What are the management options for swallowing difficulties in patients with Parkinson's disease?

Management of Swallowing Difficulties in Parkinson's Disease

Rehabilitation treatment including adapting bolus characteristics, postural maneuvers, and exercise programs should be used for Parkinson's disease patients with dysphagia, tailored to individual assessment findings. 1

Screening and Assessment

• All PD patients with Hoehn & Yahr stage above II or those with weight loss, low BMI, drooling, dementia, or signs of dysphagia should be screened for swallowing difficulties during an ON-phase 1

• Screening methods:

  • PD-specific questionnaires: Swallowing Disturbance Questionnaire (SDQ) or Munich Dysphagia Test-Parkinson's Disease (MDT-PD) 1
  • Water swallow test measuring average volume per swallow (volume below 20 ml indicates dysphagia) 1
  • Volume-viscosity swallow test for multiple consistencies 1

• Instrumental assessment is crucial due to high prevalence of silent aspiration (over 80% of PD patients develop dysphagia but only 20-40% are aware of their swallowing dysfunction) 1, 2:

  • Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
  • Videofluoroscopic Swallowing Study (VFSS)

Management Strategies

1. Bolus Modification

• Thickened liquids significantly improve swallowing safety 1:
  • Pudding-thick liquids result in lower penetration-aspiration scores than thin liquids
  • Honey-thick liquids are most effective at preventing aspiration
  • Note: Higher viscosity increases oral transit time and requires more tongue pumps

2. Postural Techniques

• Chin-down posture is least effective at preventing aspiration compared to thickened liquids 1
• 39% of PD patients and 50% of PD patients with dementia aspirate despite chin-down posture 1
• Neither chin-down posture nor thickened fluids are superior in preventing adverse outcomes in long-term follow-up 1

3. Exercise Programs

• Expiratory Muscle Strength Training (EMST) 1:

  • 4-week program improves penetration/aspiration scores
  • Enhances hypolaryngeal complex function (excursion time and displacement)
  • Improves cough function

• Oral Motor Exercise Programs 1:

  • Increases strength and range of motion of mouth, larynx, and pharynx
  • Improves oral control of bolus
  • Enhances coordination between breathing and swallowing

• Lee Silverman Voice Treatment 1:

  • Improves neuromuscular control of oral phase
  • Enhances tongue function during oral and pharyngeal phases

4. Pharmacological Management

• Optimize dopaminergic medication for fluctuating dysphagia with deterioration during off-state 2
• Some patients (50%) show objective improvement in swallowing function after levodopa administration 3

5. Novel Approaches

• Video-Assisted Swallowing Therapy (VAST) 4:
  • Patients view videos of normal swallowing and their own swallowing process
  • Demonstrates greater reduction in pharyngeal food residues compared to conventional therapy
  • Improves swallowing-related quality of life

Complications and Monitoring

• Pneumonia is the most frequent cause of death in PD, substantially related to dysphagia 1, 2
• Regular reassessment of swallowing function as disease progresses
• Monitor for:
  • Signs of aspiration pneumonia
  • Malnutrition and weight loss
  • Dehydration
  • Medication intake difficulties

Pitfalls and Caveats

• Silent aspiration is common in PD - don't rely solely on patient-reported symptoms 1, 2
• No single intervention works for all patients - 39% of PD patients and 50% with dementia aspirate despite all interventions 1
• Evidence for dysphagia interventions in PD remains limited - rehabilitation approaches show potential for long-term improvement but optimal therapy protocols are not yet established 1, 5
• Surface electrical stimulation and repetitive transcranial magnetic stimulation lack sufficient evidence for recommendation 1