Pathophysiology of diurnal drooling in Parkinson's disease

Drooling may be Associated with Dysphagia Symptoms in Multiple Sclerosis

During the process of the multiple sclerosis (MS), persons with multiple sclerosis (PwMS) may experience drooling (sialorrhea) issues that are frequently disregarded. The exact cause of drooling in PwMS is poorly understood. This study aims to assess potential risk factors for drooling seen in PwMS. The study included 20 PwMS with drooling and 19 PwMS without drooling. The participants' sociodemographic data and clinical parameters were noted. To evaluate dysphagia, fatigue, and hypersalivation, the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS), the Fatigue Severity Scale (FSS), and objective saliva flow rate measurement with cottons placed in Stensen ducts and under the tongue (swab test) were used, respectively. The study employed univariate and multivariate logistic regression models to identify the risk factors linked to drooling. Gender, age, disease duration, MS type, and Expanded Disability Status Scale scores did not differ between the two groups. There was a significant increase in the DYMUS and submandibular/sublingual (SM/SL) saliva flow rate values in PwMS with drooling (p = 0.009 and p = 0.019, respectively). However, in our study, hypersalivation was not observed in PwMS with or without drooling. In the univariate model, DYMUS, SM/SL saliva flow rate, and FSS were found to be risk factors for drooling in PwMS. But only DYMUS was shown to be a significant risk factor in the multivariate model obtained by the backward (Wald) elimination method (p = 0.023). Finally, our research is the first to demonstrate the relationship between drooling and the presence of dysphagia symptoms in PwMS. This is a very important study to determine the nature of drooling in PwMS. This finding shows that our study will serve as a reference for choosing the best method for drooling treatment.

An Overview of Gastrointestinal Dysfunction in Parkinsonian Syndromes

Gastrointestinal (GI) dysfunction is a common nonmotor symptom in Parkinson's disease (PD) as well as other parkinsonian syndromes and may precede the onset of motor symptoms by decades. Involvement of all segments of the GI tract can lead to altered responses to medications and worsened quality of life for patients. While some GI symptoms occur in isolation, others overlap. Therefore, understanding the changes in different segments of the GI tract and how they relate to altered responses to PD treatment can guide both diagnostic and pharmacological interventions. Gut microbiota plays a critical role in immune activity and modulation of the enteric and central nervous systems. Understanding this bidirectional relationship helps to elucidate the pathogenesis of neurodegeneration. This review will describe the current understanding of how GI dysfunction develops in parkinsonian syndromes, common symptoms in PD and related disorders, and available treatments.

Dysphagia in Parkinson Disease: Part I - Pathophysiology and Diagnostic Practices

Purpose of Review

Dysphagia affects the majority of individuals with Parkinson disease (PD) and is not typically diagnosed until later in disease progression. This review will cover the current understanding of PD pathophysiology, and provides an overview of dysphagia in PD including diagnostic practices, gaps in knowledge, and future directions.

Recent Findings

Many non-motor and other motor signs of PD appear in the prodrome prior to the manifestation of hall- mark signs and diagnosis. While dysphagia often presents already in the prodrome, it is not routinely addressed in standard neurology examinations.

Summary

Dysphagia in PD can result in compromised efficiency and safety of swallowing, which significantly contributes to malnutrition and dehydration, decrease quality of life, and increase mortality. The heterogeneous clinical presentation of PD complicates diagnostic procedures which often leads to delayed treatment. Research has advanced our knowledge of mechanisms underlying PD, but dysphagia is still largely understudied, especially in the prodromal stage.

A protocol for the evaluation of a wearable device for monitoring of symptoms, and cueing for the management of drooling, in people with Parkinson's disease

Drooling is a common symptom of Parkinson's Disease (PD) experienced in up to 70% of people with PD (PwP). Drooling can be a major problem in PwP leading to adverse physical and psychosocial issues. Current medical treatments decrease the production of saliva, whereas the problem is due to decreased swallowing frequency, not over production of saliva. Such treatments are problematic as saliva is essential for good oral health. Therefore, non-invasive treatments options such as behavioural cueing methods are recommended. A wrist-worn device delivering haptic cueing has been demonstrated to be an effective treatment method to increase swallowing frequency and a socially acceptable solution for PwP. However, the device had limited functionality and was tested on a small sample size over a short period of usage. Further work is required to understand the real-world behaviours and usage of the intervention to understand the longer-term effects with a larger sample size. This research will deploy CueBand, a discrete and comfortable wrist-worn device designed to work with a smartphone application to support the real-world evaluation of haptic cueing for the management of drooling. We will recruit 3,000 PwP to wear the device day and night for the intervention period to gain a greater understanding of the effectiveness and acceptability of the technology within real-world use. Additionally, 300 PwP who self-identity as having an issue with drooling will be recruited into an intervention study to evaluate the effectiveness of the wrist-worn CueBand to deliver haptic cueing (3-weeks) compared with smartphone cueing methods (3-weeks). PwP will use our smartphone application to self-assess their drooling frequency, severity, and duration using visual analogue scales and through the completion of daily diaries. Semi-structured interviews to gain feedback about utility of CueBand will be conducted following participants completion of the intervention.

Movement Disorders and the Gut: A Review

There is a close link between multiple movement disorders and gastrointestinal dysfunction. Gastrointestinal symptoms may precede the development of the neurologic syndrome or may arise following the neurologic presentation. This review will provide an overview of gastrointestinal accompaniments to several well-known as well as lesser known movement disorders. It will also highlight several disorders which may not be considered primary movement disorders but have an overlapping presentation of both gastrointestinal and movement abnormalities.

Pathophysiology and Symptomatology of Drooling in Parkinson’s Disease

Drooling can present in patients with Parkinson’s disease (PD), and it is manifested as an excessive pooling of saliva inside the oral cavity. Currently, the exact pathophysiological mechanism of drooling in PD is not yet fully explicated. Thus, it becomes crucial to understand if some clinical characteristics may emphasize drooling or if they are just concomitant. In PD, excessive drooling has been associated with a higher burden of non-motor symptoms, such as cognitive impairment, sleep problems, autonomic dysfunction, constipation and orthostatic hypotension, and of worse severity of motor fluctuations and bradykinesia. PD patients with excessive drooling also showed a reduction of striatal DAT availability at DaTSCAN imaging. Excessive drooling in patients with Parkinson’s cannot be attributed to a single factor but to a mixture of factors, including but not limited to impaired nigrostriatal pathways.

Radiation of parotid or submandibular glands is effective for drooling in patients with parkinsonism; a randomised double-blind placebo-controlled trial

Background

Drooling is a common symptom in patients with parkinsonism, causing physical and emotional distress. It is unknown which major salivary glands are the best candidates for irradiation to reduce drooling with minimal adverse events. Therefore, this study assessed the efficacy and safety of submandibular and parotid salivary gland irradiation to reduce drooling.

Methods

A prospective, randomised, double-blind, placebo-controlled trial was conducted at the University Medical Center Groningen, the Netherlands. After informed consent, 31 patients with parkinsonism and severe drooling according to the Unified Parkinson Disease Rating Scale (UPDRS) were included in this study. Exclusion criteria consisted of the use of anticholinergic drugs, the existence of salivary gland diseases, and/or an history of (pre)malignancies of the salivary glands. Patients were randomized for parotid-, submandibular- or sham irradiation (2x6 Gy with one week interval). Patients were evaluated at 1, 3, 6 and 12 months after radiation. Primary outcome measure was drooling severity according to the UPDRS. Secondary outcomes measures consisted of stimulated glandular salivary secretion rates and adverse effects.

Findings

Overall 31 parkinsonian patients were included. Initially 11 patients were radiated on the parotid glands, 10 patients on the submandibular glands and 10 patients were sham-radiated. After 6 months, the sham-radiated patients were actively treated after a second randomisation. One patient in the parotid radiation group discontinued his participation after three months due to physical deterioration. Radiation of parotid or submandibular glands significantly improved the existing drooling, as compared to placebo radiation. Parotid- and submandibular radiation was equally effective, but more patients in the submandibular radiated group reported sticky saliva vs. patients treated by parotid radiation (33∙33% vs. 13∙33%).

Interpretation

Major salivary gland radiation significantly improves drooling in parkinsonian patients with few adverse effects. However, parotid gland radiation is accompanied by fewer side effects and therefore is the preferred mode of radiation in this patient population.

Expiratory Muscle Strength Training for Drooling in Adults with Parkinson's Disease

One of the most debilitating symptoms of advanced Parkinson's disease is drooling. Currently, the main treatment that is offered for drooling is botulinum toxin injections to the saliva glands which have a number of side effects and do not treat the causes of drooling, such as impaired swallowing and lip closure. This study explored the effect of an alternative therapy approach for drooling that aimed at improving the swallow, expiratory muscle strength training (EMST). Sixteen participants received EMST over a 6- to 8-week period. Measurements were taken pre- and post-training for drooling (Sialorrhea Clinical Scale for Parkinson's Disease; SCS-PD), swallowing, lip strength and peak cough flow. Measures of drooling, swallowing and peak cough flow were stable over pre-training assessments and improved following training (p < 0.01). The most conservative estimate of the within-group change for SCS-PD was - 2.50 (95% confidence interval -  3.22 to -  1.22). No adverse effects were reported and participants gave high satisfaction ratings for the training. A programme of EMST offers promise as a therapy to reduce drooling for people with Parkinson's disease. Adequately powered randomised controlled trials of EMST are now needed.

Parkinson's Disease and the Gut: Symptoms, Nutrition, and Microbiota

Parkinson's disease (PD) is the second most common neurodegenerative disease worldwide, characterized by symptoms of bradykinesia, rigidity, postural instability, and tremor. Recently, there has been a growing focus on the relationship between the gut and the development of PD. Emerging to the forefront, an interesting concept has developed suggesting that the initial pathophysiological changes occur in the gastrointestinal tract before changes are seen within the brain. This review is aimed at highlighting the relationship between PD and the gastrointestinal tract, along with the supporting evidence for this. Firstly, we will focus on the gastrointestinal conditions and symptoms which commonly affects patients, including both upper and lower gastrointestinal issues. Secondly, the impact of nutrition and diet on neurological health and PD physiology, with particular emphasis on commonly consumed items including macronutrients and micronutrients. Finally, variability of the gut microbiome will also be discussed and its link with both the symptoms and signs of PD. The evidence presented in this review highly suggests that the initial pathogenesis in the gut may proceed the development of prodromal PD subtypes, and therefore building on this further could be imperative and lead to earlier diagnosis with new and improved therapeutics.

Evaluation of Spontaneous Swallow Frequency in Healthy People and Those With, or at Risk of Developing, Dysphagia: A Review

Dysphagia is a common and frequently undetected complication of many neurological disorders and of sarcopoenia in ageing persons. Spontaneous swallowing frequency (SSF) has been mooted as a possible tool to classify dysphagia risk. We conducted a review of the literature to describe SSF in both the healthy population and in disease-specific populations, in order to consider its utility as a screening tool to identify dysphagia. We searched Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials databases. Metadata were extracted, collated and analysed to give quantitative insight. Three hundred and twelve articles were retrieved, with 19 meeting inclusion and quality criteria. Heterogeneity between studies was high (I² = 99%). Mean SSF in healthy younger sub-groups was 0.98/min [CI: 0.67; 1.42]. In the Parkinson's sub-group, mean SSF was 0.59/min [0.40; 0.87]. Mean SSF in healthy older, higher risk and dysphagic populations were similar (0.21/min [0.09; 0.52], 0.26/min [0.10; 0.72] and 0.30/min [0.16; 0.54], respectively). SSF is a novel, non-invasive clinical variable which warrants further exploration as to its potential to identify persons at risk of dysphagia. Larger, well-conducted studies are needed to develop objective, standardised methods for detecting SSF, and develop normative values in healthy populations.

Respiratory Dysfunctions in Parkinson's Disease Patients

Respiratory dysfunctions have been associated with Parkinson's disease since the first observations of the disease in 1817. Patients with Parkinson's disease frequently present respiratory disorders with obstructive ventilatory patterns and restrictive modifications, as well as limitations in respiratory volumes. In addition, respiratory impairments are observed due to the rigidity and kyphosis that Parkinson's disease patients experience. Subsidiary pulmonary complications can also appear as side effects of medication. Silent aspiration can be the cause of pneumonia in Parkinson's disease. Pulmonary dysfunction is one of the main factors that leads to the morbidity and mortality of patients with Parkinson's disease. Here, we performed a narrative review of the literature and reviewed studies on dyspnea, lung volumes, respiratory muscle function, sleep breathing disorders, and subsidiary speech and swallow impairments related to pulmonary dysfunction in patients with Parkinson's disease.

Clinical features associated with drooling in Parkinson's disease

INTRODUCTION

Drooling is characterized by an excessive pooling of saliva in the oral cavity. The exact pathophysiological mechanism of drooling in Parkinson's disease (PD) is not yet fully understood.

OBJECTIVE

To identify the relationship between drooling and other clinical features in people diagnosed with PD.

METHOD

Research on the topic was carried out on the PubMed and ScienceDirect electronic databases. Articles published between March 2015 and March 2020 were selected. Search terms and inclusion and exclusion criteria were previously defined. The articles included met those requirements.

RESULTS

Sixteen articles were included for analysis. The prevalence of drooling varies between 9.26 and 70% and can occur at any stage of the disease. Higher prevalence of drooling is related to disease duration, disease severity, older age, male, levodopa equivalent dose, hypomimia, dysphagia, dysarthria, cognition, sleep, non-dominant tremor, motor fluctuations, bradykinesia, more symmetric pattern, gastrointestinal and urinary problems, sexual dysfunction, obstipation, and orthostatic hypotension. However, it is not related to hallucinations, rapid eye movement sleep behavior disorder, akinetic-rigid PD, mixed, nor dyskinesias.

CONCLUSION

Drooling is not caused by a single factor; it is influenced and related to several clinical features. Some clinical factors participate in the onset of drooling while others are concomitant.

Autonomic Dysfunctions in Parkinson's Disease: Prevalence, Clinical Characteristics, Potential Diagnostic Markers, and Treatment

Parkinson's disease (PD) is a common neurodegenerative disease in the middle-aged and the elderly. Symptoms of autonomic dysfunctions are frequently seen in PD patients, severely affecting the quality of life. This review summarizes the epidemiology, clinical manifestations, and treatment options of autonomic dysfunctions. The clinical significance of autonomic dysfunctions in PD early diagnosis and differential diagnosis is also discussed.

Sialorrhoea Management Practices in Residential Older Adults Care Settings: A Qualitative Study

AIM

The aim of this research was to explore both older adults' and health care professionals' experience and views of sialorrhoea management practices in older adult residential care settings.

BACKGROUND

Sialorrhoea is quite a bothersome symptom among patients with certain neurological conditions. The complexity of sialorrhoea and its complications can be quite challenging for health care professionals. In the management of sialorrhoea, a multidisciplinary approach is proposed as an effective way of sialorrhoea management.

METHODS

Thematic analysis of collected data via semi-structured qualitative interviews with five focus groups involving 28 multidisciplinary health care members and 1 patient.

RESULTS

The older adult and multidisciplinary health care professionals' view of the management of sialorrhoea in residential care settings were established under three main themes: 1) 'Sialorrhoea compromising patient's dignity', 2) 'Ad hoc local management' and 3) 'Further integration of care required'.

CONCLUSION

At present, there have been no comprehensive multidisciplinary sialorrhoea management strategies to meet the various needs of older adults with sialorrhoea.

IMPLICATION FOR NURSING MANAGEMENT

It is important to minimize the negative impact of sialorrhoea on the patients. The recognition of issues associated with sialorrhoea provides constructive scope for the health care professionals to further investigate and develop more effective integrated sialorrhoea care protocols.

Relationships of drooling with motor symptoms and dopamine transporter imaging in drug-naïve Parkinson's disease

OBJECTIVES

The aim of the present study was to determine the relationships of drooling with motor symptoms and nigrostriatal neuron loss in drug-naïve patients with Parkinson's disease (PD). We therefore examined the relationships of drooling with motor symptoms and striatal dopamine transporter (DAT) binding measured by [123-Iodine]-fluoropropyl-2beta-carbomethoxy-3beta-(4-iodophenylnortropane) dopamine transporter single-photon emission computed tomography(¹²³I-FP-CIT SPECT).

PATIENTS AND METHODS

Thirty-five untreated PD patients (14 men and 21 women with a mean age of 71.9 ± 7.2 years) were included in this study. The patients were divided into a drooler group and non-drooler group. They underwent clinical assessments and ¹²³I-FP-CIT SPECT imaging. Motor symptoms were assessed using Unified Parkinson's Disease Rating Scale (UPDRS).

RESULTS

The results showed that UPDRS motor score (p = 0.002) and akinetic-rigid score (p = 0.008) were higher and that striatal DAT availability (p = 0.03) was lower in the drooler group than in the non-drooler group. However, tremor score, age, and duration of PD showed no significant differences between the drooler group and non-drooler group.

CONCLUSIONS

Drooling in untreated PD is related to an increase in motor symptoms (especially bradykinesia and axial symptoms) and to reduction of striatal DAT availability.

Drooling in Parkinson's Disease: Prevalence and Progression from the Non-motor International Longitudinal Study

Sialorrhoea in Parkinson’s disease (PD) is an often neglected yet key non-motor symptom with impact on patient quality of life. However, previous studies have shown a broad range of prevalence figures. To assess prevalence of drooling in PD and its relationship to quality of life, we performed a retrospective analysis of 728 consecutive PD patients who had a baseline and follow-up assessment as part of the Non-motor International Longitudinal Study (NILS), and for whom drooling presence and severity were available, assessed through the Non-Motor Symptoms Scale (NMSS). In addition, we analysed the prevalence of associated dysphagia through self-reported outcomes. Quality of life was assessed through the PDQ-8 scale. Baseline (disease duration 5.6 years) prevalence of drooling was 37.2% (score ≥ 1 NMSS question 19), and after 3.27 ± 1.74 years follow-up, this was 40.1% (p = 0.17). The prevalence of drooling increased with age (p < 0.001). The severity of drooling, however, did not change (p = 0.12). While in 456 patients without drooling at baseline, only 16% (n = 73) had dysphagia (question 20 of the NMSS), in those with drooling this was 34.3% (p < 0.001). At follow-up, the number of patients with dysphagia had increased, 20.4% with no drooling had dysphagia, and 43.6% with drooling had dysphagia. Both at baseline and follow-up, drooling severity was significantly positively associated with quality of life (PDQ-8; r = 0.199; p < 0.001). In moderately advanced PD patients, subjective drooling occurs in over one-third of patients and was significantly associated with decreased quality of life. Dysphagia occurred significantly more often in patients with drooling.

The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®)

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients’ needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to.

The feasibility and acceptability of using a novel wrist worn cueing device to self-manage drooling problems in people with Parkinson's disease: A pilot study

Introduction

Daytime drooling is experienced by around 50% of Parkinson’s patients, who fail to swallow saliva in sufficient volume or regularity, despite normal production. This research explored the feasibility and acceptability of using a cueing device, to improve drooling.

Methods

During a four-week intervention, 28 participants were asked to use a cueing device for 1 h per day. During this time, the device vibrated once-per-minute, reminding the participant to swallow their saliva. A daily diary was used to collect self-report around swallowing severity, frequency, and duration. This was filled out by participants for one week before, four weeks during and for one week immediately after intervention. Diaries were also collected for one week during a follow up, carried out four weeks after intervention finished.

Results

Participants self-reported benefits in drooling severity (p = 0.031), frequency (p ≤ 0.001), and duration (p = 0.001) after using the device. Improvements were maintained at follow up. Twenty-two participants explicitly reported a positive benefit to their drooling during exit interview. All felt the intervention and device were acceptable and usable.

Conclusions

Using a cueing device for one month had perceived benefit to drooling severity, frequency and duration in patients with Parkinson’s. Participants accepted the device and treatment protocol.

Alpha-synuclein in salivary gland as biomarker for Parkinson’s disease

Estimates of the accuracy of clinical diagnosis of Parkinson’s disease (PD) range between 46% and 90%, the accuracy of diagnosis dependent on prolonged clinical observation and clinical response to levodopa. For this reason, we need reliable diagnostic biomarkers. The cardinal hallmark of PD is alpha-synuclein aggregation in the brain. Demonstrating pathological alpha-synuclein in live patients would be useful for identifying and monitoring PD patients. By autopsy studies and in vivo studies, the presence of alpha-synuclein has been demonstrated even outside the central nervous system and the gastro-enteric tract appears to be the most promising candidate tissue for biopsy-taking and the esophagus and salivary glands appear to be the area with the highest concentration of alpha-synuclein. The purpose of our study is to conduct a review to determine the utility of salivary gland biopsy for the histological diagnosis of PD. A computerized medline study was carried out through the use of pubmed: using the MeSH terms: ‘salivary gland biopsy for PD’, ‘PD and dysphagia’, ‘alpha-synuclein and salivary gland’. We found 9 articles about minor salivary glands and submandibular gland biopsy for diagnosis of PD. According to the results of this review, the submandibular gland biopsy is the test with the increased sensitivity and specificity compared to the biopsy of the minor salivary glands (sensitivity: 0.85 and 0.37 respectability and specificity: 0.96 and 0.94 respectively). New studies are necessary on a wider population to confirm these results.

Altered Gut Microbiome and Intestinal Pathology in Parkinson's Disease

Parkinson's disease (PD) is a common neurodegenerative disorder arising from an interplay between genetic and environmental risk factors. Studies have suggested that the pathological hallmarks of intraneuronal α-synuclein aggregations may start from the olfactory bulb and the enteric nervous system of the gut and later propagate to the brain via the olfactory tract and the vagus nerve. This hypothesis correlates well with clinical symptoms, such as constipation, that may develop up to 20 years before the onset of PD motor symptoms. Recent interest in the gut-brain axis has led to vigorous research into the gastrointestinal pathology and gut microbiota changes in patients with PD. In this review, we provide current clinical and pathological evidence of gut involvement in PD by summarizing the changes in gut microbiota composition and gut inflammation associated with its pathogenesis.

Predictors of Penetration-Aspiration in Parkinson’s Disease Patients With Dysphagia: A Retrospective Analysis

Objective:

Penetration-aspiration is considered the most severe sign of dysphagia, with aspiration pneumonia as one of its consequences. More than half of Parkinson’s disease (PD) patients suffer from dysphagia, and aspiration pneumonia is among the primary causes of mortality in PD patients. However, the identification of predictors of penetration-aspiration in PD patients remains an understudied topic. The purpose of this study was to identify predictors of penetration-aspiration in patients with PD.

Methods:

The data of 89 PD patients with dysphagia who underwent routinely conducted videofluoroscopic studies of swallowing (VFSS) were included in this retrospective study. The occurrence of penetration-aspiration was defined as scores ≥3 on the Penetration-Aspiration Scale (PAS). Four commonly reported signs of dysphagia in PD patients were evaluated as possible predictors. Furthermore, the relationships between the occurrence of penetration-aspiration and liquid bolus volume as well as clinical severity of PD (modified Hoehn and Yahr scale) were examined.

Results:

Logistic regression showed that a delayed initiation of the pharyngeal swallow (odds ratio [OR] = 7.47, P = .008) and a reduced hyolaryngeal excursion (OR = 5.13, P = .012) were predictors of penetration-aspiration. Moreover, there was a strong, positive correlation between increasing liquid bolus volume and penetration-aspiration (γ = 0.71, P < .001). No correlation was found between severity of PD and penetration-aspiration (γ = 0.077, P = .783).

Conclusion:

Results of the present study allow for a better understanding of penetration-aspiration risk in PD patients. They are useful for treatment planning in order to improve safe oral intake and adequate nutrition.

Dihydroergotoxine mesylate for the treatment of sialorrhea in Parkinson's disease

BACKGROUND

Many patients with Parkinson's disease (PD) suffer from sialorrhea. Sialorrhea is often treated with anticholinergics and botulinum toxin, but some adverse effects have limited the use of these treatments. Dihydroergotoxine mesylate is an α-adrenergic blocking agents as well as some affinities to the dopaminergic and serotonin (5-HT) receptors. In the current study, we examine the safety and efficacy of dihydroergotoxine mesylate in PD patients.

METHODS

This study consisted of 2 phases. The intervention was 2.5-mg oral dihydroergotoxine mesylate twice daily in both phases. The first phase is a three-week open-label single-arm trial (n = 10). The second phase was a six-week randomized controlled trials with a crossover design (n = 20). Efficacy was assessed using the United Parkinson's Disease Rating Scale (UPDRS) sialorrhrea subscore and Sialorrhea Clinical Scale for PD (SCS-PD).

RESULTS

In the first phase, the UPDRS sialorrhea score was 3.5 ± 0.53 vs. 1.9 ± 0.57 prior to and after the treatment (P = 0.004). The SCS-PD score decreased from 15.8 ± 2.78 to 9.9 ± 3.00 after the treatment (P = 0.005). The response rate (defined by at least 30% reduction in SCS-PD score) was 60%. In the second phase of crossover trial, the UPDRS sialorrhea score was 3.00 ± 0.56 in placebo weeks vs. 2.00 ± 0.65 on dihydroergotoxine in dihydroergotoxine weeks (P = 0.001). The SCS-PD was 12.50 ± 2.84 and 9.25 ± 2.86 versus, respectively (P < 0.001). The response rate was 10% and 55%, respectively (P = 0.003). There were no significant adverse effects.

CONCLUSIONS

Dihydroergotoxine mesylate is safe and effective for sialorrhea in PD patients.

Drooling in Parkinson's Disease: Evidence of a Role for Divided Attention

Drooling is a frequently reported symptom in Parkinson's Disease (PD) with significant psychosocial impact and negative health consequences including silent aspiration of saliva with the associated risk of respiratory infections. It is suggested that in PD drooling is associated with inefficient oropharyngeal swallowing which reduces the effective clearance of saliva rather than hyper-salivation. This is compounded by unintended mouth opening and flexed posture increasing anterior loss of saliva. It is reported to occur most frequently during cognitively distracting concurrent tasks suggesting an impact from divided attention in a dual-task situation. However, this supposition has not been systematically examined. This study assessed whether frequency of saliva swallows reduced, and drooling severity and frequency increased, when people with PD engaged in a cognitively distracting task. 18 patients with idiopathic PD reporting daytime drooling on the Unified Parkinson's Disease Rating Scale (UPDRS) were recruited. They completed the Radboud Oral Motor Inventory for PD saliva questionnaire and the Montreal Cognitive Assessment. UPDRS drooling score, disease stage, duration, gender, and age were recorded. Swallow frequency and drooling severity and frequency were measured at rest and during a distracting computer-based language task. There was no significant difference between drooling severity at rest and during distraction (Wilcoxon signed rank test z = - 1.724, p = 0.085). There was a significant difference between at rest and distraction conditions for both drooling frequency (Wilcoxon signed rank test z = - 2.041, p = 0.041) and swallow frequency (Wilcoxon signed rank test z = - 3.054, p = 0.002). Participants swallowed less frequently and drooled more often during the distraction task. The frequency of saliva swallows and drooling are affected by divided attention in a dual-task paradigm. Further studies are needed to explore the exact role of attention in saliva management and the clinical applications in assessment and treatment.

The Gut and Nonmotor Symptoms in Parkinson's Disease

Gastrointestinal (GI) symptoms are one of the most common nonmotor symptoms (NMS) in patients with Parkinson's disease (PD) involving the whole GI tract (GIT) and being evident throughout the whole course of the disease. Furthermore, constipation serves as a risk factor for PD as well as an early prodromal NMS of PD. The gut as gateway to the environment with its enteric nervous system (ENS) plays a crucial role in the neurodegenerative process that leads to PD. Alpha-synucleinopathy as the pathological hallmark of PD could be found within the whole GIT in a rostrocaudal gradient interacting with the ENS, the gut microbiome, and enteric glial cells. Bidirectional interactions between the ENS and the central nervous system (CNS) via a brain-gut-enteric microbiota axis have been reported. As well as there is evidence out of animal, autopsy, and epidemiological studies that α-synuclein spreads via rostrocranial transmission by transsynaptic cell-to-cell transfer via the sympathetic and parasympathetic nervous system to the CNS causing the typical neuropathological changes of PD. Recognition of GI NMS as prodromal markers of PD as well as a better understanding of the brain-gut connection offers new insights in the pathophysiology of PD and might provide the opportunity of PD diagnosis before CNS involvement. Hereby the opportunity for development of neuroprotective and disease-modifying therapeutics, respectively, seem to be promising. This chapter covers the variety of GI NMS and its consequences in PD as well as the important role of the gut as part of the pathological process in PD.

Swallowing in Parkinson's disease: clinical issues and management

Changes to swallowing affect most people with Parkinson's disease (PD). Changes may not initially exercise a decisive impact, but can later pose significant threats to nutritional, hydration and respiratory health and psychosocial quality of life. This review, from a largely clinical viewpoint, outlines the nature of changes in PD and considers the issue of how many people are affected and in what ways. It outlines main approaches to assessment and management, with an emphasis on aspects relevant to PD. Dysphagia contributes to drooling in PD. The review therefore also touches on the nature and management of this condition that has its own set of health and psychosocial quality-of-life issues.

Palliative Care for Patients and Families With Parkinson's Disease

Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of palliative care in Parkinson's disease is still poorly defined and, consequently, poorly implemented into daily clinical practice. A particular challenge is the gradually progressive nature of Parkinson's disease-with insidiously increasing disability-making it challenging to clearly define the onset of palliative care needs for Parkinson patients. As people with Parkinson's disease are now living longer than in the past, future research needs to develop a more robust evidence-based approach to clarify the disease events associated with increased palliative care needs, and to examine these, prospectively, in an integrated palliative care service. The modern palliative care outlook, termed "simultaneous care,",is no longer restricted to the final stage of disease. It involves incorporating a continuity of care, effective management of the chronic-palliative interface, and a multidisciplinary network of professionals working both in the community and in specialized clinics, with active involvement of caregivers. Although promising, there is still a need to demonstrate the effectiveness of palliative care for patients with Parkinson's disease.

Rotigotine may control drooling in patients with Parkinson's Disease: Preliminary findings

OBJECTIVE

To evaluate the efficacy of rotigotine in controlling the drooling of Parkinson's Disease (PD) patients.

PATIENTS AND METHODS

We assessed 7 PD patients (Hoehn and Yahr scale >2.5) with three different clinical scores (Drooling Severity and Frequency Scale - DSFS, Drooling Rating Scale - DRS and Sialorrhea Clinical Scale for PD - SCS) before and after 4 weeks of therapy. Statistical differences were analyzed with Wilcoxon signed-rank test.

RESULTS

We observed that rotigotine significantly improves drooling as measured by the lowering of the three scores (p<0.05).

CONCLUSIONS

Among non-motor symptoms of PD, drooling is one of the most embarrassing and disabling for patients. Current treatments are unsatisfactory and novel approaches are thus desirable. In this open-label pilot study we demonstrated on a small sample of patients that up to 4mg/24h of rotigotine, a non-ergolinic dopamine agonist with continuous transdermal delivery, may be helpful in the management of drooling in advanced PD.

Swallowing difficulties with medication intake assessed with a novel self-report questionnaire in patients with systemic sclerosis - a cross-sectional population study

OBJECTIVES

To assess subjective swallowing difficulties (SD) with medication intake and their practical consequences in patients suffering from systemic sclerosis (SSc) with a novel self-report questionnaire.

DESIGN AND SETTING

Based on a systematic literature review, we developed a self-report questionnaire and got it approved by an expert panel. Subsequently, we sent the questionnaire by post mail to SSc patients of the European Center for the Rehabilitation of Scleroderma Rheinfelden, Switzerland.

PARTICIPANTS

Patients were eligible if they were diagnosed with SSc, treated at the center, and were of age ≥18 years at the study start.

MAIN OUTCOME MEASURES

Prevalence and pattern of SD with oral medication intake, including localization and intensity of complaints.

RESULTS

The questionnaire consisted of 30 items divided into five sections Complaints, Intensity, Localization, Coping strategies, and Adherence. Of the 64 SSc patients eligible in 2014, 43 (67%) returned the questionnaire. Twenty patients reported SD with medication intake (prevalence 47%), either currently (11; 26%) or in the past that had been overcome (9; 21%). Self-reported SD were localized mostly in the larynx (43%) and esophagus (34%). They were of moderate (45%) or strong to unbearable intensity (25%). Modification of the dosage form was reported in 40% of cases with SD. Adherence was poor for 20 (47%) patients and was not associated with SD (p=0.148).

CONCLUSION

Our novel self-report questionnaire is able to assess the pattern of complaints linked to medication intake, that is, localization and intensity. It may serve as a guide for health care professionals in selecting the most suitable therapy option, enabling tailored counseling to reduce inappropriate medication modifications.

Gut dysfunction in Parkinson's disease

Early involvement of gut is observed in Parkinson’s disease (PD) and symptoms such as constipation may precede motor symptoms. α-Synuclein pathology is extensively evident in the gut and appears to follow a rostrocaudal gradient. The gut may act as the starting point of PD pathology with spread toward the central nervous system. This spread of the synuclein pathology raises the possibility of prion-like propagation in PD pathogenesis. Recently, the role of gut microbiota in PD pathogenesis has received attention and some phenotypic correlation has also been shown. The extensive involvement of the gut in PD even in its early stages has led to the evaluation of enteric α-synuclein as a possible biomarker of early PD. The clinical manifestations of gastrointestinal dysfunction in PD include malnutrition, oral and dental disorders, sialorrhea, dysphagia, gastroparesis, constipation, and defecatory dysfunction. These conditions are quite distressing for the patients and require relevant investigations and adequate management. Treatment usually involves both pharmacological and non-pharmacological measures. One important aspect of gut dysfunction is its contribution to the clinical fluctuations in PD. Dysphagia and gastroparesis lead to inadequate absorption of oral anti-PD medications. These lead to response fluctuations, particularly delayed-on and no-on, and there is significant relationship between levodopa pharmacokinetics and gastric emptying in patients with PD. Therefore, in such cases, alternative routes of administration or drug delivery systems may be required.

Spontaneous Swallowing during All-Night Sleep in Patients with Parkinson Disease in Comparison with Healthy Control Subjects

STUDY OBJECTIVES

Spontaneous saliva swallows (SS) appear especially during sleep. The rate of SS was rarely investigated in all-night sleep in patients with Parkinson disease (PD). Dysphagia is a frequent symptom in PD, but the rate of SS was never studied with an all-night sleep electroencephalogram (EEG).

METHODS

A total of 21 patients with PD and 18 age-matched healthy controls were included in the study. Frequencies of SS and coughing were studied in all-night sleep recordings of patients with PD and controls. During all-night sleep, video-EEG 12-channel recording was used including the electromyography (EMG) of the swallowing muscles, nasal airflow, and recording of vertical laryngeal movement using a pair of EEG electrodes over the thyroid cartilage.

RESULTS

The total number of SS was increased while the mean duration of sleep was decreased in PD when compared to controls. Sialorrhea and clinical dysphagia, assessed by proper questionnaires, had no effect in any patient group. The new finding was the so-called salvo type of consecutive SS in one set of swallowing. The amount of coughing was significantly increased just after the salvo SS.

CONCLUSIONS

In PD, the rate of SS was not sufficient to demonstrate the swallowing disorder, such as oropharyngeal dysphagia, but the salvo type of SS was quite frequent. This is a novel finding and may contribute to the understanding of swallowing problems in patients with dysphagic or nondysphagic PD.

Electrophysiological Techniques to Evaluate Swallowing in Central and Peripheral Nervous System Disorders

Neurogenic dysphagia is a frequent condition that may result in serious complications. Despite high incidence of neurogenic dysphagia, the neurologist is not really interested in its clinical diagnosis and management. In this review, several neurophysiological methods are described to evaluate the neurogenic dysphagia. These kinds of assessment methods are important for early diagnosis and some management strategies against to progressive swallowing pathology. The longitudinal follow-up of the patients also provides data about the prognosis of dysphagia. In our opinion, the neurophysiological methods presented in this review are reliable, cheap, and easy applicable quantitative tests to detect and follow both clinical and subclinical dysphagia. All these electrophysiological techniques can be applied within the discipline of the EMG laboratory.

Hypersialorrhea in Wilson's Disease

Hypersialorrhea, corresponding to excessive salivation is a symptom frequently reported in Wilson's disease, especially in its neurological form. The prevalence of this frequent complaint has not been often evaluated. During a 7-month period, 87 consecutive Wilson's disease patients answered to the simple question "do you have the sensation of excess saliva in your mouth?" to evaluate the frequency of this symptom. A sub-sample of 10 consecutive Wilson's disease patients with drooling was recruited to undergo quantitative and qualitative measures to evaluate the mechanism of hypersialorrhea. Excessive drooling or excess saliva was found in 46 % of patients followed at the French Reference Centre. Ninety-eight percent of them presented neurological symptoms and drooling was found in only one patient without neurological symptoms. Our study showed that patients with a complaint of excessive saliva produced significantly higher quantities of saliva at rest than controls. Endoscopic examination was abnormal in six patients. A significant decrease of swallowing frequency, longer swallow latencies, and poor swallowing capacities may partly explain the salivary stasis. Oropharyngeal sensitivity disorders were present in 50 % of our patients. The decrease of the swallowing frequency observed in all patients could be related to cognitive and behavioral abnormalities with initiation difficulties objectified by longer latencies triggered by all the ingested volumes. This study confirmed the hypothesis of a multifactorial origin of hypersialorrhea in patients who have been diagnosed in Wilson's disease. It was essential to evaluate drooling with a multidisciplinary consultation to better identify the underlying mechanisms and to implement strategies for speech therapy and therapeutic adaptation.

Diurnal drooling in Chinese patients with Parkinson's disease

OBJECTIVE

The aim of this study is to explore the prevalence and clinical correlates of diurnal drooling in Chinese patients with Parkinson's disease (PD).

METHODS

A cross-sectional analysis of 518 Chinese patients with PD was conducted. Each subject was categorized as a diurnal "drooler" or a "non-drooler" using the Non-Motor Symptoms Scale (NMSS).

RESULTS

One hundred and twenty-one (23.4%) patients exhibited diurnal drooling. Diurnal drooling was reported more frequently in male and late-onset PD patients (p<0.05). The levodopa equivalent daily doses, mean age and disease duration, the percentages of PD family history and levodopa or entacapone use, the incidences of dysarthria, dysphagia and fluctuation, and the Unified PD Rating Scale (UPDRS) part III, NMSS, Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA) and PD Questionnaire 39 (PDQ-39) scores in droolers were significantly greater than in non-droolers (p<0.05). The percentage of benzhexol use in non-droolers was significantly higher than in droolers (p<0.05). The Frontal assessment battery (FAB) and Montreal Cognitive Assessment (MoCA) scores were not different between the droolers and non-droolers. The forward binary logistic regression model indicated that dysarthria, male sex, age, UPDRS part III, sexual dysfunction and a family history of PD were associated with diurnal drooling.

CONCLUSIONS

Diurnal drooling is a relatively common debilitating symptom in Chinese PD patients. It is not only related to male sex, age, dysarthria and PD family history, but also correlates with motor and non-motor severity especially sexual dysfunction of PD. However, it is not related to cognition.

Electrophysiological evaluation of oropharyngeal Dysphagia in Parkinson's disease

Parkinson’s disease (PD) is a chronic, neurodegenerative movement disorder that typically affects elderly patients. Swallowing disorders are highly prevalent in PD and can have grave consequences, including pneumonia, malnutrition, dehydration and mortality. Neurogenic dysphagia in PD can manifest with both overt clinical symptoms or silent dysphagia. Regardless, early diagnosis and objective follow-up of dysphagia in PD is crucial for timely and appropriate care for these patients. In this review, we provide a comprehensive summary of the electrophysiological methods that can be used to objectively evaluate dysphagia in PD. We discuss the electrophysiological abnormalities that can be observed in PD, their clinical correlates and the pathophysiology underlying these findings.

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.

Drooling in Parkinson's disease: a review

Parkinson's disease (PD) is a neurodegenerative disease causing both motor and non-motor symptoms. Drooling, an excessive pooling and spillover of saliva out of the oral cavity, is one of the non-motor symptoms in PD patients that produces various negative physical and psychosocial consequences for patients and their caregivers. At present, the pathophysiology of drooling in PD is not completely certain; however, impaired intra-oral salivary clearance is likely the major contributor. There are neither standard diagnostic criteria nor standard severity assessment tools for evaluating drooling in PD. In accordance with the possible pathophysiology, dopaminergic agents have been used to improve salivary clearance; however, these agents are not completely effective in controlling drooling. Various pharmacological and non-pharmacological treatment options have been studied. Local injection with botulinum toxin serotypes A and B into major salivary glands is most effective to reduce drooling. Future research to explore the exact pathophysiology and develop standard diagnostic criteria and standard severity assessment tools are needed to formulate specific treatment options and improve patient care.

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.