Dysphagia in Parkinson’s

Swallowing difficulties rank among the top concerns for individuals with Parkinson’s disease (PD) and their caregivers. Often, these challenges go unnoticed or unreported by those affected. These issues arise from impaired muscle movements characterized by slowness, reduced accuracy, weakness, or coordination difficulties (Matsuo & Palmer, 2008). The loss of neurons in various brain regions affects overall swallowing control and coordination, making swallowing dysfunction, commonly referred to as dysphagia, a combination of non-motor and motor symptoms (Narciso, 2022). Compounding these difficulties are problems such as excessive saliva production, drooling, and hearing impairment, which significantly impact both communication and swallowing abilities.

Phases of Swallowing

Oral phase: This is when you prepare your food by chewing it in your mouth.
Pharyngeal phase: Once the food is ready, it moves from your mouth to your throat (pharynx), where it then travels down to your esophagus (the tube that connects your throat to your stomach).
Esophageal phase: In this phase, the food moves from your throat down to your stomach.

In Parkinson's disease, all three phases of swallowing can be affected. The oral phase may be impacted by difficulties in chewing or moving food around in the mouth due to muscle stiffness or slowness. The pharyngeal phase might be affected by problems with moving the food from the mouth to the throat, leading to issues like coughing or choking. Lastly, the esophageal phase may be affected by problems with moving the food from the throat to the stomach, causing difficulties in swallowing and potentially leading to food getting stuck in the throat.

Signs of Swallowing Complications

Swallowing difficulties can manifest in various symptoms, which may vary in severity from person to person. Some common signs of swallowing problems include:

Difficulty with swallowing pills
Fatigue during meals
Longer mealtimes than usual
Nasal regurgitation of food or liquid
Sensation of food sticking in the throat
Difficulty initiating the swallowing process
Need for dietary modifications, such as softer foods or thickened liquids
Coughing or choking while eating or drinking
Excessive saliva production and drooling
Recurrent pneumonia (PNA) or pulmonary infections
Unintended weight loss
Tongue pumping or repetitive tongue movements
Residue of food or liquid left in the mouth after swallowing
Weak cough reflex
Discomfort or pain while eating or drinking
Leakage of food or liquid from the mouth during meals

Risks Associated with Dysphagia

Swallowing difficulties can significantly diminish the pleasure of eating, drinking, and socializing, impacting overall health, nutrition, and quality of life. They also pose various risks, including:

Malnutrition and dehydration: Dysphagia, or difficulty swallowing, may lead to reduced food and fluid intake, resulting in malnutrition, unwanted weight loss, and dehydration.
Choking: Dysphagia increases the risk of choking, which can be life-threatening if food completely obstructs the airway.
Aspiration: Persistent dysphagia raises the likelihood of aspiration, where food or liquid enters the windpipe instead of the esophagus, potentially leading to aspiration pneumonia and pulmonary edema.
Aspiration pneumonia: This type of pneumonia occurs when foreign material, such as food, saliva, or liquids, is inhaled into the airways or lungs instead of being swallowed, causing inflammation and infection. This condition is a significant cause of mortality in individuals with Parkinson's disease, emphasizing the importance of dysphagia management (Ciucci, 2013).
Aggravated Parkinson's symptoms: Dysphagia can hinder the timely and proper ingestion of Parkinson's medications, leading to increased OFF times and poorly managed symptoms, affecting overall disease management and quality of life.

Discussing these risks with your healthcare team is crucial for implementing effective strategies to manage dysphagia and maintain optimal health and well-being (Narciso, 2022).

Swallowing Evaluation

A swallowing evaluation takes place with a qualified speech-language pathologist (SLP). They will gather information about your current concerns and medical history and may observe you eating and drinking to make initial assessments. The primary evaluation method is called a Modified Barium Swallow (MBS), where a video x-ray, or video-fluoroscopy, is performed by an SLP and radiologist. This procedure identifies specific swallowing issues and their locations. During the MBS, you'll consume food of various consistencies while x-ray videos capture the chewing and swallowing process. The SLP and radiologist analyze the footage to assess swallowing structure, function, and any risks of aspiration. The MBS evaluates all swallowing phases: oral, pharyngeal, and esophageal. Another evaluation method, the Fiberoptic Endoscopic Evaluation of Swallowing (FEES), involves passing a thin flexible tube through the nasal passage to view the pharynx and larynx directly. This allows for video and sound recording to assess the pharyngeal phase of swallowing and identify any aspiration risks. The FEES is often used as a follow-up procedure to the MBS (Ciucci, 2013). It is important to highlight that early identification and intervention can help prevent complications and improve swallowing function and overall quality of life.

Saliva Management

Saliva management is a crucial aspect of care for individuals with PD, as it directly impacts swallowing and overall quality of life. People with PD tend to swallow less frequently, leading to saliva buildup and potential drooling, known as sialorrhea. This excess saliva can overflow from the mouth, causing discomfort, irritation, and even infections around the mouth area. Drooling can interfere with daily activities such as eating, talking, and socializing, affecting one's oral health, taste perception, and overall well-being.

Addressing saliva management involves a multi-faceted approach, including medical interventions and behavioral strategies. Close collaboration with healthcare professionals such as primary care physicians, neurologists, and speech-language pathologists (SLPs) is essential for effective management. Behavioral strategies may include techniques to stimulate swallowing, such as sucking on sugarless hard candy, which can help alleviate drooling temporarily.

Medications like atropine eye drops taken orally can also be prescribed to reduce saliva production and manage drooling. However, it's crucial to balance medication benefits with potential side effects and individual patient needs. Additionally, maintaining good oral hygiene practices and regular dental care is vital to prevent complications associated with excessive saliva and drooling, such as oral infections and dental decay (Speech & Swallowing Problems, n.d.). By addressing saliva management effectively, individuals with PD can improve their swallowing function, and enhance their quality of life.

Speech Therapy

Speech therapy is a crucial component in treating dysphagia among individuals with PD and their support network. After a thorough evaluation, SLPs develop personalized intervention plans tailored to the individual’s needs. These plans include exercises to enhance speech clarity, strengthen relevant muscles, and implement communication strategies. Additionally, therapy addresses swallowing difficulties by targeting muscles involved in breathing, coughing, and swallowing, often incorporating expiratory muscle strength training (EMST). Dietary modifications and specific techniques for eating and drinking may also be suggested to improve swallowing safety. Research suggests that combining speech therapy with consistent daily practice yields more significant improvements. Periodic re-evaluation and short therapy sessions over time help individuals maintain optimal functioning (Speech & Swallowing in Parkinson’s, n.d.).

Self-help Strategies

Swallowing disorders in Parkinson's are treatable, and individuals can take proactive steps to alleviate symptoms and reduce associated risks. It's essential to consult with healthcare providers for personalized guidance, but there are self-help strategies to complement professional treatment (Swallowing Issues, 2018).

Eat in an environment free from distraction.
Take your time while eating.
Always eat sitting upright at 90 degrees.
Avoid lying down immediately after eating; sit for at least 30 minutes.
Consider eating five small meals instead of three large ones to avoid fatigue.
Chew thoroughly and discuss any changes to teeth or dentures with your dentist.
Alternate between liquids and solids, avoiding washing down food.
Eat during medication "on" times when you're at your best.
Practice oral care, including brushing your tongue, to remove excess bacteria.
Take small mouthfuls to enhance control over chewing and swallowing.
Refill your cup or glass when it’s half empty to avoid tilting your head back.
Consider iced, carbonated drinks to stimulate swallowing, taking frequent sips between bites.
Do not ignore symptoms of a swallowing disorder; consult your physician promptly.

Understanding the complexities of swallowing issues in Parkinson's disease is crucial for both individuals living with the condition and their caregivers. As Parkinson's is a progressive disease, swallowing abilities can change over time, emphasizing the importance of early intervention and regular monitoring. It's essential to remain vigilant, as signs of a swallowing disorder may be subtle. If you suspect any difficulty in swallowing, don't hesitate to seek help.

Consult your physician to be referred to a speech-language pathologist for a comprehensive swallowing evaluation. By addressing swallowing issues proactively, individuals with Parkinson's can better manage their symptoms and maintain their quality of life. If you're interested in delving deeper into the topic, we offer communication and swallow workshops throughout the year. Keep an eye out on our website for updates and sign up for the next workshop. These workshops provide invaluable strategies to enhance communication and swallow function, offering participants a deeper understanding of these essential aspects of living well with Parkinson's disease.

Sources

Ciucci, M. (2013, November 5). Swallowing and Parkinson’s Disease. The Michael J. Fox Foundation for Parkinson’s Research. https://www.michaeljfox.org/news/swallowingand-parkinsons-disease

Matsuo, K., & Palmer, J. B. (2008). Anatomy and Physiology of Feeding and Swallowing: Normal and Abnormal. Physical Medicine and Rehabilitation Clinics of North America, 19(4), 691– 707. https://doi.org/10.1016/j.pmr.2008.06.001

Narciso, S. (2022, August 19). What is Dysphagia, and How Does it Impact Living Well with Parkinson’s? Davis Phinney Foundation. https://davisphinneyfoundation.org/dysphagiaparkinsons

Speech & Swallowing in Parkinson’s. (n.d.). Parkinson’s Foundation. https://www.parkinson.org/library/fact-sheets/speech-swallowing Speech & Swallowing Problems. (n.d.). The Michael J. Fox Foundation for Parkinson’s Research. https://www.michaeljfox.org/news/speech-swallowing-problems

Swallowing Issues. (2018). Parkinson Canada. https://www.parkinson.ca/wpcontent/uploads/Swallowing.pdf

This content was published in the June 2024 edition of our monthly support group newsletter, GroupLink. The content was accurate as of this publication date.

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