Speech and Swallowing in Parkinson's Disease
In addition to the classic motor symptoms of Parkinson's (tremor, slowness, stiffness, walking and/or balance problems), a person may develop changes in speech and/or swallowing. Although these problems can occur at any time in the course of Parkinson's, they are more common as disease progresses.
Speech and swallowing therapy exercises, combined with Parkinson's medication adjustment and, if necessary, dietary and/or behavioral modifications are the mainstays of management.
Watch a webinar on the impact of Parkinson's disease (PD) on speech and swallowing.
Speech Problems Experienced with Parkinson's
Parkinson's disease can affect the volume, tone, rhythm and/or rate of speech. Many people will speak softer and convey less emotion. Words can be slurred (dysarthria) or mumbled, and speech may trail off at the ends of sentences. Some people speak more slowly, or with a breathy or hoarse quality, but a few will talk rapidly, even stammering or stuttering in a pattern known as "tachyphemia."
Cognitive dysfunction (memory and/or thinking problems) associated with PD also may affect speech -- for example, word-finding difficulty can lead to slower or more irregular speech patterns. And, although not directly related to speech, PD also can affect non-verbal cues that form a large part of communication. Decreased facial expression and general movement, along with stooped posture, could further impair a person's ability to show his or her thoughts and emotions. Speech disturbances not only lead to difficulty communicating with family and friends, they can lead to social withdrawal, limiting participation in hobbies or other activities and impacting one's occupational performance.
Treating Speech Disturbances
Adjustment of Parkinson's medication sometimes helps with speech problems but the cornerstone of treatment is speech therapy. Formal programs, including Lee Silverman Voice Therapy (LSVT) LOUD and Parkinson Voice Project SPEAK OUT! are led by certified speech therapists who teach exercises and techniques to improve the volume and clarity of speech. (SPEAK OUT! also includes cognitive exercises for those who have memory and/or thinking problems.) Communication devices, which enhance or amplify speech, also are available. Examples include everything from microphones and touchpads to gadgets that can prompt a person to increase volume when speech gets quieter.
Swallowing Problems Experienced with Parkinson's
Swallowing difficulties (dysphagia) may include coughing, choking or throat clearing during or after eating or drinking. Some people even experience a sensation after swallowing that food is getting "stuck" as it goes down.
Evaluating and Managing Swallowing Disturbances
When any of these symptoms arises, doctors may order a special imaging test -- either a videofluoroscopic swallowing study or a modified barium swallow study -- to determine where the problem is occurring (the mouth and/or throat) and if liquids or solids are going into the airway instead of the stomach (i.e., a person is "aspirating"). Based on the results, a person may be referred to a speech and swallowing therapist. This specialist performs a detailed evaluation of how well liquids and solids of different consistencies are tolerated and then makes recommendations to improve swallowing and lessen the risk of aspirating. These could include dietary modifications -- such as thickening liquids -- and/or behavioral strategies, such as avoiding drinking through straws, tucking the chin to the chest when swallowing or taking smaller bites at slower intervals.
Parkinson's medication adjustments may ease swallowing problems but don't typically alleviate them. As swallowing disturbances pose choking risks, a caregiver may want to learn the Heimlich maneuver. It may never be necessary, but it can be life-saving.
If swallowing issues lead to weight loss (because of inability to maintain adequate nutritional intake), the possibility of placing a feeding tube, such as a Percutaneous Endoscopic Gastrostomy (PEG) tube, may be raised. The decision of whether to pursue this therapy is certainly a personal one and discussion of this treatment may stimulate a bigger conversation about overall management goals and treatment strategies, particularly as related to quality of life. Evaluating current and future directions of care, especially as disease progresses and new symptoms may develop, is always a good idea.
When swallowing disturbances occur, drooling (sialorrhea) might present a problem as well. People with Parkinson's tend to swallow less frequently so saliva accumulates, leading to drooling. This can be embarrassing and can limit one's social interactions.
Keeping the chin up and lips closed when not speaking or eating can reduce drooling, but this may be challenging for those with advancing PD when the neck and shoulders may be flexed forward and the mouth automatically open at rest. Physical and occupational therapy exercises can address postural issues and sugar-free candy is helpful to stimulate swallowing.
Some medications also are beneficial to target drooling. Anticholinergic drugs -- such as Artane (trihexyphenidyl) -- actually cause dry mouth as a side effect, so these might be added to treat drooling as well as PD symptoms (they work best for tremor). Unfortunately these types of medications can cause many other side effects (e.g., constipation, memory problems, sleepiness), especially in older people, so the possible benefits must be carefully weighed against risks. Another medication that can have similar potential adverse effects but may help drooling is an antidepressant called Elavil (amitriptyline). In some cases, drugs such as Robinul (glycopyrrolate) are prescribed or Botox or Myobloc (botulinum toxin) is injected into the salivary glands specifically to target drooling.