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krich1011

Swallowing and Parkinson's

12 posts in this topic

Dr. Mahler,

There have been numerous incidents regarding people with Parkinson's choking on food, and liquids. What is the correlation between swallowing and Parkinson's?

 

Thank you!

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Thank you for writing with this interesting question. Speech is sometimes referred to as an "overlaid" function.  That means that the muscles used for swallowing and speech overlap.  Therefore, it is not surprising that if a person is having difficulty with speech, then they might also have difficulty with swallowing or vice versa.  There are a number of reasons why swallowing can be "difficult" for a person with PD and it is important for the health care team to understand these issues.  Appropriate treatment techniques to address swallowing disorders in PD need to address the motor and sensory components.

 

Dysphagia can occur in all stages of swallowing in people with PD.  Typical changes associated with the oral phase of swallowing can include:

  • Reduced tongue strength => tongue and/or palatal residue
  • Reduced anterior to posterior tongue coordination and lateralization => decreased bolus formation & transport
  • Lingual rocking during bolus formation
  • Lingual tremor
  • Prolonged ramplike posture
  • Piecemeal deglutition

(El Sharkawi et al., 2001; Volonte, Porta, & Comi, 2002; Hunter et al., 1997; Bushmann et al., 1989; Robbins et al., 1986)

 

Typical changes associated with the pharyngeal phase of swallowing include:

  • Delayed pharyngeal response
  • Delayed triggering of the swallow reflex
  • Impaired motility with residue in valleculae and pyriform sinuses
  • Penetration and/or aspiration

(El Sharkawi et al., 2001; Leopold & Kagel, 1997 ; Potulska et al., 2003; Robbins et al., 1986)

 

Aspiration before the swallow may occur as a result of premature material spilling over the tongue base with and reduced vocal fold closure.  Aspiration after the swallow may occur secondary to significant amounts of pharyngeal residue that is aspirated when respiration is resumed (Robbins et al., 1986) or incoordination of breathing and swallowing (Gross et al., 2008).

 

Please write again if you have additional questions. 

 

Sincerely,

 

Leslie Mahler

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My father was diagnosed with parkinson 10 years ago. We admitted him to hospital for hallucinations and psychosis. He was refusing to eat at home. His condition became worse when we brought him to the hospital. He was diagnosed with aspiration pneumoina . Because of this infection his body was not responding to parkinson medicines. The doctors told us they had to do tracheostomy surgery for saving his life as he was unable to take out his secreations and lot of secreations were coming at that time. Now he has recovered from pnemonia and his movements are fine. But another big issue has come now . His swallowing test is failing . Doctors says they cannot remove tracheostomy tube until the swallowing test passes. What to do now?

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The muscles of swallowing can be affected in the same was as limb muscles in people with PD.  Rigidity, weakness, bradykinesia, and tremor can be present in muscles of the mouth and throat and that can cause changes in swallowing safety.  The onset of swallowing disorders varies by individual but eventually, 90% of people with PD will have a swallowing disorder.  This means it is very important to discuss any changes in swallowing, or unexplained weight loss, or more frequent coughing during meals with your physician.  Those symptoms could indicate that you need a full swallowing evaluation with a speech-language pathologist.

 

Thank you for writing with this important question.  Please send a follow-up questions if you would like further information.

 

Sincerely,

 

Dr. Mahler

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Your father's swallowing disorder must be significant if he is have difficulty managing his own secretions and aspiration caused pneumonia that required the placement of a tracheostomy tube.  It is impossible for me to say what should come next without seeing your father in person.  Is he receiving swallowing therapy at the present time?  If he is, ask the speech-language pathologist what the goals are and whether there is an expectation that your father could recover enough swallowing ability to eventually remove the tracheostomy tube.  The speech-language pathologist in charge of his case will be able to tell you what to do next.  If he is not receiving swallowing therapy, then you could request a referral to a speech-language pathologist who is experienced in treating people with PD.

 

I wish you and your father the best.

 

Sincerely,

 

Dr. Mahler

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The muscles of swallowing can be affected in the same was as limb muscles in people with PD.  Rigidity, weakness, bradykinesia, and tremor can be present in muscles of the mouth and throat and that can cause changes in swallowing safety.  The onset of swallowing disorders varies by individual but eventually, 90% of people with PD will have a swallowing disorder.  This means it is very important to discuss any changes in swallowing, or unexplained weight loss, or more frequent coughing during meals with your physician.  Those symptoms could indicate that you need a full swallowing evaluation with a speech-language pathologist.

 

Thank you for writing with this important question.  Please send a follow-up questions if you would like further information.

 

Sincerely,

 

Dr. Mahler

 

Thank you Dr. Mahler:

 

A little background before my question.

 

My dear husband (DH) has had swallowing challenges for a few years now that involve a "clicking noise" when he does swallow (especially when he's not eating or drinking) and frequent coughing episodes during eating or drinking.  We chalked this up to excess secretions caused by seasonal allergies and to "genetics" - we remember his father having similar challenges and frequently needing to "clear his throat".

 

We finally asked our PCP if an endoscopy might help us better understand the cause and devise a "cure".  The PCP wasn't overly concerned, but agreed this was the next step.  The endoscopy revealed a small Hiatal hernia the recommended management of which didn't really seem to "correct" the symptoms we noticed, but said symptoms didn't seem to be worsening either and we felt a little "comfort" in knowing there wasn't "anything more" to worry about.  Ha!

 

Twelve days ago DH was diagnosed, by a Neurologist, with "mild PD".  The symptoms that led us to ask our PCP for a referral to said Neuro. involved left hand tremor, left foot dragging and hip pain we thought was related to trying to overcome dragging the foot.  We have been aware of these symptoms as well for over a year and when DH discussed them with his PCP last summer, PD was "ruled out" (not sure how) so we tried physical therapy which provided some relief to the hip pain (through exercises) but nothing else changed.

 

One of the PD symptoms the Neuro. "noticed" right away that we were not conscious of before the dx was facial masking.  As we shared our "news" with our neighbors/close friends a couple of them mentioned that DH has recently "looked like a deer in headlights" and they were chalking this up to emotional stress over the new dx.  While I am sure current emotional distress is exacerbating DH's facial expressions (or lack thereof) I firmly believe "masking" is the root cause.  Now after reading the plethora of information found at Parkinson.org I am wondering if his swallowing symptoms are also related to PD.  Since facial, neck, mouth muscles are involved in both, is there a greater correlation of PWP evidencing swallowing/speech symptoms with those who also evidence facial masking?

 

In addition to working with an MDS (we have asked the Neuro. for a referral thereto) should we also ask for a referral to an SLP?    Should we start one before the other?  Is it most beneficial to have these specialists part of the same PD/Movement Disorders Center?  Do exercise therapies "alone" help with masking and swallowing symptoms or will medication therapies also have to be involved?

 

Sorry for so many questions at once, my mind is just spinning with this dx and its ramifications.  I am trying to sift through all the information and do as much "leg work"  as possible this summer since I am currently employed as a public school teacher, so I have much more flexibility right now during the "normal work week" than does DH.

 

Many thanks in advance.

 

Lonnise

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Lonnise,

It sounds like you have been doing a lot of research since your husband received his diagnosis.  I am glad that you included a post to the NPF forums in your search for information.  There is significant heterogeneity among people diagnosed with PD.  Therefore, I can respond to your questions about swallowing and PD in a general way but encourage your husband to seek an evaluation with a speech-language pathologist who specializes in PD for recommendations specific to his needs.  People with PD often have swallowing problems.  I described some of the causes earlier in this email thread.  A hiatal hernia can also cause swallowing changes such as those you described in your email.  For example, frequent throat clearing and increased coughing can be associated with this diagnosis.  Therefore, the swallowing changes your husband is experiencing are probably a combination of the hiatal hernia and PD.  There are exercise programs to improve swallowing that may benefit your husband and I recommend that he begin as soon as possible.  Therefore, in answer to your question, when you see the movement disorders specialist, ask that doctor to write a script for evaluation and treatment of speech and swallowing from a speech-language pathologist.

 

Please write again if you have any additional questions. 

Sincerely,

 

Dr. Mahler

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Thank you, Dr Mahler, for your time devoted to,the NPF forum.

 

DH (71 yrs) was dx'd by MDS for PD March,2016.. DH saw a neuro 30 years ago for bilateral trigeminal neuralgia (TGN). Dr noted tremor in DH hand at first visit, so it is possible PD went undetected for a long time.

 

Since his TGN was dx'd he has had 10 attempts to destroy the trigeminal nerve bilterally with radioglysis and gamma knife, He still has TGN episodes if he reduces medication.

 

I am surprised his PD symptoms have progressed rapidly in 5 mos. Tremor, balance, cognitive, word search are noticably deteriorating and increase in excessive saliva.

 

Specifically, he recently has had speech/swallow issues. His speech is blocked by a tightening of muscles. He best explains it by having a "swallow" freeze his throat and prevents him from speaking. He was reading to me last night while holding my hand. He stopped speaking and squeezed my hand very tight for several seconds. I thought it was TGN.....until he explains this NEW symptom. Apparently he has had this for several months, and now is problematic.

 

I have PD and of course have done a lot of "google research". I thought swallowing issues occurred in later stages of PD. He is physically active.

 

I included TGN history to ask if the long standing disease and the many "assaults" to his facial nervous system could be responsible.

 

In Viet Nam, he was exposed to the herbicide, agent orange, a known carcinogen. Do neuro symptoms from such sources mimic PD? Can TGN alone cause these symptoms? His DaT is negative, but his PD symptoms dramatically improve with Ldopa.

 

So...given that I am asking only for your speculation, what do you think? We cant see MDS until Nov. What tests do you recommend for his symptoms.? Is this an urgent situation? Can his breathing be restricted enough to be an emergency? ( I feel silly asking )

 

Like Lonnise, i ask alot of questions. Dr Mahler, the unknown is very scary.

 

Thank you in advance for your response. Again, i recognize you can only speculate.

 

NN

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Dear NN,

Thank you for understanding that I cannot diagnose without seeing the patient in person. The information provided in this correspondence is not a substitute for medical or professional care.   DH should seek the advice of his  physician or other qualified health provider with questions regarding a medical condition and treatment. It sounds like there are multiple factors to consider in the case of DH.  Like many people with PD, he was diagnosed in his 70's and like many people in their 70's, PD is often not the only factor to consider when trying to evaluate and make recommendations to treat speech and swallowing disorders.  DH definitely needs an evaluation with a speech-language pathologist to address each of your important concerns.  Here are some thoughts about the different components individually:

  • The trigeminal nerve is important for speech and swallowing in several ways.  It innervates muscles that elevate and close the jaw and provides sensation for the front part of the tongue.  Therefore treatment for trigeminal neuralgia could definitely have an impact on speech (imprecise articulation) and swallowing (reduced control of the food in the oral stage).  Therefore, it would be important for the SLP who treats him to know what the impact of those treatments were prior to his diagnosis of PD earlier this year.
  • There are different types of PD.  There is idiopathic PD and there are Parkinson Plus syndromes.  Idiopathic PD does not typically progress so rapidly that there are noticeable changes in 5 months.  Therefore, DH's physician needs to know about the noticeable deterioration in tremor, balance, cognition, and word-finding. 
  • The debate about "excess saliva" has a long history with the general opinion that people with PD do not actually produce more saliva but swallow less frequently and when they do swallow the swallow is weaker and less efficient giving the appearance of excess saliva.  Exercises may be able to improve the swallow efficiency.
  • I am curious about the description of "blocked" speech.  Is that physical or is it trying to find the right word or a combination?  The answer to that would be important for treatment recommendations.
  • There has been research examining the link between pesticides and PD.  To my knowledge, the link between Agent Orange and PD is not clear.  However, if DH was in Vietnam that means that DH should be eligible to receive services from the VA, which provides speech-language pathology services.
  • Swallowing disorders can occur at any time in PD although swallowing disorders are typically more severe as the disease progresses.
  • I really don't know if his breathing will be restricted.  It does not seem like a silly concern and you must have some reason for asking. This is a medical question for the doctor.  If you see any signs of shortness of breath or difficulty getting his breath, then call the doctor immediately.
  • In the meantime, I suggest practicing safe swallow guidelines:

General Safe Swallow Recommendations:

  • Eat sitting upright – in a chair is preferable – even for swallowing pills
  • Eat slowly – take small bites and sips of liquid
  • If DH has difficulty making the food go down or clearing the liquid, then swallow effortfully for each swallow and/or swallow twice.
  • Watch the quality of foods that DH east to make sure they are high in nutrition.  When swallowing is difficult, people tend to eat less, which makes what they eat even more important.  Consult with a dietician or nutrition specialist for specific diet recommendations.
  • Eat smaller more frequent meals throughout the day so you don’t get too fatigued during a meal.
  • Be sure to stay hydrated – drink plenty of water and decaffeinated beverages.

I hope this information helps.  Please write again if you have further questions.

 

Sincerely,

 

Dr. Mahler

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Excellent response, Dr Mahler.

 

In response to your question, the "blockage" I reference is a muscle contraction "as if he is swallowing while trying to speak." (In his words.). Since it happens more often when he bows head in prayer, we speculate that lowering his head puts pressure on his throat and triggers esophagus to constrict. It does occur at other times...but we have attributed it to stress.

 

My "take away" is .... variables in his health history need to be addressed individually. We will discuss with MDS which is first, ENT or speech/language pathologist. Do you have any rhoughts on that?

 

You help us understand our disease process, but evern more importantly, you listen.

 

Thank you so much for your time.

 

NN

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Dr. Mahler

 

P.S. Saliva

 

I have times when saliva floods my mouth. One time in a clinic I needed suction tube to control flow. I am physically active with few symptoms while on meds. This did not happen prior to PD dx.

 

NN

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Some individuals with PD may have a safe swallow but one that is less "efficient".  That can result in reduced ability to manage secretions.  Although needing suction to control the flow sounds like a significant problem with saliva control.  It is possible that exercises to swallow with more effort could improve this situation.    You will need to see a speech-language pathologist in person to determine if this is an appropriate option for you.

 

Please write again if you have any further questions.

 

Sincerely,

 

Dr. Mahler

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