SWALLOWING DIFFICULTIES

JANUARY/FEBRUARY 2021SWALLOWING DIFFICULTIESin Parkinson’s DiseaseThe act of swallowing involves a complex series ofactivities that begin in the mouth, continue in thepharynx (or the throat) and end in the esophagus.These include chewing, using the tongue tomove the bolus of food to the back of the throatand then coordinating the muscles that bothpropel the food into the esophagus and protectthe airway or trachea from food penetration.Swallowing dysfunction (also called dysphagia)can be considered both a motor and a non-motorsymptom of PD. Loss of dopamine neurons inthe substantia nigra area of the brain can causethe motor dysfunction that impairs swallowing.However, loss of neurons in other areas of thebrain, such as the cortex and lower brain stem canalso affect the overall control and coordinationof swallowing, and can be thought of as a nonmotor symptom of PD. Swallowing issues are veryimportant to diagnose. Impacts on your daily lifeand your health can range from difficulties withmeals to more extreme (but less common) caseswhere it could lead to choking and aspirationwhich can be very serious or even fatal.How do you know if you or your loved onehas a problem with swallowing?Swallowing difficulties can start very subtly andinitially not be obvious to either the person withPD or their loved ones. There are signs to look outfor before swallowing difficulty becomes overt(i.e. choking on food). Some of the signs youshould pay attention to include: Slow rate of eating – people with difficultyswallowing may slow down their eating toavoid coughing or choking Fatigue during eating or decreasedenjoyment of food A sensation that food is “sticking” in thethroat Coughing or excessive throat clearingduring eating Difficulty in swallowing pills Unexplained weight loss – people withdifficulty swallowing may reduce theirconsumption in an attempt to eat withoutcoughing or choking Change in dietary habits – people withdifficult swallowing may alter their diet toavoid foods that cause difficulty. This maynot be a choice made consciously Diagnosis of a pneumonia – this could becaused by aspiration, or entry of a foreignsubstance (i.e. food) into the airway[continued on next page]www.apdaparkinson.org/greaterstlouisVolume 34, Issue 531601 Jan Newsletter v3.indd 1112/15/20 4:05 PM

BOARD OF DIRECTORSGail Glenn, PresidentKathy Schroeder, Vice PresidentBryan Graiff, TreasurerMatt Specter, SecretaryChristine AlsopChristine EasonErin FosterRob GorenAngie LawingNeil LazaroffLou Ann NolanAnn SchmelzlePaul ThakadiyilDan VogelJeff WaldmanGrant WiensCynthia WilliamsEMERITUS DIRECTORSDennis BarnesBrook DubmanBob GoldstickerMatt LaMartinaJoe MarchbeinMatt SchumacherLynda WiensAPDA STAFFCatherine Krane,Executive DirectorTerri Dietrich,Office CoordinatorMelissa Palmer,Development ManagerMelissa Skrivan,Director of DevelopmentAngela Weaver,Program ManagerIf you think there might be a swallowing issue, it isimportant to speak with your doctor about it. There aresteps you can take to properly assess the situation (i.e.,a swallowing evaluation) and improve your swallowingfunction. This can in turn reduce your risk of choking,make eating more enjoyable, and lessen the chances ofunwanted weight loss and/or other discomforts.What is a swallowing evaluation?If because of the above signs there is concernthat swallowing difficulties exist, your doctor mayrecommend a swallow evaluation, which can beperformed by a speech and language pathologist.There are two main ways to evaluate someone’s swallow: Modified barium swallow study – This is the mostcommon test that is performed. The personis asked to ingest different consistencies ofbarium and moving x-rays are taken that followthe barium as it is swallowed. This x-ray videopinpoints the areas of the swallow that areproblematic and helps to determine the correctexercises to address the problem. F iberoptic endoscopic evaluation of swallowing(FEES) is another type of test that can beperformed to evaluate swallow. During thisprocedure, a very thin flexible fiberoptic tubewhich is hooked up to a camera and lightsource, is passed through the nasal passage. Thetube does not go down the throat, but allowsswallowing to be observed. This procedure ispainless and well-tolerated by most individuals.If you have swallowing difficulty, what can be done?In some cases, swallowing function varies in responseto dopamine medication doses, much like other aspectsof motor function. Therefore, if swallowing becomesproblematic, an increase in dopaminergic medicationscan be tried. In addition, make sure you undergo aswallow evaluation when you are in the ON state.Even before a formal swallow study, you can take steps toincrease the efficiency of your swallow. These include: S it upright during all eating and drinking, evenwhen taking pills T ilt the head slightly forward, not backward, asyou swallow T ake small bites of food, chew thoroughly, and donot add any more food until everything from thefirst bite has been swallowed231601 Jan Newsletter v3.indd 212/15/20 4:05 PM

Take small sips of liquid C oncentrate while moving the foodbackward in the mouth with the tongue “ Double swallow” (swallow a second time)if the food did not go down completely withthe first swallow S ometimes taking a sip of liquid betweenbites can help to wash the food down I f eating is very tiring, try several smallermeals spaced out during the day instead ofthree large meals.Swallowing exercises can be very helpfulto improve your swallowingAfter a formal swallow assessment, swallowingtherapy sessions can be designed for you,involving exercises tailored to the specific partsof your mouth and throat that are causing theswallowing problem. Sessions may involvepracticing compensatory swallowing strategieswith various types of foods in order to maximizesafety and efficiency while swallowing.During swallow therapy, recommendations may include: Best feeding techniques Exercises to strengthen oral and throat muscles C ompensatory techniques to assist in safeswallowing Oral and mouth care techniques A ppropriate food selection and ways tomodify food texture Safe positioning strategies Patient/family educationwell-cooked fish without bones, choppedand ground meats, instead of stringy, toughmeats that require a lot of chewing. Soft casseroles and poached or scrambled eggs M ashed potatoes or rice, moistened withgravy or margarine, instead of wild rice orFrench-fried potatoes. S oft, cooked pasta elbows, instead of longspaghetti. S oft, well-cooked vegetables cut up orcreamed, instead of raw vegetables or thosewith a hard texture. P ureed or mashed fruits, fruit juices and fruitsauces, instead of fruits with seeds or hardouter skins. Avoid nuts, seeds or coconut. Custard, yogurt, ice cream or other soft dessertsTips and Takeaways S wallow impairment is common symptom oforal dysfunction in Parkinson’s disease. S ubtle signs of swallow dysfunction caninclude slow eating, coughing with eatingand weight loss. I f swallow dysfunction is suspected, aswallow evaluation can pinpoint the problemand swallow therapy can help improve it. D o not suffer silently or wait until theproblem is very advanced before seekinghelp. Talk to your doctor as soon as younotice any issues or potential difficulties soproactive steps can be taken to lessen theimpact of swallowing issues to keep you safeand comfortable.Choosing foods for successful eatingPart of formal swallow therapy will be to makeappropriate food suggestions that you can eatsafely. Good food choices include: F oods that don’t require vigorous chewing.Avoid dry and crumbly foods. M oderately textured wheat breads insteadof very coarse, nutty breads or very soft,white breads. O atmeal, cream of wheat or moistened drycereals

Part of formal swallow therapy will be to make appropriate food suggestions that you can eat safely. Good food choices include: oods that don’t require vigorous chewing. F Avoid dry and crumbly foods. ately textured wheat breads instead Moder