Are swallowing problems common in Parkinson’s disease?
Upto % of patients with Parkinson’s disease may complain of swallowing problems. The medical term for swallowing problems is “Dysphagia”.
In milder cases, you may just have the feeling that food gets “stuck” in your throat.
In more severe cases, you may tend to choke on your food if you try to swallow it too quickly. In such cases, there is a small risk that food particles may go into your lungs causing pneumonia. Therefore, severe problems with swallowing should be treated on an urgent basis.
Why do patients with Parkinson’s disease have trouble with swallowing?
Swallowing is a multistep process. If we simplify the science behind swallowing, we can divide it into 3 steps:
- Chewing food & pushing it back into the throat
- Pushing the food from the throat to the food pipe (esophagus)
- Pushing the food from the food pipe to the stomach
The last step is completely involuntary. The first two steps are voluntary, just like moving your arms or walking.
If you have Parkinson’s disease, then the first two steps become very slow – just like your walking becomes slow. Because of that food is not pushed into your throat very quickly, and your throat itself doesn’t push it downwards very quickly – this leads to the feeling that food is “stuck” inside your throat.
What is “Aspiration”?
Our mouth connects to two pipes: The food-pipe (esophagus) and the wind-pipe (trachea).
When we are swallowing, the muscles in our throat move quickly and in a very coordinated fashion. They close the opening to the wind-pipe and make the opening to the food-pipe bigger, so that food goes into the food pipe.
These movements become slow in Parkinson’s disease – as a result food may go into the windpipe instead, and ultimately end up in the Lungs. This is called “Aspiration”.
What is “Silent Aspiration”?
Usually, even when a small particle of food goes into the wind-pipe, we gag and start coughing very vigorously. This is called the “Gag” and “Cough” reflex. This is a violent attempt by the lungs to throw the food particle out.
In Parkinson’s disease, just like all other movements, these movements become slow. In fact, for smaller particles we may not even get the feeling of choking or coughing.
As a result, small particles of food may repeatedly go into the lungs while we are eating. Occasionally, they can produce an infection of the lungs – pneumonia.
It is important to detect “Silent Aspiration” early, so that aspiration of large food masses can be avoided.
How can the risk of Aspiration be detected?
For people who do not have absolutely no problems with speech or swallowing, usually further testing is not done. Some doctors routinely ask a speech-swallow therapist to see the patient at each follow-up visit.
Certainly, if you have problems with speech or swallowing you should ask your doctor to refer you to a therapist. A speech-swallow therapist is specially trained to assess the risk of swallowing by seeing how your lips, chewing, tongue and throat muscles move while you are swallowing. Click here for an excellent video by a speech & swallow therapist:
If needed the speech-swallow therapist in turn may send you to an ENT (Ear-Nose-Throat) doctor. The ENT doctor has special instruments to see whether the wind-pipe is closing while you are swallowing – as it normally should.
In rare cases, a special study called a Dynamic Swallow Study may be done to actually visualize the flow of food from the mouth to the stomach – and to see if any particles of food are ending up in the lungs instead. This is done either by having you swallowing a dye, or by using a small camera called an endoscope.
Does Levodopa (and other treatments) reduce risk of swallowing?
As described earlier, swallowing is a series of movements. These movements are slow if you have Parkinson’s disease. If your movement problems are adequately treated, then the movements of your lips, jaw, tongue and throat also improve dramatically. This significantly reduces the risk of Aspiration.
It is not just levodopa – any medication that improves your movements significantly reduces your risk of aspiration.
What can the speech-swallow therapist teach me?
The speech-swallow therapist can teach you many exercises to improve the movement of your speaking and swallowing muscles.
He/she can teach you many tips and tricks to prevent aspiration (also given below).
Finally, if your speech therapist is really good, he/she can start special training sessions such as Expiratory Muscle Strength Training (EMST) or Lee Silverman Speech Therapy (LSVT) or LOUD therapy. These specialized training sessions are extremely useful in improving voice and decreasing the risk of aspiration in patients with Parkinson’s disease.
Can you give me a few tips and tricks to prevent aspiration?
Although these tips are not a substitute for evaluation and training by a speech-swallow therapist, I think following these instructions will be very helpful for you.
- Try to avoid very hard foods: These are difficult to chew and grind. If you try to swallow larger chunks of food, you may find it difficult. For example, try to avoid hard fruits like green apples. How do you get your fiber then? Well, you can still eat these foods by putting them through an electrical mixer first to make a smoothie! (Click here).
- Put small portions of food in your mouth: This makes it easier for you to chew and grind them up adequately.
- Chew food adequately: If needed, you can count the number of times that you chew your food – Chew each piece of food that you put in your mouth at least 20 times before trying to swallow it.
- Sit upright while eating: Make gravity do your work! Sitting upright while eating helps your foodpipe to dump the food into your stomach. Never have food while lying down in bed.
- Make sure your mouth is empty before taking another bite: Once you think you have finished swallowing, use your tongue and move it around your mouth to make sure there are no un-swallowed masses of food in your mouth. If needed, use your finger for this purpose. It is always better to be careful.
Dr. Kharkar is a Neurologist, Epilepsy specialist & Parkinson’s disease specialist in Mumbai, Maharashtra, India.
He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, University of California at San Francisco (UCSF), USA & Kings College in London.
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