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Hello, everyone and welcome to a weekly were been asked, Shin, Today we have Will, um, who will be presenting about Parkinson's disease. Um, I'm going to let will start office presentation now. Hi, guys. Thanks for, um, or attending. Thanks for coming to this in Hope you're well, So Yeah, my name's will, um, one of the foundation year two doctors currently working at least general for memory. Currently on the stroke wards. Um, I'm just going to go short presentation on parks and disease so we don't cover is just going to recognize that we should be able to recognize pox disease from the cause of parkinsonism on doubt. Linus Pharmacological. Imagine management able to recognize symptoms of Parkinson's named two investigations We need to do be with that and then be aware about how to manage it and then at the end. Or just look at managing how to manage. Common scenario is that you may encounter went on a ward or maybe on cool with patients with Parkinson's disease. So So there's essentially is two things and get quite confusing. Is this idiopathic Parkinson's disease versus surgical parkinsonism? Parkinsonism is essentially the symptoms that everyone's familiar with with Parkinson's so which will go on to in a moment, spitting. You'll see things like tremor rigidity. Um, but they could have back and have many causes on DOT. All of them are related to Parkinson's disease, idiopathic Parkinson's disease. Essentially, it's own condition, or syndrome, which is progressive progressive neurological syndrome on de sensory. What they both are caused by is a reduction dope me, um, and the dopamine dopamine. Urgent neurons in your substantial Negro, which you're in your midbrain essentially stopped producing dopamine on badly the course of that when it when it's idiopathic is in the name, so it's unknown. But there's a few risk factors link to it. Um, in parkinsonism can have other causes that we can go on to things like stroke, etcetera, um, so idiopathic Parkinson's disease itself. There is no real cure. Um, what we can do is essentially try and treat symptoms. Eso there isn't any sort of long lasting effects, but essentially is inevitable that you might be able to cure the disease. So was that before this team of some of the symptoms so and quite common ones that we will note is bradykinesia, so they might be very slow in their movements, and you conducive spoiling finger from test where you get the patient to repetitive T index finger and the thumb together. And it would be quite a slow action, whereas someone who hasn't got the disease or younger can do it quite quickly. You'll see with these patients that we can maybe initially quite fast or normal, and then it slowly becomes quite difficult to do and becomes very slow virginity. So it's her stomach called lead pipe. So when you do a neurological exam, you testing motor, you sound to test the tone to try and make their arms go floppy, for example, On then was on the Parkinson's disease. They're very rigid, like a lead pipes, almost like their arm, has become this very stiff arm or stiff pipe. Um, and then again, you can get this thing called a superimposed tremor. Where example when you do sort of testing the tone in their wrists, well, then it being quite smooth and relax and nor in a fit and well patient, these patients can get something called coq breathing, so they sort of have these jerky movements where that you feel like this something that the wheel turning between the different Cox, Um, another common one is tremor. So this is importantly when they're resting on, so they're not doing any action on interested in Parkinson's disease. When they're doing an action, tremor seems to go away. Um, the one the common ones are noted Parks is he's a pill rolling where they'll, um, put their thumb and it will be rubbing their thumbs thumb on surround there index finger and that just sort of it sort of in the background. And nobody is quite a slow, low and high absolute but low frequency tremor Onda. Another common one is partial instability. So a lot of boxes of these patients, they have trouble so off standing up. So I'm getting from a sitting to standing position, maybe have difficulties walking is they sort of have a shuffling gait, um, where they'll take very minimal steps and that sort of very small steps in the foot step. If if he didn't really leave the floor, and then a common test you can do for this is shoulder took tests, so you get a patient to stand up on. Then you get obviously stand behind them and make sure that it full. And maybe it's someone as well to stand in front of them in case they go the opposite way. And then you sharply pull the shoulders back, Um, and then in a patient department disease that struggled to sort of correct their balance. So it's a sign of this impossible instability going on. Um, on this, you can see on the sides with a few of the ones that are similar. So there's like when you see the shuffling gait was quite a character of stick. They have. Whether have every static arms and I have very reduced swing, they'll be very well, be a very slow walk on that. We appear to be very rigid as they do it. Um, so So, um, or additional ones as well that you can do is further tests. Is micrographia so patient Parkinson's disease kind of very small writing on day? So it's quite a simple test to do on the bedside. Um, if you want. So listen this sign when they can either draw their name or draw a spiral, and they'll be very, very small in their writing. Ah, characteristic thing is hypomimia. So it's a it's this is brushing his face. So it's almost like looking into the distance or the and deep thought, and there won't be much. Going on in the face would be very blank. Expression is's that, as it suggests on these are quite common signs and symptoms of Parkinson's. Um, and then we mentioned about the gates a swell Onda again with the characteristic side of it is that we happen. They have their head forward was an open mouth. Um, islets might be 30 years off the normal, like a drooping or dropping on. Then, quite common is why they haven't got much control of their motor sort of swallowing on this. Quite a sequel, A lot of risk. And you have to be concerned about swallowing with Parkinson's disease patients. So there is some drooling going on essentially, um, and then other things. While that can, um, sometimes be maybe the first things that might pick up on or it might be the things that a lot of the time you might be dealing with an award or in the community that the other sort of things that you get with Parkinson's of the problems. So example of a non motor symptoms will be something like depression. Um, and it's hard to maybe tell if the depression is caused by being diet, parks and disease and not having, um, you know, the ability of slightly older or that they can get handed hand to. Also, you get the side effects of being that you can become depressed. Um, constipation is another common one in parks and disease. The non motor symptoms. Um, you get a lot of change in taste and smell. Um, so, for example, they might then start to any real take like things are quite sour or the things like, you know, sharp oranges, lemons that that they might be might start to notice three to know sort of things because they can taste those things. And another common one is urinary incontinence. So you get a lot of patients on wards who are struggling with your incontinence We might have after is inserted because it comes up. That's so that's another thing we might have to deal with on a ward, um, another common sleep disturbance. So a lot off payer Parkinson's disease patients have insomnia, so they might have had sleeping patterns might sleep a bit more in the day or and then be wide awake at night and you can't get to sleep. So it's not interesting one on the night shift your covering in an on call tonight that you might have a lot of agitated or Parkinson's patients awake at that time. So imposingly for us is how to investigate Parkinson's disease. So ideally, you can do a lot of it on a clinical assessment, which is essentially doing taking history on doing examination. So your neurological examination is really important. It's where you can test things like gait. You can have things that simple tests like the micrographia getting to try and write their name. Um, if they got any other side effects like they've got the constipation or they're in any pain. A lot of patients with Parkinson's have unexplained pain. That's not We can't really find a course for um, and then you can obviously do things like, um uh, your remote lower limbs sort of neurology. So if they've got any increased tone rigidity and that's all, they're like baseline for things like the power, sensory, etcetera. And then you can The other thing you want to do with the clinical assessment is things like Bloods, so that's good. Exclude other causes. So if patients are coming in with, maybe depression, constipation, increased rigidity on the confusion, you want to rule out things like strokes or infections on anything right done in complication of diabetes or cancer markers. So it's quite important that you can get blood test done just to make sure you're covering all bases on D. Bringing Imagings another major important thing for Parkinson's that is necessary essentially done maybe straight away. But it's done later on to try and pin down the diagnosis. So example CT heads that might just want to, uh, well, actually, I think we're going to ski make stroke. That's causing some the symptoms because they can have similar symptoms initially. Um, that scans This is quite important when you have. There's a different types of Parkinson's on different causes of Parkinson's. Um, so that can help rule out which type is a little pinpoint, maybe help me management slightly better and then quite important. Morning. Quite interesting. One is if you're unsure and maybe thinking that it was parked his disease. Um another way to sort of work hours to start him on some sort of dopamine treatment on diff symptoms improve, or they seem to get better on the dopamine. Um, it gives you a bit more certainty or confidence that it's maybe more Parkinson's that's causing these symptoms. Um, that's one that you can do is, well, so quite scary. Let's quite scary this but not It's not quite simple in the grand scheme of things on how to manage Parkinson's disease. Um, you never very, very rarely is a junior or a medical student. You're not going to be starting patients on medications or, UM, centering medications for them. But I think it is quite important, too. Understand the names, maybe just slightly, how they work, so that when maybe if you're clocking a patient or people reviewing some medications, you can understand or recognize what these medications are understand? They're important. Um, so quite a common one is the stuff the standard Leave a dope, which is essentially giving the patient dopamine, which is what they're looking on, combining that with something that can prevent the dopamine being broken down. So quite a common one is co Carl dopa, which is those two combined. And Madopar is another one that a lot of patients have this first line. Um, the good thing about this is a swell that it can last to be effective for a long time so you can start a patient on something that matter part on, but maybe increasing the dosage every so often peninsula. This can have quite good symptom control. So you can have someone who's comes in who's really struggling with short doing their daily activities, cooking into this, and you can give him the other part. And they can be quite comfortable in for the good for a long time after that. Um, so, yeah, that's the main one that's usually use first line, Um, but does it just You can have some quite common side effects that maybe you need to be aware of it. These being listed on the water that hallucinations, partial hypertension. So you don't want patients to be dropping the BP too much, just being wary that, um, she didn't have anything any complications like a fool. Um, you can also give him a competent, a bitter, and this is usually used second line when they're starting to have to lose the effects of the leave dopa on this essentially stops when you're sort of having the breach. When that those concentrations coming down, maybe near the end of the day, it can help prevent that bloke mean broke being broken down even further. So it helps just keep up symptom control and symptom management. And it started. As with all medication, you kind of still get the side effects, which we can hopefully try and treat as well and just manage. But corn is that normal here and diarrhea, and then say once he's off exhausted those or try a dose, we might not be suitable. We can move on to things like and mouths or dopamine receptor agonists. So mabs reduced. Leave it open for Flea, and they used to be first line but aren't used as much. I think leave it open so we'll take another Um, that has a lot of interactions with other medications or foods. I think it's it's less use but still can be used in marketing and then other things. If so, if people starting to get problems, maybe with swallowing dopamine receptor agonist is quite good. You get this in the patch, Um, and it's just another, um, management way We can try and help your symptoms. So there's some examples every Penarol and ridiculous. And again, as you know, some a lot of them. The common side effects are Loosen a shins on positive attention on nausea and vomiting. So as a key role, you can sort of keep those in mind full when you have a Parkinson's patient. If they are presenting these things, that could potentially be. It's part of their Parkinson's medications. So that was just a quick review. I thought I just go through a few situations or clinical scenarios that you might encounter on a war door in the examining to just appreciate it. Our old is commissions in treating people with Parkinson's disease. So is, ah, central patient who has idiopathic Parkinson's disease. It's usually well controlled, and but he's currently near one off because he's due to have a surgery. Onda, you've got a problem that as we want a boxes, these medications, they need to be given on time eggs on the exact time every day because if you start to miss the timing's, their periods where the patient isn't gonna have dopamine essentially, and they're going to get a lot off problems with that, especially if they've been on a long time. And they're dopamine levels have really their own natural openers have dropped. So if you then strict in that, they're going to get a lot more problems. Um, so it sends you a question is what if you get asked my nurse mean, what? What would you do? So there's a few ways. So while the main way So obviously we know by mouth department, the carts, one of the medications, um, so one thing to do is is a cool you're maybe the pharmacy team or the uncle pharmacist on Just gained some advice about trying to get a good history of the patient of what medicate what medications are currently on in terms of boxes, medications, work. Find out what the doses are on. Then there's quite a good website I've used called optimal calculator, and the answer could be that you essentially convert their medications to a patch, um, so that they don't have too many. Take anything orally Taken based helps me put on the on the skin and that can give him the dopamine is you can have a ticketing patches, which can give them the same dose of dopamine as then They're pretty on the medication they're currently on on. So you basically put in what they're on. What medications? That currently taking orally, what dosages. And then that the website converts the dosage into a what would need to be needed for a patch on. Then you can order this from the Pharmacy Linescores pharmacy and get it sent down. Um, alternatively, if if they know they're gonna be new amount for a long time, and they might not be able to get in a big are at risk swallow or, you know, they really strong year swallow. Take tablets. Um, you can consider an N G tube, and then medications can be given through the NGP. So next one. So you called about 75. Your patient who has Parkinson's disease, and she's very agitated what you need to do. So essentially, with an agitated patient, there's they could be lots of causes for agitation, not necessarily from Parkinson's disease. So what you want to do with it? But this is going to review the patient do a full A to be assessment on. Do you want to look for anything that essentially might be causing just stress or pain so you could ask? Well, find out any infective symptoms off that's causing them to me. So I don't have pain. Like if they've got a urine infection that might get some super pubic pain. Um, any other causes confusion like really showing any side that I had a full and the c spine tenderness, any bruising on the scalp to indicate that they have now become confused, maybe from a intercranial hemorrhage or bleed, um, on. Then, you know, even just having a good inspection of any to be, so they might start to be developing pressure ulcers that might be causing a bit discomfort when they're on the bed. So you want to make sure that you can control the things that we can control that cause agitation. A lot of the time, it might just be that you need to or intake the person to where they are, So sometimes if they're in, they're in a room on their own and they haven't got, maybe can't. They're not confused about where they are like that. There's no window or the curtains closed. All the feeling quite warm things that you can just try and resolve those environmental factors quite easily. Um, and a lot of the time you can get maybe someone to want the nurse to one toe, one them or hate. See a You can just sort of keep an eye on them. Maybe, you know, if there's asking up for things you can get in the water, things that this fluids just to help them out and then just keep an eye on them in case end up causing harm to themselves. And then you know, if they are becoming really, may be aggressive. Yeah, there a danger to themselves and they're not. They're trying to throw themselves out of bed or, you know, attacking of the members of staff. You can, at the end of it, sort of give the medication to try and calm them down. Although importantly, with not to give them antipsychotic medications that haloperidol is this has a disastrous effect in terms of interacting with medications in parking distance disease, the whole. So the agitation medication you don't want to give is lorazepam, lorazepam, sir, And start off with a very low dose. Like not 0.5 mg. You can give this. I am. Well, we're a sucker if needed Or the, um or really, if they will need to take already and they got a safe swallow. So there is a fist. The last time is the one that it seems to do quite well and on elderly patients may be a bit more frail, starting off for the lower dose and working up. So is the best thing to do. Yeah, And then next one, So never 65. Your patient who's parked disease, which is usually very well controlled. But now she's getting a side effects, potentially off nausea. So wanting to prescribe something, we've been our PSA base to get that stomach to help with the nausea. And again, you want to just make sure that you're ruling out any other causes of nausea. So you want to do any to we look for any distended abdomen If maybe they're constipated or bloated and mine is that appropriate or, and look out the things that can cause that again. Some simple things, like just infection to want to check their observations. If they've got any fever, maybe do a set of bloods just to find out cause maybe could be gastritis or even in something more so like to maybe causing like a very colic or something like into the liver. So maybe we'll just rule out those things out with a set of abdomen. Bloods, um, review the medications again, just to see if anything else that could be interrupting or causing the nausea on. Then if you do think that they could do is, um, antibiotic or you can't do anything you think that this is point like you to do is the side effects Or you think that the the your needed some antiemetics the safest wants to give a cyclizine ondansetron just in parks and these patients on. Do you want to abort? Eat metoclopramide on broken or kerosene as these anti doping been ergic. So, um, since they're working against dopamine, so you're gonna send to cause worsening of the parks and symptoms. So the main wants to give on down strong and so putting, which a bit more safer, and furthermore, if they are committing, you need to worry about things like aspiration. Um, And if it isn't if they are risk of swallowing at risk swallow. Sorry, Um, and therefore we need to start thinking again, like if they're going to be vomiting a lot if they're going to be a big surgery, aspirating to start thinking about converted to a patch. So it's probably good to get ahead of that rather than dealing with it when the time comes close that when they're medications and needed. So if you all think about that, Teo, get a patch, maybe in the pipeline, because sometimes it can take a long time to get delivered down to the wards. And then, lastly, is this patient. So he's an 85 year old patient with Parkinson's disease normally well controlled, but now he is very, very constipated, and what we need to do any, will this affect his Parkinson's disease? So again, impressive. But you need to be looking anything that, because in the constipation, on asking about their normal bowel habits, it might be that they haven't opened their bowels for three days, and then someone saying, Oh, now they're constipated. But if that's normal for the patient, or they only go once every three days, which is in the limits of normal, then isn't that much being off the patient, then doing any further and interventions is gonna be were so harmful patient than not do anything at all. Um, asking about their diets like what they've been eating is only thing that could have been obviously, cause if it's just basically having a poor diet, all they haven't eaten much in the last three days have been unwell. It might be, um, explaining why I haven't opened their bowels that much. And we need to rule out things like bowel obstruction, obstruction or any more sinister causes. So asking about their bowel habit habits, Have they had any peanuts, any bleeding PR bleeding from the back passage, or any vomiting of the inner city? Uh, right, red vomit or maybe even coffee ground vomit to make sure those are things we ruled out again. Check medication. Because a lot of these things are caused by medication, and it might just be a simple fix. Maybe either switch you or get over this hurdle and then start thinking about changing medications. Um and then So if you are thinking and then if the constipation itself. If you do think that this is no, it's, um, sort of intention. You can just give things that laxative. So Lexiva is quite a strong or laxative that we could give us a a liquid, and that usually gets a lot of people's bowels moving, um, article on. But you can also get things like cholesterol suppositories, which is another way you can if the if the oral medications are working. And then lastly, if you really struggling, you can give patients enemies. And then you can also give you a few enemies over the course today. So if it's the first, was that helping? You can try again. And but importantly, obviously, if you're thinking if someone's not, it was not constipated. You got to worry about maybe if it's been problems with absorption of the medications, well, as if you're over treating constipated participation forms with bowels become very loose. You might be losing that concentration of dopamine from the or medications, so it's just to be aware of monitoring that to actually clearly developed loose stools, maybe think, give the opposite. So maybe looking out for worsening of symptoms off park. Since these symptoms, um or if they are constipated, they might be getting more absorption, potentially from those medications. So you want to be then over medicating a patient because then your office to get more of the side effects off their pockets. Easy stuff that was just the free for over you. I hope you enjoyed it open to any questions. Thanks very much, I said. I think we do have some questions from the group. Um, if I start from the button, Haley Louise to ask how early can pockets and start in the brain when it's in the family on down, Um, in the family, parents and grandparents And I'm not in terms of there is a genetic component on D. You can either understand that men a slightly more like to get pox is easy. And women, um, the average onset for positive disease is maybe around 65 then then you can. But you can also get it when you're older. Importantly, for thing. If you do get a bit older, it's quite a good prognosis, really, because, um, if your medications, if the treatment convey successful for 10 to 15 years, that puts you into a lot of the order eight that hitting in nineties. So it's less of a concern with early onset. It can be, it can convert very much. And you know, there are police. There are the normal is or cases where you have been extremely young. But I think around early onset is around 40. I believe if there and get the office, your environment factors genetic all coming to coming up combined together, they can beat this being known that that early on separate, it can be around 40. Thank you so much for that. I think there was another question about whether or lands a pin was safe for Parkinson patients. But it looks like Gabby is kind of put a B m g link as well up there. Um, I mean, yeah. I mean, it's it's I don't think it's it's not that well tolerated. Don't think this far as I can recall in terms of I'm guessing it's because of things up to control may be psychotic symptoms and things like this that you do use it. Um, I think, uh, clozapine on Believe it, And I was not much up on psych, had a few bucks and patient I think Clozapine, um, is a bit more effective. I think that has a few more bad side effects. Well, things are unwanted that we have to take a risk with, um, and then important. You know, if if you are considering medication is always important to like the someone's put on the link, So be NF is always a good place to start if you are concerned about. I know I was always grow concerned when you're starting any medication for a patient who's got and quite a of course, it disease that box of disease. It does have potential, a lot of interactions. Things that even that antibiotic should order was just check to be enough to make sure there's no contra indication there that could cause worsening their symptoms. That's very helpful, I think. Events even note asked, Could you tell a bit about obsessive compulsive behavior? Secondary to dopamine agonists, um, and how to manage them? Yeah, So, um, people who I think are, you know, nothing. There's a lot of cases where they become quite risk takers on basements, become gambling, sort of might gamble lots of money or might just go out and buy loads of things. And it's something that you have to be careful off with a patient like that. I think it's, Ah, it is a side effect on It is a concern, I think, importantly on that side of things. It's just making sure I've got a good social network around them that could just make sure they're not, um, doing those sort of behaviors. You know, I think if you are right, you can you do things like we gonna have lasting power of attorney or maybe take over financial, um, responsibility for them. For their relative, Um, I'm not a really I don't If there's basically think you can do so apart from if it is starting to call it be a problem. You can obviously try and stop. That medication is causing the compulsions and maybe try a different one just to see how they tolerate it and be on the whole. I think it is just keeping an eye on it on just it's not anything. It's extremely common, but I do believe it is there, so I would. It's just mainly just safety net in keeping an eye on them make keeping on those behaviors really Okay, Thank you. That was really, really helpful. I think if new Adam as a question can ondansetron be given for vomiting and parkinsonism patients, Yeah, so I'm down strong is quite a safe one. Really? To give the ones that you don't want to give all that metoclopramide on and broke procort full prayer is een so I'm down strong inject in terms of in general for all patients really is quite handy. Want to give a lot of a lot of them? Chemotherapy patients have on downstream as well because it's generally quite well tolerated. Doesn't have two as worse side effects as the other anti emetics um, and could be giving you a different forms and give you an IV or really so advanced on this that Yeah, it's a it's safe in part of the disease. Got a few more questions, if you don't mind. Well, son, I member and ask could you please elaborate on drug drug induced parkinsonism? So I'm assuming Is this for things like there are a few. Let me just try and think so I know a lot off. You can get extra payment of side effects with a lot off antidepressant medications. Um, so things like some of the antidepressants and anti set of psychotic sorry can cause something that lip smacking with increased tone. And so it's mainly is far than where the ones that do with mental health patients that can cause it on. So I sent two of those. You just need Spacey to review their symptoms every so often. I think the only real answer for is to, um, stop the offending medication and sort of maybe I'll find alternative mix. And then once they've stopped that, too, treat the symptoms. Hasn't how that they're present. And then hopefully that should settle down when you change the medications. Yeah, that's that's how I was aware their drug induced ones. That's very true. Um, if new Adam has a question, he asked any nearest neurosurgical innovation under research for Parkinsonism who? Yeah, that's different. I know there's a lot. There's been a bit more move away. I think, too, in terms of interaction, they can sort of have, um or maybe a constant feed of dope me that make sense like a pump. Um, rather than taking these medications, that obviously has, like, an endosee concentration at the end. So the industry, you know, they've got a peak concentrations dose. And then after that, the stent, too reduce in effectiveness because obviously there's does the construction's going down. So I think there was a lot that is 20 looking toward maybe giving a constant dose me bit like a problem. Interim pumps, Um, and also I think is, well, things that can help with symptoms. So someone's having very severe tremors you could get Think that nerve stimulators that can try and calm those those symptoms down rather than just solely relying on dopamine is to save the sole treatment for it. You can them. So there are innovations. I wouldn't say I was an expert. Teo, give you the full breakfast. That is not sure. There are people that are trying to really change there. It's managed. But those the two I was aware of myself, I think. Thank you. I think we've got one more question. Oximeter. Um, us. I've read that domperidone is the gold standard in Parkinson's disease because it is slowly, slightly to cross the blood brain barrier. Is this not sure in practice? Um, is the gold standard sorry? Yeah, I think it's worth. I think she sounds like a hawk, says um, probably read, read in books that domperidone is the ghost under in Parkinson's patients because they don't cross the blood brain barrier. Um, and whether we actually do this in our daily practice Oh, I see. Um, yeah, I think I've heard. It's quite it is quite an effective one. I think in terms of potential in that sort of, if you're having real bad issues, I think it might be one there they look into more bit. Yeah, on the whole thing is, in practice, I have No, I don't have some reason. Yeah, I've not really seen that as much on on patients. It's more sort of leave it dopers carbidopa on the dopamine and type genist that are mainly used at the moment. I'm sure Parks is the doctor kit. Maybe give him more insight into that. But yeah, it's not. That's used as much life of as I come across. Yeah, just one more question, if you don't mind. Well, um, I think CR has a question. So you're pronouncing them wrong way. Um, regarding the agitation scenario that we discussed earlier, could the dopamine. Najid themselves be the factor off the agitation. So sit there. Questions. I think, um, there was an agitation scenario you were talking about Whether the dope in ergic medications, I'm guessing is what he means being off them being agitated. Yeah, so they can. I mean, there are side effects, and I think agitation can be a side effect of it. So you can get hallucinations from a lot off the so medications, Andi, even vivid dreams and things like this. So, um, I'm sure the biochemistry of it does indicate, you know, these are if, on the whole when you get agitated patients, in all likelihood, it's gonna it's the driving factor is going to be the thing that they've come in with presenting with or have the is their main concern. So if it is something like dementia, that's going to maybe be the driving factor is why they are gorgeous state no more. We can, uh, do other things to help that it's going to be probably That's like, That's me. So the same with park, since he's really in nature of the beast being that the main medications we give cause can cause some of these are stations or hallucinations. Um, so definitely there's So I think in that scenario, you wouldn't want to obviously stop the medications. Um, so yeah. So for the short term, you could just start, maybe give you something if they are risking themselves, or even just try and Orrin take them, maybe one toe, one them, give them maybe a small amount amount of lorazepam. And then in the on the following when there's a bit more time to sort of assess it for a week and then look into maybe they're being over medicated with the medications or if it's a certain one, they're not responding well to change that up. So definitely I think medication's going themselves conclude that nothing. I think that might be all the questions. Um, and syringes. Thank you very much. Well, and if there's no more questions, I think we can end the session now. Thank you. Have room for food in, um, to get in order to get your certificate. I have attached the feedback form just at the comment box. So if you just press that and fill that up, you'll get a certificate for attendance today. Thank you, everyone for joining in. Take care. I