What Families Need to Know About Lewy Body Dementia Diagnosis, Symptoms, and Hope

[00:00:00]In dementia with Lewy bodies, there is a different protein that builds up, and that protein [music] is called alpha-synuclein. And when they build together into big clumps, we call them Lewy bodies. The behavior and hallucinations are often very early, [music] and often way more so than it is their memory being a problem. And often the hallucinations are triggered by something. So, for example, a person might be sitting and watching television, and there's a lamp over there, but their brain will interpret that lamp as a person. Early in dementia with Lewy bodies, there are these big ranges of somebody seeming normal, and then somebody seeming terrible, and then somebody seeming out of things [music] a little bit. It can definitely seem like a psychiatric issue.

[00:01:06]>> Lewy body dementia affects more than a million Americans and is the second most common form of dementia in the country, but it may be the most commonly misdiagnosed. And patients are often told they have Alzheimer's or a psychiatric disorder or Parkinson's, sometimes even for years before the right answer finally emerges. Today, Dr. Levine explains the signs that should change your diagnosis and why they so often don't. Welcome back to What I Tell My Family. Dr. Levine, it's a pleasure to see you, as always.

[00:01:32]>> Thank you very much.

[00:01:33]>> This is a good good topic. I'm excited about this, too, because I know we've talked about this in other episodes that dementia and Alzheimer's are usually grouped together into one diagnosis, but it's actually pretty different. So, we're talking a little bit about Lewy body, and it's something I'm not familiar with, and I'm sure a lot of people haven't really heard this term, and if they have, probably don't know much about it. So, let's kind of hop right in and really get into what it is.

[00:01:57]So, what is Lewy body dementia and what's actually happening in the brain and how is it actually different than Alzheimer's at a cellular level?

[00:02:06]>> Yeah, so Lewy body dementia is actually fairly common, but as you mentioned, many people haven't heard of it.

[00:02:12]Probably the thing that drives it home a bit is that that is the disease that Robin Williams died from. And so that's I think many times how people sort of became aware of it. And as we've talked about before, dementia is really an umbrella term. So it just means something, some disease that is causing progressive loss of cognitive function.

[00:02:34]And there are many reasons for that.

[00:02:35]Alzheimer's is the most common and the second most common is this disease called dementia with Lewy bodies. And we've alluded to it a little bit in previous podcasts, but the idea is that many of these neurodegenerative diseases have proteins that build up in the brain. And so in Alzheimer's disease, we call those plaques and tangles. And those are caused by two proteins called amyloid and tau. In dementia with Lewy bodies, there is a different protein that builds up. And that protein is called alpha-synuclein.

[00:03:09]And what's interesting about alpha-synuclein is that all of our nerves have that protein. Scientists are still not 100% sure what the function of the alpha-synuclein protein is, but we think it's important in the way in which one nerve talks to another nerve. And they do that by releasing what we call chemicals or neurotransmitters. And this alpha-synuclein protein, the leading theory is that it regulates the way that one nerve talks to another. So it's a very critical protein for all of our nerves to survive. In some people, the protein undergoes a change. And when that protein changes, it starts to aggregate or bind together with other alpha-synuclein proteins. And so, it's a little bit like that old hair shampoo commercial. They told two friends who told two friends who told two friends.

[00:04:02]Over years and decades, those protein aggregates build up inside the nerves, and they cause the nerves that are important in memory and behavior and movement to become damaged. And so, if you look inside the brains of people that have died from dementia with Lewy bodies, what you see is a build up of these proteins. And those proteins are mainly the protein alpha-synuclein.

[00:04:31]And when they build together into big clumps, we call them Lewy bodies, after the French pathologist who first discovered them about 100 years ago. So, dementia with Lewy bodies means a person with a dementia where this alpha-synuclein protein is building up and causing the damage to the brain.

[00:04:50]>> Got it. And then, visual hallucinations are, I think, one of the most important diagnostic clues. So, what do they actually look like in a patient, and why do families often miss them or maybe never even mention them to a doctor?

[00:05:03]>> Yeah, so, as people progress through stages of dementia and even Alzheimer's disease, hallucinations can occur. But, they probably occur because of damage to certain pathways in the brain that allow us to understand what we see. So, if you think about it, if I'm looking at you, my brain is processing that we're having a podcast, that we're on a computer, and all these things are occurring so that my brain can understand what my eyes are seeing. In dementia with Lewy bodies, that system seems to be damaged. And so, it occurs very early in the disease course. In Alzheimer's disease, they can have hallucinations, but it's usually very late in the disease course. So, if you think of a patient or a family member that you might have known passed away from Alzheimer's, the first thing that starts to fail is really their memory. And then late in the disease, they can be aggressive or combative or hallucinate, but it's usually very much towards the end of the disease, when they're close to passing away. In dementia with Lewy bodies, it's almost the reverse. So, the behavior and hallucinations are often very early. And often way more so than it is their memory being a problem. And often the hallucinations are triggered by something. So, for example, a person might be sitting and watching television and there's a lamp over there. But their brain will interpret that lamp as a person. Or they might see a stuffed animal and they think it's a real animal. And so, because the other functions of their brain are relatively well preserved, sometimes they and the families just ignore it as a weird fluke. And sometimes, as you mentioned as well, they get labeled as being psychiatric. Because when people have hallucinations, that is one of the main symptoms of things like schizophrenia, because they hear voices, people tell them to do things. That's a auditory hallucination.

[00:07:11]Or people with psychosis will have visual hallucinations, like misinterpreting something for something else. And that very often is a symptom of a psychiatric issue. The big difference in dementia with Lewy bodies is that most people with psychotic diseases, like schizophrenia, present before they're 30 years old. It's a disease of younger people. Whereas dementia with Lewy bodies is really a disease of 50s and 60s very often. And so, call that late onset psychosis. And even with that, sometimes the psychiatrist will initially say, "Well, there's no other explanation because the patient's memory is good. And therefore, they're labeled as having a psychiatric disorder and treated that way."

[00:07:58]>> Yeah, it's definitely what I would think too if I hear like people are hallucinating, I would think it would be more like a psychiatric thing. And that's probably also hard to really diagnose cuz it could be different things that potentially like overlap or look like something else, I would imagine. Makes it more complex.

[00:08:13]>> Exactly. Yeah.

[00:08:15]>> And REM sleep behavior disorder, so acting out dreams, sometimes even violently, is often another sign. So, how early can that appear before any other symptoms start to show up?

[00:08:26]>> Yeah, so REM behavior disorder is a fascinating disease. And to understand it, we have to understand a little bit about what happens when we sleep. So, when we sleep, our brains go through different stages of sleep. We start in light sleep, we progress to deeper sleep, uh and there's three stages of that type of sleep. And then the fourth stage is what we call REM sleep. And REM sleep stands for rapid eye movement. And in REM sleep, our eyes move. You might have seen somebody sleeping and you can see their eye moving under their eyelid.

[00:09:01]But interestingly, our brains induce something that we call sleep paralysis.

[00:09:07]And the reason that our brains do that is that's when we dream. So, in REM sleep, we are dreaming. And if your body wasn't paralyzed, you would act out your dreams. So, if you were being chased by a dinosaur in your dream, you would try to run out of the bedroom. If you're being attacked by somebody in your dream, you might try to fight back. And so, people with REM behavior disorder act out their dreams because the part of their brain that we call the brain stem, which is supposed to induce sleep paralysis, is failing. And there may be other causes of REM behavior disorder, but far and away, the main cause of REM behavior disorder is the buildup of this protein called alpha-synuclein. So, we know that about 75% of people with REM behavior disorder, over the next 10 to 15 years, will go on to develop either Parkinson's disease or dementia with Lewy bodies. Because Parkinson's disease, dementia with Lewy bodies, and REM behavior disorder are all caused by the buildup of that alpha-synuclein protein. It's just what part of the brain does it start to build up in first. If it builds up first in the brainstem, the person will have REM behavior disorder, and then over years it may start to build up in the brain, and now they have the hallucinations and the memory issues of dementia with Lewy bodies. Or it may start in their brainstem spread to the deeper structures of the brain and cause movement disorders, which would be causing Parkinson's disease. So, all of these diseases are linked, and what's fascinating about REM behavior disorder is that it really is an early clue that a person is at risk for developing Parkinson's disease or dementia with Lewy bodies. So, it's very exciting for me, which is a big area of my research, because my hope is, well, if we knew this person was at high risk, 75% risk, of getting one of these brain diseases, what can we do to try to modify that risk, to slow down the progression?

[00:11:10]Right now, we don't have any medications that have been proven to do that, but we know there are some very important issues around lifestyle and wellness.

[00:11:19]So, diet and exercise and actually effective sleep, all of these things actually help slow the progression. And that's sort of given birth, if you will, to a whole field of neurology that we call preventative neurology. So, identifying somebody at risk and then treating them with what we have available to prevent the disease from progressing.

[00:11:42]>> Wow, and with fluctuating cognition, I'm not familiar with that, but that's also another hallmark. So, a patient can kind of seem totally clear one hour and severely confused the next. So, why does that pattern kind of get misread sometimes as something else maybe entirely?

[00:11:58]>> Yeah, so it is another very characteristic finding early on in dementia with Lewy bodies. Again, with any dementia, at the last stages of the patient's disease, they may wake up a bit and then become inattentive or sleepy and doze off. But again, early in dementia with Lewy bodies, there are these big ranges of somebody seeming normal and then somebody seeming terrible and then somebody seeming out of things a little bit. I don't know that we've fully understand why that occurs, but it is very much a hallmark.

[00:12:32]But again, if you think about somebody who might be severely depressed, they could seem fine one day and then the next day they can't get out of bed, right? And so, you can see how dementia with Lewy body patients might end up with a psychiatrist before they end up with a neurologist because the family's trying to understand in a 60-year-old family member, why are they so different from, as you said, one hour to the next or one day to the next? And then if you couple that with some of the hallucination issues, it can definitely seem like a a psychiatric disease.

[00:13:05]>> That's so interesting. Are there ever times where it can be both or is is that common or is that rare? Like let's say there is a psychiatric thing going on as well as dementia or Lewy body or anything like that?

[00:13:18]>> It definitely can. I mean, number one, you know, the incidence of depression, for example, in the US is very high. So, some percent of people who lived their whole life with depression will eventually get dementia with Lewy bodies. And again, that may make the psychiatrist's ability to recognize that more difficult because they have a pre-existing disease. It's a really interesting question at a broader level, which is now really being focused on in the research community, which is the idea that people may have multiple causes of their memory or behavior issues. So, just because you have Alzheimer's, doesn't mean you can't also get dementia with Lewy bodies. And we know there's a big overlap of diseases. And we call that co-pathology.

[00:14:04]So, we will see again at autopsy, when you can really study the brain, there are some people that had a clinical course that looked just like Alzheimer's, but they also have Lewy body dementia when they pass away or vice versa. Certainly, coexistent psychiatric diseases with dementia can make things more difficult. And another really important area, back to my focus on wellness and lifestyle, is as we get older, many of us have vascular disease.

[00:14:32]So, diabetes, heart disease, cholesterol. And again, just because you have, let's say, dementia with Lewy bodies, doesn't mean you also aren't at risk for strokes, which will also accelerate the disease process. So, this concept of keeping one's body and mind as healthy as possible is really critical as we talk about these diseases.

[00:14:53]>> Absolutely. And even speaking about that about how sometimes it may be hard to diagnose properly. And there's so many misdiagnoses. So, what's the most common misdiagnosis that a Lewy body patient receives before actually getting the correct one? And what are the real downstream consequences of potentially getting the wrong diagnosis?

[00:15:11]>> Yeah, so I think the two most common misdiagnoses, one would simply be Alzheimer's disease. So, a person's a little more advanced and someone just says, "Well, you have dementia and Alzheimer's is the most common form of dementia, so you probably have Alzheimer's disease. The risk there is significant because we have some FDA approved medications to treat Alzheimer's disease. But there is some risk to those medicines. And so you wouldn't want to put someone on those medications, which are designed to lower the level of the protein amyloid, unless that person has high levels of amyloid. So if we made the mistake and told a dementia with Lewy body patient that they have Alzheimer's disease, they might end up on, you know, somewhat risky medications without any benefit, because lowering amyloid in a dementia with Lewy body patient would have no benefit. So that's one category where there's a a big misdiagnosis. The other, as we've talked about, is really a psychiatric diagnosis. And there there is a bit of an issue, which is that some of the medications used to treat people with psychosis actually can make dementia with Lewy bodies worse. And so it is again very important to understand what we call precision medicine, right? To be as precise as possible, and not to say, ah, everybody with Alzheimer's has or everybody with dementia has Alzheimer's or everybody with psychosis has schizophrenia. Um we need to understand the patient better, and we have a lot of tools now available to make that diagnostic journey more effective than it's been even 10 years ago.

[00:16:52]>> And speaking about medication a little bit, there's a specific and dangerous drug sensitivity in Lewy body patients.

[00:16:58]So can you walk us through what medications can trigger a severe, maybe even life-threatening reaction?

[00:17:04]>> Yeah, so dementia with Lewy bodies and Parkinson's again run together because they both are caused by the buildup of this protein called alpha-synuclein. And what seems to be true in both diseases is that there is a loss of a chemical called dopamine. And we had talked about these neurotransmitters where one nerve is talking to another nerve by releasing these chemicals. And so one of them important chemicals in the brain is called dopamine. The trick here or the challenge here is that if people have psychosis, so they're actually hallucinating, and maybe they're becoming aggressive or combative because of the hallucination, the standard therapy for that is what we call anti-psychotic medications. So medications that really were developed for schizophrenia. And those medications predominantly work by blocking dopamine.

[00:17:59]And so they're called anti-dopamine drugs. So if you have a patient who already doesn't have enough dopamine, like a patient with dementia with Lewy bodies, and then you give them medications that block dopamine, they can have severe worsening to where they can't move, and it can even, as you said, sometimes rarely be life-threatening, and certainly can be life-shortening. And the worst-case scenario is that sometimes even a very short exposure to those medicines can really cause a very precipitous drop that isn't necessarily reversible once you remove those medications. So that symptom of psychosis, which in many people would lead toward the use of the anti-psychotic medications, is something we really avoid at all costs in people with dementia with Lewy bodies.

[00:18:48]>> Then, speaking about the diagnosis, right? How do you actually make the diagnosis? So what's the workup, and which tests most really separate Lewy body from Alzheimer's?

[00:18:57]>> Yeah, so in general, if you come to me as a neurologist, and you know, it's clear from the history that you and your family have seen some decline in your loved one's mental status and thinking and memory, the first thing that we do is we look for what we call reversible causes of dementia. It's not very often there, but sometimes it's caused because there are strokes in the brain. So, I've seen it in patients where they have a brain tumor and you can make them much better by taking the brain tumor out.

[00:19:28]There are vitamin deficiencies like vitamin B12 and inflammatory conditions and thyroid disorders. So, the initial sort of evaluation, which is very standard across all sort of cognitive issues, is an MRI scan of the brain to make sure that the structure of the brain looks okay. We do have now some very sophisticated software packed programs that many MRI facilities use where we can even measure parts of the brain. So, how big are your are the frontal lobes looking normal? Are the temporal lobes looking normal? Does an area called the hippocampus look normal?

[00:20:08]And we get the volume of the brain. That can be very helpful in addition to ruling out strokes and tumors and infections. So, it's usually an MRI scan of the brain and then some basic blood work. It's not too many tests, but to look for the diseases that I just mentioned. And that's going to tell us that for the most part, again, 90 plus percent of patients, all of that's going to be normal. That doesn't tell us that they don't have a dementia. It just tell us tells us that the structure of the brain and their metabolic processes are okay. Once we've done that, then we want to be really more specific. And this is where a lot of research has developed over the past 10 to 20 years. So, in the case of Alzheimer's disease, we now have blood tests that can measure elevations in amyloid and tau. So, very simple blood test. In the case of Alzheimer's disease, we also can do a very sophisticated type of X-ray called a PET scan to look for amyloid. And if there's too much amyloid in the brain in an Alzheimer's patient, we can see that.

[00:21:12]Over the past decade, there's been a huge breakthrough in the dementia with Lewy body diagnostic algorithm in that we know, as I mentioned earlier, that dementia with Lewy bodies is caused by a buildup of that alpha-synuclein protein.

[00:21:27]So, there are two ways in which we can look for that protein, the way that we look for amyloid and tau in blood.

[00:21:33]Unfortunately, there is no blood test for synuclein, but we can do uh and my lab kind of really helped pioneer this, a little skin biopsy. And by taking a little piece of skin, we can look at the nerves that are just below the surface of the skin, and we can see if this alpha-synuclein protein is building up.

[00:21:53]And that has turned out to be a very sensitive and specific test for dementia with Lewy bodies. The second test is by a different lab where we do a spinal tap, and we use the spinal fluid to see if that abnormal form of alpha-synuclein is present. So, these days the biomarkers for Alzheimer's and dementia with Lewy bodies really should allow physicians to be more specific, and then in some cases, as we mentioned, it might be both. A person could have amyloid, tau, and synuclein. And we are just in the process of publishing a paper to sort of talk about that.

[00:22:27]>> Wow, that's fascinating. It's That That must have taken a lot of really a lot of deep research to to get to that point, to really understand and figure all of that out.

[00:22:36]>> Yes. Yes.

[00:22:37]>> And so, when a family finally gets the Lewy body diagnosis after years of really thinking it was something else, what does that look like in your office, and what do they really need to hear first?

[00:22:49]>> So, obviously, it's not a very good diagnosis, and we don't have any medicines to cure or to really even slow down the course of the disease. So, the first thing, you know, in my office is being sympathetic, but also being honest because I think it's very important that patients and families understand what they're dealing with. And the worst case scenario is to wait until the loved one is very sick or really causing trouble to really get that answer and to understand what you're dealing with. So, I'm a big believer not in beating somebody over the head with bad news, but that knowledge is power. Knowledge allows us to plan for the future for ourselves and our loved ones. And so, what we tell people is that from the time of diagnosis, the average life expectancy is probably about 5 to 7 years. The symptoms are probably present for longer, but it generally there's a delay in that diagnosis. And to let them know that there are research studies going on and I'm always a big fan to have my patients participate in research studies, but that we don't have anything that's been proven yet to to slow down the course of the disease. So, that's that is the bad part of that conversation. I tell people very often getting bad news, which is been essentially sort of a a fatal diagnosis, is always going to be awful and it's always going to be depressing, but there's a big difference between depression and hopelessness. So, facing a fatal disease, whether it's cancer, Alzheimer's, dementia with Lewy bodies, is difficult, but it's my job to really let patients and families know all the things that we can do to improve a person's quality of life. That starts with, again, the lifestyle and wellness modification. So, diet and exercise and socialization and sleep really have been shown to have a big impact on a person's quality of life. And then also being able to plan with a person and their family, so if there are things that they want to do on their bucket list, that we help make sure that that can happen. So, again, they're not hopeless. They have something to look forward to. One of the things I tell my patients, regardless of what disease it is, when it is a fatal diagnosis, patients often want to know, you know, how long can I live? And I really try to take a very different approach, which is to say, let's focus on the next 3 to 6 months. What do you want to do in that time period that's going to make you happy and give you some joy? And then at 6 months, we can look at the next 6 months. And so, I can't predict anybody's future, like I can't predict my own future, and any of us could get hit by a bus tomorrow. But, the goal is really to always give people something to look forward to, and the families as well, because this is a disease that obviously affects the whole family.

[00:25:41]>> Wow, that is I mean, that's really touching. Like I I mean, that just made me a little emotional. But, that's touching because I think that with such a hard diagnosis, a lot of providers are not going to have that approach whatsoever. It's going to just be like, this is the diagnosis, and this is what you can do, and things along those lines. But, to really hone in on the quality of life, and like you mentioned, bucket list and things that they really want to do. And even though they have this diagnosis, still allow them to really have a good quality of life for the remainder of their life is is very niche, I would say, for sure. And I think that that's definitely what this show is about, too, and why you stand out in this field, for sure.

[00:26:18]>> Yeah.

[00:26:18]>> And so, let's say if we have a listener that suspects that their parent or a loved one might have Lewy body, but has an existing Alzheimer's diagnosis, what should they realistically do next?

[00:26:30]>> So, really work with, obviously, their their care providers. Hopefully, that's a neurologist, and there are neurologists that specialize in cognitive neurology or behavioral neurology. And that's really probably the best case scenario. Second best case is a just a general neurologist who's familiar with these diseases, and to really kind of point out to the doctor things that don't seem right for that diagnosis. So, for example, one thing we haven't discussed is that people with dementia with Lewy bodies often have some symptoms of Parkinson's because again it's the same protein, the same lack of dopamine. So, they have slowness of movement. They may develop a tremor.

[00:27:14]So, highlighting those symptoms, highlighting the hallucinations particularly early in the disease course, patients can have more trouble in dementia with Lewy bodies regulating their heart rate and their blood pressure. So, being aware of the symptoms of dementia with Lewy bodies that are different than the symptoms of Alzheimer's, and then just bringing that up to your physician, and then asking about the diagnostic test. So, asking about the skin biopsy or the spinal tap to see if the alpha-synuclein protein is at fault because that would allow the doctor then to say, "Ah, it wasn't Alzheimer's disease. It is dementia with Lewy bodies."

[00:27:52]>> And we touched on this a little bit, but what treatment options exist for Lewy body right now, and where is the research headed?

[00:27:59]>> So, right now there are some medications that are designed to increase a chemical called acetylcholine in the brain, and one in particular that does seem to provide some very good benefit for patients with dementia with Lewy bodies for a while. So, a year or maybe two, but I spoke to the physicians that really specialize only in dementia with Lewy bodies, and they tell me stories of a family that had to put their loved one into a nursing home. They made the correct diagnosis, got them onto these their symptomatic medicines, but got them onto these medicines, and they were able to come home for another year. So, really giving them again another full good year of an excellent quality of life. So, that's probably the most significant, you know, if you found out tomorrow, what would you do, those would be the medicines that your doctor would really think about. From a research standpoint, my lab is involved in many pharmaceutical trials. So, dementia with Lewy bodies a little behind Alzheimer's.

[00:29:01]So, in Alzheimer's we have the first drugs to lower amyloid. There are about 30 different medications in research studies now designed to lower alpha-synuclein. And that's really where kind of most of the research is going, which is finding ways to clear that protein out of the nerves, out of the brain, and hopefully improving the long-term prognosis of this disease.

[00:29:26]>> If there's one thing you could make sure every ER doctor and every primary care physician in the country know, just let's say one thing about Lewy body dementia, what would it be?

[00:29:35]>> Yeah, the most important thing is really avoiding those dopamine-blocking drugs.

[00:29:40]And even some medications for nausea, some of the older medications ERs use a million times a day, are medicines you really don't want to use in patients that have these synuclein disorders. And then obviously, as we talked about the antipsychotic medications, particularly the older ones that you don't want to use in these patients. So, as you said, I I think, you know, unfortunately, a large percent of the country and probably even a large percent of doctors are not that familiar with dementia with Lewy bodies, even though it is fairly common. And I think there's 1 to 1.4 million people living with it in the US.

[00:30:19]So, we we do need to try to raise awareness of how to kind of manage those people just on their day-to-day, if they come in the ER with nausea, if they're brought in by the paramedics because the hallucinations have gotten out of control. So, the ER doctors know what not to do because it can really set patients back.

[00:30:38]>> Wow, that is definitely something that I think needs a lot more awareness because it's If you don't think about that, I don't think that's at the forefront of most people's minds, especially where we are when it could be all these other things. And then knowing that have could have such a setback, I think it's it is so crucial to really spread that information and make bring more awareness to it. And before we do wrap up this episode, is there anything else that you wanted to touch on or maybe say or >> Your question is really a good one, which is I tell residents that I teach, I tell other doctors that I lecture to, when we make we as neurologists when we make a diagnosis, almost never is there sort of the absolute proof that we're right. And so, when we make that diagnosis, the next thing that we do is we say, does that patient progress the way I expected them to with the diagnosis that I gave them, right? And so, if a patient with memory issues or cognitive issues is given a diagnosis of Alzheimer's or dementia with Lewy bodies or whatever other cause of dementia there is, the doctor's job is to say, does that patient progress? And if they progress the way I expected, it's more likely that I'm right. But we know, again from autopsy studies, that there is a big misdiagnosis rate. And families play a big role in that, as I mentioned earlier, which is if you read about your loved one's dementia with Lewy bodies or Alzheimer's and they're doing something which just doesn't seem to fit, it's not in ChatGPT, it's not in Google and D, then bring that to the doctor's attention and make them just sort of think again. Because our best physicians are ones that always question themselves, right? So, I joke sometimes, if you go get a pregnancy test, the answer is either yes, you're pregnant or no, you're not pregnant. It's very simple. Neurology just doesn't work that way. And as you said, diseases can overlap, they can mimic one another, and just having that good dialogue with the physician to always be aware of the symptoms is really critical.

[00:32:40]>> Absolutely. And just thinking like piggybacking off of that a little bit from like the patient perspective, right? Or from the loved one's perspective, there could be all these things that seem minor or unrelated like not significant whatsoever and it could be very very significant for the provider. So I think it's also important from the non-medical side to really really explain and share everything. Any minor little detail that cuz it could mean something way more for the physician than it does for us and I think that that's something important that patients need to know as well.

[00:33:13]>> Yeah, it's critical. Yeah.

[00:33:15]>> Absolutely. And if you finished this conversation thinking about a parent, a spouse, or a friend who fits the picture that Dr. Levine just described, trust that instinct and I think that kind of goes back to what we just said as well.

[00:33:27]And the next episode we're going to introduce a little bit more and a little bit more in depth about something we spoke about today, but something that's remarkable, a simple skin test that can really help diagnose Lewy body and Parkinson's and really is able to catch what imaging can often can't. So I'm excited to hop into that with you next time and it was a pleasure speaking with you as always. For everyone listening, make sure that you're following, subscribing, sharing the show and it's been another great episode with you of what I tell my family and I can't wait to speak with you soon.

[00:33:57]>> Great. Thanks so much.

[00:33:58]>> [music] >> Have a good one.