Swallowing Problems

Richard M.Merson, PhD, CCC-SLP
Kathleen Roeder, MA, CCC-SLP

Speech-Language Pathology Department William Beaumont Hospital, Royal Oak, Michigan

Dr. Richard Merson is Coordinator of Research, Speech and Language Pathology, William Beaumont Hospital and a Member of MPF's Professional Advisory Board. Kathleen Roeder is Supervisor, Acute Care Speech Pathology and William Beaumont Hospital.

1. Persistent coughing after swallow

2. Regular choking on liquids

3. Difficulty maintaining your weight

4. Increasing eating time

5. Worsening tongue control

6. Chronic slow or delayed food passage

7. Significant loss of appetite

Swallowing problems in Parkinsonism are not unusual and rarely unmanageable. The typical muscle impairments of individuals with Parkinson's Disease ( i.e. weakness, slowness, delayed-initiation, freezing, or tremor) may cause significant difficulties in controlling food or liquids in the mouth, adequately chewing or masticating , quickly passing the food to the throat, , protecting the windpipe (i.e trachea) from food and liquid choking, and finally smoothly and firmly receiving the food into the esophagus for passage to the stomach. All of these actions require the coordinated work of more than two dozen muscle groups (i.e. lips, tongue, cheeks, palate, throat, voice box, and food tube) that must be performed hundreds of times each day in 4-8 seconds.

Breakdowns in this chewing-forming-pushing process can cause choking when the food particles or liquids pass into the windpipe (i.e aspiration). Further, individuals may find that eating is too time consuming, requires too much effort, or may frighten them when the food does not pass easily into the food tube. These problems may lead to weight loss or reduced calorie intake that is so critical in maintaining energy and general muscular activity. We cannot take swallowing difficulties for granted. Some swallowing difficulties may cause liquid , saliva or food to enter the lungs on a recurring basis and leave you vulnerable to a lung infection. If these symptoms are severe, unresponsive to treatment and insufficient calories are achieved daily then a medical procedure to place a tube inside the stomach (i.e. PEG tube: Percutaneous Endoscopic Gastrostomy) may be considered.

Dysphagia: Swallowing Disorders

In medical terminology a disorder of swallowing is identified as a "dys-phagia" (Latin for difficulty swallowing). Dysphagia symptoms may occur anywhere from the lips to the stomach. If swallowing difficulties occur in the esophagus (food tube) and down through the entryway into the stomach then an Esophagram (i.e. an xray to examine the swallow) may be ordered by your physician and a gastroenterologist ( G.I. physician specializing in the digestive system) may be consulted. Sometimes the G.I. specialist will perform a procedure to expand or open the esophagus by a procedure known as esophageal insufflation to improve the passage of food . The physician may also prescribe medications to assist in some esophageal swallowing disorders. If however, the swallowing difficulties occur in holding the food in the mouth, chewing the food, or safely passing the food to the esophagus then a speech-language pathologist may be consulted to identify the dysphagia and recommend some exercises or alter the diet to manage the problems.

Different types and severities of dysphagia may be present in patients after surgery, in association with chronic debilitating illness, from loss of dentition, loss of salivation or other conditions. Symptoms associated with aging, stroke, over-medication, traumatic brain injury, myasthenia gravis, muscular dystrophy, multiple sclerosis and Parkinson's disease can cause dysphagia symptoms. Individuals with chronic illness must develop a good daily nutritional program that provides adequate intake of calories, critical vitamin, protein and carbohydrates, and sufficient hydration (liquids). Patients should work closely with their physicians, nutritional experts and caregivers to maintain a daily healthy diet.

The Dysphagia Team

(Primary Care Physician, Gastroenterologist, Neurologist, Radiologist, Speech Pathologist and the Spouse/Caregiver)

The speech pathologist is often the rehabilitation professional who will assist you in maintaining good oral muscular control and prevent food from entering the windpipe through treatment techniques. If necessary a specialized xray procedure called a Modified Barium Swallow fluoroscopy will be completed. Your physician is always the first person to contact when you are experiencing difficulty swallowing. If you need some assistance or further treatment of how to improve your swallowing a consultation with a speech-language pathologist affiliated with a hospital, an outpatient rehabilitation program, a homecare service or a skilled nursing facility is available with a medical referral.

The Modified Barium Swallow Procedure is the most common medical procedure jointly conducted by a speech-language pathologist specializing in swallowing disorders and a physician-radiologist to evaluate dysphagia. This xray procedure is not a complicated or lengthy diagnostic procedure. The patient sits comfortably erect in a special chair. The speech-language pathologist prepares and feeds the patient liquids, applesauce or crackers mixed with a Barium material for brief videofluouroscopic filming of the mouth, pharyngeal and esophageal swallowing events. This usually requires 15-20 minutes. The physician identifies any anatomic or physiologic disorders as he observes the swallowing tasks and the speech-language pathologist identifies any swallowing difficulties that can be treated. There are many other medical procedures that your physician may choose to diagnose your dysphagia and recommend treatment. They may include a Radiologic Imaging, Barium Esophagram, Manometry, Bolus Scintigraphy, Flexible Endoscopic Evaluation, or Ultrasound. Your physician will decide, based on examination, what dysphagia medical procedure(s) is most appropriate.

Swallowing Rehabilitation

Speech-Language pathologists usually provide the behavioral treatment for individuals with dysphagia. Treatment may focus on one or more of the following dysphagia symptoms: (1) improving or compensating for the individual's difficulty in chewing or managing food in the mouth; (2) preventing food or liquid from entering the windpipe ( i.e. the trachea); (3) reducing delays in transit of food by adjusting the textures, timing or preparation of food to be swallowed; (4) managing the schedule of eating to reduce fatigue and muscle weakness. The speech-language pathologist or physician may recommend a consultation with a dietitian to train caregivers to provide instruction or food preparations for some patients.

When the Dysphagia Team decides that an individual's diet should be changed to make swallowing healthier and safer, they may suggest a PUREED DIET or a MECHANICAL SOFT DIET. Usually, when swallowing liquids is difficult with persistent cough on thin liquids ( i.e. water leaking into the windpipe), a PUREED DIET with THICKENED LIQUIDS may be recommended. When liquid swallowing is safe but muscular weakness persists (slow eating, food gets stuck, food is poorly chewed), then a MECHANICAL SOFT DIET may be recommended. Some individuals have difficulty chewing, but can manage thin liquids. Special adjustments can be made to suit individual needs.

Dietary Suggestions for Dysphagia

Tips & Precautions

• Don't eat when fatigued

• Sit erect

• Emphasize soft , moist foods

• Don't talk while eating

• Take smaller bites

Example of a PUREED DIET

• *Thicken liquids to honey consistency

• Cooked cereals, whipped- potatoes & squash

• Strained fruits, applesauce, mashed banana

• Strained meat, soft scrambled egg

• Strained & whipped vegetables Thickening material available at drugstores include Thick-it, Nutra Thickt, ThickenUp

Example of a MECHANICAL SOFT DIET

• Thickened liquids if necessary

• Cooked or ready-to-eat cereal, soft bread

• Well cooked vegetables

• Cut-up canned fruit without tough membrane

• Tender cuts of meat extra sauce or gravy

• Eggs, cheese, macaroni, moist casserole

Summary

Swallowing problems or Dysphagia are not uncommon in patients with Parkinson disease symptoms. You should consult your primary care physician if you have persistent difficulty choking on liquids or eating comfortably on a regular basis. Most of the swallowing problems can be managed by a few individualized exercises, swallowing techniques or modifications in your diet. Good health is dependent on a well rounded diet, the use of plenty of liquids and an enjoyable eating experience.

Website References

American Speech-Language-Hearing Association, Dysphagia Research. http://search.asha.org (Conduct a search for the keyword Dysphagia.)

Dysphagia Resource Center: www.dysphagia.com

National Institute on Deafness and other Communication Disorders [NIDCD]: http://www.nidcd.nih.gov/health/voice/Pages/dysph.aspx