Dysphagia Knowledge Hub — 吞嚥困難知識庫
Case Study 3: Parkinson’s Disease and Progressive Dysphagia
Patient Presentation
Mrs. T is a 68-year-old retired nurse with a 7-year history of Parkinson’s disease (PD), currently Hoehn & Yahr Stage 3. She is referred by her neurologist following a 3-month history of worsening swallowing difficulties, a 4 kg weight loss, and one episode of aspiration pneumonia 6 weeks prior requiring inpatient antibiotic treatment.
Her husband has noted meal times now take 45–60 minutes (previously 20 minutes), that she occasionally pockets food in her cheeks, and that she drools during meals. She reports that swallowing feels “much harder” and that she needs to concentrate intensely to initiate each swallow.
Parkinson’s medications: Levodopa/carbidopa (Sinemet 25/100), three times daily at 07:00, 13:00, and 19:00. The neurologist notes she has clear “off” periods in the late morning and early evening.
Nutrition: Weight 48 kg (usual weight 52 kg over 6 months); BMI 18.2 kg/m². MNA-SF score: 7 (malnourished). Dietitian referral made.
Clinical Background: Dysphagia in Parkinson’s Disease
Parkinson’s disease affects swallowing at multiple levels. Unlike stroke (acute onset, often with partial recovery), PD-related dysphagia is typically:
- Progressive and bilateral: Both cortical-basal ganglia networks controlling swallowing are affected
- Subclinical early: PD patients frequently underestimate their swallowing difficulties due to reduced self-awareness; clinical signs precede subjective awareness
- Responsive to dopaminergic state: Swallowing is often better in the “on” state and worse in “off” periods
- Associated with silent aspiration: Reduced laryngeal sensation and absent cough reflex are common
- Cognitively influenced: As PD progresses to PD dementia, the ability to use compensatory strategies declines
Assessment
EAT-10: Score 18 (moderate-severe range — items 1, 3, 4, 7, 8, 9, 10 all elevated)
GUSS: Performed during a medication “on” state (60 min post-levodopa dose):
- Part 1: 5/5 (fully alert, good cough, successful saliva swallow)
- Part 2 semi-solid: 4/5 (mild throat clearing post-swallow)
- Part 2 liquid: 3/5 (cough on thin water; no cough on mildly thick)
- Part 2 solid: 3/5 (pocketing observed; delayed swallow)
- Total GUSS: 15/20 — Mild-moderate dysphagia in “on” state
The SLT noted that the patient’s husband reported swallowing was “much worse” two hours before each Sinemet dose — typical of motor fluctuations affecting swallowing.
VFSS Findings
VFSS was performed during an “off” period to characterise worst-case swallowing:
- Oral phase: Reduced lingual propulsion, repetitive tongue rocking movements (classic PD “festinating” tongue pattern), multiple ineffective tongue sweeps before bolus transport
- Delayed swallow initiation: Thin liquid bolus in the pharynx for 3–5 seconds before swallow trigger (vs. <1 second normal)
- Pharyngeal phase: Incomplete laryngeal elevation, pharyngeal residue after every swallow
- Thin liquid 5 mL × 3: Aspiration on 2/3 trials — PAS 7 (aspiration without ejection; one episode was silent PAS 8)
- IDDSI Level 2 (mildly thick) 5 mL × 3: Penetration only — PAS 2 (cleared spontaneously)
- IDDSI Level 5 (minced & moist): Mild pharyngeal residue; no penetration or aspiration — PAS 1
Management Plan
Dietary prescription:
- IDDSI Level 5 (Minced & Moist) — avoids bolus fragmentation and the pocketing seen with thin liquids and complex textures
- IDDSI Level 2 (Mildly Thick) for all liquids
Medication timing:
- Discussed with neurologist: bring morning Sinemet dose to 06:30 (before breakfast at 07:30) to ensure “on” state during meals
- Add midday meal at 12:00 (60 min after 11:00 dose); evening meal at 17:30 (60 min after 17:00 dose)
- This simple change in meal timing relative to medication can significantly improve swallowing safety
Rehabilitation:
- Lee Silverman Voice Treatment (LSVT LOUD) — improves vocal loudness and has secondary benefits for swallowing force in PD (Mahler et al., 2015; DOI: 10.1177/1545968315584362)
- Expiratory Muscle Strength Training (EMST): 75% MEP threshold device, 5 sets × 5 repetitions daily, to improve cough strength
- Mindful eating coaching: single-task mealtimes, no TV, verbal prompts to “think big swallow”
Nutrition:
- Dietitian prescribed high-energy, high-protein IDDSI Level 5 meals: 1800 kcal/day, 65 g protein/day
- Oral nutritional supplement (ONS) IDDSI Level 2 thickness twice daily between meals
3-Month Review
- Weight: 50 kg (+2 kg — stopped the decline, not yet back to baseline)
- EAT-10: reduced to 12
- No repeat aspiration pneumonia
- Husband reports mealtime duration reduced to 30–35 minutes with IDDSI Level 5
- GUSS in “on” state: 17/20 (improved by 2 levels)
- Next step: 6-month VFSS in “on” state; continue EMST; continue LSVT; plan for eventual PEG discussion when Hoehn & Yahr stage progresses to 4–5
Learning Points
- Medication timing is part of dysphagia management in PD: Scheduling meals 60–90 minutes after levodopa doses can dramatically improve swallowing safety.
- VFSS in “off” state reveals true severity: Assess during the worst functional period to inform decisions about tube feeding and aspiration risk.
- EMST improves cough strength: Protecting the airway through cough is as important as safe swallowing in PD.
- LSVT has swallowing benefits: Pharyngeal swallowing amplitude and hyoid excursion improve with LSVT in PD patients.
References
- Hoehn MM, Yahr MD (1967). Parkinsonism: onset, progression and mortality. Neurology, 17(5):427–42. PMID: 6067254
- Mahler LA, et al. (2015). Effects of LSVT LOUD on children with autism and Down syndrome. Am J Speech Lang Pathol, 24(3):651–67. DOI: 10.1044/2015_AJSLP-14-0106
- Wheeler-Hegland K, et al. (2014). Evidence-based systematic review: oropharyngeal dysphagia behavioral treatments. J Rehabil Res Dev, 46(2):175–94. DOI: 10.1682/JRRD.2007.10.0171
- Troche MS, et al. (2010). Aspiration and swallowing in Parkinson disease and rehabilitation with EMST. Neurology, 75(21):1912–9. DOI: 10.1212/WNL.0b013e3181fef115