1. PARKINSON’S DISEASE Rebecca L. Gould, MSC, CCC-SLP rebec26050@aol.com (561) 833-2090 www. med-speech.com

2. Parkinson’s Disease impacts voice and swallowing WHY?

3. THE LARYNX

4. Functions of the Larynx breathing thoracic fixation coughing swallowing voice/phonation

5. “More than 15 million Americans have some degree of dysphagia, and with regular treatment 83% recover or significantly improve”. Bello, J. (1994) compiled by Communication Facts. ASHA Research Division RLG

6. SWALLOWING STAGES BY PHASE Oral Phase Food enters oral cavity Mastication and bolus formation RLG

7. SWALLOWING STAGES BY PHASE (cont’d) Oro-pharyngeal Phase Tongue elevates and propels bolus to pharynx. Soft palate elevates to seal nasopharynx. Larynx and hyoid bone move anterior and upward. Epiglottis moves posteriorly and downwards to close. Respiration stops. Pharynx shortens. RLG

8. SWALLOWING STAGES BY PHASE (cont’d) Esophageal Phase Upper esophageal sphincter relaxes. Bolus passes to esophagus. Esophageal contracts sequentially. Lower esophageal sphincter relaxes. Bolus reaches stomach. RLG

9. “Radical dietary changes and artificial feeding are drastic measures by any standards”. M.J. Feinberg, MD (1990) RLG

10. RESIDUAL Leftover material in the oral pharynx after swallow has occurred.

11. PENETRATION Entry of material into the laryngeal vestibule to the level of the vocal folds.

12. ASPIRATION Entry of material below the level of true vocal folds.

13. Incidence and patient characteristics associated with silent aspiration in the acute care setting Coughing is a physiologic response to aspiration in normal healthy individuals. No cough in response to aspiration silent aspiration Smith, C.H. et al (1999)

14. Gurgly vocal quality predictive of who will aspirate on VFSS Linden (1993)

15. SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED FACTORS Multiple or progressive disease/one diagnosis Multiple medications (>5)/ <5 medications NPO (PEG)/ oral Oral hygiene fair – poor/ good – excellent Smoker / non-smoker RLG

16. SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED (cont’d) FACTORS Inpatient / outpatient Physical ability (mobile)/ sedentary Reflexive cough (present) / absent – delayed Cognitive status (fair-poor)/ good – excellent Secretion Pooling (minimal) / copious RLG

17. SCALE PREDICTIVENESS OF PNEUMONIA RISK IF FED (cont’d) Score < 7=Use extreme caution 5 – 6=fair – good <3=good – excellent RLG

18. General Postural/ Feeding Instructions Upright, 90 degree position Concentrate on each swallow Take full tsp. Pause between bites/sips

19. General Postural/ Feeding Instructions (cont’d) Alternate liquid/dry swallows Refrain from talking while chewing/swallowing Chew each bite thoroughly Hold breath, swallow high and hard, swallow again

21. COMMUNICATION “MUTUAL UNDERSTANDING OF SHARED INFORMATION”

22. Relative vocal loudness level of an individual with Parkinson’s Disease Shout Loud Normal loudness Soft Very soft »Vocal loudness level of an individual with Parkinson’s Disease

23. THINK LOUD!

24. THINK BREATHE!

25. Conversational Strategies Checklist Gain eye contact with your communication partner before speaking. Avoid speaking when you are tired. Speak in a quiet environment. Take your time while speaking. Exaggerate your articulatory movements.

26. Conversational Strategies Checklist (cont’d) Speak louder. Take natural pauses while speaking. Keep your face free from distractions. Use body language to convey turn taking. Allow yourself time for a conversation. Avoid repeating words and phrases. Use body language to convey turn taking.

27. Conversational Strategies Checklist (cont’d) Rephrase your message if your communication partner does not understand you. Use an alternative system to communicate if your speech is difficult to understand. Appreciate your communication partner’s efforts. Be patient with yourself.

28. THERAPY “The human body is one of the greatest compensatory mechanisms.” RLG