Risks Associated With Dysphagia
Many people can find dysphagia embarrassing or frustrating. Difficulty swallowing can impact your quality of life, but it can also have serious effects.2
Dysphagia can cause malnutrition or dehydration. It can also cause aspiration, the medical term for food going down the wrong pipe. Aspiration can lead to aspiration pneumonia, which is the leading cause of death for people with PD. This is a type of lung infection that occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading into the lungs, instead of being swallowed.1
Problems With Tongue Muscles
Parkinsons can also cause problems in the tongue muscles. The tongue is important in swallowing.;We use it to move food around and push it to the back of the mouth to trigger the swallowing reflexes. Parkinsons can also impair the reflexes that protect our windpipe from food and drink. A problem coordinating breathing and swallowing may make this problem worse. ;
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.
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Oral Dysfunction In Parkinsons: Swallowing Problems And Drooling
Two common and distressing problems that can develop in Parkinsons disease are swallowing dysfunction and drooling. I want to help you better understand these issues and learn what you can do to improve them so read on!
Thank you to Christine Sapienza, PhD, CCC-SLP and Bari Hoffman Ruddy, PhD, CCC-SLP for providing some of the material below.
When Should I Call My Doctor About Difficulty Swallowing
You should see your doctor to determine the cause of your swallowing difficulties. Call a doctor right away if youre also having trouble breathing or think something might be stuck in your throat. If you have sudden muscle weakness or paralysis and cant swallow at all, call 911 or go to the emergency room.
Last reviewed by a Cleveland Clinic medical professional on 03/24/2020.
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Managing Eating And Swallowing
It is important to continue eating normally as long as it is safe to do so. This will help to keep your muscles working, and maintaining a healthy diet is vital to good health . Only when eating and swallowing become significantly uncomfortable or difficult should you adapt your diet, for example by eating pureed foods.
Swallowing difficulties are individual and solutions vary from person to person, but the following tips on diet, drinking and eating techniques may help.
Eating Swallowing Problems And Saliva Control
Eating and swallowing;problems, known as dysphagia, occur in many medical conditions and become more common as we get older.
The main risks associated with swallowing problems are:
- Choking or asphyxiation:;When food blocks the airway, preventing breathing. Also, when food or liquid enter the airway below the level of the vocal cords.
- Aspiration pneumonia: When;food or liquid enter the lungs, this may cause a lung infection.
- Increased secretion: As a reaction to food or liquid entering the lungs.
- Dehydration:;Lack of;fluids can lead to problems such as constipation.
- Malnutrition:;Lack of nourishment leads to poor health and harms the bodys ability to fight infection.
- Drooling: decrease in mouth sensitivity and / or a reduction in the frequence of swallowing saliva can cause drooling.
- Difficulties in swallowing medications.
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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 Do I Know If I Have A Speech Or Voice Problem
- My voice makes it difficult for people to hear me.
- People have difficulty understanding me in a noisy room.;
- My voice issues limit my personal and social life.;
- I feel left out of conversations because of my voice.
- My voice problem causes me to lose income.
- I have to strain to produce voice.
- My voice clarity is unpredictable.
- My voice problem upsets me.
- My voice makes me feel handicapped.
- People ask, “What’s wrong with your voice?”
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The Lee Silverman Voice Treatment
The Lee Silverman Voice Treatment is the first speech treatment for PD proven to significantly improve speech after one month of treatment.
- Exercises taught in the LSVT method are easy to learn and typically have an immediate impact on communication.
- Improvements have been shown to last up to two years following treatment.
- LSVT methods have also been used with some success in treating speech and voice problems in individuals with atypical PD syndromes such as multiple-system atrophy and progressive supranuclear palsy .;
- Must be administered four days a week for four consecutive weeks.
- On therapy days, perform LSVT exercises one other time during the day. On non-therapy days, perform LSVT exercises two times a day.
- Once you complete the four-week LSVT therapy, perform LSVT exercises daily to maintain your improved voice.
- Schedule six-month LSVT re-evaluations with your specialist to monitor your voice.
- If available in your area, participate in a speech group whose focus is on thinking loud.
- A Digital Sound Level Meter can help you monitor voice volume. Place the meter at arm distance to perform the measurement. Normal conversational volume ranges between 68-74dB.
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.
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Embarrassing Symptoms Of Parkinson’s Disease
Some symptoms that may occur in people with Parkinsons disease are not typical of it and so people noticing them may misunderstand them. These symptoms can be particularly embarrassing in social situations where other people witness their discomfort. They distress some people so much that they avoid company other than close friends or family. Most of these symptoms are caused by Parkinsons but some are side effects of the medicines used to treat it. All the symptoms tend to fluctuate in relation to the medication, and some people had learnt to adjust their medicine regime to minimise these effects.
Eating can cause embarrassment in several ways. Both tremor and dyskinesia affect the physical job of cutting up food and directing it into the mouth . Several people had a problem with a piece of steak or chicken that might fly off the plate as they tried to cut it up, or they had a choking fit if they unwisely took too big a piece into their mouth. Humphrey disliked eating out with friends because he tended to drop things.
Recently Fred Has Found His Eyes Are Closed Involuntarily Most Of The Time Though If He Makes An
You dont think, Oh, it would be nice to have my eyes closed now?
The mask that is the expressionless face, typical of many people with Parkinsons, probably distresses the people who have to live with it more than it embarrasses the person who has it. It tends to be the position the face falls into when not actively doing something else. Lack of facial expression can be hard for the family.
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Eating And Swallowing Problems And Parkinsons
Research suggests that eating and swallowing difficulties affect about a 90% of all people with Parkinsons. The true figure may be even higher as some people do not report the problem to their health care team.
Swallowing is a motor function that includes three stages.
- The first stage is the oral phase: food is chewed and mixed with saliva to form a soft ball called bolus. The tongue then pushes the bolus to the back of the mouth, triggering the swallow reflex.
- The second stage is the pharyngeal phase: it is the involuntary closure of the larynx by the epiglottis and vocal cords, which temporarily inhibites breathing. These actions prevent food from going ‘down the wrong pipe’ into the trachea .
- The third stage is the esophageal phase: the bolus moves into the esophagus, the muscular tube that contracts to push the bolus into the stomach.
Unfortunately, many people with Parkinsons experience swallowing problems due to reduced control and muscle tone of the jaw, lips, tongue and throat muscles, especially in later stages of the condition. Eating and swallowing becomes slower and requires more effort.
People with Parkinsons are at particular risk of aspiration due to a delay in the triggering of their swallow reflex. This compromises the effectiveness of the airway protection while swallowing. This can lead to aspiration pneumonia due to a lack of coughing if food enters the windpipe, allowing food to reach the lungs unchecked.
Tips For Coping With Breathing Difficulties
- Work with your doctor to identify and treat any non-PD causes of shortness of breath, such as lung disease, heart disease or lack of physical conditioning and endurance.
- Exercise as much as possible. Shortness of breath may lead a person to move less. Less physical activity reduces the ability to take deep breaths. Staying active improves pulmonary function.
- Take steps to cope with anxiety. Talk with your doctor to figure out what sets off anxiety and find treatments and techniques that work for you.
- Speak to your doctor about getting an evaluation performed by a speech-language pathologist; who can help you address issues related to swallowing.
- Give up smoking.
Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinsons Foundation Center of Excellence.
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Diet And Fluid Modifications For Dysphagia
Depending on your level of dysphagia your Speech Pathologist may suggest foods be chopped, minced or pureed and liquids thickened. The International Dysphagia Diet Framework, shown below, outlines the different types of food textures and liquid categories that may be suggested. The framework was developed to provide standardised terminology and definitions to describe food textures and liquid thickness.
Below is a brief summary of some of the common texture modified diets and thickened liquids that may be suggested for people with Parkinsons who have dysphagia. For detailed information on the different food and drink categories as well as testing methods that help ensure consistent production of prescribed foods and liquids visit iddsi.org
How Is Dysphagia Treated
Treatment for difficulty swallowing depends on the cause and severity of the problem. Your treatment might include:
- Antibiotics: Your doctor may prescribe antibiotics to treat bacterial tonsillitis .
- Medication and lifestyle changes: Treatment for GERD includes drugs to control acid reflux. Your doctor may also recommend changing your diet and eating habits.
- Other medical therapy: If a neurological condition makes it difficult for you to swallow, your doctor can offer solutions. Your options might include botulinum toxin injections to relieve muscle spasms or surgery to enlarge the esophagus.
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How Is Dysphagia Diagnosed
Diagnostic tests for swallowing disorders vary. Typical tests include:
- Flexible laryngoscopy: This test is done by an ENT specialist. It involves placing a small scope in your nose and looking at your throat and vocal cords.
- Fiberoptic endoscopic evaluation of swallowing : Performed by a speech therapist, this test involves passing a small camera into your nose and feeding you dyed liquids and food to see how you are swallowing. During the test, your provider will also look to see if the food is getting into your airway .
- Modified barium swallow: During this test, a speech therapist gives you different foods and liquids to chew and swallow. The food will be covered with barium, a minty tasting liquid or pasty material. Barium allows images of your mouth, throat and esophagus to be seen on X-ray images. The speech therapist will tell you when to chew and swallow and the radiologist will take X-ray images while youre swallowing.
- Esophagram: In this test, you drink barium and the radiologist takes pictures of your esophagus.
- Esophagoduodenoscopy or upper endoscopy: This test involves a healthcare provider called a gastroenterologist who places a scope down your throat. The scope continues down your throat, into your esophagus and down into your stomach. This test is used to look for any narrowing, tumors or Barretts esophagus.
Swallowing Exercises Can Be Very Helpful To Improve Your Swallowing
After a formal swallow assessment, swallowing therapy sessions can be designed for you, involving exercises tailored to the specific parts of your mouth and throat that are causing the swallowing problem. Sessions may involve practicing compensatory swallowing strategies with various types of foods in order to maximize safety and efficiency while swallowing.
During swallow therapy, recommendations may include:
- Best feeding techniques
- Exercises to strengthen oral and throat muscles
- Compensatory techniques to assist in safe swallowing
- Oral and mouth care techniques
- Appropriate food selection and ways to modify food texture
- Safe positioning strategies
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What Kinds Of Rehabilitation Help With Swallowing Problems
Some people find rehabilitation helpful. A speech-language pathologist can teach you exercises to strengthen your swallowing muscles. To swallow safely, your SLP may recommend:
- Changing how you eat and drink: Your therapist will guide you to take smaller bites and chew food thoroughly. You may need to add a special thickening powder to your drinks, since watery liquids can be tough to swallow.
- Sitting upright while eating: To reduce the risk of choking, your therapist will show you the best way to sit while eating. You can also learn to tilt your head to make swallowing easier. These techniques reduce the risk of liquid getting into your airway .
- Clearing your throat: Therapists can teach you how to clear your throat with a little cough if liquid or a small piece of food gets stuck.
Early Detection Of Dysphagia Can Improve The Quality Of Life In Parkinson’s Patients
Dysphagia can lead to a handful of other issues, so early detection is key. According to the Parkinson’s Foundation, trouble swallowing can lead to malnutrition, dehydration, and aspiration, the latter of which can ultimately lead to aspiration pneumoniathe leading cause of death in Parkinson’s patients. Diagnosing dysphagia sooner rather than later can be life-changing. “The early detection and intervention of dysphagia are closely related to improving the quality of life and decreasing the mortality rate” in Parkinson’s patients, the study says.
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Treating Eating And Swallowing Difficulties
If you or someone you care for is experiencing difficulties with eating, swallowing or saliva control, the first step is to consult your doctor, who may refer you on to an SLT / SLP.
Your doctor may be able to adjust the timing and dose of medicines so that these are working well at mealtimes and so swallowing problems are better managed when eating. However, for some patients, medications do not affect the swallowing function.
Your doctor may also adjust your medications, or may prescribe new ones to reduce production of saliva. Some Parkinsons medicines, including levodopa, improve muscle movement and may help to reduce drooling. However, some medications, such as clozapine, which is prescribed for mental health problems, can actually increase saliva production.
Botulinum toxin can be injected into the salivary glands to reduce saliva production. This treatment will not work for everyone and injections may need to be repeated every three to six months. However, for some patients, Botox injections are not recommended and may be dangerous.;
In severe cases when other treatments are not effective, radiotherapy to the salivary glands can restrict saliva production. In extreme cases the salivary glands can be surgically removed as a last resort.
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How Can I Help My Loved Ones
Swallowing difficulties increase risks of choking. You can learn the Heimlich maneuver which is a rapid first aid procedure to treat choking due to upper airway obstruction. You may never have to use it, but it can save a life.
If a loved one goes to a speech therapy or occupational therapy appointment, go with them. These specialists will also work with you and give you practical advice to make meals more enjoyable and less anxiety-inducing.;
Never rush your loved ones during mealtimes.