Dementia Care: Parkinson’s and Speech

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Steve Lorberbaum:

Well, I’d like to welcome you all. Thank you for joining us today on this month’s edition of What’s Your Plan. Basically, I’m the owner of Assisting Hands Home Care Potomac. We, on a monthly basis, bring in somebody who’s an expert in the field of aging to help us understand the process of aging and what happens when aging doesn’t work as way it is typically planned.

Steve Lorberbaum:

So today, we’re really fortunate to have Susan I. Wranik. And she is from SpeakSkill and she has a tremendous background, both in Parkinson’s and in speech therapy. And she’s a speech pathologist. I will let her introduce herself because she will do a much better job than I have done.

Steve Lorberbaum:

But again, a little bit about me. I’m the owner of Assisting Hands Home Care. We work with families who need a little extra help caring for their loved ones, whether it be in a hospital, a rehab, assisted living, a private residence, an apartment, wherever someone’s calling home at the moment and needs a little extra support with either companionship, meal prep, or activities of daily living.

Steve Lorberbaum:

So now, I’d like to introduce Susan. Please, Susan, give us a little bit of your bio.

Susan I. Wranik:

Good morning, Steve. Thank you. I am Susan I. Wranik, as in isn’t it ironic. I’m an author, speaker, linguist, and speech-language pathologist with a specialty in Parkinson’s. I am LSVT-certified, which means Lee Silverman voice training-certified for the treatment of Parkinson’s disease. And I’m delighted to be here.

Steve Lorberbaum:

Great. So let me jump right in and first ask a little bit about what, give us Parkinson’s. Because most people think of Parkinson’s as someone that just has maybe a shaky hand. But it’s so much more than that. So give us just a high-level overview of the kinds of neurological impacts Parkinson’s has on people.

Susan I. Wranik:

Okay. Bird’s eye view, 10 million people worldwide with Parkinson’s, approximately 60,000 new diagnoses every year in the United States. You have motor and non-motor symptoms. If you’ve seen one person with Parkinson’s disease, you’ve seen one person with Parkinson’s disease. That’s the rule of thumb.

Steve Lorberbaum:

Gotcha.

Steve Lorberbaum:

So you’re a speech pathologist. So why are you involved in the world of Parkinson’s? What do you bring to the table?

Susan I. Wranik:

Okay. As I said, there’s motor and non-motor. And sometimes, non-motor challenges can be even more challenging than the motor that we’re familiar with. The tremor, which not everybody has. And the shuffling gait, the rigidity, the slowness of movement.

Susan I. Wranik:

But one of the major issues with Parkinson’s is voice. A lot of people with Parkinson’s don’t realize that they cannot be heard. And even more than that, only 4% get help for it. But you can improve the volume, which is what LSVT is all about. People have difficulty with swallowing. If you work on your voice, you’re also working on swallowing, because the muscles are the same. And of course, there can be a cognitive component that comes with Parkinson’s. But it can also come with the aging process.

Steve Lorberbaum:

So let me get this right. So speech pathologists work on more than just speaking and projection. Do you also focus on swallowing?

Susan I. Wranik:

Indeed. Let me explain. When you think speech pathologists, think from your Adam’s apple to the top of your head. That’s our domain.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

And all that entails.

Steve Lorberbaum:

And so, what are the kinds of things, so if someone has Parkinson’s, what would be some of the symptoms that we might see that would be a reason to think about calling you in to help them out?

Susan I. Wranik:

Well, a diagnosis of Parkinson’s would be the reason. Because the most important thing is to keep exercising. But it’s not only physical exercise. It’s a vocal exercise. And my recommendation is, “Don’t wait until you have a problem to try to fix it.” You’re always better off if you do something preemptively, prophylactically, you prepare for it. And that way, you can deter it and it can help you better manage the symptoms associated with Parkinson’s.

Steve Lorberbaum:

So really, you’re like a personal trainer for speaking?

Susan I. Wranik:

A very highly skilled personal trainer, yes.

Steve Lorberbaum:

Yes. Okay. But you’re working to help people improve their muscle tone around voice projection.

Susan I. Wranik:

The voice.

Steve Lorberbaum:

And swallowing.

Susan I. Wranik:

And cognition. And memory.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

And functioning. Mm-hmm (affirmative).

Steve Lorberbaum:

So tell me about…

Susan I. Wranik:

And my…

Steve Lorberbaum:

I was going to say, tell me about cognition and memory. How does that impact Parkinson’s?

Susan I. Wranik:

Well, when people have difficult… First of all, people, you can’t remember what you can’t see and you can’t hear. And you might have difficulty with auditory perception. So that would be an issue. It’s not just Parkinson’s. It’s also aging. That can also be contributory. So people might have difficulty with word retrieval, difficulty with sequencing, difficulty with verbal expression. If people can’t hear you, they assume you don’t know. And they treat you differently. And my goal is to help everyone understand, make their voices heard, and to help the general public understand what they can do to help people with Parkinson’s continue to live a normal life. Parkinson’s is something you have. It’s not who you are.

Steve Lorberbaum:

And so, how would someone bring you in? So if let’s say I have a Parkinson’s diagnosis and I want to stay ahead of the game, I want to stay strong as I can, both physically and verbally, how do I engage someone like you?

Susan I. Wranik:

You might engage me one-to-one or you might join some of the communication clubs that I’m leading online now for the Parkinson’s Foundation of the National Capital Area. And we can provide that. That’s parkinsonsfoundation.org. I think they had that slide up.

Steve Lorberbaum:

Yeah.

Susan I. Wranik:

They offer over 30 programs, both for physical exercise and vocal exercise. So often, people with Parkinson’s only focus on the physical. But if you can’t make yourself heard, that disenfranchises you from life itself. And people don’t realize that they can’t be heard. Because people with Parkinson’s frequently have difficulty understanding that their voice is lower. It might be breathy. The volume might be diminished. And so, people would call me in perhaps to work one-on-one. And I have the privilege of working with almost 100 people each week with Parkinson’s. I refer to my group as my Parkinson’s family. And we work on speaking loudly.

Steve Lorberbaum:

Okay. So there are Parkinson’s support groups that you participate in and help lead programs for?

Susan I. Wranik:

This is more of an exercise group.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

A support group is on the other side of the house. It’s the emotional side of the house. But this is an exercise group. It’s not therapy. It’s exercise. Therapy is one-to-one, with a specific goal. Exercise, we’re one for all and all for one. And it’s, people work better together. They have a good time. You have fun. And that’s the important part.

Steve Lorberbaum:

Got it.

Susan I. Wranik:

You can have fun while making your voice heard.

Steve Lorberbaum:

So you mentioned LSVT. What’s that?

Susan I. Wranik:

Okay. LSVT stands for Lee Silverman Voice Training. It goes back to the 1980s. It was a protocol developed by Dr. Lorraine Ramig, a speech-language pathologist. It’s been funded by NIH. As I said, evidence-based. And they’ve discovered that, with a very specific format, an hour a day, four days a week, for four weeks, that’s it. That’s exactly what it is. There’s no partial, no modified. It’s either an hour a day, four days a week, for four weeks, or it’s not LSVT. They discovered that people could increase their volume by 10 decibels, which doesn’t mean anything to the audience probably. I can’t explain it. But it’s a difference between being heard and not being heard in conversation.

Susan I. Wranik:

It was so successful, and they continue to work and research on this, that it was trialed for physical therapy with the same protocol, an hour a day, four days a week, for four weeks. It is paid for by Medicare and insurance. They will cover it with a prescription. What we do know is that, in terms of LSVT-LOUD, it’s also proven beneficial to people recovering from a stroke, people with MS, people with cerebral palsy. It works for adults. It works for children. They are working on trials. Right now, only Parkinson’s is covered by insurance.

Steve Lorberbaum:

Can you give us a sample exercise that someone might do if they engaged you for the LSVT LOUD program?

Susan I. Wranik:

Regrettably not.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

Because this constitutes therapy. And as for ethics, I don’t want to go into that.

Susan I. Wranik:

But remember, the goal is to speak louder and to be socially involved. The two biggest things for Parkinson’s are exercise and socialization. And when somebody gets a diagnosis, they get discouraged. So it’s very important to stay socially engaged. It’s very important for the general public to understand how they can help people become engaged, remain engaged. When people don’t know what to do, they do nothing. And so, that’s why we work as a group to practice and to help educate other people on what they can do to keep people involved.

Susan I. Wranik:

In terms of a simple exercise, I would say smile. Just the simple act of smiling releases serotonin, which is mood-altering. Okay? It sounds like a simple no-brainer but it is very important. And then, trying to speak louder and check with people. Find out if you’re speaking loudly enough. Especially if you have a partner, a spouse. Listen to them. Ask them if you can be heard. Sometimes, a person with Parkinson’s will think that they’re yelling. We never want people to yell. But it’s important to know how much louder you have to be perceptual to be heard by somebody else.

Steve Lorberbaum:

Gotcha.

Steve Lorberbaum:

So does Parkinson’s affect only the volume of speech or the clarity? Or both?

Susan I. Wranik:

Both. Both. You can have breathiness. You can have what we call glottal fry. It affects your expression. People, on the other side, people who do therapy for this, you’ll find that they’re louder, their voice is clearer, it’s stronger, it’s not breathy. And it also affects facial expression. Because one of the characteristics; not everybody has it; but one of the characteristics…

Susan I. Wranik:

Remember that Parkinson’s is a chemical deprivation. It’s a loss of dopamine. And it affects you muscularly. So a lot of times, people have what they call a flat affect. So much of what we understand, we understand not only from words, but from facial expression. And if your face is like this, that’s very difficult to understand what’s going on. It sends a wrong message, a message of disinterest. When you do these exercises, you find, like smiling, you find that you’re using those muscles and you’re more expressive and you’re able to communicate better. And people who go through this LSVT program find that there’s a tremendous change, a tremendous, two or three or four. You get all kinds of benefits from it.

Steve Lorberbaum:

Are there other programs that you all will bring to the table when it comes to Parkinson’s? Or is LSVT really the standard and that’s what everyone does? Or there are more exercises and things to do?

Susan I. Wranik:

There are all kinds of things that you can do. There’s another program called Speak Up. And I believe, I don’t know, I’m not as well-versed in it and I am not yet certified in that program. I believe it’s a three-day-a-week requirement. I’m not certain. And I can’t speak to the evidence-based, clinical trials. But there are other things that you can do.

Susan I. Wranik:

And if people aren’t ready to make that commitment, I encourage everyone to get involved with a communication club. It’s important to use your voice. You walk. You try to stay active. You wouldn’t stay in bed for a week. Don’t not socialize vocally. It’s very important to keep your voice going and your head going. Remember, if you keep, if you’re always alone, you’re always right. And that’s a very dangerous position to be in. You want to be challenged by other people and exchange of information. You want to promote your ideas and you want to have an exchange of opinion and defend your thoughts. Or as my friend says, “I’m not arguing. I’m explaining why I’m right.”

Steve Lorberbaum:

I like that.

Steve Lorberbaum:

So it sounds like some of what you do is covered by insurance. Is that correct?

Susan I. Wranik:

Yes. This is all covered by insurance.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

Parkinson’s is covered by insurance. I personally am fee-for-service. But I know a lot of people submit to insurance. And I can tell you that Parkinson’s, LSVT LOUD, is indeed covered by insurance, as is BIG. LOUD is the voice program, BIG is the physical therapy program. To those who are contemplating, my answer is, “Take them both. Don’t take them both together. Take them sooner rather than later.”

Steve Lorberbaum:

And do you do BIG? Or you do only LOUD?

Susan I. Wranik:

I’m a speech pathologist.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

So I do LOUD. And the physical therapists do BIG. But again, do them both, but don’t dismiss the LOUD program just because you can’t hear yourself not being loud enough. Do both. And it will help with swallowing as well, which can be a huge issue.

Steve Lorberbaum:

And so, if I do the LOUD program, and that’s just a short duration program, what else can you do? Do I have an ongoing relationship with you that continues beyond just LOUD that you can help with?

Susan I. Wranik:

Okay. Once you’re trained in LOUD, in LSVT LOUD, you will have exercises to do every day. The issue is that a lot of people don’t follow up with those exercises. That can be an issue. And they will go back after a year or two. And they might repeat LSVT LOUD.

Susan I. Wranik:

Now we have LSVT LOUD for LIFE, which is like a tweak for people. And my recommendation is to stay active, to do your exercises. Even if it’s something as simple as reading the mail out loud, use your voice, practice your voice. And join the communication clubs. Stay involved. It’s important to stay social.

Steve Lorberbaum:

Okay. So now, I know we have clients at Assisting Hands that they’ll go into the hospital and they’ll end up on thickened liquids, pureed foods, because that’s what the hospital is recommending. Is this the kind of thing where you can come in and do a consult at the hospital and go, “With some therapy, we can actually return you to eating regular foods.” Is that a thing that can happen?

Susan I. Wranik:

Okay. In answer to your first question, no, I cannot go into the hospital. We don’t cross territory, all right? And generally, when a person is discharged to home, they will be discharged with home health for a certain period of time. And if deemed appropriate, they’ll assign a speech pathologist. Yes, I can go into the home. Yes, I can help people or try to help people get a chance, upgrade their diet. Back in the days when I was Director of Rehab, they used to call me the queen of lean. Because people would frequently be on tube feedings and I would work, there’s a very stringent protocol, very careful protocol, for getting people off the tubes. But yes, it can be done. Once a tube feed doesn’t necessarily mean always a tube feed. But every case is different. It’s important. I don’t want to speak generically.

Steve Lorberbaum:

Sure.

Susan I. Wranik:

But it can be done. It has been done. It is not always done.

Steve Lorberbaum:

But is that something, if somebody was interested in that, is that when you would go out to the house and do an assessment to determine whether or not you even think it’s appropriate for you to make that effort?

Susan I. Wranik:

Yes, it is.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

It’s one of the things I do. Absolutely.

Steve Lorberbaum:

Gotcha. Okay.

Steve Lorberbaum:

And so, you are presently going into clients’ homes. What kind of COVID protocols do you take?

Susan I. Wranik:

I have just resumed with a few patients.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

I don’t go with everyone yet. And I assume the standard protocol with the mask, the shield, if so desired. A lot of the people I am with were one-to-one. Both had been vaccinated. I honor their preferences. And when you’re dealing with speech, it can be a challenge. I’m not seeing everyone. I’ve got very few that I see in person right now. But I’m starting. And I’m-

Steve Lorberbaum:

Okay. But it’s something you’re open to?

Susan I. Wranik:

I am. And I’m licensed in Maryland, Virginia, and the District. I, by the way, have been vaccinated. I got my second shot back in mid-February.

Steve Lorberbaum:

Okay. Good.

Steve Lorberbaum:

And so, if somebody is interested working with you, how do they get in touch with you? Do you have a phone number, and email address? I see your email up there.

Susan I. Wranik:

I think, yeah. I believe it’s up on the screen right now. My firm name is SpeakSkill. You can Google SpeakSkill. If you can remember the spelling on my name, Susan I. Wranik, no C. Susan I. Wranik as, isn’t it ironic? You can Google that. And you can go right to my website and connect with me from there. It says, “Speak with Susan.” And you can just fill it in.

Steve Lorberbaum:

Okay. So let’s say I have a diagnosis of Parkinson’s.

Susan I. Wranik:

Mm-hmm (affirmative).

Steve Lorberbaum:

And now, I feel like you’ve got to have a team, right? To work with. Can you help somebody who’s just got this diagnosis navigate the world of who should they be calling next and how to help build a team?

Susan I. Wranik:

Absolutely. Thank you for asking that question. Anybody who has Parkinson’s should be under the care of a neurologist who is a movement specialist. There are a lot of great neurologists out there. But with Parkinson’s, you want somebody specialized in movement disorders. They’re the ones that are up to date on everything that’s new and creative in potential with Parkinson’s disease.

Susan I. Wranik:

And there’s a humongous network and PFNCA, the Parkinson’s Foundation of the National Capital Area, we’re the orange ones. There are a lot of organizations out there. PFNCA is our local one. It’s huge. As I said, they’re offering 30 classes a week online right now. We will be resuming in person. We don’t know when. There’s a great, April is Parkinson’s Awareness Month. There’s going to be a great big conference. I believe the fee is nominal, perhaps $50 for a whole year. And it entitles you to participate in any of the classes. So I recommend that people get involved with that organization because you will have access to most of the movement disorder specialists in the DMV.

Steve Lorberbaum:

Gotcha.

Steve Lorberbaum:

So are there any other symptoms or components of Parkinson’s we haven’t touched on that you want to raise as something people should be on the lookout for?

Susan I. Wranik:

Well, I hesitate to give you the whole menu.

Steve Lorberbaum:

Right.

Susan I. Wranik:

Because people think it’s a la carte and they’re going to order and they panic. But one of the things not talked about often enough is pseudobulbar affect. People will cry or laugh. Very often, they’ll cry with no provocation. And they’re terrified because they don’t know what it is. It’s not uncommon. It’s an upset to the neural system and it can happen. And if people are aware of it, I think understanding that it can exist is one of the big things.

Susan I. Wranik:

Another issue is hallucinations. You’ve heard so much about that on television with NUPLAZID. I’m pleased to say that the American Speech Hearing Association, my governing body, raised Cain with them and said, “You’re giving wrong information. Change your ad.” And they did. And they’re doing a lot of research in NUPLAZID on hallucination. The thing with hallucination; well, for people with Parkinson’s; is that people with Parkinson’s who hallucinate know that they are hallucinating. They realize that. So that’s an important thing. The next thing is dealing with it.

Susan I. Wranik:

Another thing is freezing, when you just stop. And remember, tremor with Parkinson’s is a rest tremor. If you tremor when you’re not at rest, then it’s something else, it’s a different diagnosis. But Parkinson’s tremor characteristically is a rest tremor. You don’t, when you freeze; and this is an issue when people are taking medications; a lot of times, people will freeze right before they swallow. And nursing, of course, is very concerned because they don’t want to give them something if the person can’t swallow. It’s not a swallowing issue. It’s a motor issue. They freeze when they’re not swallowing. You don’t freeze mid-swallow. So you don’t change the texture to puree. You don’t crush the meds. It’s not going to change anything. You just wait until the person unfreezes.

Susan I. Wranik:

And they’re doing a lot of research on that, on how to break the freeze. I know, in physical therapy, the suggestion has been made to step to the side.

Steve Lorberbaum:

Interesting.

Susan I. Wranik:

They haven’t done a lot of research at NIH on this. The Doctor and his team are doing a lot of research on this. They still don’t have anything for swallowing yet, to my knowledge. But I don’t know about that.

Steve Lorberbaum:

Okay. Are there…

Susan I. Wranik:

So those are some of the common ones.

Susan I. Wranik:

Anxiety is another thing. The biggest issue with Parkinson’s, forgive me, is constipation. And that can affect somebody long before they actually have a diagnosis.

Steve Lorberbaum:

Interesting. All right.

Steve Lorberbaum:

Well so, I want to open it up, because we do have seven or eight more minutes, to anybody that’s got questions. Either you can put them in the chat or feel free to unmute yourself and ask away. I will continue to ask questions unless somebody else has anything in particular that they would like to raise.

Steve Lorberbaum:

So one more than I have, Susan, is, in particular, is, how can family members participate in someone’s Parkinson’s and helping them navigate this? Are there support groups? Training? Is there tools, tricks, things that that loved ones should be doing to help support a Parkinson’s patient?

Susan I. Wranik:

By learning as much as you can about the diagnosis and how you can help the person by stepping back. And I know that’s easier said than done. But you need to preserve your own health. If possible, you might want to consider hiring a care manager to provide support. In-home health. You might refer to your religious community for support. There are all kinds of things out there. And depending upon the other diagnosis, together with Parkinson’s, there may be other options. I don’t want to open up that right now.

Steve Lorberbaum:

Sure. Okay.

Susan I. Wranik:

But learn as much as you can. That’s the first thing. Keep smiling. Remember, you can’t change what is, but you can change the way you deal with it. But you do get tired. And when you get tired, you do need help and you do need to step away. Because you have to protect yourself in order to protect another person.

Steve Lorberbaum:

Gotcha.

Steve Lorberbaum:

And so, I know you do a fair bit of speaking to groups. Are you available to speak to groups? Maybe it’s a faith-based organization or it’s a club or a neighborhood community. I don’t know. Are you available for that kind of work?

Susan I. Wranik:

Absolutely. I’ll do whatever I can to spread the word. And that’s how I got involved with the Parkinson’s Foundation of the National Capital Area. I’m in it to help people. And if I can help people, by all means, reach out to me. I’ll do whatever I can.

Steve Lorberbaum:

And so, tell me about your book. I know you have a book. At least one that I know of.

Susan I. Wranik:

Okay.

Steve Lorberbaum:

Tell me about it. And what made you write the book?

Susan I. Wranik:

The book is, Don’t Forget to Say Thank You, 20 Thoughts to Guide You Personally and Professionally Through Life. It is a synopsis of the things when my mother died 26 years ago. I’m an only child. And I thought, “Oh, my. Now, who am I going to turn to?” So I started to commit all her words of wisdom. And I draw on them frequently in speaking to groups, especially when it comes to word choice.

Susan I. Wranik:

And one of the best ones is, many years ago, she was a dancer. And I was a horrific dancer. She had me in ballet but it was because I was paralyzed and they wanted me to have bilateral arm movement. After the first recital, I downgraded the whole family name. I was just awful, very shy, and not particularly good. And I looked up at her and I said, “So what did you think of it?” It being my dancing. And she looked down at me and she said, cover girl smile, didn’t miss a beat, eyes dancing. And she said, “Susan, your potential for improvement is infinite.”

Susan I. Wranik:

And it’s things like that that I draw on, when I try to encourage people, especially people with Parkinson’s, and with any diagnosis that they’re dealing with caregivers. And we called, we referred to the group as diagnosed and undiagnosed alike. You can’t change what it is. You can change how you deal with it. And it’s important. Nothing is all good or all bad. You learn so much from it, from whatever you’re going through.

Susan I. Wranik:

So that’s the purpose of the book.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

And that’s why I share it with other people. I’m now working on Travels With my Aunt to support the program. And that will be on communicating with people who have dementia.

Steve Lorberbaum:

Gotcha.

Steve Lorberbaum:

So one last question for you. Because I think we have time for one more. Oh, gosh. I’ve just lost the question. Because a new screen came up with all this information. So I’m just going to go and move on, since I’ve forgotten my question.

Steve Lorberbaum:

Oh, I know what it is. I got it. I got it. So if someone wants to work with you, do they get a referral from their neurologist? Is that how the work begins with you?

Susan I. Wranik:

They can but they don’t need to.

Steve Lorberbaum:

Okay.

Susan I. Wranik:

If they intend to submit for insurance, they may wish to. And if they want me to have an ongoing dialogue with their medical team, I’m more than happy to. But I can go in and treat on my own because I’m fee-for-service. And because I’m fee-for-service, I can serve at will. They can have me one time a week, twice a week, three times a week, as the schedule permits, or they can stop whenever they want. It’s not that treatment has to be completed within a given period of time.

Steve Lorberbaum:

Gotcha. Okay.

Steve Lorberbaum:

So I do want to thank Susan today. This was great. I learn, always, every time I talk to you, I learn something new. And so, that’s fabulous. I do want to mention that, next month, we’re going to have Julz Abate. She is the Respite Administrator from Arc of Montgomery County. And she’ll talk about a tremendous program that the county offers, where if you are living with someone and you are the family caregiver, you can get support and hire an outside agency and they will subsidize the work of Assisting Hands. So we’re an approved provider with them. And so, Arc will actually pay us a sizable percentage of our fee for a set period of time. And she’ll give more information about that.

Steve Lorberbaum:

So again, Susan and I had an opportunity to work together with joint clients. And I can tell you, consummate professional. She’s worked even with our caregivers to help them understand how to work more effectively with their clients, which has been a tremendous value to us as a company because it’s making our aides more responsive to the needs of our Parkinson’s and patients. And I don’t… Well, this was really mostly about Parkinson’s. And the work you do to help support folks with stroke recovery is also fabulous and hugely beneficial and helpful. So I don’t want to leave that one out.

Steve Lorberbaum:

Any final comments from anybody before we’re gone today? Susan? Final words?

Susan I. Wranik:

I am available to work with families to consult if they would like some guidance with regards to dealing with Parkinson’s or a course of treatment. And my final comment is that Parkinson’s is something that you have, it’s not something that you are. So never give up.

Steve Lorberbaum:

Thank you.

Steve Lorberbaum:

Well, this has been our latest version of What’s Your Plan with Assisting Hands Home Care and Susan I. Wranik. So thank you very much for joining us today. And Susan, really appreciate it.

Susan I. Wranik:

Thank you. And thanks to the audience. Thank you for coming.

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