Validation of a swallowing disturbance questionnaire for detecting dysphagia in patients with Parkinson's disease

Low-frequency stimulation of STN-DBS reduces aspiration and freezing of gait in patients with PD

OBJECTIVES

To study whether 60-Hz stimulation, compared with routine 130 Hz, improves swallowing function and freezing of gait (FOG) in patients with Parkinson disease (PD) who undergo bilateral subthalamic nucleus (STN) deep brain stimulation (DBS).

METHODS

We studied 7 patients with PD who experienced FOG that persisted despite routine 130-Hz stimulation and dopaminergic medication. Each patient received 3 modified barium swallow (MBS) studies in a single day under 3 DBS conditions in the medication-on state: 130 Hz, 60 Hz, or DBS off, in a randomized double-blind manner. The laryngeal penetration and aspiration events were cautiously assessed, and a swallowing questionnaire was completed. The Unified Parkinson's Disease Rating Scale, Part III motor score, axial subscore, tremor subscore, and FOG by a questionnaire and stand-walk-sit test were also assessed. The best DBS condition (60 Hz here) producing the least FOG was maintained for 3 to 8 weeks, and patients were assessed again. Changes in measurements between the 60 Hz and 130 Hz were analyzed using paired t test, with swallowing function as primary and the remainder as secondary outcomes. Changes between other DBS conditions were further explored with Bonferroni correction.

RESULTS

Compared with the routine 130 Hz, 60-Hz stimulation significantly reduced aspiration frequency by 57% on MBS study and perceived swallowing difficulty by 80% on questionnaire. It also significantly reduced FOG, and axial and parkinsonian symptoms. The benefits at 60-Hz stimulation persisted over the average 6-week assessment.

CONCLUSIONS

Compared with the routine 130 Hz, the 60-Hz stimulation significantly improved swallowing function, FOG, and axial and parkinsonian symptoms in patients with PD treated with bilateral STN-DBS, which persisted over the 6-week study period.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that for patients with PD who experience FOG, STN-DBS at 60 Hz decreases aspiration events observed during MBS compared with DBS at 130 Hz.

Characterization of corticobulbar pharyngeal neurophysiology in dysphagic patients with Parkinson's disease

BACKGROUND & AIMS

Dysphagia in patients with Parkinson's disease, persisting despite dopaminergic treatment, affects intake of nutrients and medication, and reduces quality of life (QOL). We investigated the neurophysiologic mechanisms that contribute to dysphagia in these patients, on and off L-3,4-dihydroxyphenylalanine (levodopa), using transcranial magnetic stimulation.

METHODS

We studied 26 patients with Parkinson's disease (age, 65 ± 9 y; 10 men). Dysphagia and QOL were first assessed with qualitative questionnaires. Twelve hours after patients were taken off levodopa, they underwent cortical transcranial magnetic stimulation mapping of the pharyngeal musculature and trigeminal (bulbar) transcranial magnetic stimulation, as well as videofluoroscopy to examine swallowing. The analyses were repeated after administration of levodopa.

RESULTS

Eleven patients initially reported dysphagia and reduced QOL scores. Videofluoroscopy identified 10 patients with swallowing impairments on and off levodopa, and 6 patients with swallowing impairments only on levodopa; the remaining 10 subjects showed no swallowing impairments, on or off the drug. While patients were on levodopa, those with swallowing impairments had bilateral increases in pharyngeal cortical excitability compared with those with no swallowing impairment (P < .05). By contrast, with medication, amplitudes of brainstem reflexes were altered only in patients with swallowing impairments on levodopa; these were decreased compared with when the patients were off levodopa.

CONCLUSIONS

In patients with Parkinson's disease, dopaminergic medications such as levodopa can negatively affect swallowing. The increased cortical excitability observed in dysphagic patients after they begin taking levodopa likely results from compensatory mechanisms, perhaps secondary to subcortical disease, because we observed associated inhibition of brainstem reflexes in patients with affected swallowing on medication. UK clinical trials registration no., 9882.

Validation of the persian translation of the swallowing disturbance questionnaire in Parkinson's disease patients

Dysphagia, as a common finding in Parkinson's disease (PD) patients, was estimated to be present in 80–95% of this population during different stages of the disease. The Swallowing Disturbance Questionnaire (SDQ) was created as a self-rated dysphagia screening tool in PD. According to the guidelines for cross-cultural adaptation, Persian version of this questionnaire (SDQ-P) was developed. 59 Persian patients (39 men and 20 women) participated in the study. They responded to the SDQ-P and underwent videofluoroscopic swallowing study (VFSS). Aspiration during VFSS was compared with questionnaire results for each individual. Cronbach's alpha coefficient for the questionnaire was 0.86 and based on SDQ-P 15 patients (25.4%) were dysphagic, while 10 patients (16.9%) showed aspiration during VFSS. SDQ-P sensitivity and specificity in predicting aspiration were 96.7 and 91.2%; therefore, the SDQ-P could be a prognostic tool for aspiration. The positive predictive value (PPV), the negative predictive value (NPV), and the pre- and posttest probabilities of aspiration were 0.67, 1, 16.9%, and 66.7%, respectively. In summary, this study demonstrated the reliability and also the feasibility of SDQ-P for screening of aspiration in Iranian patients with PD. Further evaluation of SDQ-P in larger subject population would be suggested.

The Ability of the 10-Item Eating Assessment Tool (EAT-10) to Predict Aspiration Risk in Persons With Dysphagia

BACKGROUND

Dysphagia is common and costly. The ability of patient symptoms to predict objective swallowing dysfunction is uncertain.

PURPOSE

This study aimed to evaluate the ability of the Eating Assessment Tool (EAT-10) to screen for aspiration risk in patients with dysphagia.

METHODS

Data from individuals with dysphagia undergoing a videofluoroscopic swallow study between January 2012 and July 2013 were abstracted from a clinical database. Data included the EAT-10, Penetration Aspiration Scale (PAS), total pharyngeal transit (TPT) time, and underlying diagnoses. Bivariate linear correlation analysis, sensitivity, specificity, and predictive values were calculated.

RESULTS

The mean age of the entire cohort (N=360) was 64.40 (±14.75) years. Forty-six percent were female. The mean EAT-10 was 16.08 (±10.25) for nonaspirators and 23.16 (±10.88) for aspirators (P<.0001). There was a linear correlation between the total EAT-10 score and the PAS (r=0.273, P<.001). Sensitivity and specificity of an EAT-10>15 in predicting aspiration were 71% and 53%, respectively.

CONCLUSION

Subjective dysphagia symptoms as documented with the EAT-10 can predict aspiration risk. A linear correlation exists between the EAT-10 and aspiration events (PAS) and aspiration risk (TPT time). Persons with an EAT-10>15 are 2.2 times more likely to aspirate (95% confidence interval, 1.3907-3.6245). The sensitivity of an EAT-10>15 is 71%.

Dysphagia progression and swallowing management in Parkinson's disease: an observational study

INTRODUCTION

Dysphagia is relatively common in individuals with neurological disorders.

OBJECTIVE

To describe the swallowing management and investigate associated factors with swallowing in a case series of patients with Parkinson's disease.

METHODS

It is a long-term study with 24 patients. The patients were observed in a five-year period (2006-2011). They underwent Fiberoptic Endoscopic Evaluation of Swallowing, Functional Oral Intake Scale and therapeutic intervention every three months. In the therapeutic intervention they received orientation about exercises to improve swallowing. The Chi-square, Kruskal-Wallis and Fisher's tests were used. The period of time for improvement or worsening of swallowing was described by Kaplan-Meier analysis.

RESULTS

During the follow-up, ten patients improved, five stayed the same and nine worsened their swallowing functionality. The median time for improvement was ten months. Prior to the worsening there was a median time of 33 months of follow-up. There was no associated factor with improvement or worsening of swallowing. The maneuvers frequently indicated in therapeutic intervention were: chin-tuck, bolus consistency, bolus effect, strengthening-tongue, multiple swallows and vocal exercises.

CONCLUSION

The swallowing management was characterized by swallowing assessment every three months with indication of compensatory and rehabilitation maneuvers, aiming to maintain the oral feeding without risks. There was no associated factor with swallowing functionality in this case series.

A systematic review of self-reported swallowing assessments in progressive neurological disorders

Dysphagia experienced as a consequence of neurodegenerative disease can have severe consequences on a patient's health and well-being. Regular assessment of swallowing function can assist to achieve adequate nutrition and hydration. Here we review subjective swallowing assessments currently available are suitable for use in people with neurodegenerative disease. Measurement properties were reviewed for each tool and coverage of the World Health Organization's International Classification of Functioning, Disability and Health (WHO ICF) was considered. Assessments were identified following a review of the published literature Instruments were reviewed on the basis of reliability and validity, as well as administrative properties, such an interpretability, acceptability, and feasibility. Tools were also evaluated according to the WHO ICF framework. In total, 19 studies were identified for full-text review from 13,315 abstracts. Nine self-reported dysphagia assessment tools suitable for use in progressive neurological disorders were identified. The Swallowing Quality of Life Questionnaire (SWAL-QOL) yields the strongest combination of reliability (including internal consistency and test-retest reliability) and convergent validity while simultaneously covering all WHO ICF domains. Lengthy administration time was identified as a limitation of the SWAL-QOL. The review highlights a relative lack of well-validated self-report questionnaires in dysphagia for people with progressive neurological disease. Additional validation and evaluation of the clinical utility of the tools currently available is required to further promote an informed selection of available assessments.

Screening tools for dysphagia: a systematic review

Purpose:To perform a systematic review of screening instruments for dysphagia available in the literature.Methods:For the selection of studies, the following descriptors were used: "questionários", "questionnaires", "transtornos de deglutição", "deglutition disorders", "programas de rastreamento", and "mass screening". The online databases used for the research were Virtual Health Library (LILACS, IBECS, MEDLINE, Cochrane Library, SciELO) and PubMed. The research was performed from April to June 2013. Selection criteria articles in English, Portuguese, and Spanish, regardless of the year of publication, whose title, abstract, or text had any relation to the purpose of the research. After reading the articles in their entirety, identification data and method of the articles were extracted for later analysis.Results:The research carried out from the proposed descriptors produced 1,012 articles. After reviewing the titles, summaries, and fully reading the articles, 20 studies were chosen. The publications on instruments for the identification of dysphagic patients started in 1999, and 50% of the analyzed studies were carried out in the USA. The methods used on the instruments were questionnaires, observation of patient's clinical signals and symptoms, the request for execution of some orofacial movements, and swallowing test with water or food.Conclusion:Screening instruments in dysphagia are fairly heterogeneous and have been developed for different audiences with the main objective of identifying patients with swallowing disorders.

Orofaryngeale slikstoornissen bij de ziekte van Parkinson

OROPHARYNGEAL SWALLOWING DISORDERS IN PARKINSON'S DISEASE

Parkinson's disease is one of the most common and best studied neurodegenerative diseases. The typical motor features, like hypokinesia and rigidity are also seen in chewing and swallowing, but this 'hypokinetic dysphagia' is a complaint that generally occurs in the later stages of the disease. However, consequences as choking on liquid or food and very slow eating and drinking can contribute to a decrease of the quality of life and in combination with decreased coughing capacity cause aspiration pneumonia. Hypokinetic dysphagia can also contribute to drooling, but hypomimia is the best predictor of that complaint. Several validated questionnaires are available in Dutch to assess dysphagia complaints and their severity. The behavioural treatment consists of compensatory techniques, like adapting head posture to avoid liquid aspiration. But also training exercises can be helpful to overcome hypokinesia, similar to talking louder to overcome hypokinetic speech. Medical treatment, either with levodopa or deep brain surgery in general does not provide clinical improvement of swallowing.

Development and validation of a new screening questionnaire for dysphagia in early stages of Parkinson's disease

BACKGROUND

Dysphagia in patients with Parkinson's disease (PD) significantly reduces quality of life and predicted lifetime. Current screening procedures are insufficiently evaluated. We aimed to develop and validate a patient-reported outcome questionnaire for early diagnosis of dysphagia in patients with PD.

METHODS

The two-phased project comprised the questionnaire, diagnostic scales construction (N = 105), and a validation study (N = 82). Data for the project were gathered from PD patients at a German Movement Disorder Center. For validation purposes, a clinical evaluation focusing on swallowing tests, tests of sensory reflexes, and fiberoptic endoscopic evaluation of swallowing (FEES) was performed that yielded a criteria sum score against which the results of the questionnaire were compared. Specificity and sensitivity were evaluated for the detection of noticeable dysphagia and for the risk of aspiration.

RESULTS

The Munich Dysphagia Test - Parkinson's disease (MDT-PD) consists of 26 items that show high internal consistency (α = 0.91). For the validation study, 82 patients, aged 70.9 ± 8.7 (mean ± SD), with a median Hoehn & Yahr stage of 3, were assessed. 73% of patients had dysphagia with noticeable oropharyngeal symptoms (44%) or with penetration/aspiration (29%). The criteria sum score correlated positively with the screening result (r = 0.70, p < 0.001). The MDT-PD sum score classified not noticeable dysphagia vs. risk of aspiration (noticeable dysphagia) with a sensitivity of 90% (82%) and a specificity of 86% (71%), and yielded similar results in cross-validation, respectively.

CONCLUSIONS

MDT-PD is a valid screening tool for early diagnosis of swallowing problems and aspiration risk, as well as initial graduation of dysphagia severity in PD patients.

The Huntington's Disease Dysphagia Scale

BACKGROUND

Little is known about the swallowing disturbances of patients with Huntington's disease; therefore, we developed the Huntington's Disease Dysphagia Scale.

METHODS

The scale was developed in four stages: (1) item generation, (2) comprehension testing, (3) evaluation of reliability, (4) item reduction and validity testing. The questionnaire was presented twice to 50 Huntington's disease patients and their caregivers. The Kruskal-Wallis test was used to evaluate whether the severity of swallowing difficulties increased with advancing disease. Pearson's correlation coefficient was used to examine the construct validity with the Swallowing Disturbance Questionnaire.

RESULTS

The final version contained 11 items with five response options and exhibited a Cronbach's alpha coefficient of 0.728. The severity of swallowing difficulties was significantly higher in more advanced Huntington's disease. The correlation with the Swallowing Disturbance Questionnaire was 0.734.

CONCLUSION

We developed a valid and reliable 11-item scale to measure the severity of dysphagia in Huntington's disease.

Relative Efficacy of Swallowing versus Non-swallowing Tasks in Dysphagia Rehabilitation: Current Evidence and Future Directions

Clinical trials published in 2012 and the first six months of 2013 were reviewed. These involved either traditional dysphagia therapy, indirect methods not involving dysphagia therapy or a combination of direct and indirect methods. Of 27 studies, 7 were RCTs, 5 were controlled clinical trials and the remainder were uncontrolled case series. Sixteen studies combined an indirect treatment with traditional dysphagia therapy; only one study examined one technique for direct swallowing therapy. Effect sizes were computed and contrasted for each trial. Traditional dysphagia therapy had small to moderate effect sizes (between 0.3 and 0.6) while spontaneous recovery in acute stroke had effect sizes of 1.2. Placebo effects on patient ratings of degree of improvement on swallowing were estimated as small to moderate. To improve effect sizes, adaptive research designs are needed to develop the optimal methods and dosages of therapy before future clinical trials.

Dysphagia and sialorrhea: the relationship to Parkinson's disease

CONTEXT

Dysphagia and sialorrhea in patients with Parkinson's disease are both automatically accepted as dependent on this neurological disease.

OBJECTIVE

The aim were to establish if these two complaints are a consequence or associated manifestations of Parkinson's disease.

METHOD

Two Parkinson's diseases groups from the same outpatients' population were studied. Patients in the first group, with dysphagia, were studied by videofluoroscopy. The second, with sialorrhea, were studied by the scintigraphic method,

RESULTS

Videofluoroscopic examination of the oral, pharyngeal and esophageal phases of swallowing showed that 94% of Parkinson's diseases patients present, structural causes, not related to Parkinson's diseases, able to produce or intensify the observed disphagia. The scintigraphic examination of Parkinson's diseases patients with sialorrhea showed that there is no increase of serous saliva production. Nevertheless, showed a significantly higher velocity of saliva excretion in the Parkinson's diseases patients.

CONCLUSIONS

Dysphagia can be due to the muscular rigidity often present in the Parkinson's diseases patient, or more usually by non Parkinson's disease associated causes. In Parkinson's diseases patients, sialorrhea is produced by saliva retention. Nevertheless, sialorrhea can produce discomfort in swallowing, although without a formal complaint of dysphagia. In this case, subclinical dysphagia must be considered. Sialorrhea is indicative of dysphagia or at least of subclinical dysphagia. As final conclusion, Parkinson's diseases can be an isolated cause of dysphagia and/or sialorrhea, but frequently, a factor unrelated to Parkinson's diseases is the main cause of or at least aggravates the dysphagia.

[Advanced Parkinson's disease: clinical characteristics and treatment (part 1)]

INTRODUCTION

A large percentage of patients with Parkinson's disease (PD) develop motor fluctuations, dyskinesias, and severe non-motor symptoms within 3 to 5 years of starting dopaminergic therapy, and these motor complications are refractory to treatment. Several authors refer to this stage of the disease as advanced Parkinson's disease.

OBJECTIVE

To define the clinical manifestations of advanced PD and the risk factors for reaching this stage of the disease.

DEVELOPMENT

This consensus document has been prepared by using an exhaustive literature search and by discussion of the contents by an expert group on movement disorders of the Sociedad Española de Neurología (Spanish Neurology Society), coordinated by two of the authors (JK and MRL).

CONCLUSIONS

Severe motor fluctuations and dyskinesias, axial motor symptoms resistant to levodopa, and cognitive decline are the main signs in the clinical phenotype of advanced PD.

Evidence for adaptive cortical changes in swallowing in Parkinson's disease

Dysphagia is a relevant symptom in Parkinson's disease, whose pathophysiology is poorly understood. It is mainly attributed to degeneration of brainstem nuclei. However, alterations in the cortical contribution to deglutition control in the course of Parkinson's disease have not been investigated. Here, we sought to determine the patterns of cortical swallowing processing in patients with Parkinson's disease with and without dysphagia. Swallowing function in patients was objectively assessed with fiberoptic endoscopic evaluation. Swallow-related cortical activation was measured using whole-head magnetoencephalography in 10 dysphagic and 10 non-dysphagic patients with Parkinson's disease and a healthy control group during self-paced swallowing. Data were analysed applying synthetic aperture magnetometry, and group analyses were done using a permutation test. Compared with healthy subjects, a strong decrease of cortical swallowing activation was found in all patients. It was most prominent in participants with manifest dysphagia. Non-dysphagic patients with Parkinson's disease showed a pronounced shift of peak activation towards lateral parts of the premotor, motor and inferolateral parietal cortex with reduced activation of the supplementary motor area. This pattern was not found in dysphagic patients with Parkinson's disease. We conclude that in Parkinson's disease, not only brainstem and basal ganglia circuits, but also cortical areas modulate swallowing function in a clinically relevant way. Our results point towards adaptive cerebral changes in swallowing to compensate for deficient motor pathways. Recruitment of better preserved parallel motor loops driven by sensory afferent input seems to maintain swallowing function until progressing neurodegeneration exceeds beyond the means of this adaptive strategy, resulting in manifestation of dysphagia.

Management of dysphagia and drooling in patients with Parkinson’s disease

SUMMARY Dysphagia and drooling are frequently reported consequences of Parkinson’s disease (PD) and this article aims to review their management. Several PD-specific and validated instruments are available for the screening and evaluation of dysphagia and drooling, including the Swallowing Disturbance Questionnaire (SDQ), Sialorrhea Clinical Scale for Parkinson’s disease (SCS-PD), Radboud Oral Motor Inventory for Parkinson’s Disease (ROMP), subscales for swallowing and saliva, and non-motor questionnaires that include items on dysphagia and drooling (e.g., Scales for Outcomes in Parkinson’s disease-Autonomic [SCOPA-AUT]; Non-motor Symptoms Questionnaire for Parkinson’s disease [PD-NMSQuest]; and Non-motor Symptoms Assessment Scale for Parkinson’s disease [NMSS]). For the behavioral treatment of dysphagia traditional techniques are helpful, however, exercise training might be more effective. Dysphagia appears to be resistant to drug treatment, but dysphagic patients may benefit from deep brain stimulation. For the treatment of drooling, swallow compensations should be tried, but when saliva reduction is required, botulinum-toxin injections are currently the best option. Overall, there is an urgent need for new approaches to treat dysphagia and drooling in PD.

Nutritional risk and gastrointestinal dysautonomia symptoms in Parkinson's disease outpatients hospitalised on a scheduled basis

Dysautonomia symptoms of nutritional interest may often occur in Parkinson's disease (PD), but the role played in affecting the risk of malnutrition still needs to be clarified. A total of 208 consecutive PD outpatients hospitalised on a scheduled basis were assessed for nutritional risk by the Malnutrition Universal Screening Tool. Presence of dysautonomia symptoms (dysphagia, sialorrhoea and constipation) was investigated using clinical rating scales. In our population, prevalence of nutritional risk was 17·2 (95 % CI 12·1, 24·0) % and relied mainly on unintentional weight loss. Sialorrhoea, dysphagia, dysphagia to liquids and constipation were observed in 10·6, 11·0, 14·4 and 59·6 % of the patients, respectively. Nutritional risk was independently associated with the number of dysautonomia symptoms (OR 1·39 (95 % CI 1·00, 1·96); P= 0·048) but not with single symptoms. An independent association was also found with the severity of motor symptoms (Hoehn-Yahr stage, OR 1·48 (95 % CI 1·00, 2·55); P= 0·049) and levodopa dose (OR 1·16 (95 % CI 1·04, 1·31) mg/kg per d; P= 0·009). Nutritional risk in PD outpatients appears to depend mainly on dysautonomic syndrome, disease severity and levodopa dosage. Implications for outcome deserve further investigation. The assessment of nutritional status and of gastrointestinal dysautonomia symptoms should be part of the routine work-up of a PD patient.

Video-assisted swallowing therapy for patients with Parkinson's disease

BACKGROUND

Conventional swallowing therapy for patients with Parkinson's disease (PD) and swallowing difficulties has poor carryover to everyday life. Herein, we test the effectiveness of visual information while treating swallowing disturbances in patients with PD.

METHODS

Forty two non-demented PD patients with swallowing disturbances were randomly divided into two groups. An experimental group received video-assisted swallowing therapy (VAST) and a control group (n = 21) was given conventional therapy. Both groups were given 6 interventional sessions by the same speech and swallowing therapist. Patients in the VAST group were exposed to video of the swallowing process in general as well as of their own, as part of all therapy sessions. Swallowing function was assessed before and post-intervention by fiberoptic endoscopic evaluation of swallowing (FEES). Quality of life, quality of care and the degree of pleasure from eating were also assessed by questioners pre and post-intervention.

RESULTS

There was a significant improvement in swallowing functions following both interventions. The FEESs demonstrated a significantly greater reduction in food residues in the pharynx in the VAST group compared to the conventional treatment group. There were significant group improvement in some parameters of the quality of life, quality of care and pleasure of eating scales.

CONCLUSION

In cognitively intact patients with PD with swallowing disturbances VAST was associated with improved swallowing related QOL and less food residues in the pharynx.

Dysphagia as a risk factor for mortality in Niemann-Pick disease type C: systematic literature review and evidence from studies with miglustat

Niemann-Pick disease type C (NP-C) is a rare neurovisceral disease characterised by progressive neurological deterioration and premature death, and has an estimated birth incidence of 1:120,000. Mutations in the NPC1 gene (in 95% of cases) and the NPC2 gene (in approximately 4% of cases) give rise to impaired intracellular lipid metabolism in a number of tissues, including the brain. Typical neurological manifestations include vertical supranuclear gaze palsy, saccadic eye movement abnormalities, cerebellar ataxia, dystonia, dysmetria, dysphagia and dysarthria. Oropharyngeal dysphagia can be particularly problematic as it can often lead to food or fluid aspiration and subsequent pneumonia. Epidemiological data suggest that bronchopneumonia subsequent to food or fluid aspiration is a major cause of mortality in NP-C and other neurodegenerative disorders. These findings indicate that a therapy capable of improving or stabilising swallowing function might reduce the risk of aspiration pneumonia, and could have a positive impact on patient survival. Miglustat, currently the only approved disease-specific therapy for NP-C in children and adults, has been shown to stabilise key neurological manifestations in NP-C, including dysphagia. In this article we present findings from a systematic literature review of published data on bronchopneumonia/aspiration pneumonia as a cause of death, and on the occurrence of dysphagia in NP-C and other neurodegenerative diseases. We then examine the potential links between dysphagia, aspiration, pneumonia and mortality with a view to assessing the possible effect of miglustat on patient lifespan.

Prevalence of oropharyngeal dysphagia in Parkinson's disease: a meta-analysis

Dysphagia is a potentially harmful feature, also in Parkinson's disease (PD). As published prevalence rates vary widely, we aimed to estimate the prevalence of oropharyngeal dysphagia in PD in a meta-analysis. We conducted a systematic literature search in February 2011 and two independent reviewers selected the papers. We computed the estimates of the pooled prevalence weighted by sample size. Twelve studies were suitable for calculating prevalence rates. Ten studies provided an estimate based on subjective outcomes, which proved statistically heterogeneous (p < 0.001), with a pooled prevalence estimate with random effect analysis of 35% (95% CI 28-41). Four studies provided an estimate based on objective measurements, which were statistically homogeneous (p = 0.23), with a pooled prevalence estimate of 82% (95% CI 77-87). In controls the pooled subjective prevalence was 9% (95% CI 2-17), while the pooled objective prevalence was 23% (95% CI 13-32). The pooled relative risk was 3.2 for both subjective outcomes (95% CI 2.32-4.41) and objective outcomes (95% CI 2.08-4.98). Clinical heterogeneity between studies was chiefly explained by differences in disease severity. Subjective dysphagia occurs in one third of community-dwelling PD patients. Objectively measured dysphagia rates were much higher, with 4 out of 5 patients being affected. This suggests that dysphagia is common in PD, but patients do not always report swallowing difficulties unless asked. This underreporting calls for a proactive clinical approach to dysphagia, particularly in light of the serious clinical consequences.

Esophageal symptoms questionnaire for the assessment of dysphagia, globus, and reflux symptoms: initial development and validation

Esophageal symptoms often co-occur. A validated self-report measure encompassing multiple esophageal symptoms is necessary to determine their frequency and severity both independently and in association with each other. Such a questionnaire could streamline the diagnostic process and guide patient management. We aimed to develop an integrative measure that provides a clinical 'snapshot' of common esophageal symptoms. Internal reliability and content validity of a 38-item self-report Esophageal Symptoms Questionnaire (ESQ), measuring the frequency and severity of typical esophageal symptoms using Likert-rating scales were assessed in 211 patients presenting to gastroenterology and ENT outpatient tertiary care clinics. Reproducibility, concurrent and predictive validity were evaluated using the reduced-item ESQ. The 38-item ESQ had high internal reliability. Principal component analyses and item reduction methods identified three components, to which 30 of 38 items contributed significantly, providing 59% of total variance. The test-retest correlations were moderate-to-strong for 24 of 30 new items (r(s) ≥ 0.44, P < 0.05). The resultant subscales measuring dysphagia (ESQ-D), globus (ESQ-G), and reflux (ESQ-R) compared well against concurrent physician's 'working' diagnosis (odds ratio 1.04-1.09). The receiver operating characteristics were adequate-to-good for ESQ-D (area under the curve [AUC]= 0.87) and ESQ-G (AUC = 0.74), but poor for ESQ-R (AUC = 0.61) although it matched the content of the validated Reflux Disease Questionnaire. The brief 30-item ESQ shows good internal reliability and content validity as a summary of the extent of dysphagia, globus and reflux symptoms. As a tool measuring more than one esophageal symptom, ESQ could guide patient management by indicating which of the coexisting symptoms needs to be addressed first.

Validation of the Japanese translation of the Swallowing Disturbance Questionnaire in Parkinson's disease patients

PURPOSE

The Swallowing Disturbance Questionnaire (SDQ) was developed as a self-rated screening tool for dysphagia in patients with Parkinson's disease (PD). We developed the Japanese version of this questionnaire (SDQ-J), according to the cross-cultural adaptation guidelines, and examined its reliability.

METHODS

Subjects were 61 Japanese patients with PD (mean age, 67.0 ± 9.2 years) who answered the SDQ-J before undergoing videofluoroscopic examination of swallowing (VF). We compared the findings of the questionnaire with the patients' aspiration status during VF.

RESULTS

Cronbach's alpha coefficient for the 15 questions of the SDQ-J was 0.84. According to the SDQ-J, 15 patients (24.6%) were diagnosed with dysphagia, while 9 patients (14.8%) aspirated liquid during VF. The sensitivity and specificity of the SDQ-J in predicting aspiration were 77.8 and 84.6%, respectively; therefore, the SDQ-J significantly predicted aspiration during VF (P < 0.01). The positive predictive value (PPV) and negative predictive value (NPV) for the SDQ-J were 0.46 and 0.96, respectively.

CONCLUSIONS

The SDQ-J appears to be a reliable and useful screening tool for Japanese PD patients with aspiration. As the NPV was higher than the PPV in the SDQ-J, this questionnaire could potentially be used for early identification of severe dysphagia in patients with PD.

Stridor and dysphagia associated with subthalamic nucleus stimulation in Parkinson disease

Refractory symptoms in Parkinson disease show good response to deep brain stimulation (DBS). This procedure improves United Parkinson's Disease Rating Scale scores and reduces dyskinesias, whereas speech and swallowing dysfunction typically do not improve and may even worsen. Rarely, DBS can cause idiosyncratic dystonias of muscle groups, including those of the neck and throat. The authors describe a patient experiencing stridor and dysphagia with confirmed pulmonary restriction and aspiration following subthalamic nucleus deep brain stimulator adjustment, with a resolution of symptoms and signs when the stimulator was switched off.

Swallowing disturbance questionnaire for detecting dysphagia

OBJECTIVES

To assess the accuracy of the swallowing disturbance questionnaire (SDQ) that had originally been designed and validated for detecting swallowing problems among patients with Parkinson's disease and was now applied for identifying patients with dysphagia associated with various other etiologies.

STUDY DESIGN

Prospective.

METHODS

One-hundred patients with the complaint of swallowing disturbances who underwent a full swallowing survey at the Tel-Aviv Voice and Swallowing Disorder Clinic participated. They all filled in the SDQ. The collected data included patient characteristics, medical history, and the results of an oromotor examination and a fiberoptic endoscopic evaluation of swallowing (FEES). The SDQ results were compared to the FEES and oromotor examination findings.

RESULTS

The responses to the questions in the SDQ were highly correlated with the findings of the oral part of the oromotor examination (85.71% sensitivity, 87.6% specificity). Items on the laryngopharyngeal phase reliably assessed dysphagia symptoms in correlation to the FEES examination (67.3% sensitivity, 76.7% specificity). The total SDQ score correlated with the total oromotor and the FEES scores (79.7% sensitivity, 73% specificity).

CONCLUSIONS

The SDQ is a sensitive and accurate tool for identifying patients with true swallowing disturbances arising from different etiologies and for indicating the need for more in-depth instrumental swallowing evaluations.

Relationship between dysphagia and depressive states in patients with Parkinson's disease

Aspiration pneumonia related to dysphagia is known to be the leading cause of death in patients with Parkinson's disease (PD). We investigated the relationship between depressive states and dysphagia in patients with PD. A hundred and twenty-seven PD patients gave their informed consent and were enrolled in this study. We used the Beck Depression Inventory (BDI) questionnaire to determine the participants' depressive states, and also used a questionnaire to assess participants' state of dysphagia. Participants were divided into four groups according to their BDI score. We compared the PD patients with Swallowing Disturbances Questionnaire (SDQ) scores of more than or equal to 11 with the SDQ scores of less than 11 regarding depressive categories. A logistic regression analysis was conducted to calculate odds ratios (ORs) and their 95% confidence intervals (95%CI) adjusting for age, sex, disease duration, wearing-off phenomenon and severity of movement disorder. OR (95%CI) of depressive categories, in which the trivial class was set as a reference group, were 3.28 (0.93-11.55), 13.44 (3.10-58.16), 30.35 (5.65-162.97) in the mild class, the moderate class and the severe class, respectively. This study suggests that there may be a strong relationship between depressive states and dysphagia in patients with PD.

Endoscopic characteristics and levodopa responsiveness of swallowing function in progressive supranuclear palsy

Dysphagia is a frequent and early symptom in progressive supranuclear palsy (PSP) predisposing patients to aspiration pneumonia. Fiberoptic endoscopic evaluation of swallowing (FEES) has emerged as a valuable apparative tool for objective evaluation of neurogenic dysphagia. This is the first study using FEES to investigate the nature of swallowing impairment in PSP. Eighteen consecutive PSP patients (mean age 69.7 +/- 9.0 years) were included. The salient findings of FEES in PSP patients were compared with those of 15 patients with Parkinson's disease (PD). In 7 PSP patients, a standardized FEES protocol was performed to explore levodopa (L-dopa) responsiveness of dysphagia. Most frequent abnormalities detected by FEES were bolus leakage, delayed swallowing reflex, and residues in valleculae and piriformes. Aspiration events with at least one food consistency occurred in nearly 30% of PSP patients. Significant pharyngeal saliva pooling was observed in 4 PSP patients. We found no difference of salient endoscopic findings between PSP and PD patients. Endoscopic dysphagia severity in PSP correlated positively with disease duration, clinical disability, and cognitive impairment. No correlation was found with dysarthria severity. In early PSP patients, swallowing dysfunction was solely characterized by liquid leakage with the risk of predeglutitive aspiration during the oral phase of swallowing. Two PSP patients showed relevant improvement of swallowing function after L-dopa challenge. Chin tuck-maneuver, hard swallow, and modification of food consistency were identified as the most effective therapeutic interventions. In conclusion, FEES assessment can deliver important findings for the diagnosis and refined therapy of dysphagia in PSP patients.

Dysphagia in Huntington's disease: a review

Huntington's disease (HD) is a progressive neurodegenerative autosomal dominant disease characterized by disturbed movements and behavior and cognitive decline. The motor disturbances are both choreiform and hypokinetic. As a result of the combination of these signs, it is known that many patients with HD suffer from dysphagia. Little is known about the frequency and the characteristics of dysphagia in HD. Well-balanced strategies for treatment and prevention of dysphagia in HD are lacking. Therefore, we have performed a detailed survey of the literature. We found that the patient groups studied were heterogeneous and the methods used were highly variable, and no balanced advice for prevention and treatment was systematically proven.

Dysautonomia rating scales in Parkinson's disease: sialorrhea, dysphagia, and constipation--critique and recommendations by movement disorders task force on rating scales for Parkinson's disease

Upper and lower gastrointestinal dysautonomia symptoms (GIDS)--sialorrhea, dysphagia, and constipation are common in Parkinson's disease (PD) and often socially as well as physically disabling for patients. Available invasive quantitative measures for assessing these symptoms and their response to therapy are time-consuming, require specialized equipment, can cause patient discomfort and present patients with risk. The Movement Disorders Society commissioned a task force to assess available clinical rating scales, critique their clinimetric properties, and make recommendations regarding their clinical utility. Six clinical researchers and a biostatistician systematically searched the literature for scales of sialorrhea, dysphagia, and constipation, evaluated the scales' previous use, performance parameters, and quality of validation data (if available). A scale was designated "Recommended" if the scale was used in clinical studies beyond the group that developed it, has been specifically used in PD reports, and clinimetric studies have established that it is a valid, reliable, and sensitive. "Suggested" scales met at least part of the above criteria, but fell short of meeting all. Based on the systematic review, scales for individual symptoms of sialorrhea, dysphagia, and constipation were identified along with three global scales that include these symptoms in the context of assessing dysautonomia or nonmotor symptoms. Three sialorrhea scales met criteria for Suggested: Drooling Severity and Frequency Scale (DSFS), Drooling Rating Scale, and Sialorrhea Clinical Scale for PD (SCS-PD). Two dysphagia scales, the Swallowing Disturbance Questionnaire (SDQ) and Dysphagia-Specific Quality of Life (SWAL-QOL), met criteria for Suggested. Although Rome III constipation module is widely accepted in the gastroenterology community, and the earlier version from the Rome II criteria has been used in a single study of PD patients, neither met criteria for Suggested or Recommended. Among the global scales, the Scales for Outcomes in PD-Autonomic (SCOPA-AUT) and Nonmotor Symptoms Questionnaire for PD (NMSQuest) both met criteria for Recommended, and the Nonmotor Symptoms Scale (NMSS) met criteria for Suggested; however, none specifically focuses on the target gastrointestinal symptoms (sialorrhea, dysphagia, and constipation) of this report. A very small number of rating scales have been applied to studies of gastrointestinal-related dysautonomia in PD. Only two scales met "Recommended" criteria and neither focuses specifically on the symptoms of sialorrhea, dysphagia, and constipation. Further scale testing in PD among the scales that focus on these symptoms is warranted, and no new scales are needed until the available scales are fully tested clinimetrically.

Anxiety, depression and swallowing disorders in patients with Parkinson's disease

Swallowing disturbances (SDs), anxiety and depression are commonly present in Parkinson's disease (PD) patients. We hypothesized that there is an association between the presence of SDs and the PD affective state. Sixty-nine PD patients were assessed for the presence of SDs by undergoing cognitive screening with the Mini Mental State Examination (MMSE), completing three inventories: a swallowing disturbance questionnaire (SDQ), the Spielberger manual for the trait anxiety and Beck depression inventories. All patients underwent clinical swallowing evaluations by a speech and language pathologist (SLP). Patients diagnosed with SDs were also assessed by fiberoptic endoscopic evaluation of swallowing (FEES) performed by an ENT and SLP. Thirty-eight patients experienced SDs, the other 31 did not. The clinical characteristics of the two groups were matched. Patients with SDs experienced increased anxiety and depression compared to patients without SDs. Comparisons between patients who scored in the two opposite ends of the anxiety and depression ranges demonstrated that the most anxious and depressed patients reported more swallowing difficulties (SDQ scores) compared with the least anxious and depressed ones. In addition, the most anxious patients had significantly increased disease severity and decreased MMSE scores compared with the least anxious patients. Disease severity was also increased in the most depressed patients compared with the least depressed ones. Advanced disease emerged as being associated with high anxiety levels and greater numbers of SDs. The contribution of anxiety or depression to the development or worsening of SDs and their role in treatment strategy warrant further investigation.

A therapeutic maneuver for oropharyngeal dysphagia in patients with Parkinson's disease

OBJECTIVE

This study investigates resources to provide better conditions for oropharyngeal swallowing for improvement in the quality of life of Parkinson's disease patients.

METHOD

Three men and one woman with an average age of 70.25 years had been afflicted with Parkinson's disease for an average of 9.25 years. The patients were submitted to a rehabilitation program for oropharyngeal dysphagia after a clinical evaluation of swallowing. The rehabilitation program consisted of daily sessions for two consecutive weeks during which a biofeedback resource adapted especially for this study was used. The patients were then reevaluated for swallowing ability at follow-up.

RESULTS

The patients presenting difficulties with swallowing water displayed no such problems after rehabilitation. Only one patient exhibited slow oral transit of food and other discrete oropharyngeal food remnants when swallowing a biscuit. The sample variance was used to analyze the pressure measurements, demonstrating a numerical similarity of the results obtained with the swallowing of saliva or of biscuits (VAR = 4.41). A statistical difference was observed between the swallowing of saliva and biscuits, showing a significant pressure increase at the end of the rehabilitation program (p < 0.001).

CONCLUSION

The effortful swallow maneuver reinforced by using biofeedback appears to be a therapeutic resource in the rehabilitation of oropharyngeal dysphagia in Parkinson's disease patients.