What can be done for a patient with Progressive Supranuclear Palsy (PSP) who develops dysphagia?

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Management of Dysphagia in Progressive Supranuclear Palsy (PSP)

For patients with Progressive Supranuclear Palsy (PSP) who develop dysphagia, we recommend instrumental dysphagia assessment followed by individualized rehabilitation treatment including modified food/fluid consistencies, postural maneuvers, and exercise programs to improve swallowing safety and prevent aspiration pneumonia.

Assessment of Dysphagia in PSP

Initial Screening and Evaluation

  • All PSP patients should undergo regular dysphagia screening, especially as the disease progresses 1
  • Screening methods:
    • Self-report questionnaires (similar to those used in Parkinson's disease)
    • Swallow volume tests (maximum swallowing volume or average volume per swallow)
    • Volume-viscosity swallow test (5,10,20 ml) for multiple consistencies

Instrumental Assessment

  • Instrumental assessment is crucial due to high prevalence of silent aspiration in PSP patients 1, 2
  • Preferred assessment methods:
    1. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) - first choice due to:
      • No radiation exposure
      • Minimal patient cooperation required
      • Can be performed at bedside
      • Can be utilized as therapeutic feedback (video-assisted swallowing therapy)
    2. Videofluoroscopic Swallowing Study (VFSS) if FEES unavailable
    3. Clinical assessment only if instrumental assessment is not available

Key Dysphagia Characteristics in PSP

  • PSP patients show predominant oral phase impairments 2:
    • Back and forth rocking motion of the tongue
    • Delayed initiation of pharyngeal swallow
    • Significant oral residue
  • Pharyngeal phase impairments are relatively less severe except for:
    • Reduced tongue base retraction causing pharyngeal residue
    • Mildly disrupted laryngeal vestibule closure 2
  • Risk factors for dysphagia progression and discontinuation of oral intake:
    • Cognitive decline
    • Axial rigidity
    • Retrocollis 3

Treatment Approaches

Modified Food and Fluid Consistencies

  • We recommend modifying food and fluid consistencies according to individual assessment findings 1
  • Thickened liquids (particularly honey-thick consistency) have shown better safety outcomes than chin-down posture in neurodegenerative disorders 1
  • Pudding-thick liquids result in:
    • Higher oral transit time
    • More tongue pumps
    • Lower penetration-aspiration scores (safer swallow) 1

Postural Techniques and Compensatory Strategies

  • Chin-down posture is less effective than thickened liquids for preventing aspiration in neurodegenerative disorders 1
  • Consider other postural techniques based on specific deficits identified during instrumental assessment

Exercise Programs

  • Recommend supervised exercise programs by speech-language therapists:
    • Expiratory muscle strength training (EMST) - improves cough and swallow function 1
    • Oral motor exercise programs - increase strength and range of motion of mouth, larynx, and pharynx 1
    • Structured swallowing programs to improve neuromuscular control 1

Nutritional Support

  • Monitor nutritional status and hydration closely
  • For patients unable to maintain adequate nutrition orally:
    • Consider enteral nutrition (EN) therapy 1
    • Percutaneous endoscopic gastrostomy (PEG) is preferred over nasogastric tube for long-term feeding in chronic neurological disorders 1

Monitoring and Follow-up

  • Regular reassessment of swallowing function as PSP progresses
  • Monitor for signs of:
    • Aspiration pneumonia
    • Malnutrition
    • Dehydration
  • Early identification of factors associated with dysphagia progression (cognitive decline, axial rigidity, retrocollis) can improve patient care and management 3

Important Considerations

  • Dysphagia is common in PSP and typically occurs earlier than in Parkinson's disease 4, 2
  • Silent aspiration is very common, making instrumental assessment crucial
  • Approximately two-thirds of PSP patients report difficulties with liquids, solids, or both 2
  • Disease severity correlates with oral and pharyngeal impairments 2
  • Pneumonia is a common cause of death in neurodegenerative disorders with dysphagia 1

By implementing these assessment and management strategies, clinicians can help improve swallowing safety, maintain nutrition, and potentially reduce morbidity and mortality in PSP patients with dysphagia.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Comparison of swallowing function in Parkinson's disease and progressive supranuclear palsy.

Movement disorders : official journal of the Movement Disorder Society, 1997

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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