Eating And Swallowing Problems And Parkinsons
Research suggests that eating and swallowing difficulties affect about a 90% of all people with Parkinsons. The true figure may be even higher as some people do not report the problem to their health care team.
Swallowing is a motor function that includes three stages.
- The first stage is the oral phase: food is chewed and mixed with saliva to form a soft ball called bolus. The tongue then pushes the bolus to the back of the mouth, triggering the swallow reflex.
- The second stage is the pharyngeal phase: it is the involuntary closure of the larynx by the epiglottis and vocal cords, which temporarily inhibites breathing. These actions prevent food from going ‘down the wrong pipe’ into the trachea .
- The third stage is the esophageal phase: the bolus moves into the esophagus, the muscular tube that contracts to push the bolus into the stomach.
Unfortunately, many people with Parkinsons experience swallowing problems due to reduced control and muscle tone of the jaw, lips, tongue and throat muscles, especially in later stages of the condition. Eating and swallowing becomes slower and requires more effort.
People with Parkinsons are at particular risk of aspiration due to a delay in the triggering of their swallow reflex. This compromises the effectiveness of the airway protection while swallowing. This can lead to aspiration pneumonia due to a lack of coughing if food enters the windpipe, allowing food to reach the lungs unchecked.
How Do I Know If I Have A Swallowing Problem
- I have recently lost weight without trying.
- I tend to avoid drinking liquids.
- I get the sensation of food being stuck in my throat.
- I tend to drool.
- I notice food collecting around my gum line.
- I tend to cough or choke before, during or after eating or drinking.
- I often have heartburn or a sore throat.
- I have trouble keeping food or liquid in my mouth.
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If I Have Parkinsons Disease What Kind Of Speech And Voice Problems May I Experience
If you have Parkinsons disease, some of the voice and speech difficulties seen include:
- Softened voice. Reduced volume to your voice.
- Speaking in an unchanging pitch .
- Having a hoarse or strained quality to your voice.
- Having a breathiness to your voice. Breathiness in the quality of your voice that is easily heard by your listeners. It takes more effort and energy to speak. You run out of gas as you speak.
- Trouble clearly and easily pronouncing letters and words.
- Tremor in your voice.
- Using short rushes of speech.
- Loss of your facial expression.
If you have Parkinsons disease, you may not be aware of the problems with your spoken communication. Changes in the quality of your voice may be the first sign of speech problems followed by the inability to have fluid speech and clear and distinct speech sounds. Speech problems that are severe enough to reduce your ability to be easily understood usually do not occur until later in the course of Parkinsons disease.
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How Are Swallowing Problems Treated
The first step to addressing swallowing issues is to speak to a neurologist about getting an evaluation performed by a SLP. This professional will take a medical history and interview the person with PD about eating and swallowing.
This is typically followed by either a video X-ray or an endoscopic examination, so the medical specialist can observe the swallowing process as an individual sips liquid and eats food, as these substances flow from the mouth, down the throat and esophagus, to the stomach. With these tests it is possible to see where the trouble is occurring and to recommend therapies.
Follow the recommendations of the swallowing specialist, which may include the following:
- Exercise and Swallow Hard. Just as exercise can ease other PD-related movement difficulties, it can also help with swallowing. The Lee Silverman Voice Technique® helps a person exaggerate speaking and swallowing. Working with an SLP on an individualized program helps the person to swallow hard and move food from the mouth down the throat.
- Expiratory Muscle Strength Training. This therapy strengthens respiratory muscles, improves cough and swallowing and reduces aspiration.
- Change in food. Modifying liquids and solids can help. For people who find liquids get into the airway, liquids may need thickening. Taking bigger or smaller bites or sips or pureeing solid foods may help. First get an evaluation, so the SLP can recommend how to modify food and liquid.
How Parkinson’s May Make Swallowing Difficult
This morning I woke up with a sore throat. A mild sore throat caused by a viral infection is uncomfortable when swallowing, making you aware how often you swallow through the day. But it does not limit the efficiency or safety of swallowing food and liquid as in swallowing disorders. Parkinsons disease is one of the well-known causes of swallowing disorders also called dysphagia. Dysphagia can lead to less eating and drinking or aspiration of food and liquid resulting in coughing or near choking. That is why some researchers and clinicians advocate early screening of dysphagia in people with Parkinsons disease . But how frequently does dysphagia occur in Parkinsons disease and what are typical signs of dysphagia in PD?
Then is early screening for dysphagia in PD needed? There are several points of view depending on the disease severity and availability of services. Routinely asking about difficulties with swallowing is a good start, in particular in advanced PD, but more detailed questioning may uncover possible dysphagia more reliably than a single question. Most importantly, PwP should be aware that also difficulty with chewing or swallowing is usually caused by their Parkinsons, but can be treated or compensated quite well .
Swallowing And Saliva Management
This one-hour talk is in three parts. What a speech language pathologist is, how they can help someone with PD. Why you should be concerned about swallowing problems, some indications you may have a swallowing issue, what a swallowing assessment by an SLP might look like, and recommendations an SLP might make to improve swallowing. And, why you should be concerned about having either too much or too little saliva and how to manage either situation.
Do Swallowing Problems In People With Parkinsons Disease Also Affect Speech
Swallowing problems are a common problem in people with Parkinsons disease. They can occur at any stage of the disease, can change throughout the disease course and often get worse as symptoms progress. Let your healthcare provider and/or speech-language pathologist know as you notice you are having swallowing problems. Symptoms of swallowing problems include drooling, choking, coughing, difficulty taking pills, taking a long time to eat, weight loss and dehydration. The most serious complication of a swallowing problem–and the reason why you should see your provider right away– is aspiration. Aspiration is when food or liquid goes into your windpipe , then passes down into your lungs, which can lead to aspiration pneumonia.
Although swallowing problems may not directly affect your speech, swallowing problems and voice and speech problems often occur at the same time.
A note from Cleveland Clinic
Voice and speech difficulties are common problems in people with Parkinsons disease, especially as the disease worsens. These problems affect your ability to communicate in the work setting and with family and friends which affects the quality of your life. Fortunately a speech-language pathologist can develop an effective treatment program to help improve your ability to communicate.
Slower Reaction And Movement Times
- These can impact the persons ability to carry out certain activities safely e.g. use of machinery or the ability to drive can be affected.
- Worsening motor skills are related to reduced performance. As the changes are gradual, patients may not realize or be in denial that they are no longer able to carry out certain activities safely. Family members or the medical profession have a duty of care to intervene at this stage.
Excessive Saliva And Drooling In Parkinsons
Saliva is needed for the first stages of digestion, including chewing and swallowing. This watery substance contains enzymes that start to digest our food.
Many people with Parkinsons experience poor saliva control, which may result in excessive saliva and drooling, or alternatively, in a dry mouth and other eating problems.
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Fecal Incontinence In Advanced Parkinsons Disease
Fecal incontinence is a very debilitating symptom that can occur in advanced PD and refers to the involuntary release of fecal matter.
Once again, fecal incontinence, especially if it is a new symptom, should be fully evaluated to determine if there is a cause unrelated to PD. Diseases of the gut such as inflammatory bowel disease or compression of the lower spine cord can be the reason.
If related to PD, there are typically two situations to consider. One possibility is that severe constipation with impacted bowel movement allows loose stool from higher up in the gastrointestinal tract to escape around the edges of the obstruction. In this situation, fecal incontinence could be a harbinger of bowel obstruction. Aggressive and continuous treatment of constipation can help avoid this potential scenario.
Fecal incontinence can also be related to nerve dysfunction of the anal sphincter, or the ring of muscle that controls when feces is released. Cognitive dysfunction and mobility issues may further interfere with getting to the bathroom in time. Some treatment options are similar to urinary incontinence including the use of bedside equipment to minimize mobility issues and introduction of pelvic floor exercises to strengthen the musculature that keeps feces in place.
As with urinary incontinence, frequent and rapid exchange of dirtied incontinence products can keep skin intact and prevent infection.
Tips and Takeaways
Dr. Rebecca Gilbert
Tips For Coping With Speech Difficulties
- Exercise your voice by reading out loud or singing every day.
- Drink enough water, avoiding shouting and rest your voice when it is tired.
- Train your voice like an actorsit and stand with good posture, do exercises for articulation, breathing and projecting the voice.
- Get feedback from friends and family members about how others perceive your speech develop a cue or code word you can use in public to make you focus on speaking clearly.
- If you have soft speech, use tools such as a voice amplifier , placed on your shirt, and on the telephone . Ask an occupational therapist about other tools.
- Make eye contact with the person to whom you are speaking.
- Reduce background noise.
- Socialize in small groups or one-on-one.
- If you experience a facial masking, use feeling words to communicate your emotions . Use practice physical gestures to help convey emotions.
- Determine which times of day your speech is best. Plan social engagements around those times.
Even in the early stages of PD, many report that their voices are too soft, causing others to ask them to repeat themselves. Other people with PD may have a gruff or hoarse quality to their voice. Try these strategies:
Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinsons Foundation Center of Excellence.
For more insights on this topic, listen to our podcast episodeImportance of Early Detection of Swallowing Disturbances.
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What Type Of Healthcare Professional Helps People With Speech Problems From Parkinsons Disease
If you have speech and voice problems, see a speech-language therapist. Your primary healthcare provider can help you find a therapist in your local area. Some speech-language pathologists have specialized training that focuses on training people with Parkinsons disease to amplify their voice. This is called the Lee Silverman Voice Treatment.
Speech-language therapists are specifically trained to diagnose and treat speech, language and swallowing disorders. If you have Parkinsons disease, a speech-language pathologist can help you:
- Maintain as many communication skills as possible. Teach you techniques to conserve energy, including using nonverbal communication skills.
- Introduce you to assistive devices and techniques to help improve your communication.
- Recommend exercises to help you improve muscle strength and movements needed to improve your speech and communication options.
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.
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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.
Speaking Effectively A Strategic Guide For Speaking And Swallowing
Booklet includes self-evaluations and caregiver surveys to determine at what point professional help is needed. Professional examinations are described along with recommendations for both home and professional intervention to improve speech, make eating easier and safer, and reduce drooling. Maintaining communication to reduce isolation is encouraged.
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Breathing & Respiratory Difficulties
Some people with Parkinsons disease may experience shortness of breath. There is no clear cause underlying respiratory dysfunction in PD, its frequency or the effect that medications have on respiration. Several reasons for shortness of breath in PD include:
- Wearing off is a common experience among people with PD who have been taking levodopa for several years. These occur when the medication benefit wears off and PD symptoms return before the next dose.
- Respiratory dyskinesia refers to an occurrence of irregular and rapid breathing when levodopa medications reach their peak effect. These may accompanied by involuntary body movements, typically experienced as dyskinesia.
- Anxiety is a common symptom of PD that may also exacerbate shortness of breath, whether by itself or as a consequence of wearing off of the medication.
- Aspirationpneumonia is a pneumonia that develops after food or liquid goes down the wrong pipe. Advanced PD can increase the risk of swallowing difficulties, choking and aspiration pneumonia.
- Non-PD health issues include conditions such as asthma, allergies, lung disease, heart disease and other conditions that may cause shortness of breath.
How Do You Know If You Or Your Loved One Has A Problem With Swallowing
Swallowing difficulties can start very subtly and initially not be obvious to either the person with PD or their loved ones. There are signs to look out for before swallowing difficulty becomes overt . Some of the signs you should pay attention to include:
- Slow rate of eating people with difficulty swallowing may slow down their eating in order to avoid coughing or choking
- Fatigue during eating or decreased enjoyment of food
- A sensation that food is sticking in the throat
- Coughing or excessive throat clearing during eating
- Difficulty in swallowing pills
- Unexplained weight loss people with difficulty swallowing may reduce their consumption in an attempt to eat without coughing or choking
- Change in dietary habits people with difficult swallowing may alter their diet in order to avoid foods that cause difficulty. This may not be a choice made consciously
- Diagnosis of a pneumonia this could be caused by aspiration, or entry of a foreign substance into the airway
If you think there might be a swallowing issue, it is important to speak with your doctor about it. There are steps you can take to properly assess the situation and improve your swallowing function. This can in turn reduce your risk of choking, make eating more enjoyable, and lessen the chances of unwanted weight loss and/or other discomforts.
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Urinary Issues In Advanced Parkinsons Disease
Urinary dysfunction and symptoms in PD are most commonly caused by overactivity of the detrusor muscle, or the muscle of the bladder, which contracts excessively despite the fact that it is not filled with urine. This causes an increased urge to urinate and/or an increased frequency of urination, which can be especially prominent at night. In advanced PD, this could culminate in urinary incontinence, or involuntary release of urine. Mobility issues which make getting to the bathroom slower and more cumbersome, compound the problem.
Always remember that people with advanced PD may have other medical problems that affect their urination such as an enlarged prostate. Make sure to have a complete evaluation before assuming that the problem is only related to PD. It is also essential to keep in mind that if changes in urination occur suddenly, there could be a urinary tract infection present.
Once other medical issues and urinary tract infection are ruled out, there are a number of approaches to the issue of urinary incontinence in a person with advanced PD:
Unfortunately, for some, the above available options may not be sufficient to effectively treat urinary incontinence in advanced PD. If this is the reality, it becomes extremely important to keep the skin dry with frequent changes of incontinence products to prevent skin breakdown and the potential development of skin infection.