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Dr. Mahler

Swallowing and PD

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Changes in swallowing are frequently found in PD. It has been reported that as many as 95% of people with PD have dysphagia (Bird, Woodward, Gibson, Phyland, & Fonda, 1994; Logemann, Blonsky & Boshes, 1975; Potulska, Friedman, Krolicki & Spychala, 2003). When dysphagia is present it has a negative impact on quality of life by interfering with the ability to take medications, maintain hydration and nutrition, and may result in aspiration pneumonia. Pneumonia is one of the leading causes of death in PD (Beyer, Herlofson, Arsland, & Larson, 2001; D’Amelio, Ragonese, Morgante, Reggio, Callari, Salemi & Savettieri, 2006). Even when there are no difficulties with swallowing, mealtimes can be effortful for people with PD possible causing them to fatigue easily and eat less.

 

Muscle rigidity, weakness and bradykinesia that are present in the limbs can also affect all phases of swallowing (Robbins et al. 1986; Labuszewski & Lidsky, 1979). In addition, sensorimotor abnormalities may reduce the person’s awareness of symptoms of dysphagia.

 

Some Symptoms of swallowing disorders called, “dysphagia” may include:

• Frequent coughing during meals

• Coughing while drinking liquids or taking pills

• A wet gurgly sounding voice quality

• Recent unexplained weight loss

• Recent diagnosis of pneumonia

• Difficulty making the food “go down”

 

There are a number of reasons why swallowing can be "difficult" for a person with PD. The reason you need to get a referral for an evaluation with a speech- language pathologist (SLP) is so that they can identify the unique causes of the swallowing difficulty for you as an individual. The evaluation usually consists of an examination of the muscles for chewing and swallowing and then possibly a modified barium swallow study if the SLP suspects a problem in the pharyngeal stage of the swallow which is more difficult to observe directly. When the evaluation is done the SLP should be able to describe your swallowing problems, the underlying physiology causing the problems, your risk for aspiration, and treatment strategies that appropriately address the cause of the problems.

 

Although people with PD share a common etiology there may still be heterogeneity within the population regarding the cause of swallow problems. Appropriate treatment techniques to address swallowing disorders in PD need to address the motor and sensory components. Common treatment approaches for swallowing deficits in PD include:

• Modifying bolus flow with postures

• Maneuvers to improve airway protection or airway clearance

• Alterations in diet consistency

• Sensory stimulation

• Exercises to improve swallow function

• Alterations in feeding environment

Discuss getting a referral to a speech-language pathologist for a swallowing evaluation with your physician. Speech-language pathologists are trained to be experts in swallowing and swallowing disorders and can identify what can be done to maximize swallow safety and oral intake. Please write to the this forum if you have any questions about swallowing.

 

Sincerely,

 

Leslie Mahler, PhD, CCC-SLP

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Is it common to experience dysphagia 1/2 way through a meal. I can be really hungry and about half way through the meal I start finding it hard to swallow. I have had 2 swallow studies and although it should a mild amount of problems, the half way through the meal think started about 2 weeks ago.

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Yes, it is possible for the muscles to fatigue making swallowing more difficult part way through the meal. It is very important to have this evaluated further to start appropriate swallowing exercises. Get a referral from your physician to a speech-language pathologist who is skilled in the evaluation and treatment of swallowing disorders in Parkinson disease. This evaluation will determine the specific causes of you swallowing problem and make recommendations to maximize safety and efficiency of swallowing so you can enjoy mealtimes and meat your hydration and nutrition needs.

 

Write again if you have any further questions. However, without seeing you in person it is not possible for me to diagnose your specific problem with swallowing.

 

Sincerely,

 

Leslie Mahler

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This seemed like the best place to address my issue: I consistently have a large mass of mucus located in the nasopharnyx region that I cannot swallow down or blow out through the nose. The only way to remove it is to manipulate it by inhaling air from my nose until it activates my gag reflex. Then, if I'm lucky,I will vomit it out. I never regurgitate anything from my stomach at this time. This will clean it up but it will be back by the next day. Does this sound familiar to any other Parkinsonians out there?

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So are you saying that there is actually mucus present? Sometimes the sensation of something being stuck in your throat can result from reflux. The reflux irritates the pharynx and causes a "globus" sensation - the feeling that something is stuck in your throat but it actually isn't. Have you ever discussed reflux with your physician?? Write again and tell us about other signs of dysphagia that you might have.

 

Sincerely,

 

Leslie Mahler

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Dr. Mahler raises a good question - "Is there really mucus present?" If so, you might want to try some ways to thin your mucus. There are facial steamers that can be purchased on-line or at a store that has a pharmacy. They typically cost under $40. I advise my patients to steam for 5 minutes twice daily, particularly during the dry winter months (low humidity) or if you live in a dry or arid climate. Maintaining adequate body hydration is also important. Drinking sips of room temperature water throughout the day will help to keep you body adequately hydrated. Buy a water bottle and keep it handy so you can take sips. Remember that beverages that have caffeine contribute towards dehydration, so make sure you compensate with sips of water. Also, if you have allergies and are taking antihistamines, they will also contribute towards dehydration. There are over the counter medications, such as mucinex that help the body to reabsorb mucus, but consult with your doctor to make sure they are safe for you. Finally, you might want to see an Ear, Nose, and Throat doctor (ENT) and have the doctor examine your nose and nasopharynx (the back part of your nose that is connected to your throat). This doctor might help you to determine if your problem is a reflux issue or a true problem with mucus. Sincerely, Celia Bassich Ph.D., CCC-SLP

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Hi - I think this might be the best place for my question.  My father has PD and is coughing at night which we suspect is due to an inability to swallow saliva.  He had an MBS where the barium pill stuck at the UES but cleared with a second swallow using a thin liquid.  Of course the test is in an upright position and didn't reveal the issues he has when he's laying down.  My dad is extremely disappointed because he knows there's a problem and went as far as testing what conditions lead to coughing.  It appears that he only has a problem when he is laying on his left side.  He had expected exercises that he can do for the issues he has at night but only got the following recommendation:  Put pills in applesauce or pudding.  Any suggestions on where to go from here?

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You are right that gravity is a positive factor for swallowing safely when people are sitting or standing.  This is one reason why positioning is so important during meals or drinking or taking pills.  Even if your father has no overt symptoms of swallowing problems during the day he likely has changes in the swallowing muscles.  Putting pills in applesause or yogurt or any thicker substance can help some people for swallowing pills.  I would recommend an intensive swallowing exercise treatment program for your father to see if he can improve the safety and efficiency of his swallowing and possibly reduce the coughing at night.

 

Sincerely,

 

Dr. Leslie Mahler

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