Parkinson's Disease - Dysphagia

8/08/01 (Ansari)

RE: A 75 year old female with history of Parkinson's disease who presented with difficulty swallowing. 

Question: Why do patients with Parkinons's disease get dysphagia?

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[Link Directly to Fulltext Article in OVID]

Unique Identifier: 21092257 / PubMed Identifier: 11176964

Authors: Muller J. Wenning GK. Verny M. McKee A. Chaudhuri KR. Jellinger K. Poewe W. Litvan I.

Institution: Cognitive Neuropharmacology Unit, The Champlain Building, 6410 Rockledge Dr, Suite 600, Bethesda, MD 20817-1844, USA.

Abstract: BACKGROUND: Dysarthria and dysphagia are known to occur in parkinsonian syndromes such as Parkinson disease (PD), dementia with Lewy bodies (DLB), corticobasal degeneration (CBD), multiple system atrophy (MSA), and progressive supranuclear palsy (PSP). Differences in the evolution of these symptoms have not been studied systematically in postmortem-confirmed cases. OBJECTIVE: To study differences in the evolution of dysarthria and dysphagia in postmortem-confirmed parkinsonian disorders. PATIENTS AND METHODS: Eighty-three pathologically confirmed cases (PD, n = 17; MSA, n = 15; DLB, n = 14; PSP, n = 24; and CBD, n = 13) formed the basis for a multicenter clinicopathological study organized by the National Institute of Neurological Disorders and Stroke, Bethesda, Md. Cases with enough clinicopathological documentation for the purpose of the study were selected from research and neuropathological files of 7 medical centers in 4 countries (Austria, France, England, and the United States). RESULTS: Median dysarthria latencies were short in PSP and MSA (24 months each), intermediate in CBD and DLB (40 and 42 months), and long in PD (84 months). Median dysphagia latencies were intermediate in PSP (42 months), DLB (43 months), CBD (64 months), and MSA (67 months), and long in PD (130 months). Dysarthria or dysphagia within 1 year of disease onset was a distinguishing feature for atypical parkinsonian disorders (APDs) (specificity, 100%) but failed to further distinguish among the APDs. Survival time after onset of a complaint of dysphagia was similar in PD, MSA, and PSP (15 to 24 months, P =.7) and latency to a complaint of dysphagia was highly correlated with total survival time (rho = 0.88; P<.001) in all disorders. CONCLUSIONS: Latency to onset of dysarthria and dysphagia clearly differentiated PD from the APDs, but did not help distinguish different APDs. Survival after onset of dysphagia was similarly poor among all parkinsonian disorders. Evaluation and adequate treatment of patients with PD who complain of dysphagia might prevent or delay complications such as aspiration pneumonia, which in turn may improve quality of life and increase survival time.

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[Link Directly to Fulltext Article in OVID]

Unique Identifier: 98253447 / PubMed Identifier: 9591222

Authors: Briani C. Marcon M. Ermani M. Costantini M. Bottin R. Iurilli V. Zaninotto G. Primon D. Feltrin G. Angelini C.

Institution: Department of Neurology, University of Padua, Italy.

Abstract: Dysphagia in motor neuron disease (MND) may lead to dangerous complications such as cachexia and aspiration pneumonia. Functional evaluation of the oropharyngeal tract is crucial for identifying specific swallowing dysfunctions and planning appropriate rehabilitation. As part of a multidisciplinary study on the treatment of dysphagia in patients with neuromuscular diseases, 23 MND patients with different degrees of dysphagia underwent videofluoroscopy, videopharyngolaryngoscopy and pharyngo-oesophageal manometry. The results of the three instrumental investigations were analysed in order (1) to define the pattern of swallowing in MND patients complaining of dysphagia; (2) to evaluate whether subclinical abnormalities may be detected; and (3) to assess the role of videofluoroscopy, videopharyngolaryngoscopy and manometry in the evaluation of MND patients with deglutition problems. Correlations between the instrumental findings and clinical features (age of the patients, duration and severity of the disease, presence and degree of dysphagia) were also assessed. The results of our study showed that: (1) The oral phase of deglutition was compromised most often, followed by the pharyngeal phase. (2) In all patients without clinical evidence of dysphagia, subclinical videofluoroscopic alterations were present in a pattern similar to that found in the dysphagic group. (3) Videofluoroscopy was the most sensitive technique in identifying oropharyngeal alterations of swallowing. Impairment of the oral phase, abnormal pharyngo-oesophageal motility and incomplete relaxation of the upper oesophageal sphincter were the changes most sensitive in detecting dysphagia. Videofluoroscopy was also capable of detecting preclinical abnormalities in non-dysphagic patients who later developed dysphagia. Practical guidelines for the use of instrumental investigations in the assessment and management of dysphagia in MND patients are proposed.

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Unique Identifier: 97396626 / PubMed Identifier: 9252799

Authors: Coates C. Bakheit AM.

Institution: Southampton General Hospital, UK.

Abstract: The prevalence of dysphagia and its relationship to the nutritional status of the subject was examined in 53 patients with Parkinson's disease (PD). Forty-three patients (81%) had swallowing difficulties but this was mild in most of them. The nutritional status of patients with PD was similar to that of age- and sex-matched control subjects. Disease duration and severity correlated with the severity of dysphagia. The study also identified tremor and speech disturbances as the main predictors of dysphagia in PD.

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[Link Directly to Fulltext Article in OVID]

Unique Identifier: 97151878 / PubMed Identifier: 8997827

Authors: Leopold NA. Kagel MC.

Institution: Department of Medicine, Crozer-Chester Medical Center, Upland, Pennsylvania 19013, USA.

Abstract: The radiologic characteristics of pharyngoesophageal (PE) dysfunction in Parkinson's disease (PD) are not well established, partly because most previous studies have examined only small numbers of patients. We administered a dynamic videofluoroscopic swallowing function study to 71 patients with idiopathic PD. Using the Hoehn and Yahr disease severity scale, patients were subdivided into those with mild/moderate disease, subgroup I (n = 38), and advanced PD disease, subgroup II (n = 33). From pharyngeal ingestion to gastric emptying, bolus transport was normal in only 2 patients. The most common abnormalities occurring during pharyngeal ingestion included impaired motility, vallecular and pyriform sinus stasis, supraglottic and glottic aspiration, and deficient epiglottic positioning and range of motion. Esophageal abnormalities were multiple but most commonly included delayed transport, stasis, bolus redirection, and tertiary contractions. Typical aberrations of lower esophageal sphincter (LES) function included an open or delayed opening of the LES and gastro-esophageal reflux. A pathogenesis linking PE with the pathology of PD is proposed.

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Unique Identifier: 96339030 / PubMed Identifier: 8721075

Authors: Leopold NA.

Institution: Department of Medicine, Crozer Chester Medical Center, Upland, PA 19013, USA.

Abstract: Dysphagia complicates both idiopathic Parkinson's disease (IPD) and drug-induced parkinsonism (DIP). Although parkinsonism of DIP and IPD are often clinically indistinguishable, there is no assurance that their abnormalities of swallowing will be similar. We evaluated a patient with DIP who complained of difficulty chewing and swallow initiation. The dysphagia evaluation demonstrated abnormalities during all stages of ingestion. However, the prepharyngeal stages were disproportionately affected when compared with patients with IPD and similar levels of parkinsonian functional disability. This case gives additional support for a significant basal ganglia influence on motor deglutitive functions.

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Unique Identifier: 96156039 / PubMed Identifier: 8566584

Authors: Ali GN. Wallace KL. Schwartz R. DeCarle DJ. Zagami AS. Cook IJ.

Institution: Department of Gastroenterology, St. George Hospital, University of New South Wales, Sydney, Australia.

Abstract: BACKGROUND & AIMS: Oral-pharyngeal dysphagia in Parkinson's disease is well recognized. The aim of this study was to establish the mechanisms of oral-pharyngeal dysphagia in these patients. METHODS: Using simultaneous videoradiography and pharyngeal manometry, we studied 19 patients with Parkinson's disease (12 with oral-pharyngeal dysphagia and 7 without oral-pharyngeal dysphagia) and compared them with 23 healthy controls. RESULTS: the clinical severity of Parkinson's disease predicted neither the presence nor the severity of dysphagia. Minor alterations in oral function were common in controls and patients, but pharyngeal dysfunction was significantly more prevalent in patients. Incomplete upper esophageal sphincter (UES) relaxation was present in 4 patients (21%), all of whom showed increased hypopharyngeal intrabolus pressure, but not all of whom had a diminished UES opening. The patients had a reduced UES diameter (P = 0.004) and a higher intrabolus pressure compared with the controls (P = 0.007). Pharyngeal contraction pressures were lower in patients, but 6 patients with dysphagia and an abnormal pharyngeal wall motion had normal peak pressures. CONCLUSIONS: An incomplete UES relaxation and a reduced UES opening, both associated with high intrabolus pressure, are prevalent in Parkinson's disease. Oral-pharyngeal dysphagia in Parkinson's disease is multifactorial, with the majority of patients showing oral and pharyngeal dysfunction, even before the clinical expression of dysphagia. Impaired pharyngeal bolus transport is the major determinant of dysphagia.

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Unique Identifier: 96148184 / PubMed Identifier: 8556872

Authors: Leopold NA. Kagel MC.

Institution: Department of Medicine, Crozer-Chester Medical Center, Upland, PA 19013, USA.

Abstract: Dysphagia in patients with Parkinson's disease (PD) is most often attributed to pharyngeoesophageal motor abnormalities. In our study of patients with idiopathic PD, attention was focused on prepharyngeal symptoms and motor functions. Using the Hoehn and Yahr disease severity scale, patients were grouped into those with mild/moderate disease [subgroup I (n = 38)] and those with advanced disease [subgroup II (n = 34)]. Dysphagia symptoms were present in 82% of all patients, but subgroup I patients voiced significantly more complaints. Conversely, many prepharyngeal abnormalities of ingestion, including jaw rigidity, impaired head and neck posture during meals, upper extremity dysmotility, impulsive feeding behavior, impaired amount regulation, and lingual transfer movements were statistically more frequent in subgroup II patients. Impaired mastication and oral preparatory lingual movements were the most common aberrations observed during dynamic videofluoroscopy (48/71), with most patients being concordant for both. The motor disturbances of ingestion reported herein reflect the disintegration of volitional and automatic movements caused by PD-related akinesia, bradykinesia, and rigidity.

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Unique Identifier: 94236512 / PubMed Identifier: 8180906

Authors: Wintzen AR. Badrising UA. Roos RA. Vielvoye J. Liauw L. Pauwels EK.

Institution: Department of Neurology, University of Leiden, The Netherlands.

Abstract: To assess the frequency of subjective and objective dysphagia and its possible pulmonary sequelae, we prospectively studied 22 out-patients with Parkinson's disease; 15 spouses served as controls. All subjects answered a standard questionnaire concerning swallowing and respiratory functions and underwent barium swallow videofluoroscopy. Possible pulmonary infection was investigated by recordings of body temperature, ESR, leucocyte count, and chest X-ray. Patients had significantly more symptoms than controls, especially choking, piece-meal deglutition and regurgitation. Videofluoroscopy revealed tracheal aspiration in one patient, vestibular aspiration in one patient and in one control. Non-fluent swallowing movements were common in patients: abnormal bolus formation, delayed swallowing reflex, vallecular stasis, and piriform sinus residue. None of the subjects had signs of pulmonary infection. Both subjective and objective oro-pharyngeal dysfunction is frequent in ambulant Parkinson patients, but apparently does not produce demonstrable pulmonary infection.

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Unique Identifier: 81083217 / PubMed Identifier: 6778203

Authors: Lieberman AN. Horowitz L. Redmond P. Pachter L. Lieberman I. Leibowitz M.

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Unique Identifier: 76122880 / PubMed Identifier: 1243574

Authors: Logemann JA. Blonsky ER. Boshes B.

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Unique Identifier: 74300436 / PubMed Identifier: 4408187

Authors: Palmer ED.