Management of Dysphagia in Patients with Parkinson's Disease and Related Disorders

Cardiac arrest during deep brain stimulation: A case report

We present the case of a 54-year-old male with severe Parkinson's disease and chronic, non-reversible pulmonary artery hypertension who had seizures and a cardiorespiratory arrest during surgery for deep brain stimulation, a minimally invasive procedure usually associated with a low risk of complications. This case illustrates how perioperative changes in antiparkinsonian therapy in patient with multiple comorbidities may significantly affect the risk profile.

Association between motor symptoms of Parkinson's disease and swallowing disorders

BACKGROUND

Parkinson's disease (PD) presents with motor symptoms that hinder physical activity. This study aimed to thoroughly investigate swallowing dysfunction in patients with PD using videofluoroscopy (VF) and the Movement Disorder Society (MDS)-Unified PD Rating Scale (UPDRS) sub-scores.

METHODS

This study was part of an intervention project to evaluate the effectiveness of cervical percutaneous interferential current stimulation in patients with Hoehn and Yahr stages 2-4 PD. Baseline data, including swallowing-related indicators such as VF, were obtained and compared to the MDS-UPDRS sub-scores including rigidity, tremor, postural instability/gait difficulty, and limb scores.

RESULTS

Twenty-seven patients were included in this study. In the VF analysis, laryngeal penetration/aspiration, oral cavity residue, epiglottic vallecular residue, and pharyngeal residue were observed with remarkable frequency. The multivariate analysis revealed that the mean rigidity score of UPDRS was an independent and significantly correlated factor with laryngeal penetration/aspiration during the ingestion of 10 mL of water (odds ratio 1.294, 95% confidence interval 1.035-1.617; p = 0.024).

CONCLUSION

This study revealed a correlation between muscle rigidity and laryngeal penetration or aspiration risk. The detailed comparative analysis of various individual PD symptoms and swallowing disorders was substantial, which enabled early detection of the risk of swallowing disorder and the implementation of appropriate measures.

TRIAL REGISTRATION NUMBER

jRCTs062220013.

Effect of respiratory training on swallowing function in swallowing disorders: a systematic review and meta-analysis

PURPOSE

To determine the clinical efficacy of different respiratory training interventions on swallowing function in patients with swallowing disorders through the systematic review.

METHODS

We reviewed the literature regarding the application of respiratory training therapy in patients with swallowing disorders, followed by a PRISMA search of published literature in five databases (PubMed, Web of Science, The Cochrane Library, CINAHL and EMBASE) in December 2022. Two reviewers performed study selection, quality evaluation, and risk of bias, followed by data extraction and detailed analysis.

RESULTS

A total of six randomized controlled studies with a total sample size of 193 cases were included. Respiratory training improved swallowing safety (PAS (n = 151, SMD = 0.69, 95% CI - 1.11 to - 0.26, I2 = 36, p < 0.001)) and swallowing efficiency [residual (n = 63, SMD = 1.67, 95% CI - 2.26 to - 1.09, I2 = 23%, p < 0.001)] compared to control groups. The results of the qualitative analysis conducted in this study revealed that respiratory training enhanced hyoid bone movement but had no effect on swallowing quality of life.

CONCLUSIONS

Respiratory training interventions may improve swallowing safety and efficiency in patients with dysphagia. However, the level of evidence is low, and there is a limited amount of research on the effectiveness and physiology of this intervention to improve swallowing function. In the future, there is a need to expand clinical studies, standardize measurement tools, and improve study protocols.

Dysphagia Pattern in Early to Moderate Parkinson's Disease Caused by Abnormal Pharyngeal Kinematic Function

Airway invasion is common in patients with Parkinson's disease (PD) and can cause serious complications. However, a PD-related dysphagic pattern has not been clearly elucidated. In this study, 53 patients with early to moderate PD were enrolled to undergo a videofluoroscopic study of swallowing evaluation (VFSS) and a battery of neuropsychological assessments. A set of VFSS variables (three visuoperceptual, nine temporal, and six spatial) were measured. The main effects of bolus viscosity and volume on airway invasion were calculated. Statistical analyses were performed to determine key kinematic factors of airway invasion for swallowing each bolus type. Airway invasion frequency was significantly higher for liquid boluses (liquid vs. pudding P < 0.001; liquid vs. honey P = 0.006). Laryngeal vestibule closure reaction time (LVCrt) was the key kinematic factor of airway invasion for 3 ml liquid swallow (P = 0.040), anterior displacement of hyoid bone was the key kinematic factor for both 5 ml and 10 ml liquid swallows (P = 0.010, 0.034, respectively). Male sex and advanced Hoehn and Yahr stage were significantly related to reduced anterior displacement of hyoid bone. These results reveal the dysphagic pattern related to PD, demonstrating that prolonged LVCrt and reduced anterior displacement of hyoid bone are two crucial kinematic factors contributing to airway invasion during the liquid swallow. In addition, hyoid bone dysfunction was correlated with disease severity and male sex. Our findings warrant further investigation of the pathophysiological mechanism of dysphagia in PD and would guide clinical intervention.

Sensitivity and specificity of the EAT-10 and SDQ-DP in identifying the risk of dysphagia in Parkinson's disease

BACKGROUND

 The early identification of risk for dysphagia in patients with Parkinson's disease (PD) is essential for the prevention of nutritional and pulmonary complications.

OBJECTIVE

 To analyze the sensitivity and specificity of the Swallowing Disturbance Questionnaire (SDQ-PD) and the Eating Assessment Tool (EAT-10) in identifying dysphagia risk in patients with early and intermediate stages of PD.

METHODS

 Twenty-nine patients with PD participated in the study. EAT-10 and SDQ-PD questionnaires were applied, and a videofluoroscopic swallowing study. Dysphagia Outcome and Severity Scale (DOSS) was used to classify the presence and severity of dysphagia, and the Penetration-Aspiration Scale (PAS) was used to identify the presence of penetration/aspiration. In the statistical analysis, the sensitivity and specificity of the risk questionnaires were calculated, as well as positive predictive value, negative predictive value, and accuracy.

RESULTS

 EAT-10 to identify the risk of penetration/aspiration revealed a sensitivity of 71.42% and specificity of 45.45%; in the identification of the presence of dysphagia, the sensitivity was 47.61%, and the specificity was 12.5%. The SDQ-PD questionnaire for risk of penetration/aspiration demonstrated a sensitivity of 28.57%, and a specificity of 68.18%. In terms of identifying the presence of dysphagia, the sensitivity was 20%, while the specificity was 44.44%.

CONCLUSION

 The SDQ-PD revealed low sensitivity and low specificity to identify the presence of dysphagia and/or penetration/aspiration in patients with early and intermediate stages of PD in this sample. Despite its low specificity, the EAT-10 exhibited good sensitivity in indicating the risk of penetration/aspiration.

Role of Brain Liver X Receptor in Parkinson's Disease: Hidden Treasure and Emerging Opportunities

Parkinson's disease (PD) is a neurodegenerative disease due to the degeneration of dopaminergic neurons (DNs) in the substantia nigra (SN). The liver X receptor (LXR) is involved in different neurodegenerative diseases. Therefore, the objective of the present review was to clarify the possible role of LXR in PD neuropathology. LXRs are the most common nuclear receptors of transcription factors that regulate cholesterol metabolism and have pleiotropic effects, including anti-inflammatory effects and reducing intracellular cholesterol accumulation. LXRs are highly expressed in the adult brain and act as endogenous sensors for intracellular cholesterol. LXRs have neuroprotective effects against the development of neuroinflammation in different neurodegenerative diseases by inhibiting the expression of pro-inflammatory cytokines. LXRs play an essential role in mitigating PD neuropathology by reducing the expression of inflammatory signaling pathways, neuroinflammation, oxidative stress, mitochondrial dysfunction, and enhancement of BDNF signaling.In conclusion, LXRs, through regulating brain cholesterol homeostasis, may be effectual in PD. Also, inhibition of node-like receptor pyrin 3 (NLRP3) inflammasome and nuclear factor kappa B (NF-κB) by LXRs could effectively prevent neuroinflammation in PD. Taken together, LXRs play a crucial role in PD neuropathology by inhibiting neuroinflammation and associated degeneration of DNs.

The potential role of cholesterol in Parkinson's disease neuropathology: perpetrator or victim

Parkinson's disease (PD) is a neurodegenerative disease characterized by deposition of α-synuclein and aggregation of Lewy bodies. Cholesterol is involved with PD neuropathology in bidirectional ways that could be protective or harmful. Thus, the objective of the present review was to verify the potential role of cholesterol in PD neuropathology. Deregulation of ion channels and receptors induced by cholesterol alteration suggests a possible mechanism for the neuroprotective effects of cholesterol against PD development. However, high serum cholesterol level increases PD risk indirectly by 27-hydroxycholesterol which induces oxidative stress, inflammation, and apoptosis. Besides, hypercholesterolemia triggers the accumulation of cholesterol in macrophages and immune cells leading to the release of pro-inflammatory cytokines with progression of neuroinflammation subsequently. Additionally, cholesterol increases aggregation of α-synuclein and induces degeneration of dopaminergic neurons (DN) in the substantia nigra (SN). Hypercholesterolemia may lead to cellular Ca2+ overload causing synaptic and the development of neurodegeneration. In conclusion, cholesterol has bidirectional effects on PD neuropathology and might be protective or harmful.

Factors that impact dysphagia and discontinuance of oral intake in patients with progressive supranuclear palsy

Objective

To evaluate the swallowing function in the advanced stages of progressive supranuclear palsy (PSP) and clarify the factors that lead to adjustment of food consistency and discontinuation of oral intake.

Methods

A total of 56 patients with PSP were recruited. Based on medical records, information about the basic attributes, clinical features (including axial rigidity and dementia), food intake, the results of a videofluoroscopic swallowing study (VFSS), and the timing of nasogastric tube transition and gastrostomy were extracted. From the VFSS images, the presence or absence of aspiration and retrocollis were assessed.

Results

The average age at the onset, diagnosis, and the final follow-up examination were 67.6 ± 6.4 years, 71.6 ± 5.8 years, and 75.4 ± 5.6 years, respectively. The average duration of illness was 64.6 ± 42.8 months. Twenty-four individuals (42.9%) were continuing oral intake, while 32 were tube-fed, among whom 16 (50.0%) underwent gastrostomy tube placement. There were significant differences in the duration from the disease onset to tube feeding between the patients with and without cognitive decline at the time of the diagnosis (p < 0.01) and in the duration from the initial VFSS to tube feeding between the patients with and without aspiration on the initial VFSS (p < 0.01). There were significant differences in the duration from the diagnosis to tube feeding and from the initial VFSS to tube feeding between patients with and without axial rigidity at the time of the diagnosis (p < 0.05 and p < 0.05, respectively). Additionally, there was a significant association between axial rigidity and retrocollis (p < 0.01).

Conclusion

Cognitive decline, axial rigidity and retrocollis, which are associated with the deterioration of dysphagia in PSP, are the highest risk factors for the discontinuation of oral intake. The early identification of these factors associated with the progression of dysphagia can contribute to the improvement of patient care and management.

Impact of neck percutaneous interferential current sensory stimulation on swallowing function in patients with Parkinson's disease: A single-arm, open-label study protocol

Background

Parkinson's disease (PD) can lead to swallowing dysfunction, resulting in aspiration pneumonia. Among the types of swallowing disorders, a characteristic and serious problem associated with PD is silent aspiration due to pharyngeal and laryngeal hypoesthesia.

Methods

This single-arm, open-label study aims to evaluate the effectiveness of percutaneous neck interferential current sensory stimulation in enhancing swallowing function in patients with PD. The efficacy and safety of percutaneous neck interferential current sensory stimulation will be investigated for patients diagnosed with PD, based on the Movement Disorder Society criteria, of Hoehn-Yahr stages 2-4. The patients will receive neck percutaneous interferential current sensory stimulation for 20 min twice a week for 8 weeks using a Gentle Stim® (FoodCare Co., Ltd., Kanagawa, Japan) device. Once the intervention is initiated, evaluations will be performed every 4 weeks for a 16-week period. The primary endpoint to be assessed is the proportion of patients with normal cough with 1% citric acid at the end of the intervention (8 weeks after intervention initiation) compared with that at the beginning. This clinical trial will examine the usefulness of percutaneous neck interferential current sensory stimulation in patients with PD. In addition, this study will use novel instruments, such as multichannel surface electromyography and electronic stethoscope, to evaluate swallowing function.

Discussion

This novel evaluation can provide insights into dysphagia in patients with PD and the usefulness of percutaneous neck interferential current stimulation. This exploratory study is limited by its single-arm, open-label design and small size.

Trial registration number

jRCTs062220013; pre-results.

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 systematic review and meta-analysis of acupuncture in Parkinson's disease with dysphagia

Objective

The systematic review and meta-analysis aimed to comprehensively evaluate acupuncture's efficacy and safety in treating dysphagia in Parkinson's disease (PD).

Methods

We searched PubMed, Cochrane Library, Embase, Web of Science, China Knowledge Infrastructure (CNKI), China Science Journal Database (VIP), Wan-fang Database, and the China Biomedical Literature Service System (CBM) for randomized controlled trials (RCTs) comparing the efficacy of acupuncture alone or in combination with control treatment in improving dysphagia by October 2022. The degree of dysphagia was the primary outcome indicator, with secondary outcomes including serum albumin (ALB) and hemoglobin (Hb) levels, the incidence of pneumonia, and adverse events. Two investigators independently extracted information according to the inclusion and exclusion criteria. Data synthesis was calculated by RevMan (V.5.4.1) software.

Results

This study included ten randomized controlled trials with 724 patients. Most RCTs have a high or uncertain risk of bias due to the lack of a blinded design. Meta-analysis showed that acupuncture combined with control treatment was superior to control treatment alone in improving Videofluoroscopic Swallowing Study (VFSS) scores (MD: 1.48; 95% CI: 1.16, 1.81; P < 0.00001) and reducing Standardized Swallowing Assessment (SSA) scores (MD: -3.08; 95% CI: -4.01, -2.15; P < 0.00001). Acupuncture combined with control therapy has a more significant benefit in improving the clinical efficiency of dysphagia in PD (RR: 1.40; 95%CI: 1.25, 1.58; P < 0.00001). Compared to the control group without acupuncture, acupuncture improved the nutritional status of patients and increased their serum ALB (MD: 3.38, 95%CI: 1.83, 4.92, P < 0.00001) and Hb levels (MD: 7.66; 95%CI: 5.57, 9.75; P < 0.00001). Three RCTs reported that the rate of pulmonary infections in the acupuncture group was lower than without acupuncture intervention (RR: 0.29, 95% CI: 0.14, 0.63; P = 0.001).

Conclusion

Acupuncture could be recommended as an adjunctive treatment for dysphagia in PD. However, due to the high risk of bias in the included studies, more high-quality evidence is needed to confirm the efficacy and safety of acupuncture for dysphagia in PD.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022370221.

Palliative care in advanced Huntington's disease: a scoping review

BACKGROUND

As Huntington's disease (HD) is a progressive disease for which there is no cure yet, patients in the advanced stage of HD may benefit from palliative care.

OBJECTIVE

To review the literature focusing on palliative care in advanced stage HD, and the level of evidence.

METHODS

Publications between 1993 and October 29th, 2021 from 8 databases (Embase, Web of Science, Cochrane, Emcare, PsycINFO, Academic Search Premier, PMC PubMed Central and Pubmed) were included. The literature was deductively classified based on topics that are part of the definition of palliative care, or as care-related topics that emerged from the literature. Levels of evidence I (high) - V (low) were determined as defined by the Joanna Briggs Institute.

RESULTS

Our search resulted in 333 articles, 38 of which were included. The literature covered four domains of palliative care: physical care, psychological care, spiritual care, and social care. Four other topics in the literature were: advance care planning, end-of-life needs assessments, pediatric HD care, and need for health care services. Most literature was underpinned by a low level of evidence, except for the topics on social care (Level III-V), advance care planning (Level II-V) and end-of-life needs assessments (Level II-III).

CONCLUSIONS

To deliver adequate palliative care in advanced HD, both general and HD-specific symptoms and problems need to be addressed. As the level of evidence in existing literature is low, further research is essential to improve palliative care and to meet patient's wishes and needs.

Levodopa/carbidopa intestinal gel via percutaneous endoscopic transgastric jejunostomy in advanced Parkinson's disease: hitting two birds with one stone?

Here we focus on people with advanced PD undergoing percutaneous endoscopic transgastric jejunostomy (PEG-J) ("one stone") for LCIG infusion therapy for managing severe motor fluctuations ("first bird") and discuss its implications for improving accompanying symptoms of cardiovascular, urinary, and gastrointestinal autonomic failure ("second bird").

Developing strategies "SATIA": How to manage dysphagia in older people? A Delphi panel consensus

AIM

To develop a set of evidence-informed strategies to assist older people to improve swallowing functions and prevent further damage from complications.

DESIGN

A two-round Delphi survey.

METHODS

An initial set of dysphagia care strategies with 74 relevant items for older people was formed based on a literature review by seven researchers. An online survey was conducted by 21 panellists, and data of experts' opinions were collected and analysed by improved Delphi method.

RESULTS

The positive coefficients in the two rounds of expert consultation were 85.71% and 83.33%, respectively. Consensus was reached with 53 items included and was allocated into the following five sections: (1) screening, (2) assessment, (3) training, (4) interventions and (5) management. These strategies were named with the acronym of each section-"SATIA". The management strategy can be applied to guide the management of older people with dysphagia.

Nutrition impact symptoms and the risk of malnutrition in people with Parkinson's disease: A cross-sectional study

BACKGROUND

People with Parkinson's disease (PD) often experience symptoms that affect their ability to eat. This may contribute to weight loss and increased risk of malnutrition. The present study aimed to quantify the extent of nutrition impact symptoms (NIS) in the population and a scoring system of NIS was incorporated in the tool used to identify malnutrition.

METHODS

In this cross-sectional study, members of the Norwegian Parkinson's Association, with any PD diagnosis and stage of illness, were invited to respond to an online 24-item questionnaire. Questions from two validated questionnaires, comprising the abridged Patient-Generated Subjective Global Assessment (aPG-SGA) and the Radboud Oral Motor Inventory for Parkinson's disease (ROMP), were adapted to an online format.

RESULTS

The questionnaire was sent to 3047 members, of which 508 persons (17%) responded (61% men). In total, 59% were categorised as well-nourished, 34% at risk of malnutrition and 6.5% as malnourished. One quarter of all participants reported symptoms that affected food intake. The most frequent symptoms were constipation (14.2%) and dry mouth (13.4%). Malnourished participants reported a mean ± SD of 3.4 ± 1.4 symptoms versus 0.1 ± 0.3 per well-nourished participant. Malnourished participants had more swallowing problems than well-nourished participants, with a mean ± SD total ROMP score of 15.5 ± 6.0 versus 9.0 ± 2.9 (p < 0.001). As the number of points in the ROMP score increased by one, the points in the aPG-SGA score increased with 37% (95% confidence interval = 0.309-0.428).

CONCLUSIONS

Risk of malnutrition was largely related to NIS, especially dysphagia in people with PD. Symptoms affecting food intake should be systematically mapped and treated in conjunction with PD to prevent malnutrition.

Premotor, nonmotor and motor symptoms of Parkinson's Disease: A new clinical state of the art

Parkinson's Disease (PD) is a neurodegenerative disorder that affects dopaminergic neurons in the mesencephalic substantia nigra, causing a progressive clinical course characterized by pre-motor, non-motor and motor symptoms, which negatively impact the quality of life of patients and cause high health care costs. Therefore, the present study aims to discuss the clinical manifestations of PD and to make a correlation with the gut-brain (GB) axis, approaching epidemiology and therapeutic perspectives, to better understand its clinical progression and identify symptoms early. A literature review was performed regarding the association between clinical progression, the gut-brain axis, epidemiology, and therapeutic perspectives, in addition to detailing pre-motor, non-motor symptoms (neuropsychiatric, cognitive, autonomic, sleep disorders, sensory abnormalities) and cardinal motor symptoms. Therefore, this article addresses a topic of extreme relevance, since the previously mentioned clinical manifestations (pre-motor and non-motor) can often act as prodromal markers for the early diagnosis of PD and may precede it by up to 20 years.

X-linked dystonia parkinsonism: epidemiology, genetics, clinical features, diagnosis, and treatment

X-linked dystonia parkinsonism (XDP) is a rare X-linked recessive degenerative movement disorder that only affects Filipino descent, predominantly males. Its underlying cause is associated with the genetic alterations in the TAF1/DYT3 multiple transcription system. SINE-VNTR-Alu (SVA) retrotransposon insertion was suggested to be the responsible genetic mutation. Clinically, it initially presents as focal dystonia and generalizes within years. Parkinsonism arises years later and coexists with dystonia. Nonmotor symptoms like cognitive impairment and mood disorders are also common among XDP patients. XDP diagnosis relies on clinical history and physical examination. On imaging, abnormalities of the striatum, such as atrophy, are widely seen and can explain the clinical presentations with a three-model pathway of the striatum. Treatments aim for symptomatic relief of dystonia and parkinsonism and to prevent complications. Oral medications, chemo-denervation, and surgery are used in XDP patients. This review summarizes the currently important information regarding XDP, providing a synoptic overview and understanding of XDP for future studies.

Repaglinide Elicits a Neuroprotective Effect in Rotenone-Induced Parkinson's Disease in Rats: Emphasis on Targeting the DREAM-ER Stress BiP/ATF6/CHOP Trajectory and Activation of Mitophagy

Repaglinide, a meglitinide insulinotropic antidiabetic, was unraveled as a promising therapeutic agent for Huntington's disease by targeting the neuronal calcium sensor downstream regulatory element antagonist modulator (DREAM). However, its mechanistic profile in Parkinson's disease (PD) especially its impact on endoplasmic reticulum (ER) stress, mitophagy, and their interconnections is poorly elucidated. This study is the first to examine the neuroprotective potential of repaglinide in rotenone-induced PD in rats by exploring its effects on DREAM, BiP/ATF6/CHOP ER stress pathway, apoptosis, mitophagy/autophagy, oxidative stress, astrogliosis/microgliosis, and neuroinflammation. Male Wistar rats were randomly assigned to four groups: groups 1 and 2 received the vehicle or repaglinide (0.5 mg/kg/day p.o). Groups 3 and 4 received rotenone (1.5 mg/kg/48 h s.c) for 21 days; meanwhile, group 4 additionally received repaglinide (0.5 mg/kg/day p.o) for 15 days starting from day 11. Interestingly, repaglinide lessened striatal ER stress and apoptosis as evidenced by reduced BiP/ATF6/CHOP and caspase-3 levels; however, it augmented striatal DREAM mRNA expression. Repaglinide triggered the expression of the mitophagy marker PINK1 and the autophagy protein beclin1 and alleviated striatal oxidative stress through escalating catalase activity. In addition, repaglinide halted astrocyte/microglial activation and neuroinflammation in the striatum as expressed by reducing glial fibrillary acidic protein (GFAP) and ionized calcium-binding adaptor protein 1 (Iba1) immunostaining and decreasing interleukin (IL)-6 and IL-1β levels. Repaglinide restored striatum morphological alterations, intact neuron count, and neurobehavioral motor performance in rats examined by an open field, grip strength, and footprint gait analysis. Conclusively, repaglinide modulates the DREAM-ER stress BiP/ATF6/CHOP cascade, increases mitophagy/autophagy, inhibits apoptosis, and lessens oxidative stress, astrocyte/microglial activation, and neuroinflammation in PD.

Association between board-certified physiatrist involvement and functional outcomes in sarcopenic dysphagia patients: a retrospective cohort study of the Japanese Sarcopenic Dysphagia Database

Objective: Dysphagia rehabilitation is an important area in geriatric nutrition due to the commonality of sarcopenic dysphagia in older adults. However, there have been no reports on the efficacy of treatment by board-certified physiatrists (BCP) in patients with sarcopenic dysphagia. This study therefore aimed to investigate whether intervention by board-certified physiatrists affects the functional prognosis of patients with sarcopenic dysphagia. Materials and Methods: Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia database between November 2019 and March 2021, 433 met the study eligibility criteria. The patients were divided into two groups based on whether or not they received intervention by a BCP. The clinical characteristics and outcomes of the two groups were compared. Statistical analyses were performed by inverse probability weighting (IPW). Results: BCPs were involved in the management of 57.0% of patients with sarcopenic dysphagia. These patients had a significantly higher increase in the Barthel index both before and after IPW correction than those not managed by a BCP (P=0.001 and P=0.016, respectively). However, sarcopenic dysphagia significantly improved in the non-BCP group before IPW correction (P<0.001), although there was no significant difference after IPW correction (P=0.301). Conclusion: BCP management was significantly associated with higher activities of daily living (ADL), but not with an improvement in sarcopenic dysphagia. To provide and manage effective rehabilitation, it is necessary to familiarize patients with the management and training of sarcopenic dysphagia rehabilitation for BCP in order to cope in regions with few rehabilitation units.

A narrative review on the role and main findings of the Videofluoroscopic Study of Swallowing in Parkison's disease

PURPOSE

Dysphagia is a common symptom in patients with Parkinson's disease (PD), though it may go undiagnosed until severe complications arise. Dysphagia can be suspected on a clinical basis, but an instrumental assessment is mandatory to confirm its presence and evaluate pathophysiological aspects and severity of the swallowing impairment. Aim of this review is to inform the clinician and the radiologist on the importance and the main radiological findings of the Video-Fluoroscopic-Swallow-Study (VFSS) in patients with PD starting from the most recent literature data on the topic.

MATERIALS AND METHODS

Databases analysis identified 98 papers (January 2000/October 2022) of which 55 were excluded after reading title, abstract and full-text. After evaluation of the selected articles and their references 7 additional papers were added.

RESULTS

Fifty papers were reviewed to answer the following four main questions: Should VFSS be routinely used to screen dysphagia? Compared to other diagnostic tools, what is the role of VFSS in PD patients with suspected dysphagia? What are the main VFSS findings and technical expedients ? What is the role of VFSS in the choice of the best treatment strategy ?

CONCLUSIONS

VFSS represents a gold standard technique in the diagnostic evaluation of dysphagia in PD, having a fundamental role in the identification of patients with high risk of aspiration pneumonia and also being extremely helpful to guide to the choice of treatment strategies for dysphagia.

Effects of thickened carbonated cola in older patients with dysphagia

Carbonated beverages initiate the swallowing reflex earlier than water and have a shorter pharyngeal transit time. However, the effects of carbonation in thickened beverages of the same flavor on swallowing dynamics have not been reported. Therefore, we investigated the effects of thickened carbonated beverages on swallowing in patients with dysphagia by comparing the swallowing dynamics between thickened carbonated and thickened non-carbonated beverages. We enrolled 38 patients with dysphagia and divided them into two groups. Thickened carbonated and thickened non-carbonated beverages were used. Videoendoscopic swallowing evaluations were performed. Aspiration, penetration, pharyngeal residue, and initiation position of the swallowing reflex were evaluated. The reduction in the amount of residue in both the vallecula (p = 0.007) and pyriform sinus (p = 0.004) was greater after ingestion of thickened carbonated cola than thickened non-carbonated cola. The onset of the swallowing reflex was significantly earlier after ingestion of thickened carbonated cola than thickened non-carbonated cola (p = 0.007). There were no significant differences in the extent of penetration. Thickened carbonated beverages positively affected swallowing compared with thickened non-carbonated beverages. Thus, the use of thickened carbonated beverages may be helpful for patients with dysphagia.

Relationship between motor dysfunction and chewing movement in patients with Parkinson's disease: A transversal study

Objective

To assess the impact of chewing movement in patients with Parkinson's disease (PD), we examined the relation between chewing movement and motor dysfunction in association with PD progression.

Methods

Thirty patients with PD (mean age, 68.9 ± 9.0 years; mean Hoehn and Yahr stage, 3.0 ± 0.7) were recruited. The PD condition was assessed in each patient by using the score of Movement Disorder Society Unified PD Rating Scale (MDS-UPDRS) part III score, body mass index (BMI), serum albumin (Alb), and tongue pressure, number of chews, mealtime, and chewing speed were collected. The patients were divided into two groups (mild and moderate PD groups) based on an MDS-UPDRS part III cut-off value of 32.

Results

The chewing speed positively correlated with tongue pressure (rho = 0.69, p < 0.01) in the mild group, and with BMI (rho = 0.54, p = 0.03), serum Alb (rho = 0.63, p = 0.02), and number of chews (rho = 0.69, p < 0.01) in the moderate group. The MDS-UPDRS part III scores for all participants correlated negatively with chewing speed (rho = -0.48, p < 0.01), serum Alb (rho = -0.49, p < 0.01), and positively with mealtime (rho = 0.43, p = 0.01). Tongue pressure and serum Alb were identified to be as factors affecting the chewing speed (β= 0.560, p < 0.01; β= 0.457, p < 0.01, respectively).

Conclusions

These results indicated that the progression of motor dysfunction in patients with PD is likely to affect chewing speed and the nutritional status decline may be linked to the impairment of chewing movement in these patients.

Prevalence of Malnutrition in Patients with Parkinson's Disease: A Systematic Review

OBJECTIVES

This systematic review analyzed the prevalence of malnutrition in patients with Parkinson's Disease.

STUDY DESIGN

a systematic review.

METHOD

Four databases-Cochrane, PubMed, Embase and Web of Science-were searched from October 2021 to June 2022 by two independent researchers. The inclusion criteria were as follows: patients above 18 years old with confirmed Parkinson's Disease, performed screening nutritional assessment, cohort studies, case-control studies, and cross-sectional studies. Patients without Parkinson's Disease and with other parkinsonian syndromes were excluded.

RESULTS

49 studies were included in this systematic review. Patients ranged in age from 20 to 96 years. There were 5613 subjects included. According to Mini Nutritional Assessment, 23.9% (n = 634) participants were at risk of malnutrition and 11.1% (n = 294) were malnourished. According to BMI score, most patients were either obese or overweight.

CONCLUSIONS

the prevalence of malnutrition or risk of malnutrition in the study group was significant. Therefore, more specific and detailed studies on the prevalence of malnutrition in patients with Parkinson's Disease are needed.

A Systematic Review of Swallowing Training Measures for Postoperative Oral Cancer Patients

Swallowing disorder is one of the most common postoperative complications for oral cancer patients and seriously influences quality of life. Limited attention has been paid to evaluating swallowing training measures in postoperative oral cancer patients. This study systematically reviewed swallowing training measures for these patients. A comprehensive search strategy was undertaken across various databases for studies published between database inception and 15 June 2021. Raters independently judged titles, abstracts and full articles for selection according to inclusion and exclusion criteria. The included literature was evaluated for quality and data were extracted. Meta-analyses were conducted using RevMan 5.3. Ten intervention studies (four randomized controlled trials and six quasi-experimental studies) involving 588 patients were identified. Across the studies, most started in the early postoperative stage; however, there were differences in starting time, training time and duration, and type of training. We summarized four training methods: oral exercise, oral sensory stimulation, compensatory strategies and protective airway manoeuvres. The meta-analysis indicated that swallowing training could improve patients' swallowing function and quality of life in the short term, but the long-term effects were not obvious. Swallowing training mostly occurred in the early postoperative period and training measures were often used in combination. The timing, frequency and content of interventions varied between studies, and the effectiveness of any single measure was unclear. High-quality randomized controlled trials are necessary to study the efficacy and clinical applicability of various training measures, to provide a theoretical basis for their optimal selection and to develop a standardized training programme for postoperative oral cancer patients.

Pharmacological Management of Dysphagia in Patients with Alzheimer's Disease: A Narrative Review

Alzheimer's disease (AD) and dysphagia are important health and socioeconomic problems in the aging population. Currently, the medical treatment of dysphagia in AD patients remains insufficient, and there are significant gaps in the management and clinical needs to postpone tube feeding. Literatures published over the last 30 years were searched in the PubMed and Embase databases. All relevant and promising pharmacological management studies were included. Because of the heterogeneity in design and methodology, only narrative reports were mentioned. Nine studies were included with two case reports, two case series, and two observational and three randomized controlled trials. The key approaches and clinical problems related to dysphagia include onset pattern, dementia stage, review of offending drugs and polypharmacy, and comorbidities (cerebrovascular disease, hypertension, parkinsonism, depression, and anorexia). The corresponding strategies of pharmacological treatments are further proposed and discussed comprehensively, with transient receptor potential channel modulators as promising treatment. With the integration of adequate and potential pharmacomanagement, AD patients with dysphagia can achieve a good prognosis and postpone tube feeding to maintain a better quality of life. More rigorous studies are needed to verify the effectiveness of innovative strategies and develop targets for neurostimulation.

The Role of Diet and Dietary Patterns in Parkinson's Disease

Parkinson's Disease (PD) is a neurodegenerative disorder associated with diminished nutrition status and decreased quality of life. While the prevalence of PD is expected to increase, no preventative or curative therapy for PD exists at this time. Although nutrition and diet represent modifiable risk factors for reducing chronic disease risk, research on the impact of single nutrients on PD has yielded mixed results. As a result, this single-nutrient approach may be the driving force behind the inconsistency, and a holistic dietary approach may overcome this inconsistency by accounting for the interactions between nutrients. The following review aims to examine the impact of a generally healthy dietary pattern, the protein-restricted diet (PRD), the ketogenic diet (KD), the Mediterranean diet (MD), and the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet on PD risk, progression, and severity. While most of the included studies support the role of diet and dietary patterns in reducing the risk of PD or alleviating PD severity, the inconsistent results and need for further evidence necessitate more research being conducted before making dietary recommendations. Research on the potential beneficial effects of dietary patterns on PD should also investigate potential risks.

Management of dysphagia and gastroparesis in Parkinson’s disease in real-world clinical practice – Balancing pharmacological and non-pharmacological approaches

Gastrointestinal (GI) issues are commonly experienced by patients with Parkinson’s disease (PD). Those that affect the lower GI tract, such as constipation, are the most frequently reported GI problems among patients with PD. Upper GI issues, such as swallowing dysfunction (dysphagia) and delayed gastric emptying (gastroparesis), are also common in PD but are less well recognized by both patients and clinicians and, therefore, often overlooked. These GI issues may also be perceived by the healthcare team as less of a priority than management of PD motor symptoms. However, if left untreated, both dysphagia and gastroparesis can have a significant impact on the quality of life of patients with PD and on the effectiveness on oral PD medications, with negative consequences for motor control. Holistic management of PD should therefore include timely and effective management of upper GI issues by utilizing both non-pharmacological and pharmacological approaches. This dual approach is key as many pharmacological strategies have limited efficacy in this setting, so non-pharmacological approaches are often the best option. Although a multidisciplinary approach to the management of GI issues in PD is ideal, resource constraints may mean this is not always feasible. In ‘real-world’ practice, neurologists and PD care teams often need to make initial assessments and treatment or referral recommendations for their patients with PD who are experiencing these problems. To provide guidance in these cases, this article reviews the published evidence for diagnostic and therapeutic management of dysphagia and gastroparesis, including recommendations for timely and appropriate referral to GI specialists when needed and guidance on the development of an effective management plan.

Effects of Respiratory Muscle Strength Training on Respiratory-Related Impairments of Parkinson's Disease

In addition to typical motor dysfunction, Parkinson's disease is also characterized by respiratory-related dysfunction. As a means of rehabilitation, respiratory muscle strength training (RMST) has been applied to restore Parkinson's disease (PD) functions. However, the current clinical value of RMST in the application for PD has not been widely established. This article aims to review the research progress of the application of RMST in PD rehabilitation to provide new sight into respiratory-related impairments management in people with PD.

Severity of dysphagia is associated with hospitalizations and mortality in patients with Parkinson's disease

BACKGROUND

Aspiration pneumonia is the commonest cause of hospitalizations and death in patients with Parkinson's disease (PD). Among these patients, the relationships between severity of dysphagia, hospitalizations for related complications, and death are not robustly defined. Our aim was to characterize the relationship between PD-related oropharyngeal dysfunction and clinically relevant outcomes.

METHODS

Retrospective cohort study of 312 patients with PD at a tertiary center who underwent videofluoroscopic swallow studies conducted by expert therapists between 2010 and 2015. Level of swallowing function was represented using the 7-point Functional Oral Intake Scale (FOIS) (7 = normal function). Significance and relative risk calculations utilized Poisson regression. Time to composite outcome of first hospitalization or death was summarized using Kaplan-Meier curve with log-rank test.

KEY RESULTS

One hundred thirty eight patients had a recorded FOIS score. The prevalence of oropharyngeal dysfunction was 76.1%. The median duration of follow-up was 26.8 months. In multivariate analyses, patients with FOIS 5 (RR = 2.01 [95% CI: 1.22, 3.32]), FOIS 3 (RR = 2.78 [95% CI: 1.75, 4.40]), and FOIS 1 (RR = 2.50 [95% CI: 1.49, 4.20]) were significantly associated with increased risk of hospitalization or death compared to FOIS 7 after co-variate adjustments. GERD was also associated with a significant increased risk of hospitalization or death (RR = 1.28 [95% CI: 1.01, 1.64]). Time to first hospitalization or death was shorter in patients with lower FOIS scores (p < 0.00005).

CONCLUSIONS AND INFERENCES

Severity of oropharyngeal dysphagia, as measured by the FOIS, is associated with poorer survival and shorter time to hospitalization for dysphagia-related complications, pneumonia, or death in PD.

The Prevalence of Off-label Prescribing of Transmucosal Immediate-Release Fentanyl in France

CONTEXT

The abuse of opioids and opioid-related harms, including deaths, in the United States are well documented. In the European Union, opioid use has also been increasing, particularly of fentanyl.

OBJECTIVE

We assessed the prevalence of off-label prescribing of transmucosal immediate-release fentanyl (TIRF), in France, in 2019. We looked at the patients' and prescribers' characteristics and compared the population of patients who received TIRF in off-label prescriptions with those taking it on-label. We also examined the differences between the patients with and without cancer in the off-label use population.

METHODS

This was a population-based cross-sectional study conducted in 2019, using the French national insurance claims database Système National d'Informations Inter-Régimes de l'Assurance Maladie, covering 98.8% of the French population, or 66 million people.

RESULTS

We selected 224,000 patients with fentanyl prescriptions. Among them, 23,209 had at least one TIRF delivered. The median age was 71 years (59-85) and most patients were female (55.8%). The prevalence of off-label prescribing of TIRF was 51.8% (n = 12,031), corresponding to 9827 patients not diagnosed with cancer. The three main pharmaceutical TIRF specialties prescribed in two groups were Abstral, Pecfent, and Instanyl. Overall, TIRF was mainly prescribed by private general practitioners (64.8%).

CONCLUSION

The prevalence of off-label prescribing of TIRF in France is extremely high. A field survey is now needed 1) to better understand why TIRF is used in conditions not indicated in its marketing authorization, and in what clinical situations, and 2) to determine whether the benefit/risk ratio of such use is favorable.

Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

Parkinson Disease, Dysphagia, and Cervical Spine Surgery

STUDY DESIGN

An analysis of a National Database.

OBJECTIVE

The objective of this study was to evaluate the rate of dysphagia for Parkinson disease (PD) patients undergoing cervical spine surgery for cervical myelopathy.

SUMMARY OF BACKGROUND DATA

Cervical spondylotic myelopathy (CSM) is an increasingly common problem in the aging population. Several surgical options exist to treat this condition including anterior, posterior and combined surgical approaches. Each approach carries its own set of postoperative complications. Little is known of the of outcomes after cervical spine surgery in PD.

MATERIALS AND METHODS

The National Inpatient sample was queried 1998 to 2016, all elective admissions with CSM were identified. Surgical treatments were identified as either: anterior cervical discectomy and fusion (ACDF), posterior laminectomies, posterior cervical fusion or combined anterior/posterior surgery. Preexisting PD was identified. Endpoints included mortality, length of stay (LOS), swallowing dysfunction measured by placement of feeding tube (NGT), and postprocedure pneumonia.

RESULTS

A total of 73,088 patients underwent surgical procedures for CSM during the study period. Of those, 552 patients (7.5%) had concomitant PD. The most common procedure was ACDF. Patients with PD had a higher rate of dysphagia (NGT placement) after surgery compared with those without PD (P<0.001). Multiple regression analysis showed that PD patients had a higher risk of having NGT placement or developing pneumonia [odds ratio 2.98 (1.7-5.2), P<0.001] after surgery.Patients with PD who underwent ACDF, posterior laminectomies or posterior cervical fusion had a longer LOS compared with those who did not have PD (P<0.001). There was no difference in LOS for patients who underwent combined anterior/posterior surgery. Inpatient mortality was higher in patients with PD who underwent ACDF or combined surgery (P<0.001).

CONCLUSIONS

While ACDF is the most commonly performed procedure for CSM in patients with PD, it is associated with longer LOS, higher incidence of postoperative dysphagia, and postprocedural pneumonia, as well as higher inpatient mortality compared with posterior cervical procedures.

LEVEL OF EVIDENCE

Level III.

Acupuncture Reduces the Risk of Dysphagia in Stroke Patients: A Propensity Score-Matched Cohort Study

Background: Post-stroke dysphagia (PSD) affects the quality of life in stroke patients, impairs their rehabilitation ability, and causes other complications following stroke. Currently, there is currently some understanding of PSD risk factors, but its protective factors remain largely unknown. Objective: To analyze the effects of acupuncture (AP) on dysphagia in stroke patients and explore its potential as a preventive therapy. Methods: Patients with a diagnosis of stroke from 2010 to 2019 were selected and followed until 2020, utilizing factors such as age, gender, stroke location, stroke type, and baseline comorbidity. To compare the incidence of dysphagia, equal numbers of stroke patients treated with and without AP (n = 1,809) were matched by 1:1 propensity scoring. The Cox proportional hazards model and Kaplan-Meier method were used to assess the risk of dysphagia as an outcome measure. Results: The stroke patients treated with AP had a lower risk of dysphagia after adjusting for age, gender, stroke location, stroke type, and baseline comorbidity [adjusted hazard ratio (AHR) = 0.43, 95% confidence interval = 0.37-0.49] compared with those in the non-AP cohort. AP also decreased the risk of PSD among different gender groups. The risk ratios were AHR = 0.45 and AHR = 0.33 for males and females, respectively. AP also reduced the risk for PSD among different age groups. The risk ratios were AHR = 0.20, AHR = 0.37, AHR = 0.41, and AHR = 0.45 for the 18-39, 40-59, 60-79, and >80 years-old groups. Regarding stroke types (ischemic, hemorrhagic, and mixed type), patients treated with AP had a lower risk (AHR = 0.47, 0.28 and 0.17, respectively). With respect to stroke location, the risk of PSD in AP-treated patients was decreased regardless of location: brain stem (AHR = 0.41), diencephalon (AHR = 0.13), or multiple lesions (AHR = 0.40), the risk of PSD in AP-treated patients was decreased. For all baseline comorbidities, AP attenuated the risk of dysphagia. The cumulative incidence of dysphagia was remarkably lower in the AP group than in the non-AP group (log-rank test, P = 0.000). Limitations: First, this was a single-center clinical retrospective study. Second, we did not classify the severity of stroke and dysphagia. Third, all data were extracted manually. Lastly, the sample size was relatively small. Thus, future studies with larger sample sizes are warranted to verify our findings. Conclusion: Acupuncture treatment attenuates the risk of dysphagia in stroke patients. Future research should increase the sample size and elaborate further on the details of the AP protocol.

Surgical management of Diffuse Idiopathic Skeletal Hyperostosis (DISH) causing secondary dysphagia (Narrative review)

Objectives: To summarize the current evidence on surgical treatment for large bridging osteophytes of the anterior cervical spine from Diffuse Idiopathic Skeletal Hyperostosis (DISH). Overview of Literature: In the current review, the surgical treatment of secondary dysphagia from DISH was the most useful treatment. We propose a treatment algorithm for management of this condition because currently there are only case reports and retrospective studies available. Methods: Literature search was performed using the MeSH terms "Anterior Cervical Osteophyte," "Diffuse Idiopathic Skeletal Hyperostosis (DISH)," and "Dysphagia" and "Treatment" for articles published between January 2000 and February 2020. PubMed search identified 117 articles that met the initial screening criteria. Detailed analysis identified the 40 best matching articles, following which the full inclusion and exclusion criteria left 11 articles for this review. Results: Incidence of secondary dysphagia was associated with DISH in elderly patients (average 65 years). The major clinical findings were dysphagia or respiratory compromise, with the most common level of bridging osteophytes of the cervical spine at C3-C5. There were 10 articles on surgical treatment involving anterior cervical osteophytectomy without fusion, 1 for multilevel cervical oblique corpectomy, 1 for anterior cervical discectomy with fusion plus plate, and 1 for anterior cervical osteophytectomy with stand-alone PEEK cage or plus plate. All the cases resulted in significant improvement without recurrence, with only 1 case having post-operative complications. Follow-up duration was 3-70.3 months. Conclusions: Surgical intervention for anterior cervical osteophytectomy appears to result in improved outcomes. However, there could be disadvantages concerning cervical spine motion if cervical osteophytectomy with cervical discectomy and fusion (ACDF) plus plate system is done.

Tongue cleaning in the elderly and its role in the respiratory and swallowing functions: Benefits and medical perspectives

Oral dysfunction, including oral uncleanness and decline in tongue motor function, tongue pressure and swallowing function, precedes frailty. The tongue's dorsum is a reservoir of oral microbiota, desquamated epithelial mucosa and leukocytes due to the multi-papillate anatomy, and leads to tongue coating. The tongue coating is frequently found in older adults because of hyposalivation, immunity's hypoactivity, diminished motor function and compromised tongue's pressure with age. Anaerobe-driven volatile sulphur compounds in tongue coating are a major cause of intra-oral malodor. Dysbiosis of the tongue-coating microbiome rather than the amount of microorganisms is associated with a risk of aspiration pneumonia. Daily tongue cleaning with a brush or scraper is an easy way to control tongue coating deposits and quality. Using mouth wash or rinse-containing germicides is also a way to control the microbiota of tongue coating. The tongue function is closely related to swallowing. Tongue and suprahyoid muscles are linked with respiratory muscles through the endothoracic fascia. The mechanical stimulation during the cleaning of the tongue may stimulate the respiratory muscles. An intervention trial revealed that tongue cleaning by mucosal brush improves tongue pressure, swallowing and respiratory function in old residents of nursing homes, suggesting a rehabilitative effect of tongue cleaning on the swallowing and respiratory functions, preventing aspiration pneumonia. This narrative review assesses the tongue-cleaning benefits for respiratory and swallowing functions and the possibility of preventing aspiration pneumonia.

The Impact of SNCA Variations and Its Product Alpha-Synuclein on Non-Motor Features of Parkinson's Disease

Parkinson’s disease (PD) is a common and progressive neurodegenerative disease, caused by the loss of dopaminergic neurons in the substantia nigra pars compacta in the midbrain, which is clinically characterized by a constellation of motor and non-motor manifestations. The latter include hyposmia, constipation, depression, pain and, in later stages, cognitive decline and dysautonomia. The main pathological features of PD are neuronal loss and consequent accumulation of Lewy bodies (LB) in the surviving neurons. Alpha-synuclein (α-syn) is the main component of LB, and α-syn aggregation and accumulation perpetuate neuronal degeneration. Mutations in the α-syn gene (SNCA) were the first genetic cause of PD to be identified. Generally, patients carrying SNCA mutations present early-onset parkinsonism with severe and early non-motor symptoms, including cognitive decline. Several SNCA polymorphisms were also identified, and some of them showed association with non-motor manifestations. The functional role of these polymorphisms is only partially understood. In this review we explore the contribution of SNCA and its product, α-syn, in predisposing to the non-motor manifestations of PD.

Sensorimotor Cough Dysfunction Is Prevalent and Pervasive in Progressive Supranuclear Palsy

BACKGROUND

Pneumonia, a leading cause of death in progressive supranuclear palsy (PSP), results from progressive and pervasive deficits of airway protection, including both cough and swallowing dysfunction. Cough protects the airway by expelling aspirate and may be an important therapeutic target to protect against pneumonia in the presence of dysphagia. However, cough has not been objectively characterized in PSP or compared to other common forms of parkinsonism, such as Parkinson's disease (PD).

OBJECTIVE

The purpose of this study was to examine voluntary and reflex cough function in PSP, as compared to patients with PD matched for disease duration.

METHODS

Twenty-six patients with PSP and 26 with PD completed voluntary and reflex cough testing via spirometry. Linear mixed effects models examined comparisons between groups and within cough types across cough sensory and motor outcomes.

RESULTS

Patients with PSP demonstrated significantly reduced cough motor function compared to PD, specifically reduced peak expiratory flow rate (P < 0.001), cough expiratory volume (P < 0.001), and cough inspiratory volume (P = 0.008). Both groups showed similar reflex cough thresholds (P = 0.694), but PSP demonstrated an increased perception of cough stimuli (P = 0.041).

CONCLUSIONS

These findings suggest that sensorimotor cough dysfunction is prevalent in PSP, and cough motor deficits, in particular, are worse in PSP than in PD. These deficits likely contribute to the pathogenesis of pneumonia in PSP. Therefore, cough should be integrated into assessments of airway protection and considered as a therapeutic target to potentially reduce adverse health events and improve quality of life in this population. © 2021 International Parkinson and Movement Disorder Society.

Suboptimal Tongue Pressure Is Associated with Risk of Malnutrition in Community-Dwelling Older Individuals

The tongue plays an important role in swallowing, and its dysfunction theoretically leads to inadequate oral intake and subsequent malnutrition. This study aimed to explore how different levels of tongue pressure are related to malnutrition among community-dwelling older individuals. The target population was community-dwelling adults aged ≥ 65 years. Tongue pressure was measured using the Iowa Oral Performance Instrument, whereas the mini nutrition assessment (MNA) test was administered to determine the nutritional status. A full MNA score of less than 24 points was defined as risk of malnutrition. Multivariate logistic regression analyses were conducted to calculate the odds ratio (OR) of risk of malnutrition among different quartiles of tongue pressure. Among the 362 participants, 26 (7.1%) were classified as having risk of malnutrition. Body weight, body mass index, handgrip strength, skeletal muscle mass index, sum MNA score, and serum levels of albumin were lower in the malnutrition risk groups than in the normal nutrition status group. A positive correlation was identified between tongue pressure and the MNA score (r = 0.143, p < 0.01). Treating the subgroup of the highest quartile of tongue pressure as the reference, the crude odds ratio (OR) of having risk of malnutrition was 5.37 (95% CI, 1.14–25.28) in the subgroup at the third quartile, 3.10 (95% CI, 0.60–15.84) in the subgroup at the second quartile, and 3.95 (95% CI, 0.81–19.15) in the subgroup at the lowest quartile. After adjustment for age and sex, the subgroup in the third quartile still presented with a significantly higher risk (OR, 4.85; 95% CI, 1.02–22.99) of risk of malnutrition. Compared with the subgroup at the highest quartile of tongue pressure, the crude OR for all the subgroups in the lower three quartiles was 4.17 (95% CI, 0.96–18.04), showing borderline significance (p = 0.05). In conclusion, we found hints for an association between decreased tongue pressure and an increased risk of malnutrition in community-dwelling older individuals. Older people with suboptimal tongue pressure should undergo a thorough assessment of their nutritional status and swallowing function for the early identification of subclinical malnutrition and dysphagia.

Impact of Progression of Parkinson's Disease on Swallowing Ability and Oral Environment

This study investigated the impact of the severity and treatment of Parkinson's disease (PD) on the swallowing ability and oral environment of patients. Swallowing dysfunction increases the aspiration risk and may lead to poor oral health among patients with PD. We investigated the influences of PD progression and drug treatment on the swallowing ability and oral environment using simple noninvasive screening measurements. We recruited 87 patients with PD (mean age, 71.9 ± 8.0 years; mean Hoehn and Yahr score, 2.9 ± 0.9). The PD condition was assessed in each patient using the unified Parkinson's disease rating scale (UPDRS) part III, diet type and oropharyngeal function using the swallowing disturbances questionnaire (SDQ), maximum bite force (MBF), tongue pressure (TP), and oral bacterial count (OBC). Levodopa equivalent daily dose (LEDD) was also calculated for 56 participants. Based on an SDQ score of ≥11, 29.5% of patients were dysphagic, but almost all were still on a regular diet. The SDQ score was positively correlated with disease duration (rho = 0.228, p=0.047) and UPDRS part III score (rho = 0.307, p=0.007) but was negatively correlated with OBC (rho = -0.289, p=0.012). OBC was significantly higher among patients with an SDQ score of <11 (nondysphagic) (p=0.01), and the SDQ score was lower in patients with higher OBC requiring professional oral care (p=0.03). However, OBC was also negatively correlated with LEDD (rho = -0.411, p=0.004). These results indicated low self-awareness of dysphagia among the participants and an association between dysphagia and PD progression. Moreover, the oral environment could have deteriorated with swallowing dysfunction. Patients and clinicians should be aware that higher LEDD can increase xerostomia and associated deficits in oral health.

Comparison of Patient-Reported and Caregiver-Reported Swallowing-Related Quality of Life in Parkinson's Disease

This pilot study explored agreement on swallowing-related quality-of-life scores reported by individuals with Parkinson's disease (PD) and their caregivers. Thirty-six patient-caregiver pairs completed the Swallowing Quality of Life Questionnaire (SWAL-QOL) using an online survey format. Additional background and clinical information was ascertained. A Wilcoxon signed-rank test was completed to compare the means of scores between individuals with PD and caregivers. Factors potentially influencing SWAL-QOL scores (age, employment status, sex, ethnicity, race, previous history of swallowing evaluation or treatment, caregiver concern about patient cognition, caregiver burden, and time since onset of disease) were explored using Spearman Coefficient Correlation tests. The Holm-Bonferroni method was used to adjust for multiple comparisons. Results did not reveal significant differences in SWAL-QOL scores between individuals with PD and caregiver pairs. There was a moderate degree of reliability and agreement between paired patient and caregiver scores, with the average ICC measures being 0.598 (95% CI [358, 0.748]) (F(71, 72) = 2.451, p < 0.0001). After adjusting for multiple comparisons, caregiver burden was found to be the only significant factor associated with caregivers' reported scores. No significant influential factor on reported scores by individuals with PD was found. These pilot results suggest individuals with PD and their caregivers may report similar swallowing-related quality-of-life scores. Further, caregiver burden appears to be an influential factor for caregiver-reported scores. Future studies should investigate the clinical benefits of including caregiver SWAL-QOL ratings in assessments, either as a supplement to patient scores to identify discrepancies across the dyad or in place of patient scores if needed. Further, caregiver burden and its influence on dysphagia identification and management should be explored, with targeted interventions to manage caregiver burden.

Dysphagia in multiple system atrophy consensus statement on diagnosis, prognosis and treatment

Multiple system atrophy (MSA) is a neurodegenerative disorder characterized by a combination of autonomic failure plus cerebellar syndrome and/or parkinsonism. Dysphagia is a frequent and disabling symptom in MSA and its occurrence within 5 years of motor onset is an additional diagnostic feature. Dysphagia can lead to aspiration pneumonia, a recognized cause of death in MSA. Guidelines for diagnosis and management of dysphagia in MSA are lacking. An International Consensus Conference among experts with methodological support was convened in Bologna to reach consensus statements for the diagnosis, prognosis, and treatment of dysphagia in MSA. Abnormalities of the oral and pharyngeal phases of swallowing, esophageal dysfunction and aspiration occur in MSA and worsen as the disease progresses. According to the consensus, dysphagia should be investigated through available screening questionnaires and clinical and instrumental assessment (videofluoroscopic study or fiberoptic endoscopic evaluation of swallowing and manometry) at the time of MSA diagnosis and periodically thereafter. There is evidence that dysphagia is associated with poor survival in MSA, however effective treatments for dysphagia are lacking. Compensatory strategies like diet modification, swallowing maneuvers and head postures should be applied and botulinum toxin injection may be effective in specific conditions. Percutaneous endoscopic gastrostomy may be performed when there is a severe risk of malnutrition and pulmonary complications, but its impact on survival is undetermined. Several research gaps and unmet needs for research involving diagnosis, prognosis, and treatment were identified.

Knowledge and Practice of Health Professionals in the Management of Dysphagia

The aim of this study was to determine healthcare providers' knowledge and practices about dysphagia. A descriptive cross-sectional study was carried out based on a self-administered and anonymous questionnaire addressed to healthcare providers in Spain. A total of 396 healthcare providers participated in the study. Of these, 62.3% knew the definition of dysphagia as a swallowing disorder. In addition, up to 39.2% of the participants reported that they did not know whether the EatingAssessmentTool (EAT-10) dysphagia screening test was usedin their own clinical settings. Similarly, up to 49.1% of them did not know the ClinicalExaminationVolume-Viscosity (MECV-V) method. Nearly all participants (98.8%) reported that thickeners must be used forall liquids administered to patients. A higher percentage of respondents based the choice of texture on patient's tolerance (78.2%) rather than on the MECV-V result (17.3%). In addition,76.4% of the professionals had witnessed a bronchoaspiration; after it, 44.4% (n = 175) of them reported the appearance of pneumonia, and 14.5% (n = 57) the death of the patient (p = 0.005). The participants revealeda moderate/low knowledge ofthe definition, diagnosis, and clinical management of liquid dysphagia, which indicates some room for improvements.

Four-Repeat Tauopathies: Current Management and Future Treatments

Four-repeat tauopathies are a neurodegenerative disease characterized by brain parenchymal accumulation of a specific isoform of the protein tau, which gives rise to a wide breadth of clinical syndromes encompassing diverse symptomatology, with the most common syndromes being progressive supranuclear palsy-Richardson's and corticobasal syndrome. Despite the lack of effective disease-modifying therapies, targeted treatment of symptoms can improve quality of life for patients with 4-repeat tauopathies. However, managing these symptoms can be a daunting task, even for those familiar with the diseases, as they span motor, sensory, cognitive, affective, autonomic, and behavioral domains. This review describes current approaches to symptomatic management of common clinical symptoms in 4-repeat tauopathies with a focus on practical patient management, including pharmacologic and nonpharmacologic strategies, and concludes with a discussion of the history and future of disease-modifying therapeutics and clinical trials in this population.

Care complexity individual factors associated with adverse events and in-hospital mortality

Introduction

Measuring the impact of care complexity on health outcomes, based on psychosocial, biological and environmental circumstances, is important in order to detect predictors of early deterioration of inpatients. We aimed to identify care complexity individual factors associated with selected adverse events and in-hospital mortality.

Methods

A multicenter, case-control study was carried out at eight public hospitals in Catalonia, Spain, from January 1, 2016 to December 31, 2017. All adult patients admitted to a ward or a step-down unit were evaluated. Patients were divided into the following groups based on the presence or absence of three adverse events (pressure ulcers, falls or aspiration pneumonia) and in-hospital mortality. The 28 care complexity individual factors were classified in five domains (developmental, mental-cognitive, psycho-emotional, sociocultural and comorbidity/complications). Adverse events and complexity factors were retrospectively reviewed by consulting patients’ electronic health records. Multivariate logistic analysis was performed to identify factors associated with an adverse event and in-hospital mortality.

Results

A total of 183,677 adult admissions were studied. Of these, 3,973 (2.2%) patients experienced an adverse event during hospitalization (1,673 [0.9%] pressure ulcers; 1,217 [0.7%] falls and 1,236 [0.7%] aspiration pneumonia). In-hospital mortality was recorded in 3,996 patients (2.2%). After adjustment for potential confounders, the risk factors independently associated with both adverse events and in-hospital mortality were: mental status impairments, impaired adaptation, lack of caregiver support, old age, major chronic disease, hemodynamic instability, communication disorders, urinary or fecal incontinence, vascular fragility, extreme weight, uncontrolled pain, male sex, length of stay and admission to a medical ward. High-tech hospital admission was associated with an increased risk of adverse events and a reduced risk of in-hospital mortality. The area under the ROC curve for both outcomes was > 0.75 (95% IC: 0.78–0.83).

Conclusions

Several care complexity individual factors were associated with adverse events and in-hospital mortality. Prior identification of complexity factors may have an important effect on the early detection of acute deterioration and on the prevention of poor outcomes.

Consensus-Based Recommendations for Advance Directives of People with Parkinson's Disease in Regard to Typical Complications by German Movement Disorder Specialists

A huge proportion of people with Parkinson’s disease (PwP) in Germany have written an advance directive (AD). However, the content of these forms in regard to specific Parkinson’s disease (PD)-related complications is rather low. There is an urgent need to specify ADs of PwP and consequently to improve decision-making concerning end-of-life aspects for affected patients. Evidence- and consensus-based PD-specific recommendations for ADs might help to close this gap. A Delphi study with two online Delphi rounds was initiated. Initial recommendations were built on findings from previous studies and derived from evidence-based literature. Consensus on recommendations was defined as ≥80% concordance regarding clarity of formulated aspects and relevance for clinical practice. A total of 22 experts (15.2% response rate) predominantly from the workgroup ‘neuro-palliative care’ in Germany performed two Delphi rounds. Consensus was achieved for 14 of 24 initially presented recommendations. Recommendations relating to dopaminergic therapy as well as to non-oral therapy options were considered important by the expert panel. The recommendations should be taken into account when developing and giving advice on ADs for PwP. Health professionals should be trained in counselling ADs of PwP and in integrating these recommendations in ADs during the disease course of PD.

Estado nutricional de idosos com doença de Parkinson e seus fatores associados: uma revisão integrativa

Resumo Objetivo Identificar os fatores associados ao Estado Nutricional de idosos com doença de Parkinson (DP) por meio de uma revisão integrativa da literatura. Método Foram utilizadas as bases de dados LILACS, MEDLINE, BDENF, Scielo e Pubmed, sem filtros para ano de publicação e desenho do estudo. Foram incluídos os estudos disponibilizados em português, inglês ou espanhol com população idosa (idade ≥60 anos). Foram excluídos estudos que não tratavam da temática, publicações não disponíveis na íntegra e que não atenderam à pergunta norteadora. Extraíram-se informações referentes aos objetivos, desenho de estudo, amostra investigada, instrumentos para a avaliação nutricional e principais resultados, além dos fatores associados. A qualidade metodológica dos estudos foi avaliada pelos instrumentos Critical Appraisal Skill Programme e Agency for Health care and Research and Quality. Para sumarização dos fatores associados foi considerado o percentual de estudos cuja análise intergrupo, associação ou correlação foi significativa para o desfecho esperado. Resultados A análise final resultou em 8 artigos. Os fatores associados ao Estado Nutricional entre as variáveis clínicas relacionadas à DP foram duração e gravidade da doença, sintomas motores e função cognitiva. Com relação às variáveis clínico-nutricionais apresentaram associação à gordura corporal, parâmetros bioquímicos, atividade física, doméstica e mobilidade, ingestão de energia e hábitos alimentares. Conclusão A perda de peso na DP é uma consequência complexa e multifatorial, sendo primordial diagnosticar precocemente mudanças nutricionais nesses pacientes. A realização de mais estudos nessa população é necessária, visando compreender melhor esse processo de perda de peso nos pacientes idosos com DP.