A multinational consensus on dysphagia in Parkinson's disease: screening, diagnosis and prognostic value

Evaluation Methods of Dysphagia in Adults With Intellectual Disability: A Scoping Review

Dysphagia is a serious but underdiagnosed health-related condition in people with intellectual disability (ID). In this scoping review, we provide an overview of dysphagia evaluation methods used in adults with ID. The data from 31 studies were analyzed qualitatively by identifying the evaluation methods and the validity and reliability of the methods. To summarize, dysphagia has been evaluated in many ways and for different purposes. The most common evaluation method was a videofluorographic swallowing study (VFSS). Four of the reviewed methods were found to be valid and reliable in detecting swallowing problems in adults with ID.

Interoception in Parkinson's disease: A narrative review and framework for translational research

Parkinson's disease (PD) is the second most common, and the fastest growing, neurodegenerative disease worldwide. Non-motor manifestations, particularly autonomic nervous system dysfunction, are common throughout the disease course, in some cases preceding motor symptom onset by years, and are often more disabling and harder to treat than motor symptoms and contribute significantly to disability. An understudied consequence of autonomic and visceral dysfunction in PD is interoception, the neural processing of internal organ system signals. Interoceptive processes form a foundational body-brain interface, mediating basic homeostatic reflexes and complex physiologic and behavioral adaptive responses to internal perturbations. Emerging evidence exists that interoception is impaired in some individuals with PD, potentially explaining why those who have objective evidence of autonomic dysfunction do not always report typical symptoms. Failure to recognize these impairments may lead to missed opportunities for early intervention, particularly in addressing 'silent' autonomic disturbances (e.g., orthostatic hypotension leading to sudden falls, dysphagia leading to aspiration pneumonia). In this narrative review, we synthesize current findings on the neuroanatomical networks underlying interoception, examine clinical manifestations of interoceptive dysfunction across multiple organ systems in PD, and identify key gaps in knowledge. We propose a translational research framework to enhance early detection, symptom management, and intervention strategies for PD. This framework integrates cognitive, mood, and autonomic dysfunctions with clinical factors (disease stage, duration, motor subtype, levodopa status) to understand interoceptive dysfunction within a translational model. This approach highlights novel opportunities for personalized care and improved therapeutic interventions in PD.

Correlation between voice intensity and swallowing function in subjects with Parkinson's disease

INTRODUCTION

People with Parkinson's Disease (PD) experience reduced voice intensity and dysphagia. Organs related to voice production and swallowing are structurally and neurologically intertwined. Thus, instrumental voice assessment may be useful in identifying voice impairments that can show swallowing disorders. Timely assessment of swallowing disorders may prevent the occurrence of malnutrition, dehydration, pneumonia, and death.

OBJECTIVE

The aim of this study was to investigate the relationship between voice intensity and swallowing function in PD.

METHODS

30 participants with PD were recruited. Motor disability was evaluated by the Unified Parkinson's Disease Rating Scale part III; voice intensity was assessed by PRAAT software during sustained /a/ and 1 min of monologue. The Penetration Aspiration Scale, the Dysphagia Outcome Severity Scale, and the Videofluoroscopic Dysphagia Scale were used to assess swallowing during videofluoroscopy. Spearman correlation coefficients, logistic, and linear models were used to analyze data.

RESULTS

Voice intensity correlated with swallowing: as voice intensity decreased, swallowing function deteriorated (Spearman coefficients from -0.42 to -0.72 across scales), and this holds even when adjusted for MDS-UPDRS motor scores. Swallowing impairment is 56 times more likely (p<0.01) when the voice intensity is below the normal cut-off score (60 dB) with a positive predictive value of 93%.

CONCLUSIONS

Reduction in voice intensity is indicative of a higher risk of swallowing dysfunction. Thus, an instrumental voice analysis seems to be a non-invasive, lowcost, easy-to-use tool to identify people with PD in need of an assessment to allow for timely swallowing management and reduction of complications caused by dysphagia.

Identifying High-Quality Non-Instrumental Dysphagia Screening Tools for Detection of Adult Dysphagia Case in Acute-Care Settings: A Systematic Review

INTRODUCTION

As patients nowadays tend to have multiple diseases and complex medical histories, our aim was to identify high-quality, non-instrumental dysphagia screening tools used for the detection of adult dysphagia cases in all disease categories in acute-care settings.

METHOD

A literature search was conducted in five databases from each database's earliest inception to 31 July 2021 and guided by five keywords: 'dysphagia', 'deglutition', 'screening', 'test' and 'measure'. Without limiting the search in any specific disease category, reviewers assessed original studies and identified tools if they had been validated against instrumental evaluations and if they had been designed as a pass-fail procedure to screen whether dysphagia is absent or present. We further excluded any tool if it was (1) for pediatric focus, or (2) a patient self-report questionnaire. All final tool candidates underwent a methodological quality appraisal using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

RESULT

Out of 195 studies with 165 tools identified, 20 tool candidates underwent QUADAS-2 review. We found six high-quality, non-instrumental screening tools for detecting adult dysphagia cases in acute-care settings, including the Yale Swallow Protocol, Gugging Swallowing Screen, Toronto Bedside Swallowing Screening Test (both English and Portuguese versions), Sapienza Global Bedside Evaluation of Swallowing and Two-Step Thickened Water Test. These high-quality tools were developed primarily for patients with stroke. Only Yale Swallow Protocol was originally tested for heterogeneous populations with stroke, multiple sclerosis, traumatic brain injury, oesophageal surgery, neurosurgery and head-and-neck cancer.

CONCLUSIONS

The results highlight the gap in the unavailability of high-quality dysphagia screening tool in several emerged high-risk populations including elderly inpatients, or patients following endotracheal extubation. Further research is needed to determine whether these six tools can be effectively applied across different high-risk populations in acute-care settings to screen for cases finding.

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.

Pharyngeal adaptation to bolus properties in patients with Parkinson's disease

PURPOSE

Dysphagia is common in people with Parkinson's disease (PD). Yet, literature describing swallow function in PD using high-resolution manometry is limited. This study explored swallowing pressure metrics for varied bolus conditions in people with PD.

METHOD

A solid-state unidirectional catheter was used to acquire manometric data for triplicate swallows (5 ml, 10 ml, 20 ml; IDDSI 0, 2 & 4). Penetration-aspiration severity was rated during videofluoroscopy. Patient-reported measures included PDQ-8: Parkinson's Disease Questionnaire-8 and EAT-10: Eating Assessment Tool-10. Quantitative manometric swallow analysis was completed through Swallow Gateway™. Metrics were compared to published normative values and generalized linear model tests explored modulatory effects.

RESULTS

21 participants (76% male; mean age 69.6 years, SD 7.1) with mild-moderate severity PD were studied. Two patients (9%) aspirated for single bolus thin liquid and paste trials and 15 patients (73%) scored > 3 EAT-10. Standardized PDQ-8 scores correlated with EAT-10 (p < 0.05). Abnormality in UES relaxation and distension was demonstrated by high UES integrated relaxation pressure and low UES maximum admittance (UES MaxAdm) values across varied bolus conditions. Participants demonstrated abnormally elevated pharyngeal contractility and increased post-swallow upper-esophageal sphincter (UES) contractility for thinner liquid trials. Alterations in volume and viscosity had significant effects on the bolus timing metric-distention to contraction latency. UES peak pressure measures were altered in relation to bolus viscosity.

CONCLUSION

This study identifies early pharyngoesophageal contractile changes in relation to bolus volume and viscosity in PD patients, associated with subtle deterioration of self-reported swallow scores. Manometric evaluation may offer insight into PD-related swallowing changes and help optimize diagnostics and treatment planning.

The discriminant ability of the Eating Assessment tool-10 to detect swallowing efficiency in neurogenic dysphagia

PURPOSE

Neurogenic dysphagia causes complications such as malnutrition, dehydration, and aspiration pneumonia. Therefore, early detection with clinically valid tools is essential. This study aimed to investigate the Eating Assessment Tool-10 (EAT-10) ability to detect swallowing efficiency at three different consistencies in neurogenic dysphagia.

METHODS

One hundred twelve patients with neurogenic dysphagia (74 males and 38 females, mean ± SD age 61.83 ± 9.72 years) were included in the study. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed in the clinic following EAT-10 to assess swallowing efficacy at International Dysphagia Diet Standardization Initiative (IDDSI) consistencies of 0, 3, and 7. The swallowing efficiency of the patients was assessed using the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS). Area under the curve, sensitivity, and specificity values were calculated to evaluate the ability of EAT-10 to discriminate between participants with and without residue and between participants with and without moderate-to-severe residue.

RESULTS

The EAT-10 significantly detected participants with and without residues for three IDDSI consistent: for IDDSI 0 residue in the vallecula and pyriform sinus (cutoff score ≥ 14, p < 0.001), for IDDSI 3 residue in the vallecula and pyriform sinus (cutoff score ≥ 13, p < 0.001), for IDDSI 7 residue in the vallecula and pyriform sinus (respectively, cutoff score ≥ 13, cutoff score ≥ 14, p < 0.001). Additionally, the EAT-10 significantly detected those with and without moderate-to-severe residue.

CONCLUSIONS

The EAT-10, frequently used in swallowing clinics, can determine swallowing efficiency in individuals with neurogenic dysphagia. Additionally, it has the power to detect moderate-to-severe pharyngeal residue.

Parkinson's disease is associated with low striated esophagus contractility potentially contributing to the development of dysphagia

BACKGROUND

Parkinson's disease (PD) is the second most common neurodegenerative disorder, and more than 80% of PD patients will develop oropharyngeal dysphagia. Despite its striated histology, proximity to airway, and potential negative impact of its dysfunction on bolus transport and airway safety, the contractile function of the striated esophagus in PD patients has not been systematically studied.

METHODS

Using our repository of clinical manometry and the Milwaukee ManoBank, we analyzed high-resolution manometry (HRM) studies of 20 PD patients, mean age 69.1 (range 38-87 years); 30 non-PD patients with dysphagia, mean age 64.0 (44-86 years); and 32 healthy volunteers, mean age 65.3 (39-86 years). Patients with abnormal findings based on Chicago Classification 4.0 were identified. Repeat analysis was performed in 20% of the manometric tracings by a different investigator with inter-rater concordance between 0.91 and 0.99.

KEY RESULTS

The striated esophageal contractile integral in PD patients was significantly lower than that in non-PD dysphagic patients and healthy controls (p = 0.03 and <0.01, respectively). This significant difference persisted after excluding patients with concurrent Chicago Classification motility disorders (p = 0.02 and 0.01, respectively). In both analyses, the distal esophageal contractile integral did not show any significant difference between groups (p = 0.58 and 0.93, respectively).

CONCLUSIONS & INFERENCES

PD is associated with a significant decrease in striated esophagus contractility compared to non-PD and healthy controls. This finding may play a pathophysiologic role in development of dysphagia in this patient population.

User-centred design, validation and clinical testing of an anti-choking mug for people with Parkinson's disease

Oropharyngeal dysphagia, or difficulty initiating swallowing, is a frequent problem in people with Parkinson's disease (PD) and can lead to aspiration pneumonia. The efficacy of pharmacological options is limited. Postural strategies, such as a chin-down manoeuvre when drinking, have had some degree of success but may be difficult for people who have other limitations such as dementia or neck rigidity, to reproduce consistently. Using a user-centred design approach and a multidisciplinary team, we developed and tested an anti-choking mug for people with PD that helps angle the head in the optimum position for drinking. The design reflected anthropometric and ergonomic aspects of user needs with features including regulation of water flow rate and sip volume, an inner slope, a thickened handle and a wide base, which promoted a chin-down posture when used. Prototype testing using digital technology to compare neck flexion angles (the primary outcome), plus clinical outcomes assessed using standard tools (Swallowing Clinical Assessment Score in Parkinson's Disease (SCAS-PD) and Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Parts II and III), found significant improvements in a range of parameters related to efficient swallowing and safe drinking when using the anti-choking mug versus a sham mug.

Comprehensive assessment and treatment strategies for dysphagia in the elderly population: Current status and prospects

As the population ages, the prevalence of dysphagia among older adults is a growing concern. Age-related declines in physiological function, coupled with neurological disorders and structural changes in the pharynx associated with aging, can result in weakened tongue propulsion, a prolonged reaction time of the submental muscles, delayed closure of the laryngeal vestibule, and delayed opening of the upper esophageal sphincter (UES), increasing the risk of dysphagia. Dysphagia impacts the physical health of the elderly, leading to serious complications such as dehydration, aspiration pneumonia, malnutrition, and even life-threatening conditions, and it also detrimentally affects their psychological and social well-being. There is a significant correlation between frailty, sarcopenia, and dysphagia in the elderly population. Therefore, older adults should be screened for dysphagia to identify both frailty and sarcopenia. A reasonable diagnostic approach for dysphagia involves screening, clinical assessment, and instrumental diagnosis. In terms of treatment, multidisciplinary collaboration, rehabilitation training, and the utilization of new technologies are essential. Future research will continue to concentrate on these areas to enhance the diagnosis and treatment of dysphagia, with the ultimate aim of enhancing the quality of life of the elderly population.

Tongue Acupuncture to Treat Dysphagia in Patients with Parkinson's Disease: A Randomized Controlled Trial

Objective

Parkinson's disease (PD) is a chronic degenerative disease that lacks specific treatment. The incidence of dysphagia in patients with PD is 35%-82%. Dysphagia not only affects nutritional intake but also leads to pneumonia, even asphyxia. This study explored the efficacy of tongue acupuncture for treating dysphagia in patients with PD.

Materials and Methods

From March 2021 to June 2023, 64 patients with PD-related dysphagia were chosen from Qingdao Central Hospital and the Affiliated Hospital of Qingdao Binhai University, both in Qindao, Shandong, China. The patients were divided into a tongue acupuncture group (n = 32) and a control group (n = 32). The control group was treated with a VitalStim® 5900 Swallowing Disorder Therapeutic Instrument (CA, USA), and the tongue acupuncture group had tongue acupuncture at Juquan (Ex-HN-10) and Haiquan (Ex-HN-11). Swallowing function and nutritional conditions were compared between the 2 groups after all treatments.

Results

The total clinical effective rate in the tongue acupuncture group was higher than that of the control group (P < 0.05). The proportion of grade 1 and grade 2 of the 5-scaled Kubota drinking-water test in the tongue acupuncture group was significantly higher than that in the control group (78.13 % versus 31.26 %; P < 0.05), and the proportion of grade 3, grade 4, and grade 5 was significantly lower than that in the control group (21.87 % versus 68.74 %; P < 0.05). After tongue acupuncture, levels of body mass index, upper-arm circumference, triceps skinfold thickness, hemoglobin, serum albumin, and prealbumin were significantly higher than those in the control group (P < 0.05) and the incidence of complications caused by PD was significantly lower than that in the control group (P < 0.05).

Conclusions

Treatment of dysphagia in PD by tongue acupuncture significantly improved swallowing function and nutritional level, and decreased the incidence of complications.

The association between methylmalonic acid, a biomarker of mitochondrial dysfunction, and cause-specific mortality in Alzheimer's disease and Parkinson's disease

Background

Alzheimer's disease (AD) and Parkinson's disease (PD) are the leading causes of death among the elderly. Recent research has demonstrated that mitochondrial dysfunction, which is hallmark of neurodegenerative diseases, is a contributor to the development of these diseases.

Methods and materials

Methylmalonic acid (MMA), AD, PD, inflammatory markers and covariates were extracted from the National Health and Nutrition Examination Survey (NHANES). The classification of the inflammatory markers was done through quartile conversion. A restricted cubic spike function was performed to study their dose-response relationship. MMA subgroups from published studies were used to explore the correlation between different subgroups and cause-specific mortality. Multivariable weighted Cox regression was carried out to investigate MMA and cause-specific mortality in patients with AD and PD. Weighted survival analysis was used to study the survival differences among MMA subgroups.

Results

A non-linear correlation was observed between MMA and AD-specific death and PD-specific mortality. The presence of MMA Q4 was linked to increased death rates among AD patients (HR = 6.39, 95%CI: 1.19-35.24, P = 0.03) after controlling for potential confounders in a multivariable weighted Cox regression model. In PD patients, the MMA Q4 (Q4: HR: 5.51, 95 % CI: 1.26-24, P = 0.02) was also related to increased mortality. The results of survival analysis indicated that the poorer prognoses were observed in AD and PD patients with MMA Q4.

Conclusion

The higher level of mitochondria-derived circulating MMA was associated with a higher mortality rate in AD and PD patients. MMA has the potential to be a valuable indicator for evaluating AD and PD patients' prognosis in the clinic.

Investigating Parkinson's disease with dual high resolution pharyngeal manometry with impedance and videofluoroscopy

PURPOSE

To characterize pharyngeal function in people with Parkinson's Disease using both high resolution impedance manometry (HRIM) and videofluoroscopy (VFSS) and to explore correlations between VFSS and HRIM metrics.

METHODS

All participants received both VFSS and HRIM within 24 h-time window. A standard VFSS protocol (IDDSI 0: 1 mL, 3 mL, 20 mL, and 100 mL) was performed. A solid-state unidirectional catheter (36 pressure sensors) was used to acquire manometric data for triplicate swallows (IDDSI 0: 5 mL, 10 mL, 20 mL), quantitative swallow analysis was completed through Swallowtail™ and SwallowGateway™. Parameters were compared to published norms and statistical tests explored correlational associations (p < 0.05).

RESULTS

Twenty-one participants (76% male; mean age 70 years, SD7.16) with mild-moderate severity PD were recruited with 73% reporting Eating Assessment Tool (EAT-10) scores ≥3 indicating swallow impairment. Compared to normal metrics, one third of participants had abnormally elevated hypopharyngeal contractile integral (HPCI), hypopharyngeal peak pressure, upper esophageal sphincter (UES) integrated relaxation pressure (UES IRP), and reduced UES maximum admittance. Five participants showed compromised swallow safety (Penetration-Aspiration Scale score ≥6). One third of participants had abnormal VFSS values for pharyngoesophageal segment (PES) opening duration, maximum PES opening distance, and maximum hyoid displacement measures. Some HRIM metrics had a strong correlation with pharyngeal VFSS measures (r > 0.60, p < 0.05).

CONCLUSION

This study identifies early manometric signs of pharyngeal dysfunction in people with PD. The congruence of the VFSS and HRIM measures confirms the hypothesis of insidious early decline in swallow function in PD despite maintenance of airway safety (i.e., low aspiration rates).

Relationship Between Subjective Questionnaires and Videofluoroscopy of Dysphagia Evaluation: A Systematic Review and Meta-Analysis

BACKGROUND

Early detection of dysphagia is important for preventing aspiration pneumonia. Although videofluoroscopy is currently the primary diagnostic tool for dysphagia, access to this tool may be limited because of radiation exposure risk, high cost, and other factors.

PURPOSE

In this study, a meta-analysis was used to determine the strength of the correlation between dysphagia detection outcomes obtained using subjective questionnaires and videofluoroscopy.

METHODS

The PubMed and Embase databases were searched for original articles up to December 2022. Studies published in English that used cross-sectional designs to assess the correlation between subjective questionnaires and videofluoroscopy were considered eligible for inclusion. The search terms used included "dysphagia," "questionnaire," and "videofluoroscopy." Two reviewers critically appraised and extracted the correlation coefficient r values. In addition, a random-effects meta-analysis was conducted. The Q statistic was used to assess the heterogeneity among the included studies. Publication bias was checked using the funnel plot and Egger's tests. Multilevel analysis was used to determine sensitivity to consider within-study correlations. In addition, subgroup analyses were conducted based on type of questionnaire, head and neck cancer, and English-speaking regions.

RESULTS

The meta-analysis included five studies and 856 patients using the Eating Assessment Tool-10 and one study and 27 patients using the Sydney Swallow Questionnaire. The results of the random-effects meta-analysis showed a moderate relationship between the subjective questionnaires and videofluoroscopy ( r = .35, 95% CI [0.20, 0.48]). Similar results were also obtained using multilevel analysis ( r = .34, 95% CI [0.25, 0.42]). No publication bias was found for any of the studies ( p = .88). In the subgroup analyses, a moderate relationship between Eating Assessment Tool-10 and videofluoroscopy ( r = .31, 95% CI [0.19, 0.42]) and an ultrahigh relationship between Sydney Swallow Questionnaire and video-fluoroscopy ( r = .74, 95% CI [0.50, 0.87]) were found. Furthermore, moderate associations were observed within each head and neck cancer and English-speaking regions subgroup. However, no significant differences were found between these two subgroups.

CONCLUSIONS

These results indicate the subjective questionnaires considered in this study share a moderate relationship with videofluoroscopy. Subjective questionnaires may be used as an auxiliary tool by nurses and homecare givers for the early assessment of dysphagia risk in patients.

Research hotspots and frontiers in post-stroke dysphagia: a bibliometric analysis study

Background

Dysphagia is a common complication of stroke that can result in serious consequences. In recent years, more and more papers on post-stroke dysphagia have been published in various journals. However, there is still a lack of bibliometric analysis of post-stroke dysphagia. This study visually analyzes the global research situation of post-stroke dysphagia from 2013 to 2022, aiming to explore the current research status, frontier trends, and research hotspots in this field.

Methods

Articles and reviews relevant to post-stroke dysphagia were obtained and retrieved from the Web of Science core collection database in the last 10 years (from 2013 to 2022). CiteSpace and Microsoft Excel 2019 were used for bibliographic analysis.

Results

A total of 1,447 articles were included in the analysis. The number of publications showed an overall upward trend, from 72 in 2013 to 262 in 2022. The most influential authors, institutions, journals, and countries were Hamdy S, University of London, Dysphagia, and the People's Republic of China. An analysis of keywords and the literature indicated that current studies in the field of post-stroke dysphagia focused on dysphagia and aspiration, dysphagia classification, dysphagia rehabilitation, and daily living.

Conclusion

This bibliometric analysis reveals the latest advancements and emerging trends in the field of post-stroke dysphagia, spanning the years 2013 to 2022. It highlights the paramount importance of conducting large-scale randomized controlled trials examining the efficacy of dysphagia screening protocols and non-invasive intervention techniques in improving the quality of life for these patients. Such research efforts hold significant academic implications for the development of evidence-based treatment strategies in this field.

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.

Clair KA, Toledo S, York MK, Todaro R, Yarab N, Wallock K. Delivering Multidisciplinary Rehabilitation Care in Parkinson's Disease: An International Consensus Statement

BACKGROUND

Parkinson's disease (PD) is a complex neurodegenerative disorder impacting everyday function and quality of life. Rehabilitation plays a crucial role in improving symptoms, function, and quality of life and reducing disability, particularly given the lack of disease-modifying agents and limitations of medications and surgical therapies. However, rehabilitative care is under-recognized and under-utilized in PD and often only utilized in later disease stages, despite research and guidelines demonstrating its positive effects. Currently, there is a lack of consensus regarding fundamental topics related to rehabilitative services in PD.

OBJECTIVE

The goal of the international Parkinson's Foundation Rehabilitation Medicine Task Force was to develop a consensus statement regarding the incorporation of rehabilitation in PD care.

METHODS

The Task Force, comprised of international multidisciplinary experts in PD and rehabilitation and people directly affected by PD, met virtually to discuss topics such as rehabilitative services, existing therapy guidelines and rehabilitation literature in PD, and gaps and needs. A systematic, interactive, and iterative process was used to develop consensus-based statements on core components of PD rehabilitation and discipline-specific interventions.

RESULTS

The expert-based consensus statement outlines key tenets of rehabilitative care including its multidisciplinary approach and discipline-specific guidance for occupational therapy, physical therapy, speech language pathology/therapy, and psychology/neuropsychology across all PD stages.

CONCLUSIONS

Rehabilitative interventions should be an essential component in the comprehensive treatment of PD, from diagnosis to advanced disease. Greater education and awareness of the benefits of rehabilitative services for people with PD and their care partners, and further evidence-based and scientific study are encouraged.

The Evaluation of Benzodiazepine-induced Dysphagia Using High-resolution Manometry

We evaluated the pathophysiology of dysphagia considered to be induced by benzodiazepine using high-resolution manometry (HRM). A 53-year-old man with Parkinson disease had had dysphagia for over 3 months. He had been taking several benzodiazepines for more than four years. Two weeks after discontinuation of the benzodiazepines, HRM revealed increased pharyngeal contractility and residual pressure at the upper esophageal sphincter. A video-fluoroscopic swallowing study showed improved pharyngeal bolus passage. Benzodiazepine-induced dysphagia may be due to the muscle relaxant effects on the swallowing muscles and attenuation of the barrier function which prevents reflux from the esophagus into the pharynx.

Exploring the Efficacy of the Effortful Swallow Maneuver for Improving Swallowing in People With Parkinson Disease-A Pilot Study

Objectives

To determine the immediate (compensatory) and longer term (rehabilitative) effect of the effortful swallow (ES) maneuver on physiological swallowing parameters in Parkinson disease.

Design

Virtual intervention protocol via Microsoft Teams with pre- and post-videofluoroscopic swallowing studies.

Setting

Outpatient hospital setting, with intervention performed virtually.

Participants

Eight participants (median age 74 years [63-82])with Parkinson disease (years post onset 3-20) with a Hoehn and Yahr scale score between 2 and 4 (N=8).

Interventions

ES maneuver, initiated using a maximum effort isometric tongue-to-palate press, with biofeedback provided using the Iowa Oral Performance Instrument. The protocol included 30 minute sessions twice daily, 5 days/week for 4 weeks.

Main Outcome Measures

Penetration-Aspiration Scale scores, time-to-laryngeal-vestibule-closure, total pharyngeal residue, and pharyngeal area at maximum constriction as seen on lateral view videofluoroscopy.

Results

No consistent, systematic trends were identified in the direction of improvement or deterioration across Penetration-Aspiration Scale scores, time-to-laryngeal-vestibule-closure, pharyngeal area at maximum constriction, or total pharyngeal residue.

Conclusions

Heterogeneous response to the ES as both a compensatory and rehabilitative technique. Positive response on the compensatory probe was predictive of positive response after rehabilitation.

Chaudhuri's Dashboard of Vitals in Parkinson's syndrome: an unmet need underpinned by real life clinical tests

We have recently published the notion of the "vitals" of Parkinson's, a conglomeration of signs and symptoms, largely nonmotor, that must not be missed and yet often not considered in neurological consultations, with considerable societal and personal detrimental consequences. This "dashboard," termed the Chaudhuri's vitals of Parkinson's, are summarized as 5 key vital symptoms or signs and comprise of (a) motor, (b) nonmotor, (c) visual, gut, and oral health, (d) bone health and falls, and finally (e) comorbidities, comedication, and dopamine agonist side effects, such as impulse control disorders. Additionally, not addressing the vitals also may reflect inadequate management strategies, leading to worsening quality of life and diminished wellness, a new concept for people with Parkinson's. In this paper, we discuss possible, simple to use, and clinically relevant tests that can be used to monitor the status of these vitals, so that these can be incorporated into clinical practice. We also use the term Parkinson's syndrome to describe Parkinson's disease, as the term "disease" is now abandoned in many countries, such as the U.K., reflecting the heterogeneity of Parkinson's, which is now considered by many as a syndrome.

Gastrointestinal Dysfunction in Parkinson's Disease: Neuro-Gastroenterology Perspectives on a Multifaceted Problem

Patients with Parkinson's disease (PD) face a multitude of gastrointestinal (GI) symptoms, including nausea, bloating, reduced bowel movements, and difficulties with defecation. These symptoms are common and may accumulate during the course of PD but are often under-recognized and challenging to manage. Objective testing can be burdensome to patients and does not correlate well with symptoms. Effective treatment options are limited. Evidence is often based on studies in the general population, and specific evidence in PD is scarce. Upper GI dysfunction may also interfere with the pharmacological treatment of PD motor symptoms, which poses significant management challenges. Several new less invasive assessment tools and novel treatment options have emerged in recent years. The current review provides an overview and a practical approach to recognizing and diagnosing common upper and lower GI problems in PD, e.g., dyspepsia, gastroparesis, small bowel dysfunction, chronic constipation, and defecatory dysfunction. Management aspects are discussed based on the latest evidence from the PD and general populations, with insights for future research pertaining to GI dysfunction in PD.

The impact of dysphagia in Parkinson's disease patients treated with levodopa/carbidopa intestinal gel

BACKGROUND

Dysphagia is common in advanced phases of Parkinson disease (PD), and is a risk factor for aspiration pneumonia. Nonetheless, dysphagia has been poorly investigated in PD patients treated with levodopa-carbidopa intestinal gel (LCIG). We aimed to analyze the impact of dysphagia on mortality in LCIG treated patients and its relationship with other PD disability milestones.

METHODS

We retrospectively evaluated 95 consecutive PD patients treated with LCIG. Kaplan-Meier and log-rank test were used to compare mortality in patients with dysphagia from others. Cox regression was used to estimate the impact of dysphagia, age, disease duration, and Hoehn and Yahr (H&Y) on mortality in the entire cohort. Finally, univariate and multivariate regression analyses were used to estimate the association between dysphagia and age, disease duration, H&Y, hallucinations, and dementia.

RESULTS

A significantly higher mortality rate was observed in patients with dysphagia. In the Cox model, dysphagia was the only feature significantly associated with mortality (95%CI 2.780-20.609; p < 0.001). Univariate analyses showed a significant correlation between dysphagia and dementia (OR: 0.387; p:0.033), hallucinations (OR: 0.283; p:0.009), and H&Y score (OR: 2.680; p < 0.001); in the multivariate analysis, only the H&Y stage was associated with the presence of dysphagia (OR: 2.357; p:0.003).

CONCLUSION

Dysphagia significantly increased the risk of death in our cohort of LCIG-treated patients, independently from other relevant features such as age, disease duration, dementia, and hallucinations. These findings support the management of this symptom as a priority in the advanced PD stages, even in people treated with LCIG.

Awareness of Dysphagia-Related Complications and Risks and the Importance of Early Intervention in Patients with Parkinson's Disease: A Qualitative Study

OBJECTIVE

To investigate the awareness of dysphagia-related complications and risks and the importance of early intervention in patients with Parkinson's disease (PD).

METHODS

Using the phenomenological approach of the qualitative study, 18 patients with PD in a Grade A tertiary hospital in Nantong were selected, and semistructured personal in-depth interviews were conducted. The interview content was analyzed using Colaizzi's seven-step method, and the topics and subtopics were further refined.

RESULTS

Awareness of dysphagia-related complications and risks and the importance of early intervention in patients with PD can be summarized into three topics: lack of knowledge about PD and dysphagia, changes in emotional cognition, and low need for early intervention for dysphagia.

CONCLUSIONS

Patients with PD have a low awareness of dysphagia, do not follow any preventative measures, and have difficulty in recognizing the disease symptoms; hence, there is a vital need for early intervention. Medical staff need to create awareness among patients and their families, provide health education through multiple channels, popularize the knowledge of PD complications such as dysphagia, improve patient compliance with respect to medication, regular consultation, and medical treatment, guide the transformation of negative emotions in patients to positive emotions, and help patients with PD to actively prevent dysphagia and other complications and improve their quality of life.

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.

Assessment and treatment of neurogenic dysphagia in stroke and Parkinson's disease

PURPOSE OF REVIEW

Neurogenic dysphagia worsens quality of life and prognosis of patients with different neurological disorders. Management of neurogenic dysphagia can be challenging. This review provides a comprehensive overview of current evidence on screening, diagnosis, and treatment of neurogenic dysphagia in stroke and Parkinson's disease, suggesting clues for clinical practice.

RECENT FINDINGS

The pros and cons of diagnostic techniques are discussed in the light of updated evidence. Findings from recent meta-analyses of different treatment approaches, including traditional dysphagia therapy, peripheral and central neurostimulation techniques, and treatment with botulinum toxin, are critically discussed, emphasizing inconsistencies and controversial issues.

SUMMARY

Screening tests and clinical swallow examination should be routinely performed in neurological patients at risk for dysphagia. In patients testing positive for dysphagia, first-line instrumental investigations, represented by fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallow study, should be performed to confirm the presence of dysphagia, to assess its severity, and to inform the treatment. Second-line and third-line instrumental methods can be used in selected patients to clarify specific pathophysiological aspects of oropharyngeal dysphagia. Treatment strategies should be personalized, and combination of traditional dysphagia therapy with innovative treatment approaches may increase the chance of restoring effective and safe swallowing.

Cardiac sympathetic denervation could be associated with dysphagia in Parkinson's disease

Background

Dysphagia is an important non-motor symptom that is closely associated with quality of living and mortality in Parkinson's disease (PD). However, the pathophysiology of dysphagia in PD remains inconclusive. We tried to confirm whether the occurrence of dysphagia could be related to sympathetic degeneration using cardiac 123I-metaiodobenzylguanidine (MIBG) scintigraphy.

Methods

We prospectively recruited 27 PD patients and classified them into two groups (PD with dysphagia vs. PD without dysphagia) by Swallowing Disturbance Questionnaire (SDQ) score and compared the clinical characteristics, videofluoroscopic swallowing study (VFSS) findings and parameters from cardiac MIBG scintigraphy.

Results

The mean early and late H/M ratios were significantly lower in the PD with dysphagia group than those in the PD without dysphagia group (1.39 ± 0.21 vs. 1.86 ± 0.21, p &lt; 0.01; 1.26 ± 0.18 vs. 1.82 ± 0.29, p &lt; 0.01). In the correlation analysis, both the early and late H/M ratios were negatively correlated with the SDQ score and total VDS score (r = −0.65, p &lt; 0.01; r = −0.53, p &lt; 0.01; r = −0.65, p &lt; 0.01, r = −0.58, p &lt; 0.01).

Conclusion

We confirmed that cardiac sympathetic denervation might be associated with the presence and severity of dysphagia. This finding indicates that dysphagia in PD could be associated with a nondopaminergic mechanism.

The prevalence and associated factors of dysphagia in Parkinson's disease: A systematic review and meta-analysis

Background

The prevalence and associated factors of dysphagia in Parkinson's disease (PD) are different in studies conducted in different countries. The purpose of our systematic review and meta-analysis was to evaluate the prevalence of dysphagia in PD and to clarify its associated factors.

Methods

Two researchers systematically searched PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang Database, SinoMed and VIP databases and manually searched references in the retrieved articles to identify potential research subjects. The last search was conducted on June 28, 2022. Finally, a total of 58 studies including 60 observations with 20,530 PD patients were included in our meta-analysis.

Results

The meta-analysis estimated that the pooled prevalence rate of dysphagia in PD was 36.9% (95% CI: 30.7–43.6%) and instrumental examination showed a higher prevalence (57.3%, 95% CI: 44.3–69.1%). Oceania showed the highest prevalence of dysphagia in PD (56.3%) compared to Africa (39.5%), Asia (38.6%), Europe (36.1%) and America (28.9%). Dysphagia in PD was associated with older age, lower body mass index, longer disease duration, higher Hoehn and Yahr stage and levodopa equivalent daily dose, PIGD subtype, severe motor symptoms, drooling and higher levels of depression, and lower quality of life.

Conclusions

In conclusion, our meta-analysis showed that dysphagia occurs in more than one-third of PD patients and was associated with several demographic characteristics and PD-related characteristics, motor symptoms, non-motor symptoms, as well as decreased quality of life. It deserves early screening, diagnosis, and treatment in clinical practice to prevent serious complications from dysphagia.

Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project

Background

Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN—with weight loss and mortality.

Methods

A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff.

Results

The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31–1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments.

Conclusions

Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.

Intestinal Transit in Early Moderate Parkinson’s Disease Correlates with Probable RBD: Subclinical Esophageal Dysmotility Does Not Correlate

Background

Nonmotor symptoms, including constipation and dysphagia, are very common in Parkinson's disease (PD) and Lewy pathology is widespread in the gastrointestinal tract, particularly in the lower esophagus. Constipation and REM sleep behavior disorder (RBD) may present prior to clinical diagnosis. Yet, little is known about esophageal dysfunction and its connection to constipation in early PD.

Objective

This study aimed to investigate esophageal and colonic transit in early moderate PD and to study correlations between symptoms and objective measures.

Methods

Thirty early moderate PD patients and 28 healthy controls (HC) were included in this cross-sectional study. Esophageal transit times were determined by esophageal scintigraphy and colonic transit times by CT after radio-opaque marker ingestion. Olfaction tests, clinical evaluation, and nonmotor questionnaires were also performed.

Results

Distal esophageal transit times and colonic transit times were both significantly prolonged in the PD group compared to HC (p < 0.05 andp < 0.01, respectively) and a moderate-strong positive correlation was found between colonic transit time (CTT) and RBDSQ score (r = 0.61,p < 0.001). Significant correlations were also found between CTT and SCOPA-AUT scores as well as between CTT and ROME III functional constipation scores.

Conclusion

Colonic transit correlates with probable RBD and is more severely prolonged in early moderate PD than is the distal esophageal transit time.

The Preventive Effect of Dysphagia Screening on Pneumonia in Acute Stroke Patients: A Systematic Review and Meta-Analysis

(1) Background: Dysphagia is common in acute stroke patients and is a major risk factor for aspiration pneumonia. We investigated whether the early detection of dysphagia in stroke patients through screening could prevent the development of pneumonia and reduce mortality; (2) Methods: We searched the PubMed, Embase, Cochrane Library, and Scopus databases for relevant studies published up to November 2021. We included studies that performed dysphagia screening in acute stroke patients and evaluated whether it could prevent pneumonia and reduce mortality rates. The methodological quality of individual studies was evaluated using the Risk Of Bias In Non-randomized Studies of Interventions tool, and publication bias was evaluated by the funnel plot and Egger’s test; (3) Results: Of the 6593 identified studies, six studies met the inclusion criteria for analysis. The screening group had a significantly lower incidence of pneumonia than the nonscreening group did (odds ratio (OR), 0.60; 95% confidence interval (CI), 0.42 to 0.84; p = 0.003; I², 66%). There was no significant difference in mortality rate between the two groups (OR, 0.61; 95% CI, 0.33 to 1.13; p = 0.11; I², 93%); (4) Conclusions: Early screening for dysphagia in acute stroke patients can prevent the development of pneumonia.