then this technique really builds on itself, and people find that they're able to do more and more.

Okay. The second thing that I think about when I think about ways to improve mood in PD is cognitive behavioral therapy, or CBT. This is a technique that is based on this idea that when we develop unhelpful ways of thinking, that leads to a poor ability to cope with stressors, and then that limits our functioning in the world. The idea in CBT is that by changing the thought patterns, by changing the way we think, we can help the mind get out of some cognitive ruts and pave new, better roads of thinking. That can really make people feel much stronger in terms of their coping, and that will help them improve their functioning and do more of the activities that they like, like we just talked about. That ultimately helps reduce isolation and build social connection, right?

Usually CBT is offered as a pretty structured approach. It's a kind of therapy where you usually have a set number of sessions, and it can vary. Sometimes it's as few as five sessions. It might be as many as more like 20, but usually it's quite structured. It's not really the kind of therapy where you are lying down on a couch and just talking in an unstructured way. It's kind of like a training program, and there's usually homework to practice these skills. I think it's actually quite easy to compare it to physical therapy. It's kind of like physical therapy for your brain to help it get out of those ruts into healthier patterns of thinking. It takes practice, but there has been some really wonderful research in PD showing that this is really helpful for folks in terms of reducing their depression and anxiety and improving function.

Dr. Ellen Bradley 00:40:40
Then the third thing that I want to highlight, the third piece of addressing mood issues in PD, is of course treating them with medication. This is a really important option to consider. There are quite a few different kinds of medications that we use to help with depression and anxiety in PD. They range in terms of how they work, so there is often a good fit for a lot of different people. If there's something that you try and you don't like, there's probably another thing to try. There's a whole array.

These medications are quite safe to take in PD. You can take them with levodopa and other medications that you might be using for motor symptoms. They can really, really help people feel more resilient, less like they're on an emotional roller coaster.

I always say to patients that they're not happy pills. Medications for mood do not kind of, it's not like you snap your fingers and you suddenly aren't going to feel depressed or anxious anymore. What I would say that they do is, or at least this is what patients with PD usually say to me, they say, 'Taking these medications gave me what feels like a thicker skin to deal with that roller coaster, to deal with what's coming my way, and it let those things not have such a big impact on me.' That's what I think they can be helpful for. Combined with something like behavioral activation techniques and CBT, they can do a lot in terms of increasing activity, increasing engagement, and letting us connect with the people that we care about.

Really important just to highlight quickly: if you're thinking about medications, finding the right medication for mood and the right dose can take time. I always like to highlight that because I think it can be really frustrating that so much of treatment for PD in general, we still have to do through trial and error. That is hard. Unfortunately, the medications that we have for mood don't work quickly. They don't work on the order of hours or even days.

Kind of very different than how levodopa works, these medications for mood tend to work on the order of weeks to months. I always talk with patients before we decide we might start, say, a selective serotonin reuptake inhibitor for treating depression, and say, 'You're not going to feel better in a week, and probably not in a month either. This is a slow process.'

We don't really know why these medications do work slowly, but we just see there's a lot of evidence that folks really have to be patient, and then gradually that effect builds. In addition to just giving the medications enough time to work, and I always tell people that we're really talking about trying them for at least two months to see if they're beneficial, we also usually start at quite low doses and then gradually step up the dose.

For instance, if somebody tries a medication, like the one I mentioned, an SSRI for their mood, but they only take it for two weeks at a very low dose, we really have no information about whether that is a medication that could help them. It's just not enough time, and it may not have been enough to see any difference.

I always encourage folks, if you want to try to find a medication to help with mood, just know going in that it's going to take some time. If you can stick with it and be patient with it, and really wait to see the effect, you have a much better chance of finding the medication that is a good fit for you.

Dr. Ellen Bradley 00:45:35
We talked about three things. We talked about behavioral activation, we talked about cognitive behavioral therapy, and then we've talked about the medications. We can talk in more detail about any of those during the Q&A, but I just want to say, sometimes when I talk to folks in clinic, it's interesting. Sometimes people feel like they have to choose. They have to choose a treatment strategy if they want to work on their mood, if they want to improve depression or anxiety. I would encourage you to think of these options as a buffet and to try whatever is available to you.

Some folks get a really good effect from one medication. Other people work on just behavioral activation for a while, and that's really helpful for them. Some people find that doing behavioral activation day to day, doing ten sessions of cognitive behavioral therapy, and combining that with two different medications, that's the best fit for them. That gives them the best effect. Everyone's body is of course different. Everyone's experience of PD is different.

I think it's really important to just know that all these options are out there, and you don't have to choose between them. You can do all of them. You can try all of them. You may find that some are more helpful at certain times. Sometimes, for instance, when we have patients in our clinic who are facing a particularly difficult patch with PD, we recommend maybe doing that course of cognitive behavioral therapy, maybe doing those 10 sessions to try to build that coping, strength, and resilience to be able to manage the challenges that are coming with the illness.

Okay. The last thing I'll say before we get into questions is, if we want to really work on reducing isolation and strengthening our social connections in PD, we have to advocate. Advocate for yourself as the person with PD, or also if you're here because you have a loved one with PD. I think we're still in a place with PD care where, like I said at the beginning, those problems that are at the very bottom of the iceberg underwater don't always get as much attention. They can be more hidden. There's less awareness of the mood issues in PD and how those contribute to people getting isolated.

It's really important, I think, for all of us here to try to be advocates for making sure that we're paying attention to that problem and that we are trying to tackle it with proactive solutions. We know that when we have visits for PD care, I think everyone is familiar with this. Everyone knows that they're going to do a motor exam, right? This is a key part of your visit with a provider for PD. You never miss that.

I really want us all to keep front of mind that that is not the only thing that we need to be attending to in PD, right? We have to be thinking about the whole experience of the disease. This is especially true for veterans. We know that if people came in already dealing with PTSD or TBI, they may have a bigger burden of those mood symptoms. They may be facing an additional challenge in terms of building that resilience, staying connected to other people, and avoiding isolation. I really encourage folks: bring this up in your visits. It's a critical part of being able to live well with PD.

Providers, I can tell you, learn so much from people who are actually living with the disease, people who have that lived experience. Help educate us. Try to engage your providers as much as you can in brainstorming with you. 'Hey, this is becoming an issue for me. I see the way it's taking a toll on my health. Let's brainstorm strategies for how to tackle it. What can we do?' I hope that what we've talked about today has given a couple of ideas, but I'm going to stop here and open up so we can have more of a discussion and hopefully I can answer some folks' questions.

Crista Ellis 00:50:16
Thank you so much, Dr. Bradley, for your insights and the way that you encourage us to understand that this is a part of our life and navigating Parkinson's, but also in our history of being a veteran and service to the United States. Thank you for making those connections for us, offering us an opportunity to explore resources, and educating us on what this means for someone living with Parkinson's as a veteran.

We have a few questions that came in. The first question, Dr. Bradley, our attendee asks: How does acute PTSD, particularly experiences of anger and stress, impact the symptoms and progression of Parkinson's?

Dr. Ellen Bradley 00:51:06
Yeah, that's a great question. In particular, you said acute symptoms, including the kind of, could you just say that part again?

Crista Ellis 00:51:18
Acute PTSD, experiences of anger and stress.

Dr. Ellen Bradley 00:51:22
Anger and stress. Yeah, okay. I can't cite too much research on this particular issue, but I can say from clinical experience that I definitely feel like anger and stress are acute symptoms as part of that emotional roller coaster that can come with depression, anxiety, and PTSD. There's a lot of overlap between these disorders. I think that roller coaster absolutely exacerbates symptoms.

I think lots of patients will report to me that when they find themselves feeling angry, feeling more stressed, or maybe feeling anxious, they feel like all of a sudden they have more tremor. They feel like they might have more freezing. They really are making that connection. I absolutely think that is true.

How those symptoms of anger and stress affect disease progression, I think we know less about. Like I mentioned, there's this hypothesis that maybe one of the things that happens is upregulation of that stress response all the time. Obviously, we always want a stress response. That's something our body is designed to do. It's really important. Managing stress is not inherently unhealthy, but when it's an upregulated stress response all the time, which can happen in PTSD, what we think is that maybe that starts to take a toll on the body over time. It's possible that that does relate to disease progression in PD.

It's possible, like I talked about, we know there's that dysfunctional HPA axis, that hypothalamic pituitary adrenal axis, in PD. We know that there's elevated inflammation in PD. It may be that stress over time contributes to those problems. It could be that it kind of serves to accelerate them, but that's something that's still being figured out.

Crista Ellis 00:53:41
What can, or how can, our veterans impacted with Parkinson's disease develop stress-reducing habits?

Dr. Ellen Bradley 00:53:51
I think there are a few different ways. Like I said, I would encourage people to consider the whole buffet. I think the first thing to do is to understand where you're at. I find that many veterans have maybe not been diagnosed with PTSD or anxiety or depression, but they have been dealing with those symptoms for a long time.

Whether it's through your VA or, if you're not in the VA, you're seeing other providers, either way, I would encourage folks to just start by bringing up those symptoms so your providers can start to get a handle on, 'What's going on here? Does it seem like PTSD is a big driver here?' Because then that would help guide you toward more of the treatments that we use for PTSD. That is a really important first step.

There are some things that everyone can do on their own without seeing a provider, like the behavioral activation. People can also do things like mindfulness exercises and breathing exercises that a lot of folks find really helpful to reduce stress. But I would encourage folks to report those symptoms to their providers because there is this buffet of treatment options. It may be that actually doing something like cognitive behavioral therapy, there are particular types of cognitive behavioral therapy that are designed for PTSD that are a really good fit for folks with PTSD, and that could really help. Maybe that combined with a medication could really help bring down that chronic level of stress that's affecting the brain and the body.

Crista Ellis 00:55:45
You mentioned CBT, and one of our viewers, Linda Marie, and her husband are joining us today. She writes in and shares: Can a person with Parkinson's still benefit from CBT if they experience cognitive decline and slow processing?

Dr. Ellen Bradley 00:56:04
Such an important question. Thanks for bringing that up. I think the short answer is yes. I think it's really good that there's a lot more attention to adaptations of CBT for Parkinson's in recent years. Like I said, there's this great research that's being done, some of it in the VA, where people are trying to engage folks with PD more and more in cognitive behavioral therapy and understand what are the best adaptations to make it a good fit for folks with PD.

It is a cognitive therapy at the end of the day, though. I wouldn't say that for folks who maybe are at a point where they're dealing with dementia, it may not be a good fit. I think there's a lot that we can do. We can slow it down, accommodate slower processing, space it out a bit more, and do shorter sessions. There are a lot of adaptations that can be done. I'd really encourage folks to talk about it with their providers, to talk about whether it would be a good option. I think, yes, it's absolutely still worth pursuing and considering.

Because it is a somewhat cognitively demanding therapy, I'll say, it is something that, that's one of the reasons why when we talk about putting money in the bank, it's one of these things that we do encourage folks to do even if they're not totally sure, 'Do I need it right now?' We always say, 'Go ahead, if you can, and invest in it.' I think that when we build those stronger coping skills, we carry them with us forward into the future. I do encourage folks to try to access it early if they can.

Crista Ellis 00:57:57
Is there a way that we can filter or find a CBT-certified therapist who understands the unique challenges of Parkinson's disease?

Dr. Ellen Bradley 00:58:11
That's a great question. I would love if that were available. I don't know of a site off the top of my head that does that, but I will definitely ask some of our CBT providers.

I would say, in the absence of a website you could go to, trying to access a CBT therapist or a CBT group through a movement disorders clinic is probably going to be the easiest way to do that. What you really want is providers who, although there isn't a separate certification at this point for CBT for folks with PD, you are probably more likely to get connected with somebody if you go through a movement disorders clinic that they refer to again and again. Someone who does have a lot of experience working with older folks.

I also think it doesn't have to be PD. You can find CBT therapists maybe through a geriatrics clinic as well. Folks that are just used to working with an older population that may have different kinds of neurodegeneration that they're dealing with. I'd say try to ask through those providers for referrals.

Crista Ellis 00:59:44
Connections, right? Through people that we trust. If there's a provider that we trust who is a movement disorder specialist or works within the movement disorder clinic, that would be a great place to start. Thank you for highlighting that, Doctor.

Another comment and share from Linda Marie. She shares that she's wanting to learn how she can encourage her husband to engage and stay motivated while also respecting his autonomy and managing his own care. She wants to be sure that we all know that they're both here listening. Thank you, Linda Marie, for being here.

Dr. Ellen Bradley 01:00:21
Thank you. Yeah. This is such a big question. It's really important and obviously comes up a lot in our clinics. This is really hard. It's really hard, and it's very personal, I think, where people feel those boundaries are.

One of the things that I often talk about with patients is the idea that enhancing, increasing activity, helping folks get more motivated, or at least even if they don't feel motivated, to still be able to do that behavioral activation and do more things that are important to them, can often be helped by taking the pressure off of the relationship.

What I mean by that is, the reason that we really harp on that idea of it's so important to schedule activities and it's so important to create this structure is because once you create a calendar, it helps to make a little distance between you and your loved one with PD and often that tension felt like, 'Can you get up and do this? I want you to do this.' Just making it a schedule that you've made, you can print it out or put it on the fridge, whatever is a way that you know you'll both be reminded that it's there.

It can help us give some scaffolding, rather than having to have that debate in the moment, which can be quite challenging for a relationship. I always encourage folks, if possible, to sit down during a time where you are least stressed, during a time where you're doing something enjoyable already, and make that map of structured activities. Again, start really small because I think we always set ourselves up for failure if we start too big.

I always actually say, start with things that almost seem too silly to schedule. You know what I mean? Like it's kind of trivial. On Tuesday, I had a patient who scheduled going outside to sit and drink his coffee on the front porch in the sun for 10 minutes at 7:00 a.m. He's going to do that for three days this next week. It's probably not the kind of thing that he would have put on his calendar a few years ago, but now with the motivational challenges with PD, with the fatigue he's dealing with, and with the low mood, it does really help to schedule it.

It helped his partner. They put it on the fridge, they marked it down, and now his partner feels like they don't have to be nagging, bothering, or trying to push so much because it's already a schedule that they've agreed upon. They set alarms to remind him of when it's happening. That's something to think about that may be helpful.

Crista Ellis 01:03:38
That is a very useful tool, and acknowledging that it does take effort and it takes work and communication to get to this point of agreement between partners. The question I'll offer is, are you willing to put in that effort to make your wife feel more at ease and the conversations feel more peaceful when the time comes to committing to whatever activity it might be that you or your husband need or want to do? It takes time and effort to get there.

Dr. Ellen Bradley 01:04:11
Yeah, I love that. Thanks.

Crista Ellis 01:04:14
Many veterans are used to being self-sufficient. How can we shift our mindsets to seek and be willing to accept support?

Dr. Ellen Bradley 01:04:28
Great question. Like I said, I definitely have worked with a lot of veterans where I am just floored by what they have been able to withstand and deal with, right? It's very common that they will tell me that, no, they've never gotten help for any of this stuff. They feel like that's good. That's what they were supposed to do.

I think that really trying to keep front of mind that living well with PD takes an incredibly proactive mindset and set of skills. There is a lot to be done to live well with PD, right? It's a big job. When I'm working with veterans, I try to frame it that way. Some people feel like it's difficult to, quote, ask for help. If that idea feels really hard, then think about trying to take as much control as possible of your health and wellness, if that's a better framing. Part of taking control and being proactive with your own health is making sure that you are supporting your mood and supporting your social connection as much as possible.

It is part of this job if your goal is to live well with this disease. Sometimes, actually, the diagnosis of PD can be the thing that pushes people over that hump, right? Realizing that they have been dealing with and surviving with maybe these problems, like PTSD symptoms, for a long time. Sure, they can get by, but are they going to be able to live well with PD now? Maybe not.

That sometimes pushes people over into that more proactive stance of, I can have a much better quality of life with this disease if I get appropriate treatment for these very real illnesses, whether they're illnesses from war or sometimes they're not directly from war. Still, the consequences are the same when you have PTSD. I think recognizing these are very real problems with very real health consequences, we know that there's a ton of research showing that, and they really deserve the same attention that we give your tremor and your gait.

Crista Ellis 01:07:28
I've often heard in my years of working with and advocating for people with Parkinson's that it's not the motor symptoms that impact our well-being and our livelihood. It's the unseen, the unspoken symptoms. That speaks to the importance of breaking the silence of what's happening in here and in here that goes beyond the flesh and bones that we see externally.

Dr. Ellen Bradley 01:07:55
Yes. It's so easy, right? It's so easy for all of us to focus on the stuff that feels more tangible. You can see a tremor. You can see issues with gait. It's harder to deal with the stuff where we can't quite see it, but it's so important. Just because you can't see it doesn't mean it is not harming your body, right? Getting back to the way you all titled this webinar, I think that idea of breaking the silence, the veteran or the person a few minutes ago asked how to shift that mindset. One of the ways to shift that mindset is to break that silence. Don't try to shift it alone.

Consider showing up at a support group. Drop in. Hearing from other people who are having the same experience or navigated it a few years ago is incredibly powerful in terms of people realizing, 'Oh, I'm not alone in this,' and 'Oh, lots of people are doing lots of things. What can I learn from this person? What can I learn from that person? Oh, that doesn't sound like that would work for me, but that sounds really good.' It can be a really motivating and helpful data gathering mission. I also really encourage people to do that.

Crista Ellis 01:09:16
We have an interesting question here. I'm just wondering if you've noticed a difference in mental wellness from the generations of veterans that you may be treating in your practice, Dr. Bradley, if you've noticed a difference in the generations of veterans with their mental wellness.

Dr. Ellen Bradley 01:09:35
Oh, interesting. I like that question. I think I'd say that, often, like I mentioned a bit about this earlier, a lot of the folks I meet who are older, who maybe are veterans from Vietnam or even earlier, many of them, because there was less availability of support at that time, unfortunately, than there is now, have been dealing with the consequences of something like PTSD for a very long time.

I'd say one of the challenges there is that sometimes because of those untreated symptoms, folks, like the guy I mentioned who didn't go to baseball games, have narrowed their lives and their social orbits and have become more isolated or are staying in this much smaller, safe-feeling orbit. I think that can be a real challenge, thinking about how do I re-expand that orbit safely, which may mean that symptoms that have been dormant for a while because you've been avoiding having them by keeping this small orbit, those symptoms might start to feel a little more present.

That's why I really encourage those people. I'm like, even if it has been decades since your injury and you have never gotten help from a psychiatrist, a psychotherapist, or a counselor before, now is still the time. Now is absolutely the time because that will give you a safe environment where you can work on fighting that isolation and work on re-expanding.

I think that's something that we often see, especially in the older generations of veterans. I hope it's changing for the younger generation as there's more awareness of injuries like PTSD and TBI and their consequences, and hopefully better treatment right after people have these initial injuries.

Crista Ellis 01:12:06
We're getting more questions about CBT, Dr. Bradley. Thank you, Gregory, for sharing in the Q&A. They're sharing that he himself is a veteran and his wife has Parkinson's disease. The question that he offered is, would CBT help us together? Then they followed up with, my wife just left. She doesn't think that CBT would be helpful. I'm curious, Dr. Bradley, if you could speak to perhaps the resistance or hesitation of doing what we call thought work and how you need to be prepared to come into that mindset of being willing to shift the way that we think about things.

Dr. Ellen Bradley 01:12:54
Yeah, absolutely. Look, it's hard to initiate any treatment. It's hard to initiate especially one that you know is going to take practice and some homework. There isn't a CBT pill that we can take. I totally understand that. We also know that the toll that PD takes on motivation makes everything feel harder from the get-go, right? Often people can do a lot more than they think, but usually in a non-PD state, we rely a lot on our sense of motivation, that sense of a reward of what's going to come in the future.

It's harder with PD to generate that motivation. It's really so understandable when people are like, 'That is overwhelming. That's too much.' What I would say is that something I really like about CBT, and the same is true with behavioral activation, is CBT doesn't start by, you don't come to whether it's group or individual, you don't come into the room and the therapist says, 'Now it's time to shift your mindset.' That is not what happens.

It is a gradual, stepwise process where you really learn techniques. You learn strategies, just like when you go to PT and you learn some exercises. The real work is then, each day, you do a little bit of practicing that. Just a little bit. You're not living your life totally differently. You're not changing your whole schedule. You're just trying to bring in these new skills where you are starting to become a little more aware of certain thoughts and those cognitive ruts and practicing stepping out of them. Just practicing little by little.

Over time, I think people find that they experience quite a shift in how they see themselves and how they see how they're doing, right? Like that guy going back to church, that patient that I worked with, right? Over time, he did just feel differently about whether he should go and what if he got really bad, what if he was shaking really bad in church. What would happen? He ended up deciding that was okay if that happened. That was okay. He could cope with that in a few different ways, and he came up with those strategies. That allowed him to then do the thing he wanted to do.

I would always tell people, don't start by thinking, 'Oh my God, I have to shift my mindset.' All you have to do is show up and start this little kernel of noticing and shifting. The CBT therapists are going to help you figure out how to do that. You don't have to learn it yourself. There are ways that they help you practice that in small ways, but it's really gradual and stepwise.

Crista Ellis 01:16:15
You're reminding me of a phrase that my therapist offered me when I was going through CBT. She said to me, 'Little by slowly,' again and again.

Dr. Ellen Bradley 01:16:28
I love that. If we had a T-shirt for CBT, that's what we should put on it. That's great. Exactly.

Crista Ellis 01:16:40
I'm keeping an eye on our time, Dr. Bradley. We have about eight minutes left to share with our community and a couple of questions here. There are a couple of questions about medications. Are you in a place to respond to questions about medications?

Dr. Ellen Bradley 01:16:55
Sure.

Crista Ellis 01:16:56
Several of our community members are asking if you could share some medications that work well with Sinemet that treat symptoms of depression and anxiety. They wrote in here, 'I've heard that some can worsen dyskinesia.' Could you address those?

Dr. Ellen Bradley 01:17:18
Yeah, absolutely. I'm not sure about the dyskinesia. I wonder which medication, if you can tell me which medication you might be thinking of, that might jog my memory. What usually stands in people's way is that sometimes there are certain medications that primarily work on serotonin that, not just in PD, can cause tremor.

That's something that sometimes people are like, 'Oh no, I can't have that.' I think the thing that is important to know is, first of all, that only happens in a minority of people. That does not happen in most people. It's not happening in most people with PD when they start these medications. The second thing is, it's not a worsening of Parkinson's. If you do get some tremor related to those medications, it resolves when you stop the medication. I don't want people to be worried that this is somehow worsening their illness. Like I said, we don't see it that much.

The medications that we use to treat mood in PD mostly come from the way we treat depression and anxiety in non-PD patients, just in the general population. There are medications a lot of folks are very familiar with, like the selective serotonin reuptake inhibitors. Examples of those are medications like escitalopram, or Lexapro; sertraline, the brand name is Zoloft; and fluoxetine, the brand name is Prozac. All of those are in that class.

There are other medications that are not only serotonin but also norepinephrine reuptake inhibitors. They work a little bit differently, more involved with this other neurotransmitter, norepinephrine, which is also important for mood. Those are duloxetine, the brand name is Cymbalta, or venlafaxine, the brand name is Effexor. Then there is another class of medications that we give, we just have people take at night. Mirtazapine, or Remeron, is one that we often prescribe for folks to take at night.

Dr. Ellen Bradley 01:19:47
That's a medication that, the reason people take it at night is because it is a bit sedating. It can help with both mood and sleep. It also can boost appetite a little bit, so it's often a very good fit for folks with PD because it gives you that, dealing with three potential problems at the same time.

There are other ones. If people have specific questions about one, there's a newer medication that came out a few years ago that's now, I think, more widely available called vortioxetine, or Trintellix, that is helpful for mood but also seems to have some benefits for cognition. The way that we usually approach this, as you can see, even just within medications, there's a buffet. There's definitely this buffet.

The way that we usually choose a medication to start with is we look at the combined effects. The serotonin norepinephrine reuptake inhibitors, the SNRIs, like duloxetine and venlafaxine, we use a lot in our pain clinics to treat pain. They don't just treat mood. They also seem to treat chronic pain, especially when it's nerve-related pain, which a lot of folks with PD are dealing with.

If I see a patient who is dealing with some depression, dealing with some anxiety, and also has chronic pain, I might suggest, let's try one of these SNRIs because it might help with multiple problems at once. That's really how we do it. It's very individualized, usually, the way we select medications. Like I said, we want to give each one a couple months, but if one doesn't work well or is not a good enough fit, we try another one, maybe one that has a slightly different mechanism.

They are also okay to use together. A lot of times, we will use, say, maybe that medication that I just mentioned, one of the SNRIs, but maybe somebody is also still struggling with sleep, so we might add a little bit of mirtazapine, or Remeron, at bedtime to try to help them get a little bit more sleep. It might help with mood a little more at the same time. Sometimes you get these synergistic effects between medications, just like when you're treating motor symptoms, that give certain people a better result.

Crista Ellis 01:22:21
Thank you, Doctor. What's obvious in your response to that question is there are so many resources, whether it's medication, cognitive therapy, outdoor therapy, singing your favorite song, or sitting down and creating a schedule. There are ways to manage our mental wellness, and there is an effort that's required on behalf of ourselves to get us there.

We went pretty deep into the medications in that last response, so I'll just encourage folks to browse the Parkinson's Foundation's website. We have whole entire webinars dedicated to understanding different types of medications, whether that's treating symptoms of depression and anxiety, low mood, apathy, dyskinesia, and gold-standard options for people with Parkinson's. I'll ask my team to drop a link in the chat to our recorded webinars for you to browse more in depth about medication options.

Dr. Ellen Bradley 01:23:24
Awesome.

Crista Ellis 01:23:25
Dr. Bradley, as we wrap up our time today, I'm curious if you have sort of a pearl, the most important piece of advice that you could give to a veteran who's struggling with emotional and social challenges of living with Parkinson's disease.

Dr. Ellen Bradley 01:23:45
I think the most important thing that I want to get across as a doctor who has worked with veterans quite a bit is, you really deserve treatment for these symptoms. Feeling isolated and lonely is not just something that people can necessarily shake off or tackle on their own. Like we focused on here, underlying problems like depression, anxiety, and PTSD are often driving that isolation and loneliness.

I really want veterans to feel and know that they absolutely have earned and deserve treatment for those problems, and we have a lot of treatments. Please bring them up to your providers, whether it's in the VA or outside the VA, and let's try to get you connected with these treatment resources that are the best fit for you. We'll show you the whole buffet.

Crista Ellis 01:24:50
Yeah. Thank you for highlighting the importance of what's available to our community of veterans living with Parkinson's disease, Dr. Bradley. Thank you so much for sharing your time today. Such a pleasure to hear from you and to work with you, and I hope that our community will continue to be curious about their mental wellness thanks to your inspiration.

Dr. Ellen Bradley 01:25:14
Thank you so much for having me. Thanks, everyone who joined. I really appreciate everyone's time today and the fantastic questions that I think will probably be helpful to lots of people watching. Thanks.

Crista Ellis 01:25:26
Today's webinar and the entire Veterans Webinar Series is presented with support from the Don and Lorraine Freberg Foundation. We want to take this moment to thank the Freberg Foundation for helping to make these programs possible.

The Parkinson's Foundation wants to hear from you through our PD Story page. The Foundation shares stories written by anyone in the Parkinson's disease community. These stories help bring awareness to this life-changing disease and help to inspire others. As a veteran or the loved one of a veteran, your experience with PD is unique. We encourage you to submit your PD story and share your experience with others in the community. To learn more and to submit your PD story, you can visit Parkinson.org/MyPDStory.

Don't forget to visit our webpage and explore the resources offered by the Parkinson's Foundation that can support your navigation of living with Parkinson's as a veteran. That website again is Parkinson.org/Veterans. There were a few questions that we weren't able to answer today, things like how to get connected with a therapist who knows Parkinson's disease, or looking for a movement disorder specialist that you know and that you trust. If you have a question that did not get answered today, do not hesitate to reach out to our Helpline by calling 1-800-4PD-INFO. You can also email them at Helpline@Parkinson.org.

Our Helpline is staffed by Parkinson's specialists and can get you connected to resources in your area or virtually online in the safety of your home. All the things are listed here on the website. Again, we thank you for joining us today and hope to see you again soon. Be well.