Do Parkinson’s Patients Have Trouble Swallowing

My Parkinsons Story: Speech And Swallowing

This 8-minute video alternates between an interview with a man and his wife and healthcare professionals. The man and his wife share how Parkinsons has affected his speech and swallowing. The healthcare professionals explain how Parkinsons affects speech and swallowing. Speech therapy can improve speech volume and enunciation as well as swallowing control and drooling. They also advise specific changes to eating habits and avoiding some types of foods to prevent choking.

Development Of The Classification Of Dysphagia For Medication In Pd

The classification was developed by an interdisciplinary team of neurologists and speech-language therapists . Thirty selected FEES videos of PD patients with swallowing of medication, previously recorded for diagnostic reasons, were analyzed. In the first step, characteristic findings of impairment were collected that deviated from physiological medication swallowing. The latter was defined as complete swallowing of the medication during the first swallowing attempt without risk of aspiration. Subsequently, the described findings were examined with regard to different dimensions of impairment . Next, different levels of impairment severity were identified for each impairment dimension previously defined. In a final step, it was checked whether all levels of impairment could be clearly distinguished from each other. If this was not the case, the classification level was specified and more clearly demarcated from the other levels. In case of disagreement within the group, the discussion continued, and more video examples were viewed until a mutual consensus was reached.

Review Articleconsensus On The Treatment Of Dysphagia In Parkinson’s Disease

PD treatments should be optimized to minimize the impact on swallowing function

Treatment of dysphagia should be guided by an instrumental assessment of swallowing

There is insufficient evidence to support the use of neuromodulation techniques

Botulinum toxin is an option for isolated upper esophageal sphincter impairment

PEG feeding must be considered on an individual basis, but not in case of dementia

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Effect Of Deep Brain Stimulation On Swallowing Function: A Systematic Review

• 1Department of Neurology, Beijing Hospital, National Center of Gerontology, Beijing, China
• 2Department of Neurology, The University of Chicago Medicine, Chicago, IL, United States
• 3Department of Organismal Biology and Anatomy, The University of Chicago, Chicago, IL, United States
• 4Speech and Swallowing Service, The University of Chicago Medicine, Chicago, IL, United States

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If I Have Speech And Voice Problems How Can I Maintain And Improve My Communication

Some tips to improve communication include:

• Choose a quiet, low-noise space. Turn off televisions, radios and other devices that create noise.
• Make sure your listener can see your face. Look at the person while you are talking. A well-lit room improves face-to-face conversation, increasing the ability to be understood.
• Use short phrases. Say one or two words or syllables per breath.
• Plan periods of vocal rest before planned conversations or phone calls. Know that fatigue significantly affects your ability to speak. Techniques that work in the morning might not work later in the day.
• Keep your throat hydrated. Drink plenty of water. Dont drink caffeinated or alcoholic beverages. Use a humidifier if the air in your home is dry.
• Keep an upright posture, straight chin, slightly lifted neck to improve airflow from lungs to your vocal cords.
• If you are soft spoken and your voice has become low, consider using an amplifier.

If some people have difficulty understanding you, these additional strategies might help:

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Treatment And Therapy Options

If you are worried about dysphagia, a good first step is to speak with your neurologist. Your neurologist can recommend a speech-language pathologist . The SLP will examine you and recommend therapy or treatment options.1

An examination will likely include a questionnaire and imaging test. During the imaging test, the SLP will use a video X-ray or a small camera in your nose to watch you eat and drink. Your SLP may also give you a water swallowing test. In this test, your SLP determines how much water you can easily drink. These exams show your SLP where problems are happening and help them recommend options for you.2

There are different types of therapy your SLP may recommend. One method is the Lee Silverman Voice Technique . The LSVT was first designed as a therapy to help people with speaking difficulties from PD. However, the therapy can also help people swallow safely. The LSVT is a regular regimen that emphasizes exaggerated swallowing and speaking. This helps people practice swallowing hard, which can help move food down the throat.4,5

Another therapy option is called Expiratory Muscle Strength Training . This training focuses on strengthening the muscles that help you breathe. During EMST, your SLP may have you use a handheld tool. This tool trains and strengthens your breathing muscles, just like how someone might lift weights at the gym. Training these muscles also impacts swallowing and makes it safer and easier.6

How Do People Experience Difficulty Swallowing With Parkinsons

Many people diagnosed with Parkinsons experience difficulties swallowing at some point while living with the condition. Dysphagia can occur at any point over the course of the disease, even during the early stages. As one member wrote, I have trouble swallowing now. This is new to me its only been a problem over this last week. It makes it hard to swallow my meds.

Having trouble swallowing can cause many other problems, depending on why a person struggles to swallow and how severe their dysphagia is. Many people find that they drool or cant keep food and drinks in their mouths. Others find themselves sputtering, choking, or dealing with a sore throat during or after meals. Some may not even realize there is a problem until they start losing weight without trying.

Some people with dysphagia start to avoid certain foods or drink fewer liquids when swallowing becomes difficult. Over long periods of time, this can lead to other problems. As one member observed, My husband has had the same swallowing problems and was losing way too much weight.

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How Do I Know If I Have A Swallowing Problem

• I have recently lost weight without trying.
• I tend to avoid drinking liquids.
• I get the sensation of food being stuck in my throat.
• I tend to drool.
• I notice food collecting around my gum line.
• I tend to cough or choke before, during or after eating or drinking.
• I often have heartburn or a sore throat.
• I have trouble keeping food or liquid in my mouth.

Traditional Dysphagia Assessments And Therapies In Stroke

More than 50% of stroke survivors experience dysphagia however, most of them recover their swallowing function within a week . The proportion of stroke survivors with dysphagia at 6 months is reported to be approximately 11-13% . Constant awareness and review of swallowing are needed after stroke because of the diverse course of the symptoms over the six subsequent months. The assessment and management of dysphagia are important for minimizing the risk of food and liquid aspiration as well as pneumonia.

Screening for dysphagia includes the water-swallowing test and repetitive saliva-swallowing test. To assess the swallowing dysfunction in detail and detect silent aspiration, a video fluoroscopic swallowing study or fiberoptic endoscopic evaluation of swallowing should be used. A VFSS provides information on bolus flow, the movement of each organ, and the anatomy . A FEES can be performed even at the bedside and is able to detect silent saliva aspiration.

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Dysphagia For Medication Depending On Od For Food And Liquid

The cross-tabulation of dysphagia for medication with OD for food and liquid and the PAS is presented in Table . There was a moderate correlation between the severity of OD for food and liquid and dysphagia for medication and a weak correlation between the PAS and dysphagia for medication . However, 6 out of 9 subjects with severe or very severe dysphagia for medication showed only mild or no OD for food and liquid without penetration or aspiration.

Table 3 Cross-tabulation of the severity of oropharyngeal dysphagia for food and liquid and overall dysphagia for medication: OD oropharyngeal dysphagia, PAS Penetration Aspiration Scale.

Eating Swallowing And Saliva Management

Some people with Parkinsons may find they have difficulties with eating, swallowing and saliva control at some stage of their journey with Parkinsons.

Parkinsons can cause the muscles in the jaw and face to become stiff which affects the control of chewing and swallowing.

Another symptom of Parkinsons can be producing excessive saliva. The stiffer facial muscles can change the nature of saliva, which may become thicker and stickier.

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If You Have Swallowing Difficulty What Can Be Done

In some cases, swallowing function varies in response to dopamine medication doses, much like other aspects of motor function. Therefore, if swallowing becomes problematic, an increase in dopaminergic medications can be tried. In addition, make sure you undergo a swallow evaluation when you are in the ON state.

Even before a formal swallow study, you can take steps to increase the efficiency of your swallow. These include:

• Sit upright during all eating and drinking, even when taking pills
• Tilt the head slightly forward, not backward, as you swallow
• Take small bites of food, chew thoroughly, and do not add any more food until everything from the first bite has been swallowed
• Take small sips of liquid
• Concentrate while moving the food backward in the mouth with the tongue
• Double swallow if the food did not go down completely with the first swallow
• Sometimes taking a sip of liquid between bites of food can help to wash the food down
• If eating is very tiring, try several smaller meals spaced out during the day instead of three large meals.

How Are Speech Problems Treated

There are many options to help improve your speech. A speech-language pathologist can help you pick the right approaches for you. SLPs are trained health care professionals who specialize in evaluating and treating people with speech, swallowing, voice and language problems.Ask your doctor for a referral to a speech-language pathologist. It is also important to contact your health insurance company to find out what therapy and procedures are eligible for reimbursement and to find a list of SLPs covered by your plan.Finally, visit a SLP who has experience treating people with PD. Call the Parkinsons Foundation Helpline at 1-800-4PD-INFO for help locating a speech-language pathologist in your area. Lee Silverman Voice Treatment, discussed below, is a specific voice therapy for PD but it is not the only way to obtain high quality speech therapy for PD.

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Minced And Moist Diet

Minced and moist food looks like puree but with small soft lumps no bigger than 4mm x 4mm x 15mm in size. This category of food requires minimal chewing and can be eaten with a fork or spoon. Lumps can be easily mashed with just a little pressure from a fork and are easy to squash with your tongue. Minced and moist food should not be sticky, and no thin liquid should separate from the food. It is safest to test minced and moist food using the IDDSI Fork Drip Test and IDDSI Spoon Tilt Test.

Speaking Effectively A Strategic Guide For Speaking And Swallowing

Booklet includes self-evaluations and caregiver surveys to determine at what point professional help is needed. Professional examinations are described along with recommendations for both home and professional intervention to improve speech, make eating easier and safer, and reduce drooling. Maintaining communication to reduce isolation is encouraged.

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Signs And Symptoms Of Dysphagia

Signs and symptoms of dysphagia can range from mild to severe. If you think you or a loved one might have a swallowing problem, it is important to get professional help as soon as possible. Speech Pathologists are experts in dysphagia and can assess your swallowing ability and safety. Seek help from your doctor and a Speech Pathologist if you notice any of the following signs or symptoms:

• A feeling that food or drink gets stuck in your throat
• A feeling that food or drink is going the wrong way
• Long mealtimes or eating slowly
• Coughing, choking or frequent throat clearing during or after eating and drinking
• Becoming short of breath or your breathing changes when eating and drinking
• Avoiding certain foods because they are difficult to swallow
• Unplanned weight loss, or failing to put on weight because of avoiding foods or finding it hard to eat
• Frequent chest infections with no known cause

Swallowing Exercise Introduced Early May Benefit People With Parkinsons Disease

When attending seminars for persons with Parkinsons disease I am always a bit annoyed when I hear speakers refer to swallowing and speech symptoms as non-motor symptoms of Parkinsons disease . After all, approximately 100 muscles are involved in speech production and 50 paired muscles involved in swallowing, hence when patients present with problems, they are manifesting motor speech or swallowing symptoms.

Current models that attempt to explain the pathway for Parkinsons such as the one proposed by Braak et al give evidence for the presence of speech and swallowing abnormalities as early motor signs of the disease, or what are referred to as preclinical or prodromal stages of the disease .

Involvement of the dorsal motor nucleus of the glossopharyngeal and vagal nerves in the early stages of PD, suggest that voice and speech abnormalities might be among the first manifestations of the disease, perhaps developing at stages 1-2 in Braak et als model.

It has also been suggested by some researchers that the voice and speech abnormalities during the initial phases of the disease are too subtle to be detected, perhaps due to compensatory adjustments, and later in the disease these motor speech symptoms are often not as responsive to dopamine replacement as the limbs.

How early should swallowing exercises begin?

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Swallowing Difficulties In Parkinsons Disease

The act of swallowing involves a complex series of activities that begin in the mouth, continue in the pharynx and end in the esophagus. These include chewing, using the tongue to move the bolus of food to the back of the throat and then coordinating the muscles that both propel the food into the esophagus and protect the airway or trachea from food penetration. Swallowing dysfunction can be considered both a motor and a non-motor symptom of PD. Loss of dopamine neurons in the substantia nigra area of the brain can cause the motor dysfunction that impairs swallowing. However, loss of neurons in other areas of the brain, such as the cortex and lower brain stem can also affect the overall control and coordination of swallowing, and can be thought of as a non-motor symptom of PD. Swallowing issues are very important to diagnose. Impacts on your daily life and your health can range from difficulties with meals to more extreme cases where it could lead to choking and aspiration which can be very serious or even fatal.

Swallowing Disturbances In Parkinsons Disease

Eating is not just essential to maintaining healthy nutrition it is also a social activity, yet because it is a semi-automatic activity that takes little concentration or effort, the complexity of the normal swallowing process which involves precise coordinated muscular activity is under-appreciated. Swallowing disturbances are common in Parkinsons, bringing with them a multitude of health-related problems and risks as well as psychosocial distress. By recognizing the symptoms that indicate swallowing problems, you or your loved one can get the help you need to keep living an active, fulfilling life.

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Progression And Management Of Dysphagia In Pd

Unlike stroke, dysphagia in PRD degenerates with disease progression. Although their swallowing dysfunction is assessed by using VFSS or FEES, rehabilitation is required for determining PD patients’ quality of life. A transdisciplinary approach, including physicians, nurses, physical therapists, speech pathologists, and nutritionists, is required for long-term management.

Two specific questionnaires have been developed to detect dysphagia in PD: the swallowing disturbance questionnaire and the Munich Dysphagia test-Parkinson’s disease . The SDQ containing 15 questions is more basic and an easier screening test for asking about specific symptoms with dysphagia and their frequencies. The MDT-PD can detect the beginning of oropharyngeal symptoms and the risk of laryngeal penetration or aspiration. It consists of 26 items divided into 4 categories: difficulty in swallowing food and liquids, difficulty in swallowing independent of food intake, further swallowing-specific and associated problems, swallowing-specific health questions.

Strategy For Rapidly Progressive Dysphagia In Prd Psp And Msa

Dysphagia symptoms in PRD, PSP, and MSA appear earlier after the onset than in PD . The median dysphagia latencies were reported to be 42 months in PSP, 67 months in MSA, and 130 months in PD. This suggests that early dysphagia symptoms in PRD are distinguishable from those in PD.

In PSP, the most common cause of death is pneumonia that occurs subsequent to silent aspiration . The reported prevalence of dysphagia in PSP is up to 80%, and the early development of dysphagia leads to repeated aspiration pneumonia and a short survival time . Medication, adjustment of food consistency, feeding techniques, and PEG feeding should be attempted in order to prevent pneumonia. Relative to PD patients, PSP patients exhibit a poorer response to medications with mild improvement in dysphagia , and the management of dysphagia in the later stages of PSP is more challenging than in the earlier stages. The early deterioration of the cognitive function or dementia may influence the treatment difficulty. However, despite adjusting the food consistency and feeding techniques, most PSP patients ultimately require PEG feeding within a few months after the initial development of pneumonia . Nevertheless, whether or not PEG placement prolongs the survival time is unclear .

The authors state that they have no Conflict of Interest .

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