At what stage do swallowing problems typically start in patients with Parkinson's disease?

Swallowing Problems in Parkinson's Disease

Swallowing problems typically begin at Hoehn & Yahr stage III of Parkinson's disease, although they can occur earlier in the disease course and should be screened for regardless of stage if warning signs are present. 1

Prevalence and Recognition

• More than 80% of patients with Parkinson's disease (PD) develop dysphagia during the course of their disease 1, 2
• Only 20-40% of PD patients are aware of their swallowing dysfunction 1
• Less than 10% of PD patients spontaneously report dysphagia 1
• Silent aspiration (aspiration without coughing) is very common in PD patients 1

This significant discrepancy between the actual prevalence of swallowing problems and patient awareness highlights the importance of proactive screening rather than relying on patient self-reporting.

Risk Factors and Warning Signs

Patients should be monitored closely for dysphagia if they present with:

• Hoehn and Yahr stage above III 1
• Weight loss 1
• BMI below 20 kg/m² 1
• Drooling or sialorrhea 1
• Dementia 1
• Coughing during meals or when drinking 1
• History of pneumonia 1

Screening Recommendations

Regular screening is recommended for:

• All patients with Hoehn & Yahr stage above II 1
• Any patient with warning signs (weight loss, low BMI, drooling, dementia) 1
• Any patient with signs of dysphagia (coughing during meals/drinking, pneumonia) 1

Effective screening methods include:

• PD-specific questionnaires such as the Swallowing Disturbance Questionnaire (SDQ) and the Munich Dysphagia Test-Parkinson's Disease (MDT-PD) 1
• Water swallow test with measurement of average volume per swallow 1
• Volume-viscosity swallow test 1

Consequences of Untreated Dysphagia

Dysphagia in PD is associated with:

• Increased risk of aspiration pneumonia 1, 3
• Pneumonia as the most frequent cause of death in PD 1, 3
• Decreased intake of food and fluids 1
• Malnutrition 3, 2
• Reduced quality of life 3, 1
• Insufficient medication intake 3

Management Approach

For patients who screen positive for dysphagia:

1. Perform instrumental assessment with FEES (preferred) or VFSS 1
2. Optimize dopaminergic medication for fluctuating dysphagia 1, 4
3. Implement swallowing therapy with:
   • Expiratory Muscle Strength Training (EMST) 1
   • Shaker Head Lift Exercise 1
   • Oral Motor Exercise Program 1
   • Lee Silverman Voice Treatment 1
4. Consider dietary modifications:
   • Thickened liquids (honey-thick more effective than nectar-thick) 1
   • Chin-down posture for specific swallowing problems 1

Common Pitfalls to Avoid

• Relying on patient self-reporting of dysphagia (most cases are silent) 1
• Waiting until advanced stages to screen (dysphagia can occur early) 1
• Using standard water swallowing tests without volume measurement (not predictive in PD) 1
• Failing to perform assessments during medication ON-phase 1
• Not monitoring for aspiration pneumonia, which is a leading cause of mortality 1

Follow-up Recommendations

Regular reassessment of swallowing function is necessary as the disease progresses to prevent complications and maintain quality of life 1. This is particularly important as dysphagia tends to worsen with disease progression, and early intervention can help prevent serious complications.