Eating is not just essential to maintaining healthy nutrition – it is also a social activity, yet because it is a semi-automatic activity that takes little concentration or effort, the complexity of the normal swallowing process which involves precise coordinated muscular activity is under-appreciated. Swallowing disturbances are common in Parkinson’s, bringing with them a multitude of health-related problems and risks as well as psychosocial distress. By recognizing the symptoms that indicate swallowing problems, you or your loved one can get the help you need to keep living an active, fulfilling life.

Swallowing is Part of Living

Eating is among the most basic of human functions. It is necessary for sustaining life, but even more importantly, it is essential to enjoying life. In many cultures, eating is central in social gatherings, in celebrations, and in everyday family life. When we eat, our brain typically rewards us and reinforces that behavior to survive. It is well known that when we taste food with our taste buds, a message is sent to our brain regarding taste, texture, and temperature. Thus, eating certain foods causes the brain to release endorphins, serotonin, and dopamine, also called “happiness hormones".

When we swallow, our brain orders our muscles – from our lips to the ring-like sphincter muscle at the bottom of our esophagus – to carry out a tightly choreographed series of actions so that the food entering our mouth is chewed, processed, carefully swallowed, and pushed down to our stomach – all while protecting delicate nearby structures such as the nasal cavity, the voice box, the airway, and the lungs.

Parkinson’s and Swallowing

Since swallowing is a process that involves highly coordinated and precise movements, and since Parkinson’s disease (PD) affects the way the brain controls movement, swallowing is often affected in people with PD. In fact, everyone with Parkinson’s has, or will have at some point, some sort of swallowing disturbance, also known as dysphagia. It is also interesting to note that the severity of a patient’s swallowing disturbance does not necessarily correspond to the severity of their disease; in other words, some patients at an earlier stage of the disease may have serious swallowing problems, and vice versa.

By far the most common troublesome, and potentially dangerous, swallowing disturbance involves aspiration. When we swallow, a series of muscle movements raises the soft palate to prevent food from going up into the nasal cavity, while the larynx – the voice box – moves upward and forward as the vocal folds close to protect the airway. After food has passed into the esophagus, the upper esophageal sphincter closes in order to keep it from moving back up once the airway opens again. If these movements are impaired due to Parkinson’s, we risk having food or other debris enter our windpipe and ultimately our lungs – a phenomenon called aspiration.

Parkinson’s patients are often “silent aspirators”, i.e. they aspirate food without realizing it and without showing any clear signs that they have aspirated food, meaning they won’t cough or even feel the need to cough, and neither will they have any choking sensation. More than half of people with Parkinson’s suffer from aspiration, and this is important as it may lead to serious complications such as aspiration pneumonia, whereby food and liquids that entered the airways and found its way to the lungs causes infection there.

Another problem people with Parkinson’s may experience when swallowing is impaired tongue movements. If a patient’s tongue isn’t moving properly, they can have trouble manipulating the mixture of food and saliva in their mouth and bringing it toward the back of their mouth before it is swallowed.

Do I Have Swallowing Disturbances?

As mentioned, it may be difficult to identify swallowing disturbances in people with Parkinson’s because they don’t always present with the typical symptoms of a swallowing problem. It is important to recognize any sign of swallowing disturbances, which may include:

• Complaints of swallowing difficulties
• Food getting stuck in the throat
• Difficulty placing and manipulating food in the mouth
• Drooling
• Coughing or choking before, during, or after swallowing
• Difficulty swallowing pills
• Unexplained weight loss
• Gurgly or “wet-sounding” voice immediately after swallowing
• Increase in saliva in the mouth after a swallow, toward the end of the meal or after a meal
• Recurrent chest infections
• Weight loss
• Choking on food, liquids, or saliva
• Problems swallowing medication
• Pain when swallowing
• Discomfort in the chest or throat
• Heartburn or reflux
• Loss of appetite

Impact on quality of life

Since eating is such a social activity (can you think of a social event where food and drink don’t play a central role?), when we lose confidence in our eating abilities (which include our ability to use our hands to control our utensils and bring food to our mouth) we feel embarrassed and even anxious about eating in front of others. As for swallowing problems, there may also be a fear of choking or aspirating, both because these events can be quite dramatic and gain people’s attention and because of their inherent dangers.

Therefore, if you or your loved one with Parkinson’s are experiencing any of these symptoms, talk to your doctor about whether you should investigate swallowing difficulties. Your doctor may refer you for further assessment to a Speech Language Pathologist (SLP), a health care professional who specializes in the functioning of the speech apparatus.

An SLP may use a combination of techniques to establish how exactly your swallowing is affected. One or more of three procedures are typically used in the assessment of swallowing difficulties – a clinical or bed-side evaluation by the pathologist, a video fluoroscopy swallowing study, and a fiber-optic endoscopic evaluation of swallowing. These evaluations enable the SLP to identify exactly how swallowing is affected and to offer a course of treatment to address the issue.

Treatment Options

The main treatment objectives for swallowing disturbances in people with PD are to maintain good quality of life, by maintaining a safe swallowing function that helps to ensure efficient nutrition and hydration, as well as by attaining normal eating functionality to the extent that the patient’s condition permits.

An SLP who specializes in swallowing disturbances typically lays out an intervention plan based on their assessment of the issue. This can be done through direct intervention, such as making sure that the patient consumes food that is suitable for their swallowing ability, and teaching the patient special swallowing maneuvers or postures to be used while eating in order to improve the swallowing process. An indirect therapy involves exercises aimed at improving the coordination of muscles involved in the swallowing process, as well as breathing and vocal exercises, in order to maintain normal swallowing functions.

Successful treatment depends to a great extent on patients’ willingness to work together with their therapist, as well as their ability to follow the treatment plan and practice any techniques they are taught. Therefore, finding an SLP who understands the needs of Parkinson’s patients and whom you trust is key to a positive outcome.