How to manage aspiration in patients with parkinsonism?

Management of Aspiration in Parkinson's Disease

A comprehensive, individualized approach combining swallowing evaluation, rehabilitation exercises, and dietary modifications is essential for managing aspiration in patients with parkinsonism, with expiratory muscle strength training showing the most promising evidence for improving swallowing safety.

Initial Assessment

1. Screening and Evaluation

   • All Parkinson's disease 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, 2
   • Instrumental assessment is crucial due to high prevalence of silent aspiration (up to 80% of PD patients develop dysphagia) 1, 3:
     • Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
     • Videofluoroscopic Swallowing Study (VFSS)

2. Risk Factors for Aspiration

   • Delayed initiation of pharyngeal swallow (7.5x higher risk) 4
   • Reduced hyolaryngeal excursion (5.1x higher risk) 4
   • Residue in the vallecula (4.1x higher risk) 5
   • Piecemeal deglutition (3.8x higher risk) 5
   • Residue in the upper esophageal sphincter (2.9x higher risk) 5

Treatment Algorithm

1. Rehabilitation Exercises (First-Line)

• Expiratory Muscle Strength Training (EMST)

  • Recommended for patients with motor-neuron disorders and Parkinson's disease 1
  • Improves penetration/aspiration scores and enhances hypolaryngeal complex function 1, 2
  • Apply for 4 weeks to improve cough and swallow function 1

• Shaker Head Lift Exercise

  • Strong evidence (Grade A recommendation) for improving suprahyoid muscle strength and upper esophageal sphincter opening 1
  • Combine isometric component (three 60-second head lifts with 60-second rest periods) with isokinetic component (30 consecutive head lifts) 1

• Oral Motor Exercise Program

  • Increases strength and range of motion of mouth, larynx, and pharynx 1, 2
  • Improves oral control of bolus and coordination between breathing and swallowing 1

• Lee Silverman Voice Treatment

  • Improves neuromuscular control of oral phase and tongue function 1, 2

2. Compensatory Strategies

• Chin-Down Posture

  • Recommended for patients with premature spillage and predeglutitive aspiration (Grade B recommendation) 1
  • Note: Less effective than thickened liquids in preventing aspiration in PD patients 1
  • Caution: 39% of PD patients and 50% of PD patients with dementia still aspirate despite this intervention 1

• Dietary Modifications

  • Thickened Liquids
    • Pudding-thick or honey-thick liquids significantly improve swallowing safety 1, 2
    • Honey-thick liquids more effective than nectar-thick liquids in preventing aspiration 1
    • Caution: Thickened liquids associated with higher rates of dehydration (6% vs 2%), urinary tract infection (6% vs 3%), and fever (4% vs 2%) compared to chin-down posture 6

Monitoring and Follow-up

• Regular reassessment of swallowing function as disease progresses 2
• Monitor for:
  • Signs of aspiration pneumonia (major cause of death in PD) 1, 7
  • Malnutrition and weight loss 1
  • Dehydration 2
  • Medication intake difficulties 2

Important Considerations and Pitfalls

1. Silent Aspiration

   • Occurs frequently in PD patients; only 20-40% are aware of their swallowing dysfunction 1
   • Emphasizes need for objective instrumental assessment rather than relying on patient self-reporting 3

2. Treatment Limitations

   • No single intervention works for all patients 2
   • Neither chin-down posture nor thickened fluids are definitively superior in preventing aspiration pneumonia long-term 1, 6
   • Surface electrical stimulation lacks sufficient evidence for recommendation 1, 2

3. Medication Timing

   • Perform swallowing assessments and therapy during ON-phase of medication cycle 1, 2
   • Optimize dopaminergic medication for fluctuating dysphagia 3

4. Liquid Volume Consideration

   • Strong positive correlation between increasing liquid bolus volume and penetration-aspiration risk (γ = 0.71) 4
   • Consider smaller volume sips when drinking

The management of aspiration in parkinsonism requires a systematic approach focusing on early detection through proper screening and instrumental assessment, followed by targeted rehabilitation exercises, particularly EMST which shows the most promising evidence for improving swallowing safety 1, 2. While dietary modifications with thickened liquids can improve immediate swallowing safety, they must be balanced against the risks of dehydration and reduced quality of life 1, 6.