Why Do Parkinson’s Patients Drool

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.

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 Parkinsons disease have not

What Lifestyle Changes Can I Make To Ease Parkinsons Symptoms

Exercise: Exercise helps improve muscle strength, balance, coordination, flexibility, and tremor. It is also strongly believed to improve memory, thinking and reduce the risk of falls and decrease anxiety and depression. One study in persons with Parkinsons disease showed that 2.5 hours of exercise per week resulted in improved ability to move and a slower decline in quality of life compared to those who didnt exercise or didnt start until later in the course of their disease. Some exercises to consider include strengthening or resistance training, stretching exercises or aerobics . All types of exercise are helpful.

Eat a healthy, balanced diet: This is not only good for your general health but can ease some of the non-movement related symptoms of Parkinsons, such as constipation. Eating foods high in fiber in particular can relieve constipation. The Mediterranean diet is one example of a healthy diet.

Preventing falls and maintaining balance: Falls are a frequent complication of Parkinsons. While you can do many things to reduce your risk of falling, the two most important are: 1) to work with your doctor to ensure that your treatments whether medicines or deep brain stimulation are optimal and 2) to consult with a physical therapist who can assess your walking and balance. The physical therapist is the expert when it comes to recommending assistive devices or exercise to improve safety and preventing falls.

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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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Side Effects Of Using Botox

In general, side effects of Botulinum toxin can be due to over-weakening of the injected muscle, which, if done on leg and foot muscles, for example, could interfere with walking.

Uncommonly, Botulinum toxin can diffuse to neighboring muscles and cause more widespread side effects. For example, injections of neck muscles could result in toxin diffusing locally to muscles used for swallowing and cause difficulty swallowing. Even less common, are side effects due to travel of the toxin to more distant parts of the body via the bloodstream. For example, injections of any body part could theoretically result in difficulty swallowing or breathing if the toxin travels to these muscles. This is very rare however and Botulinum toxin injections are typically very safe. The full risk profile for your particular situation however, needs to be discussed with the physician performing the injections.

There are typically no limitations after the injections and you can return immediately to your normal activities.

Although dermatologists often use Botulinum toxin for cosmetic purposes, only a neurologist is qualified to determine whether the injections can help with certain PD symptoms. If you are interested to investigate whether Botulinum toxin injections may help you, discuss this with your neurologist. If he/she feels that they may be helpful, but does not perform them, he/she can refer you to a neurologist who does.

Tips and takeaways

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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 Parkinsons 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.

Assessment Tools For Drooling In Pd

The assessment tools to evaluate drooling in PD include both objective and subjective measures. Objective tools were developed to measure the volume of saliva and salivary flow. The limitations of these tools are that they are time-consuming and cannot evaluate the psychosocial impairment. Therefore, subjective tools were developed. The subjective measures in many previous studies were the UPDRS part II salivary subscores to evaluate drooling treatment responses and visual analog scales to assess the frequency, familial and social distress however, not all scales are validated. Three drooling-specific rating scales including the Drooling Severity and Frequency Scale , Drooling Rating Scale and Sialorrhea Clinical Scale for PD have been used to evaluate drooling in PD. The DSFS, a semi-quantitative scale, was used in studies to evaluate drooling in PD and cerebral palsy . The scale is composed of two domains: the severity of drooling rated on a five-point scale and frequency of drooling rated on a four-point scale. Since the DSFS is easy to administer it is widely used. However, the limitations of this scale are no assessment of the psychosocial impact, no validation and no evidence of correlation between this scale and the objective measures of salivary secretion.

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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.

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

Correspondence

Department of Voice, Speech and Hearing Disorders, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Correspondence

Funding information

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What Can A Person With Parkinsons Do To Improve Drooling By Themselves Or With Specialist Help

In some cases, simply improving posture can alleviate the problem. A physiotherapist can advise on problems of posture. See the Parkinsons Associations Information Sheet on Physiotherapy and Parkinsons Disease.

Referral to a Speech and Language Therapist for assessment and advice is important to identify the problems of poor posture, lip seal, tongue control and awareness, as well as any difficulties with swallowing that may be contributing to the problem of drooling. A GP or consultant can provide a referral to a Speech and Language Therapist working within the HSE or directly to private SLTs. Self-referral to see a Speech and Language Therapist privately is also possible.

The Speech and Language Therapist can advise on techniques to improve lip closure and techniques and exercises to facilitate a more functional swallow. People who experience poor lip closure may be able to close their lips with their fingers or support their head up by cupping their chin in their hand. This can be tiring and is not very practical. There are devices which can be used to retrain lip seal and these are very effective. A Speech and Language Therapist can advise further.

Swallowing Difficulties In Parkinsons Disease

The act of swallowing involves a complex series of activities that begin in the mouth, continue in the pharynx and end in the esophagus. These include chewing, using the tongue to move the bolus of food to the back of the throat and then coordinating the muscles that both propel the food into the esophagus and protect the airway or trachea from food penetration. Swallowing dysfunction can be considered both a motor and a non-motor symptom of PD. Loss of dopamine neurons in the substantia nigra area of the brain can cause the motor dysfunction that impairs swallowing. However, loss of neurons in other areas of the brain, such as the cortex and lower brain stem can also affect the overall control and coordination of swallowing, and can be thought of as a non-motor symptom of PD. Swallowing issues are very important to diagnose. Impacts on your daily life and your health can range from difficulties with meals to more extreme cases where it could lead to choking and aspiration which can be very serious or even fatal.

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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.

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.

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Conditions Treated Using Botulinum Toxin In Parkinsons Disease

Dystonia Dystonia refers to an involuntary twisting of a body part, which can be painful and can interfere with a persons desired movement. In PD, dystonia can be a motor symptom due to the disease, appearing first thing in the morning before taking medication or as a dose of medication is wearing off. Alternatively, dystonia can be a side effect of Levodopa. A common dystonia in young onset PD involves toe curling or foot inversion . This dystonia often occurs only in particular circumstances such as while walking or running. Other dystonias involve frequent and persistent eye closure, known as blepharospasm, or neck turning, known as cervical dystonia. These can be associated with PD, but may also accompany other forms of parkinsonism such as Multiple System Atrophy or Progressive Supranuclear Palsy. Botulinum toxin injections, targeting the particular muscles that are moving excessively, can be effective in all these scenarios.

Tremor Although Botulinum toxin is not commonly used for this purpose, there are case reports in the literature showing its effective use for the control of tremor.

Drooling Likely due to the decreased swallowing rate of patients with PD, sialorrhea, or drooling, can be a feature of the disease. Drooling is not only an annoyance, but can result in significant embarrassment and social isolation. Botulinum toxin injections into the salivary glands can decrease production of saliva and thereby decrease drooling.

Treating Eating And Swallowing Difficulties

If you or someone you care for is experiencing difficulties with eating, swallowing or saliva control, the first step is to consult your doctor, who may refer you on to an SLT / SLP.

Your doctor may be able to adjust the timing and dose of medicines so that these are working well at mealtimes and so swallowing problems are better managed when eating. However, for some patients, medications do not affect the swallowing function.

Your doctor may also adjust your medications, or may prescribe new ones to reduce production of saliva. Some Parkinsons medicines, including levodopa, improve muscle movement and may help to reduce drooling. However, some medications, such as clozapine, which is prescribed for mental health problems, can actually increase saliva production.

Anticholinergic medications may help to reduce the amount of saliva you produce but are not suitable for everyone. For more information see Managing medication.

Botulinum toxin can be injected into the salivary glands to reduce saliva production. This treatment will not work for everyone and injections may need to be repeated every three to six months. However, for some patients, Botox injections are not recommended and may be dangerous.

In severe cases when other treatments are not effective, radiotherapy to the salivary glands can restrict saliva production. In extreme cases the salivary glands can be surgically removed as a last resort.

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Different Types Of Botulinum Toxin

There are eight different botulinum toxin species that occur in nature. There are only two however, that are produced commercially Botulinum toxin A and B.

The commercially available products are:

Botox® Botulinum toxin A

Xeomin® Botulinum toxin A which is produced free of complexing proteins

Myobloc® Botulinum toxin B

Each of the above agents are FDA approved for a slightly different list of clinical indications.

Assessment Of Saliva Flow

Evaluation of saliva flow is challenged by a range of issues, including: difficulty obtaining objective measures in naturalistic settings time and place variability that exists in respect of natural variation in flow rates fluctuations in motor function experienced by pwPD that can impact on swallowing and saliva control the variety of situations across pwPD concerning where they experience difficulties or not and the subjective nature of whether an individual perceives there to be a problem present or not. Similar to other activity limitations in PD such as dysphagia and dysarthria, perceived magnitude of psychosocial impact of drooling, dry mouth and excess saliva does not necessarily correlate significantly with objective measures of saliva flow and loss.3,19,6567

These factors underline that no single assessment captures all dimensions important for establishing baseline and outcome measures of salivation/drooling. Accordingly, outcome evaluation covers a range of measurements, with a focus on key variables that encompass the patients own chosen concerns and goals.

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Swallowing Difficulties And Parkinsons Medication

If swallowing tablets or capsules becomes difficult, it may be tempting to crush tablets or open capsules, but this should never be done, as it can cause serious side effects and/or prevent the medication working properly. Always ask your pharmacist or doctor, or check the patient information leaflet before tampering with medicines in any way. Swallowing medications with jelly, yoghurt or apple sauce may help you swallow medication more comfortably.

Many Parkinsons medicines are prepared or designed to work in a particular way that will be harmed by crushing or opening capsules. For example, some medicines have:

• Sugar or film coating: This is usually to make them taste better, but crushing may make them taste unpleasant.
• Enteric coating: This coating is designed to keep the tablet whole in the stomach, in some cases to protect the stomach or to protect the medicine from stomach acid so that it is released after passing through the stomach, for example in the intestine. This type of tablet should never be crushed.
• Modified or controlled release: These medications have been designed to release slowly and act over a longer period, so they can be taken less often. Crushing this type of tablet would lead to a rapid release of the medicine which could be harmful.

If you experience any problems you should talk to your doctor, so that he or she can prescribe medication in a form that is easier to take. Some medicines are available in liquid form.