Do You Have Swallowing Problem?
Oro-pharyngeal dysphagia is a common symptom in patients with Parkinson’s disease (PD) and related disorders, even in the early stage of disease, however, dysphagia in persons with Parkinson’s (PWP) has been underdiagnosed and may be due in part to poor self-awareness of the conditions and also the underuse of validated tools and objective instruments for assessment. The EAT-10 (Eating Assessment Tool) is a common screening tool used by healthcare providers when inquiring about dysphagia. But when a group of researchers used the tool to investigate the prevalence of dysphagia in multiple countries and across multiple nationalities the degree to which a person was concerned about their swallow was not necessarily reflected in their EAT-10 score. Some survey respondents expressed concern about their swallowing, but this was not reflected in their responses to the questions. Others scored high in their responses but denied that they had a swallowing problem yet when probed further they reported that they avoid certain food types, have changed their posture, always take drinks to help move material down their throats, etc. And when asked “so do you have any problems swallowing?” they still said no.
I had a recent patient who had multiple vigorous coughing episodes when drinking of water and he could hardly catch his breath, yet, when I referred to those incidents as evidence of a swallowing problem, he was adamant that he did not. Only when we reviewed his video fluoroscopic swallowing study did he acknowledge the presence of dysphagia, stating: “no one told me before that I had a swallowing problem.” Coughing during or after a meal, food or pills getting stuck in the throat , and drooling, are all common symptoms reported by people with PD, yet are not often recognized by patients as a symptom of a swallowing problem, and hence do not report it to their physicians. In addition, if when visiting their neurologist a great deal of attention is placed on gross motor symptoms such as balance or falling, swallowing issues may not be prioritized as an issue. Often it is the person’s spouse who will report observations during mealtime, suggestive of dysphagia.
Are Swallowing Problems Inevitable in Parkinson’s?
Dysphagia resulting from neurological disorders including Parkinson’s disease affects approximately
300,000 to 600,000 people every year. It can lead to malnutrition, weight loss, choking, aspiration, pneumonia, and death. Oral phase abnormalities are common in Parkinson’s and include inefficient mastication, impaired bolus formation, and delayed initiation of swallowing. Impaired mastication and oral preparatory lingual movements are most commonly seen during dynamic videofluoroscopy and may be caused by PD-related akinesia, bradykinesia, and rigidity. Impaired pharyngeal bolus transport is a major determinant of dysphagia and pharyngeal phase abnormalities in PD include delayed pharyngeal swallowing reflex, vallecula and pyriform sinus pooling, reduced pharyngeal peristalsis/constrictor function, and incomplete upper esophageal sphincter relaxation. Cricopharyngeal achalasia (poor relaxation of upper esophageal sphincter) has been reported to be present in 30% of PD patients with dysphagia and, thus, thought to be a major factor in the pathogenesis of dysphagia in some PD patients. Relaxation abnormalities of the upper esophageal sphincter in PD patients in combination with impaired or weak voluntary cough and reflex sensitivity contributes to an even higher potential level of aspiration risk.
Why Are Swallowing Problems Under-reported?
Even in the general population, patients may not always report a swallowing problem, or they may consider symptoms as a part of normal aging, but in individuals with Parkinson’s this may be even more pronounced. Subtle problems presenting early in disease diagnosis may be compensated for, but as the disease progresses, cognitive and motor changes may begin to be more pronounced, and compensatory behaviors that once worked may no longer be sufficient to prevent more serious problems. Aspiration pneumonia, the leading cause of death in individuals with PD does not need to be inevitable but rather is often an avoidable problem resulting from dysphagia that may be undetected and untreated.
A systematic review showed that patients with Parkinson’s developed oro-pharyngeal dysphagia approximately three times more than healthy elderly people. Dysphagia undetected or un-managed can result in clinical complications, including malnutrition, dehydration, and aspiration pneumonia, affecting quality of life and eventually increasing the mortality rate in patients.
Early detection and individualized treatment of dysphagia for each patient with PD is crucial to prevent complications of the disease and improve the quality of life. Screening an individual with PD by simply asking them whether they have swallowing problems may not be sensitive enough due to their poor awareness of the problems and reduced sensation in the oro-pharyngeal and laryngeal musculature. An instrumental swallowing assessment which enables visualization of physiology and structures can help with accurate identification of dysphagia early in a patient diagnosis and may also help to differentiate patients with atypical Parkinson’s disease diagnosis.
Are Swallowing Problems Avoidable in Parkinson’s?
Once a swallowing problem has been identified, speech-language pathologists have many tools which can help to improve and preserve swallowing function. These might include instruction in compensatory strategies identified on the instrumental assessment to be of benefit or swallowing exercises which can include resistive strengthening devices, biofeedback devices, and in some instances, a few pilot studies have reported that voice treatment with the Lee Silverman Voice Treatment (LSVT) showed some beneficial effects on swallow and involuntary cough functions. Treatment should always be individualized and may include one or many approaches and may change with time and disease progression.
References: J Neuropathol Exp Neurol. 2012 June ; 71(6): 520–530. doi:10.1097/NEN.0b013e318258381b.Altered Pharyngeal Muscles in Parkinson Disease Liancai Mu, MD, PhD1 et al.
El Sharkawi et al. (2002). Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): A pilot study. https://doi.org/10.1136/jnnp.72.1.31 OPEN ACCESS
Miles et al. (2017). Effect of Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in Parkinson’s disease: A pilot study. https://doi.org/10.1016/j.jns.2017.11.015 OPEn ACCESS
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Thank you for your comment, Valerie. I should add that aspiration alone, in the absence of other risk factors does not necessarily lead to aspiration pneumonia, and in fact, most healthy adults aspirate at one time or another.So before you add thickeners to your drinks, which are actually NOT good if they are aspirated, you might review with your SLP and physician some of the other risk factors specific to you. We know from the literature, that poor oral hygiene, immobility, and weak cough are all risk factors. I often recommend use of a respiratory muscle trainer or PEP device as an additional pulmonary hygiene measure. Aspiration pneumonia is an opportunistic infection, meaning: something must be aspirated, the aspirated material must be able to overwhelm the system, and the immune system of the host (person)who has aspirated. I’m glad you are being proactive and taking steps to avoid any complications form dysphagia.
I found this particular article both particularly enlightening & relevant, Mary! Having been diagnosed with Parkinson’s in January, 1992, at the age of 38 & after seeing doctor after doctor for approximately 8 years prior,I was recently referred by my current neurologist for a new “Swallow Study.” At the conclusion of the Study, I was informed that I did indeed have some concerning swallowing issues, including getting pills stuck in my throat & even aspirating some liquids into my lungs. The SLP who conducted the Study recommended several different strategies ranging from consulting a GI.specialist to determine if there is an esophageal disorder that s/he
might be able to treat,, undergoing outpatient speech
therapy, to purchasing & adding a liquid thickening agent called “Simply Thick” to my drinks with meals, among other things..