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

The profile of gastrointestinal dysfunction in prodromal to late-stage Parkinson's disease

Gastrointestinal dysfunction (GID) may play a key role in Parkinson's disease (PD) but its relationship with disease progression remains unclear. We recruited 404 PD cases, 37 iRBD (isolated REM Sleep Behaviour Disorder) and 105 controls. Participants completed the Gastrointestinal Dysfunction Scale for PD (GIDS-PD) and standardised disease severity assessments. Whole gut transit time (WGTT) was measured by ingestion of blue dye and recorded time to blue stools appearance ('Blue Poop Challenge') in a subset of PD cases. Gastrointestinal symptoms were more common and prevalent in iRBD and PD versus controls, and WGTT was significantly higher in PD versus controls. After adjustment for confounding factors, disease stage was not a significant predictor of GIDS-PD Constipation or Bowel Irritability scores. Longitudinal assessment of GIDS-PD scores and WGTT confirmed stability over a 4 year period. Bowel dysfunction may be a phenotypic feature in a subset of Parkinson's with implications for patient stratification and management.

Factors influencing oropharyngeal dysphagia in individuals with chronic neurological disorders presenting to the outpatient swallowing disorder clinic

BACKGROUND

This study aims to evaluate neurogenic dysphagia in individuals with various neurological disorders.

METHOD

A prospective cross-sectional study was conducted adults with Multiple Sclerosis (MS), stroke, or Parkinson's Disease (PD) who presented with dysphagia. Assessments included the Functional Oral Intake Scale (FOIS) for dietary status, the Flexible Endoscopic Evaluation of Swallowing (FEES) with Penetration-Aspiration Scale (PAS) for swallowing function, and the Eating Assessment Tool (EAT-10) and Swallow Quality of Life Questionnaire (SWAL-QOL) for dysphagia severity and swallowing/eating-related quality of life (SRQoL), respectively. Statistical analyses included ANOVA.

RESULTS

The study included 105 participants with MS, stroke, and PD groups. SWAL-QOL scores were significantly higher in the MS and PD groups compared to the stroke group (p = 0.001). Stroke patients had the most severe overall swallowing difficulties, while MS patients experienced the highest rate of aspiration (37 %). Fatigue levels were significantly higher in the MS and PD groups (p = 0.001), and social function scores were lowest in the stroke group (p = 0.041). No significant differences were observed in eating desire, fear of eating, sleep quality, communication, or EAT-10 scores across the groups.

CONCLUSION

This study highlights the differential impact of neurogenic dysphagia on swallowing function and SRQoL. Although dysphagia is a known issue in acute neurological conditions such as strokes, individuals with progressive diagnoses such as MS should be referred to swallowing clinics at an early stage, keeping in mind that it can lead to serious consequences that can affect their quality of life.

Change in Feeding and Swallowing Function in Elderly Patients with Isolated Hospitalization for COVID-19: A Retrospective Cohort Study

BACKGROUND

Isolation was implemented for elderly patients with coronavirus disease 2019 (COVID-19), which interrupted care including oral intake support.

OBJECTIVE

To assess the changes in feeding and swallowing function measured by the functional oral intake scale (FOIS) and their association with post-discharge mortality in elderly COVID-19 patients.

DESIGN

Single-center retrospective cohort study.

PARTICIPANTS

We included patients aged ≥ 65 years and admitted for COVID-19 between December 1, 2021 and March 31, 2023. Those with FOIS before onset (pre-FOIS) 1-3 were excluded.

MAIN MEASURES

We measured FOIS (1-7, 1: no oral intake, 7: normal) before onset and at discharge, and assessed mortality for 180 days after onset. The primary outcome was decrease in FOIS during hospitalization; in-hospital mortality was assumed as 4-level decreases in FOIS. The secondary outcome was 180-day mortality. Association of each pre-FOIS (6, 5, 4) relative to pre-FOIS 7 with the primary outcome was estimated as adjusted common odds ratios (ORs) and 95% confidence intervals (CIs). Association of decreases in FOIS with 180-day mortality was assessed with Kaplan-Meier curve.

KEY RESULTS

We included 337 patients whose median age was 81 years, and 56% of them were men. The distribution of pre-FOIS was 7 (190 patients), 6 (89), 5 (40), and 4 (18). The severity of COVID-19 was generally similar among pre-FOIS levels. The pre-FOIS was significantly associated with decreases in FOIS: adjusted common OR 2.23 [95%CI 1.27-3.92] for pre-FOIS 6, 2.96 [1.46-6.05] for pre-FOIS 5, 2.89 [1.14-7.40] for pre-FOIS 4. The degree of decrease in FOIS was significantly associated with 180-day mortality: no decrease, 4.7%; 1-level decrease, 1.2%; 2-level decrease, 27.9%; 3-level decrease, 46.0%.

CONCLUSIONS

Lower pre-FOIS was associated with further decreases in FOIS in elderly patients who were isolated due to COVID-19, and the degree of decrease was further associated with post-discharge mortality.

Validation of the DIGEST-FEES as a Global Outcome Measure for Pharyngeal Dysphagia in Parkinson's Disease

Flexible Endoscopic Evaluation of Swallowing (FEES) is one of two diagnostic gold standards for pharyngeal dysphagia in Parkinson's disease (PD), however, validated global outcome measures at the patient level are widely lacking. The Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) represents such an outcome measure but has been validated primarily for head and neck cancer collectives. The objective of this study was, therefore, to investigate the validity of the DIGEST-FEES in patients with PD. Content validity was evaluated with a modified Delphi expert survey. Subsequently, 66 FEES videos in PD patients were scored with the DIGEST-FEES. Criterion validity was determined using Spearman's correlation coefficient between the DIGEST-FEES and the Penetration-Aspiration Scale (PAS), the Yale-Residue-Rating-Scale, the Functional-Oral-Intake-Scale (FOIS), and the swallowing-related Unified-Parkinson-Disease-Rating-Scale (UPDRS) items. Inter-rater reliability was determined using 10 randomly selected FEES-videos examined by a second rater. As a result, the overall DIGEST-FEES-rating exhibited significant correlations with the Yale-Valleculae-Residue-Scale (r = 0.84; p < 0.001), the Yale-Pyriform-Sinus-Residue-Scale (r = 0.70; p < 0.001), the FOIS (r =  - 0.55, p < 0.001), and the UPDRS-Swallowing-Item-Score (r = 0.42, p < 0.001). Further, the DIGEST-FEES-safety subscore correlated with the PAS (r = 0.63, p < 0.001). Inter-rater reliability was high for the overall DIGEST-FEES rating (quadratic weighted kappa of 0.82). Therefore, DIGEST-FEES is a valid and reliable score to evaluate overall pharyngeal dysphagia severity in PD. Nevertheless, the modified Delphi survey identified domains where DIGEST-FEES may need to be specifically adapted to PD or neurological collectives in the future.

Parkinson's Disease and Diabetes Mellitus: Synergistic Effects on Pathophysiology and GI Motility

PURPOSE OF REVIEW

Parkinson's disease and diabetes affect an increasing proportion of the aging global population. Both conditions extensively affect gastrointestinal (GI) motility with similar and differing clinical symptoms. Nonetheless, GI symptoms in Parkinson's disease and diabetes pose significant morbidity and impairment of quality of life. Their pathophysiology is poorly understood, and therefore, effective treatment options are lacking.

RECENT FINDINGS

Parkinson's disease patients have oropharyngeal dysphagia and constipation. They also have mild or absent upper GI symptoms associated with delayed gastric emptying, which is prevalent in 70% of patients. Delayed gastric emptying in Parkinson's disease leads to erratic medication absorption and fluctuating motor symptoms. Half of diabetics have upper GI symptoms, which correlate to gastric emptying and changes in brain activity of the insular cortex. The majority of diabetics also have constipation. Diabetics have an increased risk for developing Parkinson's disease and anti-diabetic medications are associated with risk reduction of developing Parkinson's disease. Hyperglycemia is associated with advanced glycated end products formation and acceleration of α-synuclein aggregation. GLP-1 receptor agonists have also demonstrated efficacy in improving motor symptoms and cognition in Parkinson's disease patients with diabetes. Parkinson's disease and diabetes are pan-enteric disorders with significant GI symptoms and impairment of gut motility. Both conditions have synergistic pathophysiologies that propagate neurodegenerative changes. Treatment options for GI symptoms in diabetic and Parkinson's disease patients are lacking. Anti-diabetic treatment improves motor symptoms in Parkinson's disease, however, its effect on GI symptoms is unclear.

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.

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.

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.