Dan Keller 0:08
Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research—the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.
Many people with Parkinson's disease will have problems swallowing, which is understandable given that Parkinson's is a movement disorder, and swallowing involves the coordinated movement of muscles in the mouth, throat, and into the stomach. This may lead to drooling, having trouble eating certain foods or drinking liquids, and may even cause food or liquids to enter the airway instead of going to the stomach. Problems such as weight loss, coughing, choking, or lung infections can result.
The medical professional who is trained and best equipped to deal with these problems is the speech-language pathologist. Besides working on speech, language, and communication problems, they are experts at evaluating and diagnosing swallowing difficulties and providing training and education to people with PD and care partners about ways to best manage these problems. I spoke with speech-language pathologist Yael Manor of the Tel Aviv Medical Center in Israel about evaluating people with PD, diagnosing dysphagia, and some techniques to lessen swallowing difficulties. People hear the technical term dysphagia. What does that mean to the layperson?
Yael Manor 2:04
Dysphagia is swallowing disorders, swallowing disturbances, and it occurs between 90 to 100% of the Parkinson's disease population.
Dan Keller 2:16
What are some of the early signs of swallowing difficulties that people should be aware of?
Yael Manor 2:21
One of the early signs is difficulty to swallow medications, some drooling, and then there are more advanced signs like coughing when drinking, coughing when eating, problem to chew food, or even choking, and the worst sign is aspiration pneumonia.
Dan Keller 2:41
Why is it important to detect and remediate these kinds of problems early?
Yael Manor 2:47
It is very important and very crucial to detect swallowing disturbances early as possible, because first of all, patients need to be educated about the signs and be ready to get an early treatment. Otherwise, they can develop some complications, such as weight loss, hospitalization, dehydration, and even social isolation. When people have swallowing problems, they don't like to eat in front of, you know, other people. So then they become depressed and stay at home, and in this way they decrease of quality of life. So we would like to see the patient as early as possible, and to give them the tools that are going to help them to swallow safely.
Dan Keller 3:32
So, if there is some indication of a swallowing difficulty or disturbance, how do you evaluate that person?
Yael Manor 3:39
First of all, the easiest way, there is a swallowing disturbances questionnaire. It's a screening tool, and it's not evaluation, but it can help us to detect which patient should go to have full swallowing evaluation or not. So it calls Swallowing Disturbances Questionnaire. Now, if a patient gets a score of 11 and above, so then we refer him to a full bedside evaluation by a speech therapist, and then one of the recommendations by the speech pathologist could be refer the patients to instrumentation evaluation, which could be videofluoroscopy, which is like roentgen in motion, X-ray in motion. Or another kind of instrumentation is called FEES, which stands for Fiberoptic Endoscopic Evaluation of Swallowing, and it can be done either by ENT and speech pathologist or just by speech pathologists in United States, where a scope inserted in the patient's nose, and then we can view the swallowing mechanism and see what's happening to the food or liquids while the patient is swallowing. So these are the three kinds of swallowing evaluations.
Dan Keller 4:50
Is that sort of an advanced kind of procedure? Not everyone would need that, would they?
Yael Manor 4:56
No, usually we start at bedside evaluations, that is done by the speech pathologist, and then after the evaluation, then she gives recommendations for any kind of swallowing tips and therapy, but also she can refer the patient to do instrumentation evaluation. It depends on the severity of the swallowing problem of the patient.
Dan Keller 5:20
So, if problems are detected, what would be the goal of therapy?
Yael Manor 5:24
Okay, first of all, we want the patient to swallow safely and be able to have enough calories to live. The common problem is like getting food or liquid into the trachea, and we want to eliminate this. This calls aspiration. So, according to the bedside evaluations, we write down some recommendations to the patients. For example, if the patient coughs while you swallow a liquid, so we can tell the patient to drink while he's doing chin tuck, he's getting his chin down and swallow with his head down the thin liquid. Or another technique is where we thicken the liquid into a thickened consistency, so then it would be easier for the patient and safer for the patient to swallow.
Dan Keller 6:15
What are some of the consequences of what we would say food going down the wrong way, going into the trachea?
Yael Manor 6:22
So then could be increasing mucus, some breathing difficulties, and the worst thing is aspiration pneumonia, which we know that 54% of patients who develop aspiration pneumonia die due to this.
Dan Keller 7:34
So that's actually causing an infection in the lungs.
Yael Manor 6:41
Exactly.
Dan Keller 6:42
Besides these techniques for swallowing liquids and thickened liquids, are there other techniques or tools that can help these people?
Yael Manor 6:53
Yeah, usually interventions we work on like three areas. We work on different consistencies, okay? So sometimes, as I said, thickening the liquid or getting the food, like blenderized food, when the patient had a problem to chew the food or to swallow the food. So this would be one area.
The second area is we work on, like posture, as I said, like chin down, or sometimes leaning their head to one side or the other, swallow this way. Again, it depends on the problem.
And the third area is swallowing compensatory techniques, where we ask the patient to swallow in a certain way. I'll give you an example: like if the food gets stuck in the patient's throat because the muscles are weak, and we're afraid that the food that got stuck there get into the trachea, so we would ask the patient to make like forceful swallow or double forceful swallow, so the patients will swallow twice and then will cough, it's like clearing his throat and swallow again. So in this way, the swallowing become like more safe, like a safe way to swallow the chewable food.
Dan Keller 8:04
Do these techniques continue to work, or as the disease progresses, do they start to have less effect?
Yael Manor 8:11
It depends on how the patients really comply with the exercises and the techniques, and of course, for this you need cognition. So, my suggestion is always to start as early as possible, so in this way it becomes more automatic, so then the patient can get used to swallow in this way. But as the disease progresses, sometimes it's more difficult for them to follow the instructions and remember how to swallow, and it gets frustrating. Definitely.
Dan Keller 8:41
Have we missed anything important or anything interesting to add?
Yael Manor 8:45
The most important thing, as I said before, and I will stress it, is to make the patients, the caregivers, be aware of the swallowing problem, the importance of early detection as early as possible, in order to provide early interventions, and to eliminate all these complications.
Dan Keller 9:03
Very good. Thank you.
As Dr. Manor advised, it is better to be evaluated for swallowing problems early on, and it's not too early to see a speech-language pathologist as soon as you are diagnosed with Parkinson's, even before you experience swallowing difficulties. That way, you can implement behavioral strategies and learn swallowing exercises that may delay or prevent problems later by protecting your airway and improving the efficiency of swallowing.
To learn more about speech and swallowing with PD, and what can be done to alleviate these challenges, please visit parkinson.org/swallowing and parkinson.org/dysphagia, that's d-y-s-p-h-a-g-i-a. You can also tune in to podcast episode 47 of this series, which talks about swallowing issues and oral care with Parkinson's. To download or order our free publication covering the topic, titled Speech and Swallowing: A Body Guide to Parkinson's Disease, please visit parkinson.org/store. You can find more articles and frequently asked questions about swallowing and feeding by searching the website of the American Speech-Language-Hearing Association at asha.org.
And of course, our PD Information Specialists can answer questions and provide information in English or Spanish about today's topic or anything else having to do with Parkinson's. You can reach them at 1-800-4PD-INFO. To receive news and updates about future events and resources, you can opt into our email list at the bottom of our website's homepage. If you have questions or want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback, or if you prefer, email us at podcast@parkinson.org.
If you enjoyed this podcast, be sure to subscribe and rate and review the series on Apple Podcasts, or wherever you get your podcasts. At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every other week. Until then, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO, that's 1-800-473-4636. This episode is supported by a grant from Genentech, a member of the Roche Group. Thank you for listening.
