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A comprehensive review of the diagnosis and treatment of Parkinson’s disease dysphagia and aspiration

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Congratulations to Drs Patel, Legacy, Hegland, Okun and Herndon on the publication of “A comprehensive review of the diagnosis and treatment of Parkinson’s disease dysphagia and aspiration,” in the July issue of Journal Expert Review of Gastroenterology & Hepatology.

ABSTRACT

Introduction

Bulbar dysfunction is common in Parkinson’s disease (PD) with more than 80% of affected individuals developing dysphagia during the course of the disease. Symptoms can begin in the preclinical stage and individuals may remain clinically asymptomatic for years. Furthermore, patients may be unaware of swallowing changes, which contributes to the difference between the prevalence of self-reported dysphagia and deficits identified during instrumental evaluations. Dysphagia is underrecognized and contributes to the development of aspiration pneumonia which is the leading cause of death in PD. Dysphagia in PD is complex and not completely understood. Both dopaminergic and nondopaminergic pathways likely underpin dysphagia.

Areas covered

This comprehensive review will cover the epidemiology, pathophysiology, clinical evaluation, and expert management of dysphagia and aspiration in patients with PD.

Expert Opinion

A multidisciplinary team approach is important to properly identify and manage PD dysphagia. Regular clinical screenings with objective instrumental assessments are necessary for early detection of dysphagia. Studies are needed to better understand the mechanism(s) involved in PD dysphagia, establish markers for early detection and progression, and develop evidence-based treatment options.

Article highlights

  • More than 80% of patients with PD develop dysphagia during the course of their disease, and it may occur even in pre-symptomatic stages.

  • PD dysphagia is associated with aspiration pneumonia, which is the most frequent cause of PD related death.

  • Routine screening for dysphagia with swallowing-specific questionnaires and/or clinical bedside swallow evaluation, as well as instrumental evaluation utilizing either videofluoroscopic swallow study (also known as modified barium swallow study) or fiberoptic endoscopic evaluation of swallowing are necessary for detection of dysphagia.

  • Management of dysphagia includes compensatory strategies (i.e. postural changes, pacing of bites and sips, bolus volume, etc.), diet modifications, and exercises aimed to strengthen muscles, improve airway safety, and swallow efficiency.

  • Clinical predictors of dysphagia in patients with PD include Hoehn and Yahr greater than 3 (advanced PD), dementia, anterior spillage of food and/or liquid from oral cavity (i.e. drooling), weight loss, and a body mass index of <20 kg/m2.

  • There is one randomized clinical study revealing that expiratory muscle strength training (EMST) may be helpful in the prevention of aspiration in PD.

  • A multidisciplinary team approach for early detection and management of dysphagia can improve quality of life, swallowing safety and efficiency, nutrition, and hydration.