Hard to Swallow: Dysphagia in Parkinson’s Disease
Most people are well aware of the communication difficulties that occur with Parkinson’s disease, but many are surprised to learn that swallowing issues are common as well, especially in the later stages. Swallowing is one of those bodily processes that we often don’t give a second thought to… until it becomes a problem.
A speech language pathologist (SLP) is trained to evaluate and manage both communication and swallowing impairment in a variety of conditions, including Parkinson’s disease. Swallowing issues (medically referred to as dysphagia) became under the purview of SLPs because the process of swallowing involves much of the same anatomy and physiology involved in speaking. Speech pathologists have specialized training in head and neck anatomy and physiology. They also study voice, articulation, respiration, resonance and motor speech. Most SLPs who work with adults have extensive training in dysphagia and complete clinical practicums to manage all manners of swallowing disorders.
This leads us to the obvious question… Why do swallowing issues occur in Parkinson’s? What exactly is happening here?
Along with the hallmark feature of difficulty initiating movement, Parkinson’s is known for making movements smaller. It’s often referred to as the disease of low amplitude. We often think of these smaller movements as they refer to gross motor movements such as having a smaller shuffling gait pattern or reduced arm swing when walking.
Now think of it in terms of communication. Vocal projection becomes reduced resulting in a soft, difficult to hear voice. Articulation and facial movements become reduced resulting in less precise speech and masked facial expression. Even intonation and prosody in the voice can be affected, resulting in flat robotic sounding speech.
With respect to swallowing function: jaw, lip, tongue and throat movements can become reduced in range resulting in difficulty chewing food, controlling liquid in the mouth and triggering a strong, timely swallow.
But it’s not simply an issue of direct muscle weakness, for example like what may occur in a stroke. There is a two-fold effect happening. The dopamine deficiency in Parkinson’s disease results in a perceptual impairment, a “faulty feedback loop” if you will. Your brain gives you incorrect information about the SIZE of the movements you are making. You may think that you are speaking loudly or smiling widely because your brain tells you that you have put sufficient effort into these movements. But this is often false information! Your voice may in fact be too quiet and your smile minimal. Because of this perceptual issue, you don’t adjust the movement to make it bigger. And as the old saying goes… if you don’t use it, you lose it. Over time, reduced movement and range results in further weakening of those muscles and systems.
The Three Phases of the Swallow
It’s also important to know that there are three distinct phases of the swallow. Any or all of these swallowing phases can be impacted in Parkinson’s disease.
The Mouth Phase
During the mouth or oral phase of the swallow, food or liquid must be prepared, controlled and transferred to the back of the mouth. This part of the swallow is completely under your volitional control. For example you can choose to hold a sip of water in your mouth for several seconds or chew a tough piece of steak extensively before swallowing, if needed.
The Throat Phase
The second phase of the swallow is the throat or pharyngeal phase of the swallow. This is where the brain takes over and completes a complex set of movements to safely transport the food or liquid into the food tube. An important part of the pharyngeal phase is ensuring that the airway is sufficiently closed to prevent food or liquid from “going down the wrong pipe”. When something goes down the wrong way it’s called aspiration. Aspiration events can lead to aspiration pneumonia which can be deadly if left untreated.
The Food Tube Phase
The third phase of the swallow is the food tube or esophageal phase where the food is transported to the stomach. Speech pathologists primarily manage the first two phases of the swallow as this last phase is largely treated and managed with medication and/or surgical intervention.
Common Swallowing Difficulties in Parkinson’s Disease
So what are some of the typical swallowing difficulties that can occur with Parkinson’s disease?
- Spillage of food/liquid from the lips or prematurely into the throat due to difficulty with mouth control
- Trouble initiating the transfer of food from the front to the back of the mouth
- Trouble triggering a timely throat (pharyngeal) phase of the swallow
- Reduced range of movement of the throat’s laryngeal structure resulting in reduced closure of the airway during the swallow
- Food residue in the throat after the swallow (especially with dense food like bread or a thick pudding)
- Reduced sensation of food/liquid entering the airway (aspiration!) resulting in an absent or ineffective cough response to clear
People with Parkinson’s disease have a higher risk of silent aspiration (not sensing/responding to things going down the wrong way) which puts them at a significantly higher risk of developing aspiration type pneumonia. There are ways to significantly reduce your risk of developing aspiration pneumonia in Parkinson’s disease, including ensuring that you have a thorough oral care routine.
If you have Parkinson’s disease and have started to experiencing any swallowing difficulty it’s essential to seek out a clinical swallowing assessment with a trained speech language pathologist near you.
What’s Involved in a Swallowing Assessment for Parkinson’s Disease?
The Importance of a Swallowing Evaluation in Parkinson’s Disease
If you are experiencing any difficulty swallowing in the course of your Parkinson’s disease, it is important to seek out a clinical swallowing evaluation with an experienced speech language pathologist to best determine an individualized treatment plan. It is particularly imperative for those with PD to have this test as there is a higher risk of something called “silent aspiration”. This is when food, liquid or medication goes down the wrong way however the body doesn’t respond appropriately to expel it (i.e. cough).
What’s Involved in a Swallowing Evaluation?
The first part of a swallowing evaluation is the clinical assessment. The speech pathologist will take a detailed medical history and ask you about the swallowing issues you are experiencing. Next is the oral motor exam. This is a test that looks at how the muscles in your face, mouth and throat are functioning. Your therapist may ask you to smile widely, press your tongue against a tongue depressor, wiggle it side to side, cough, wrinkle your brow, puff your cheeks with air, voice different sounds etc.
The next part involves having you swallow different textures of food: liquid, puree, mixed texture, harder solids etc. The therapist will be observing different things: How are you able to chew, prepare, control and transfer various food textures? How long does it take? Is there any spillage from the lips? How well are you able to clear food from your mouth? Are you aware when food spills out? Next they will likely feel your throat when you swallow. They are testing for how briskly your throat rises when you swallow. This indicates how well you are closing your airway when you swallow and how well you are opening your food tube to allow the food to pass through to the stomach. Next they will observe what happens after the swallow. Is there coughing or throat clearing? Is there a change in voice quality? A wet or bubbly sounding voice can indicate that something has gone down the wrong way as food and liquid that passes over the vocal folds will change the sound of the voice.
The Instrumental Assessment
If your speech pathologist feels it is indicated, they may book you for a swallow x-ray. This could be referred to as an MBS (Modified Barium Swallow) or a VFSS (Video-Fluoroscopic Swallowing Study). This test is performed in an x-ray department. The therapist will mix different food textures with barium (a chalky white mineral that shows up on x-ray). They will ask you to swallow these items while you are being x-rayed. This test allows the speech pathologist to see exactly what is happening when you swallow and will help to guide the treatment plan. During the test they may have you do special head positions or specific manoeuvres to see if there are any strategies that improve swallow efficiency and airway protection.
After the test, the speech pathologist will meet with you to review the results and discuss your treatment plan.
Treatment may involve any of the following:
- Food texture modifications
- Positioning strategies or specific swallowing tips/manoeuvres during meals
- Specific swallowing exercises
- Speech/voice therapy or exercise program
Speech Therapy for Swallowing Issues in Parkinson’s?
Yes! Parkinson specific speech and voice exercises can help with strengthening the respiratory, articulatory and phonatory systems. Remember that speech therapists manage both communication and swallowing issues because of the similarities in anatomy and physiology. When you regularly engage in Parkinson specific voice and speech exercises you are also targeting swallowing function!
How’s that for a two for one deal!?
Top Ten Safer Swallow Tips for Parkinson’s Disease
Living with Parkinson’s disease can present a range of challenges, and one often underestimated difficulty is swallowing. Known as dysphagia, this condition can lead to a higher risk of aspiration pneumonia, a potentially serious complication. However, with the right strategies and habits, you can significantly reduce the risks associated with swallowing difficulties. Let’s explore the top ten safer swallow tips for individuals with Parkinson’s disease.
1. Seek a Clinical Swallowing Assessment
Anyone experiencing swallowing difficulties, whether due to Parkinson’s disease or any other condition, should seek out a clinical swallowing assessment with a speech-language pathologist. They can provide personalized recommendations and therapies to address your unique needs.
2. Maintain Excellent Oral Hygiene
Implementing diligent oral care is one of the most important habits to lower your risk of aspiration pneumonia. Keeping your mouth clean and healthy helps prevent mouth bacteria from entering your lungs and causing infections. Did you know that the real culprit for aspiration pneumonia is not the food or liquid entering the lungs; it’s the mouth bacteria that hitch a ride with them? To combat this, make it a habit to brush your teeth and swish with alcohol-free mouthwash both before and after meals. A cleaner mouth translates to healthier lungs.
3. Optimal Seating
Ensure you are seated optimally for a meal, ideally fully upright in a chair. This position promotes better control over your food and minimizes the risk of choking.
4. Minimize Distractions
During mealtime, avoid distractions and refrain from talking when food or fluid is in your mouth. Focus on the task at hand to prevent accidental aspiration.
5. Slight Chin Tuck Position
When chewing food, tip your chin slightly down. For swallowing fluids, try a slightly deeper chin tuck. These maneuvers help close the airway tighter during the swallow, reducing the risk of fluids going down the wrong way.
6. Small Bites and Careful Chewing
Take small bites and chew your food carefully. This not only aids in digestion but also makes it easier to manage your food in your mouth before swallowing.
7. Choose Moist and Cohesive Foods
Opt for foods that are moist and cohesive. Fibrous or granular foods, such as celery, pineapple, dry seeds, nuts, granola, dry rice, and crumbly biscuits or crackers, can be challenging to control and swallow.
8. Be Cautious with Two-Textured Foods
Two-textured or “mixed-textured” foods, like chicken noodle soup or cereal with milk, require extra caution. These foods challenge your mouth to manage both solid and liquid components simultaneously, increasing the risk of choking or aspiration.
9. Sip Liquids Wisely
When drinking liquids, ensure your mouth is completely clear of food. This practice avoids the simultaneous presence of solids and liquids in your mouth, reducing the risk of aspiration.
10. Be Mindful of Parkinson “OFF” Periods
Start to track when your medication “off” periods are. At these times of the day choose easier to swallow foods such as smooth cream soups, puddings or soft moist casseroles.
While Parkinson’s disease may bring its share of challenges, adopting these 10 safer swallow tips can significantly improve your quality of life and reduce the risk of aspiration pneumonia. Remember, seeking professional guidance through a clinical swallowing assessment is the first and most crucial step towards managing swallowing difficulties effectively. By implementing these strategies and maintaining good oral hygiene, you can enjoy safer and more comfortable meals while safeguarding your lung health. A cleaner mouth truly does equal healthier lungs.
Navigating Mixed Texture Foods with Parkinson’s Disease: Tips for Safe Swallowing
What are Mixed Texture Foods?
If you or a loved one is living with Parkinson’s Disease (PD), you may be familiar with the unique challenges it presents, especially when it comes to safely enjoying a variety of foods. One particular hurdle that individuals with PD often face is the difficulty of handling “two-textured” or “mixed texture” foods. These are foods that combine both a liquid and a solid component, like chicken noodle soup, cereal with milk, fruit cocktail in syrup, or even a succulent piece of watermelon. In this blog post, we’ll explore why these two-textured foods can be tricky for those with Parkinson’s Disease and share some practical tips to make mealtime safer and more enjoyable.
The Challenge of Mixed Texture Foods
Why are mixed texture foods so challenging for individuals with Parkinson’s Disease? The key issue lies in the simultaneous management of two different textures in the mouth: chewing the solid bits and controlling the liquid portion. For people with PD, initiating and controlling movements can be impaired, and this applies to the mouth and throat muscles as well. When both solids and liquids are introduced into the mouth at the same time, it’s akin to trying to pat your head and rub your belly simultaneously – it’s more challenging.
So, does this mean you have to bid farewell to your favorite two-textured foods? Absolutely not! There’s a simple solution that can help you continue enjoying these delicious dishes without the added stress.
The Solution: Divide and Conquer
To make two-textured foods easier to manage, try this straightforward approach: alternate spoonfuls of the dish. Here’s how:
- Only the Liquid: Start by spooning just the liquid portion into your mouth, like the broth in chicken noodle soup.
- Only the Solids: After swallowing the liquid portion, take a spoonful of just the solid bits, making sure to drain off any excess liquid. This method eliminates the challenge of dealing with two different textures in your mouth at once.
By alternating between the two components, you can relish the full flavor of your favorite mixed texture dishes while reducing the risk of choking or aspiration.
Additional Protection: Slight Chin Tuck
For added protection during meals, consider tilting your chin slightly downward when there’s food or liquid in your mouth. This technique takes advantage of gravity to keep the food bolus in the front part of your mouth, reducing the chances of premature spillage into your throat before you’re ready to swallow. It’s important to note that this is not the same as a full “chin tuck posture” used by some individuals with swallowing issues to enhance airway closure during swallowing. The slight chin tuck is a milder adjustment that can help better control two-textured foods.
Pill-Taking Made Easier
Lastly, don’t forget that taking pills with water is also considered a mixed texture challenge. Many people, not just those with Parkinson’s, struggle with swallowing pills because of this reason. An easy solution is to coat pills in either applesauce or yogurt before swallowing. This makes the pill easier to swallow, and you can always take a small sip of water afterward to ensure it goes down smoothly.
So, there you have it – practical tips to help you navigate the challenge of two-textured foods with Parkinson’s Disease. By alternating textures and using a slight chin tuck when needed, you can enjoy your favorite dishes safely. And when it comes to pills, a little applesauce or yogurt can make a big difference. Bon appétit!
Remember, it’s always a good idea to consult with speech language pathologist (SLP) for personalized advice on managing swallowing difficulties associated with Parkinson’s. Seek out a clinical swallowing assessment with an SLP near you.