Drooling Is No Early Sign Of Dysphagia In Parkinsons Disease
Department of Voice, Speech and Hearing Disorders, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Department of Voice, Speech and Hearing Disorders, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Stooping Or Hunching Over
Are you not standing up as straight as you used to? If you or your family or friends notice that you seem to be stooping, leaning or slouching when you stand, it could be a sign of Parkinson’s disease .
What is normal?If you have pain from an injury or if you are sick, it might cause you to stand crookedly. Also, a problem with your bones can make you hunch over.
Discuss With Your Physician
Non-motor symptoms can sometimes be difficult to recognize. Therefore, it is important to make your doctor aware of them.
One useful resource is the PD NMS Questionnaire. You can use this to record your symptoms and discuss them with your doctor.
Dr. Ron Postuma, whose research was funded by donations to the Parkinson Canada Research Program, has also developed tools to help people with Parkinsons and their physicians identify and manage non-motor symptoms.
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Drooling In Parkinsons Disease: A Multifactorial Symptom
1Neuromuscular Rehabilitation Research Center, Semnan University of Medical Sciences, Semnan, Iran
2Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
3School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
How to Cite:BakhtiyariJ, MehriA, MaroufizadehS, AmanianH. Drooling in Parkinsonâs Disease: A Multifactorial Symptom,Arch Neurosci.2020 7:e99300. doi: 10.5812/ans.99300.
Archives of Neuroscience:Article Type:
Role Of Saliva In Health And Well
Two primary functions of saliva concern its role in maintaining oral pH and microbiotic homeostasis, and facilitating swallowing and speaking.46 Saliva possesses antimicrobial, anti-viral and anti-fungal properties which aid oral cleansing, protect against infection and support tissue repair it dilutes sugars and helps stabilize acidity it contributes to remineralization of dental enamel. It serves as a buffer for extremes of temperature or against noxious substances. It lubricates the oral cavity, thereby supporting formation and transport of the bolus to the pharynx. It acts as a first stage in digestion and stimulates interaction with chemosensory receptors to aid taste and smell perception. It supports smooth and accurate movement of the tongue and lips for speech.
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Cognitive And Psychiatric Symptoms
- depression and anxiety
- mild cognitive impairment slight memory problems and problems with activities that require planning and organisation
- dementia a group of symptoms, including more severe memory problems, personality changes, seeing things that are not there and believing things that are not true
Anxiety Drooling May Be Early Signs Of Parkinson’s Disease Study Suggests
Before the classic movement problems of Parkinson’s disease appear, more benign-seeming symptoms — such as anxiety and drooling — may occur, according to a new study in the journal Neurology.
“These results show that Parkinson’s affects many systems in the body, even in its earliest stages,” study researcher Tien K. Khoo, Ph.D., of the UK’s Newcastle University, said in a statement. “Often these symptoms affect people’s quality of life just as much if not more than the movement problems that come with the disease. Both doctors and patients need to bring these symptoms up and consider available treatments.”
For the study, researchers asked 159 people who had recently been diagnosed with Parkinson’s — as well as 99 age-matched people without Parkinson’s — to report whether they’d experienced any of 30 potential non-motor symptoms. These issues ranged from problems sleeping, to digestive issues, to sexual problems.
Researchers found that the people who had been diagnosed with Parkinson’s experience an average of eight of these problems, while those without Parkinson’s experienced an average of three problems.
The most common symptoms experienced by the people with Parkinson’s included drooling , constipation , and anxiety .
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How Is Psp Diagnosed
Currently there are no tests or brain imaging techniques to definitively diagnose PSP. An initial diagnosis is based on the persons medical history and a physical and neurological exam. Identifying early gait problems, problems moving the eyes, speech and swallowing abnormalities, as well as ruling out other similar disorders is important. Diagnostic imaging may show shrinkage at the top of the brain stem and look at brain activity in known areas of degeneration.
Impaired Posture And Balance
Postural instability is the most difficult Parkinsons symptom to treat, and one of the most important criteria for diagnosing Parkinsons.
Postural instability is the inability to balance due to loss of postural reflexes and often leads to falls. Patients with impaired posture and balance might revert to a stooped posture and have a shuffling gait.
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Slow Muscles Carrying Food To Your Stomach
Parkinsons may also slow down the muscles carrying food down into your stomach. Food moving slowly down your food pipe to your stomach can make you feel full up. But once it arrives at your stomach you realise youre still hungry. By this time the food on your plate may have gone cold and be unappealing.
What Research Is Being Done
The National Institute of Neurological Disorders and Stroke , a component of the National Institutes of Health, is the primary funder of research on the brain and nervous system. NIH is the leading funder of biomedical research in the world.
PSP is one of the diseases being studied as part of the NINDS Parkinsons Disease Biomarkers Program. This major NINDS initiative is aimed at discovering ways to identify individuals at risk for developing Parkinsons disease and related disorders, and to track the progression of these diseases. NINDS also supports clinical research studies to develop brain imaging that may allow for earlier and more accurate diagnosis of PSP.
Genetic studies of PSP may identify underlying genetic causes. Previous studies have linked regions of chromosomes containing multiple genes, including the gene for the tau protein , with PSP. Researchers hope to identify specific disease-causing mutation and are also studying how genetics and environment interaction may work together to contribute to disease susceptibility.
Animal models of PSP and other tau-related disorders, including fruit fly and zebrafish models, may identify basic disease mechanisms and lead to preclinical testing of potential drugs. Other studies in animal models focus on brain circuits affected by PSP, such as those involved in motor control and sleep, which may also yield insights into disease mechanisms and treatments.
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What Is The Prognosis
The disease gets progressively worse, with people becoming severely disabled within three to five years of onset. Affected individuals are predisposed to serious complications such as pneumonia, choking, head injury, and fractures. The most common cause of death is pneumonia. With good attention to medical and nutritional needs, it is possible for individuals with PSP to live a decade or more after the first symptoms of the disease appear.
Excessive Drooling A Sign Of Greater Dysfunction In Parkinson’s Disease
Excessive drooling by patients with advanced Parkinson’s disease is an indicator of greater motor and nonmotor dysfunction, new research shows.
“Sialorrhea is not just a cosmetic problem,” study investigator Francesca Morgante, MD, associate professor of neurology, St. George’s University, London, United Kingdom, told Medscape Medical News.
“We need to understand the relationship between sialorrhea and these speech and swallowing disturbances and whether treatment for sialorrhea improves that,” Morgante added.
The findings were presented at the virtual Congress of the European Academy of Neurology 2021.
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Is There Any Treatment
There is currently no effective treatment for PSP and symptoms usually do not respond to medications.
- Parkinsons disease medications, such as ropinirole, rarely provide additional benefit. In some individuals, other antiparkinsonian medications, such as levodopa, can treat the slowness, stiffness, and balance problems associated with PSP, but the effect is usually minimal and short-lasting.
- Botulinum toxin, which can be injected into muscles around the eyes, can treat excessive eye closing.
- Some antidepressant drugs may offer some benefits beyond treating depression, such as pain relief and decreasing drooling.
Non-drug treatment for PSP can take many forms.
- Weighted walking aids can help individuals avoid falling backward.
- Bifocals or special glasses called prisms are sometimes prescribed for people with PSP to remedy the difficulty of looking down.
- Exercise supervised by a healthcare professional can keep joints limber but formal physical therapy has no proven benefit in PSP.
A gastrostomy may be necessary when there are swallowing disturbances or the definite risk of severe choking.
Deep brain stimulationwhich uses surgically implanted electrodes and a pacemaker-like medical device to deliver electrical stimulation to specific areas in the brain to block signals that cause the motor symptoms of several neurological disordersand other surgical procedures commonly used in individuals with Parkinson’s disease have not
Risk Factors For Drooling In Pd
If susceptibility to anterior drooling is not related to hypersalivation, other factors must be at work. Suggested candidates have been dysphagia, oro-facial rigidity/hypomimia, lingual bradykinesia, cognitive status, male gender and more advanced disease stage.23,24,28,31,39,43,50,51 Individuals with non-tremor dominant PD phenotypes were at higher risk of drooling.31,52 The precise contribution of these factors remains unsettled. The uncertainty rests partly on general issues above regarding why estimates of drooling prevalence and flow rates exist, but variability in individual profiles of impairment and disability also contributes.
Susceptibility of males probably relates to greater absolute flow rate when body mass and gland sizes are not controlled for though not all studies have found a male predominance.23,24,29 Relationship to greater disease severity likely reflects increased rigidity, poorer cognitive status and more marked dysphagia of later stages, and, in as far as medications may alter the picture, higher medication dependency.21
L-dopa can influence variables in swallowing efficiency,3,58 and thus indirectly change drooling. Currently, dysphagia study outcomes do not afford sufficient evidence to conclude a positive, neutral or negative effect of possible swallowing changes on sialorrhoea.
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What Is A Swallowing Evaluation
If because of the above signs there is concern that swallowing difficulties exist, your doctor may recommend a swallow evaluation, which can be performed by a speech and language pathologist.
There are two main ways to evaluate someones swallow:
- Modified barium swallow study This is the most common test that is performed. The person is asked to ingest different consistencies of barium and moving x-rays are taken that follow the barium as it is swallowed. This x-ray video pinpoints the areas of the swallow that are problematic and helps to determine the correct exercises to address the problem.
- Fiberoptic endoscopic evaluation of swallowing is another type of test that can be performed to evaluate swallow. During this procedure, a very thin flexible fiberoptic tube which is hooked up to a camera and light source, is passed through the nasal passage. The tube does not go down the throat, but allows swallowing to be observed. This procedure is painless and well-tolerated by most individuals.
Treatment Options For Drooling In Pd
First, treatment should begin by withdrawing medications that aggravate drooling such as cholinesterase inhibitors, clozapine or quetiapine. Next, the target might be to improve motor symptoms by using dopaminergic medications or by performing deep brain stimulation if the motor symptoms otherwise justify these approaches. However, the response of drooling is usually only partial and there is clearly a need for a specific adjunctive treatment for this problem. Specific treatment options for drooling in PD are both pharmacological and nonpharmacological.
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Oral Dysfunction In Parkinsons: Swallowing Problems And Drooling
Two common and distressing problems that can develop in Parkinsons disease are swallowing dysfunction and drooling. I want to help you better understand these issues and learn what you can do to improve them so read on!
Thank you to Christine Sapienza, PhD, CCC-SLP and Bari Hoffman Ruddy, PhD, CCC-SLP for providing some of the material below.
Measurement Of Related Variables
In as far as ptyalism in PD may be linked to other symptoms, other assessments may be pertinent to place real and perceived drooling in its broader context. These cover assessment of swallowing, speech and voice.3,65 Detailed dental examination and monitoring of oral health may be indicated for some individuals, over and above routine dental supervision.22,83
People with PD may experience dry mouth/xerostomia.21 Perceived dryness does not necessarily reflect objective levels of dryness defined by salivary flow rate/volume, mucosal wetness and saliva consistency.84 The Clinical Oral Dryness Score 85 is a validated clinician-administered semi-quantitative tool. The score comes from observing the presence/absence of ten symptoms and signs characteristic of dry mouth. It is combined with a 010 rating by the patient on how far they are bothered by xerostomia. Perceived impact has also been gauged using five questions related to possible activity and participation restrictions commonly reported by people with xerostomia.85
The PDQ3944 contains items on avoiding eating and drinking in public and speech/communication problems, but has nothing specific to drooling, despite several studies employing it as a sialorrhea rehabilitation outcome measure.
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Embarrassing Symptoms Of Parkinson’s Disease
Some symptoms that may occur in people with Parkinsons disease are not typical of it and so people noticing them may misunderstand them. These symptoms can be particularly embarrassing in social situations where other people witness their discomfort. They distress some people so much that they avoid company other than close friends or family. Most of these symptoms are caused by Parkinsons but some are side effects of the medicines used to treat it. All the symptoms tend to fluctuate in relation to the medication, and some people had learnt to adjust their medicine regime to minimise these effects.
Eating can cause embarrassment in several ways. Both tremor and dyskinesia affect the physical job of cutting up food and directing it into the mouth . Several people had a problem with a piece of steak or chicken that might fly off the plate as they tried to cut it up, or they had a choking fit if they unwisely took too big a piece into their mouth. Humphrey disliked eating out with friends because he tended to drop things.
Inflammation Of The Epiglottis
Epiglottitis is inflammation of the epiglottis, tissue that covers the trachea , which helps prevent coughing or choking after swallowing. It is usually caused by the bacteria H. Influenzae but can also be caused by other bacteria or viruses that cause upper respiratory infections.
Top Symptoms: being severely ill, shortness of breath, fever, sore throat, pain with swallowing
Symptoms that never occur with inflammation of the epiglottis: cough
Urgency: Emergency medical service
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Eating Swallowing And Saliva Management
Some people with Parkinsons may find they have difficulties with eating, swallowing and saliva control at some stage of their journey with Parkinsons.
Parkinsons can cause the muscles in the jaw and face to become stiff which affects the control of chewing and swallowing.
Another symptom of Parkinsons can be producing excessive saliva. The stiffer facial muscles can change the nature of saliva, which may become thicker and stickier.
Pathophysiology Of Drooling In Pd
In addition, a recent study showed that severe hypomimia, unintentional mouth opening and stooped posture with dropped head, could cause drooling in PD patients by losing the ability to maintain saliva within the oral cavity . In contrast, there is no obvious evidence that medication-induced dyskinesia can produce drooling. The possible domains contributing to the pathophysiology of drooling in PD are summarized in .
Possible pathophysiology of drooling in Parkinson’s disease
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Managing Eating And Swallowing
It is important to continue eating normally as long as it is safe to do so. This will help to keep your muscles working, and maintaining a healthy diet is vital to good health . Only when eating and swallowing become significantly uncomfortable or difficult should you adapt your diet, for example by eating pureed foods.
Swallowing difficulties are individual and solutions vary from person to person, but the following tips on diet, drinking and eating techniques may help.
Swallowing Exercises Can Be Very Helpful To Improve Your Swallowing
After a formal swallow assessment, swallowing therapy sessions can be designed for you, involving exercises tailored to the specific parts of your mouth and throat that are causing the swallowing problem. Sessions may involve practicing compensatory swallowing strategies with various types of foods in order to maximize safety and efficiency while swallowing.
During swallow therapy, recommendations may include:
- Best feeding techniques
- Exercises to strengthen oral and throat muscles
- Compensatory techniques to assist in safe swallowing
- Oral and mouth care techniques
- Appropriate food selection and ways to modify food texture
- Safe positioning strategies
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Increased Urination Urgency And Frequency
Bladder problems are a common occurrence in people with Parkinsons, occurring in 30-40 percent of people with the disease. The most common urinary symptom is a frequent and urgent need to urinate even when the bladder is empty, as well as trouble delaying urination.
Trouble emptying the bladder is a less common feature of Parkinsons urinary dysfunction. It may be caused by difficulty in relaxing the urethral sphincter muscles that allow the bladder to empty.
Prevalence Associated Factors And Negative Impacts Of Drooling In Pd
Due to the lack of a standard definition and criteria for diagnosing drooling in PD patients, estimates of prevalence vary. Previous studies showed that prevalence ranged from 10 to 84% . Various tools such as the Unified Parkinson’s Disease Rating Scale part II Scales for Outcomes in PD for Autonomic Symptoms PD non-motor symptoms questionnaire and different types of screening questionnaires were used to screen drooling. The factors associated with drooling have been reported. However, results vary among studies and the conclusion remains unclear. Factors possibly associated with drooling were severity of PD , male gender , aging , hallucinations , duration of PD , the sum of the scores of UPDRS part II and III greater than 28 points, dysarthria, dysphagia, orthostatic hypotension, and a history of using antidepressants . Drooling during PD can have negative impact for both patients and caregivers. Many negative physical sequelae were reported to follow the course of drooling such as perioral dermatitis, poor oral hygiene, bad breath, increased amount of intra-oral occult bacteria, eating and speaking difficulty, and an increased rate of respiratory tract infection from silent aspiration of saliva . Psychosocially, drooling PD patients showed poor quality of life , i.e., social embarrassment and increasing emotional distress . In addition, drooling patients affected their caregivers by increasing their burden, depression and anxiety, and reducing their QoL .
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