Eating and swallowing problems, known as dysphagia, occur in many medical conditions and become more common as we get older.
The main risks associated with swallowing problems are:
- Choking or asphyxiation: When food blocks the airway, preventing breathing. Also when food or liquid enter the airway below the level of the vocal cords.
- Aspiration pneumonia: If food or liquid enter the lungs it can cause a lung infection.
- Dehydration: Not drinking enough fluids is bad for health and can lead to problems such as constipation.
- Malnutrition: Lack of nourishment leads to poor health and harms the body’s ability to fight infection.
Eating and swallowing problems and Parkinson’s
Research suggests that eating and swallowing difficulties affect about a 90% of all people with Parkinson’s. The true figure may be even higher as some people do not report the problem to their health care team.
Swallowing difficulties are common in people with Parkinson’s because swallowing is a motor function. The first stage of the digestive process happens in the mouth as we chew food. The tongue then pushes the moist ball of food (the bolus) to the back of the mouth, triggering the swallow reflex. Unfortunately, many people with Parkinson’s experience swallowing problems due to reduced control and muscle tone of the mouth, tongue and throat muscles, especially in later stages of the condition. Eating becomes slower and requires more effort.
People with Parkinson’s are at particular risk of aspiration (food or liquid entering the lungs) due to a delay in the triggering of their swallow reflex. This compromises the effectiveness of the airway protection while swallowing. This can lead to aspiration pneumonia due to a lack of coughing if food enters the windpipe, allowing food to reach the lungs unchecked.
Diagnosing swallowing difficulties
Eating and swallowing difficulties can affect your diet and eating habits and may cause embarrassment and anxiety. They can also affect your home and social life and result in malnutrition and poor health.
If you notice any problems with eating and swallowing, either in yourself or in someone you care for, it is important to talk to your doctor and be referred to a speech and swallowing therapist for a swallowing evaluation. Warning signs to look out for include:
- hesitation in swallowing
- food getting stuck in the throat or left in the mouth after eating
- a repeated need to swallow in order to clear food
- swallowed food backs up and enters the nose
- difficulty chewing
- regurgitation of food
- coughing during or after swallowing
- frequent throat clearing, a hoarse voice or sore throat
- change in voice quality and a gurgled voice after swallowing
- pain in the throat or chest
- reflux or heartburn
- a need to sip water often to swallow food
- taking a long time to finish a meal, or giving up part way through
- loss of appetite or refusal to eat
- unexplained weight loss
- recurring chest infections
- aspiration pneumonia or upper respiratory infection.
If eating and swallowing difficulties persist, your doctor may refer you for a clinical swallowing evaluation performed by a speech and language therapist (SLT), also known as a speech and language pathologist (SLP) in some countries. The clinical or bedside evaluation is performed by an SLT or SLP and includes:
- taking a medical history
- assessment of mental ability
- management of saliva
- mouth structure and function including the lips, tongue, jaw, cheeks
- sensation in the mouth
- function of the larynx (voice box)
- testing the quality of swallow reflexes and direct swallow assessment with different food and liquid consistencies.
The clinical swallowing evaluation is designed to detect swallowing difficulties and a high risk of food or liquid entering the lungs (aspiration). It also provides the clinician with information to decide on any further diagnostic tests and treatment strategies. After this evaluation the SLT/SLP may refer you for special tests to find out what is causing swallowing difficulties. The most commonly used assessment tools are Videofluoroscopy Swallowing Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES).
- Videofluoroscopy is a radiographic procedure that provides objective information on the four stages of swallowing, on the time it takes food to pass and any difficulties in its movement. Food or liquid containing barium is given in different consistencies. The barium allows progress through the mouth, pharynx and oesophagus to be video recorded and observed. Therapy techniques and compensatory postures can also be tried out during the assessment and their effectiveness can be evaluated.
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES) assesses swallowing function in the pharynx (the part of the throat that lies between the mouth and the larynx or voice-box). A fiberoptic laryngoscope is passed through the nose to view the larynx and surrounding structures when food and liquid are swallowed. The FEES provides information regarding the safety of the swallow and oral feeding as well as enabling assessment of an individual’s response to strategies to improve swallow.
Excessive saliva and drooling in Parkinson’s
Saliva is needed for the first stages of digestion, including chewing and swallowing. This watery substance contains enzymes that start to digest our food.
Many people with Parkinson’s experience poor saliva control, which may result in excessive saliva and drooling, or alternatively, in a dry mouth and other eating problems.
We all produce about one litre of saliva each day, which we swallow without thinking about it. But because swallowing is a motor function, this mechanism can be disrupted by Parkinson’s. Saliva may then build up in the mouth and, as the muscles which seal the lips also become weaker, it can escape, causing dribbling or drooling (sialorrhoea).
The stooped posture of many people with Parkinson’s, with head forwards and chin pointing downwards, can add to poor saliva control, as it causes saliva to pool in the front of the mouth.
Excessive saliva and drooling occurs in 50-80% of people with Parkinson’s and is more common in men than women. An excessively runny nose is also common in Parkinson’s. This may lead to nasal discharge, coughing and sneezing, and poor sleep for those who experience it at night.
Drooling can cause considerable social embarrassment. Clothes may become stained and breath may be stale as the saliva pools in the mouth. It may make the skin around your mouth sore.
If excessive saliva is inhaled by mistake it can cause aspiration pneumonia. Good saliva control is therefore important both for personal safety and for good quality of life.
Improving saliva control
The following suggestions may help you to control excessive saliva:
- Take sips of drink more often so saliva is ‘washed down’ with fluids.
- Swallow saliva often, and make a conscious effort to do so before eating.
- Keep your head up so that saliva flows to the back of your throat to make swallowing easier.
- Dairy products can cause an increase in mucus in some people, so consider reducing dairy in your diet. However, note that milk provides calcium and other nutrients, which are beneficial to health.
- If you have good control of your mouth structures chew gum or a suck on a sweet as this reminds you to swallow.
Changes in posture and swallowing can help to improve saliva control. You may find the following suggestions useful:
- Try to sit upright.
- Keep your head up so that saliva flows to the back of your throat where it can be swallowed.
- Make a conscious effort to swallow saliva often. Using a special badge or button or brooch that bleeps discretely to remind you to swallow may help with this.
- Drink more often so saliva is ‘washed down’ with fluids.
- Avoid sugary foods, as these encourage saliva to develop.
- Reducing your intake of dairy products can help to reduce mucus production.
- If you suffer from dry mouth and your swallowing reflex is good, suck on sweets, ice chips or chew gum to encourage saliva production.
- Clean teeth and mouth regularly, particularly after meals, to guard against infections that can result from stale saliva.
Lip seal exercises
These simple exercises can help to improve lip seal. For each exercise hold your lips in position for a count of four, then relax and try to repeat at least five times.
- Close your lips as tightly as you can.
- Hold a wide smile.
- Hold your lips as if you are going to kiss someone or blow a whistle.
- Hold your lips together as if smoking a pipe.
- Try sitting for five minutes with a lolly stick or pen held between your lips and swallow every 30 seconds.
- Strongly swallow your saliva throughout the day.
In contrast, some people with Parkinson’s experience a dry mouth because they swallow repeatedly, which removes saliva from the mouth. The lack of lubrication can result in a sore or dry throat, which can make talking and eating uncomfortable.
Dry mouth may also be caused by some Parkinson’s medicines, particularly anticholinergic medications.
Some people find that Parkinson’s medicines cause tastes to alter. Foods may taste metallic and unappetising, which will reduce production of saliva. This not only aggravates the problem of dry mouth, but also the enzymes in saliva that begin to break down food are lacking.
If you have a dry mouth, you could try taking frequent sips of water, sucking on ice chips or using a mouth spray. Avoid caffeine, soft drinks, alcohol and tobacco, which all dry the mouth.
Other eating difficulties
In some people with Parkinson’s, the tongue bunches up, forcing food through the teeth and out of the mouth instead of being swallowed.
As facial muscles are affected it can become harder to move food around the mouth when chewing. This can make eating a lengthy and tiring process. Food remaining in the mouth can increase the risks of choking, aspiration and infections.
You may start to experience problems with teeth and gums. Combined with motor problems, these can make chewing uncomfortable or difficult.
Parkinson’s can also affect muscles in the oesophagus which push swallowed food down to the stomach. Movement of food towards the stomach may become slower, which may make you feel full even if you haven’t eaten much. Only when food reaches the stomach do you feel hungry again. It is therefore important that you take your time when eating. You may also find it helpful to eat small but more frequent meals.
If eating becomes difficult and tiring, and food seems unappetising, your food intake is likely to drop, and you could start to lose weight. It is important to eat enough food and maintain a healthy weight to stay well and fight infection. A dietician can advise on high calorie items to help you maintain your weight.
Difficulties with eating, swallowing or saliva control can cause embarrassment. Eating should be an enjoyable social activity, but many people with Parkinson’s start to avoid social situations while eating. Fear of choking can add to stress and even cause panic attacks before mealtimes. These problems can affect your quality of life.
It is important that your carer, family and friends understand why you have problems with eating and that these are often part of life with Parkinson’s. If they know how to support you and give you more time it will help you to enjoy meals both at home and in social settings.
Swallowing difficulties and Parkinson’s medication
If swallowing tablets or capsules becomes difficult, it may be tempting to crush tablets or open capsules, but this should never be done, as it can cause serious side effects and/or prevent the medication working properly. Always ask your pharmacist or doctor, or check the patient information leaflet (PIL) before tampering with medicines in any way. Swallowing medications with jelly, yoghurt or apple sauce may help you swallow medication more comfortably.
Many Parkinson’s medicines are prepared or designed to work in a particular way that will be harmed by crushing or opening capsules. For example, some medicines have:
- Sugar or film coating: This is usually to make them taste better, but crushing may make them taste unpleasant.
- Enteric coating: This coating is designed to keep the tablet whole in the stomach, in some cases to protect the stomach or to protect the medicine from stomach acid so that it is released after passing through the stomach, for example in the intestine. This type of tablet should never be crushed.
- Modified or controlled release: These medications have been designed to release slowly and act over a longer period, so they can be taken less often. Crushing this type of tablet would lead to a rapid release of the medicine which could be harmful.
If you experience any problems swallowing your medication you should talk to your doctor, so that he or she can prescribe medication in a form that is easier to take. Some medicines are available in liquid form.
Treating eating and swallowing difficulties
If you or someone you care for is experiencing difficulties with eating, swallowing or saliva control, the first step is to consult your doctor, who may refer you on to an SLT or SLP.
Your doctor may be able to adjust the timing and dose of medicines to improve your swallowing at mealtimes. He or she may also adjust your medications, or may prescribe new ones to reduce production of saliva. Some Parkinson’s medicines, including levodopa, improve muscle movement and may help to reduce drooling. However, some medications, such as clozapine, which is prescribed for mental health problems, can actually increase saliva production.
Botulinum toxin (Botox) can be injected into the salivary glands to reduce saliva production. This treatment will not work for everyone, and injections may need to be repeated every three to six months.
In severe cases when other treatments are not effective, radiotherapy to the salivary glands can restrict saliva production. In extreme cases the salivary glands can be surgically removed as a last resort.
Who can help?
Your doctor can also refer you to other specialists, such as a speech and language therapist or pathologist, physiotherapist or occupational therapist, who can help with swallowing and eating problems and saliva control.
A speech and language therapist can help with eating and swallowing disturbances by:
- recommending specific compensatory swallowing techniques and postures for efficient and safe swallowing
- suggesting exercises to strengthen muscles used for swallowing
- suggesting strategies to reduce the risks of asphyxiation and aspiration
- providing advice on diet to make sure you eat and drink enough, including tips on the consistency and texture of foods that are easier to swallow
- identifying specific areas of difficulty with saliva control – for example poor posture, lip seal, tongue or swallowing problems. He or she can suggest exercises and also devices to achieve good lip seal.
An occupational therapist can advise on practical ways to make eating easier by making changes to your eating environment. He or she can also advise on the many special tools and equipment available to help with eating. For more information see Occupational therapy.
A physiotherapist can give advice on exercises to improve posture when eating, for example so that saliva doesn’t pool at the front of your mouth.
A dietician will advise on diet to maintain good nutrition and a healthy weight. For more information see Eating well.
Managing eating and swallowing
It is important to continue eating normally as long as it is safe to do so. This will help to keep your muscles working, and maintaining a healthy diet is vital to good health (see Eating well). Only when eating and swallowing become significantly uncomfortable or difficult should you adapt your diet, for example by eating pureed foods.
Swallowing difficulties are individual and solutions vary from person to person, but the following tips on diet, drinking and eating techniques may help.
Choose moist and soft foods that are easier to eat, such as soups, omelette, well-cooked meats in sauces or casseroles, pasta (not spaghetti), mashed vegetables, custards, jelly, pureed fruit, yoghurt, ice cream and mashed banana.
- Eat wholemeal bread rather than white as it is less likely to get stuck around your mouth.
- Try pasta or noodles instead of bread as carbohydrate in a meal.
- Foods with appetising smell and flavour tend to be easier to swallow as they stimulate saliva production.
- Thick drinks such as milk shakes and smoothies may be easier to control and swallow than thin drinks. Thickeners can be added to thin drinks to reduce the likelihood of choking.
- A semi-solid diet will make swallowing easier. In extreme difficulty a pureed diet may be appropriate, but you should only follow such a diet on the advice of your doctor, dietician or speech and language therapist. It is important to maintain your energy intake, so when liquid meals are introduced your dietician may recommend special drinks to provide nutrients.
- Try to keep your meals well presented – if they look and smell appetising you are more likely to enjoy your meal.
Avoiding the following foods may make eating easier:
- Dry, crumbly or hard foods that are harder to swallow and more likely to cause choking
- Soups and other foods with mixed consistencies, that is solid and liquid together. Choose thick, creamy soups rather than thin, watery soups instead
- Foods that stick to the roof of the mouth or get caught around the mouth, such as tomato with the skin on, biscuits, bran flakes and hard-boiled eggs
- ‘Sticky’ foods such as white bread and mashed potato
- Nuts, grains and seeds
- Tough, fibrous fruit and vegetables
- Dairy products can increase mucous levels in some people. Consider reducing dairy intake if this is a problem.
Advice on drinking
Take regular sips of water while eating and take a break between mouthfuls so that you can empty your mouth fully.
- Try refilling your glass when it is half empty so that you do not have to tilt your head so far back when drinking – this can make you choke. Or use a special cup designed so that you can drink without tilting your head.
Advice on eating techniques
- Try eating smaller portions but have more meals and frequent snacks.
- Use a teaspoon rather than a dessert spoon to encourage small mouthfuls.
- Relax and enjoy your meal. If you are relaxed your throat is likely to be relaxed too, which will make swallowing easier.
- Relax your throat muscles by yawning before and during eating.
- Sit upright for 10 minutes before eating, while eating and for 30 minutes afterwards. Good posture helps with eating, swallowing and digestion.
- Tucking your chin down to your chest may make swallowing easier. Some people find it helps to bend forward when swallowing – see Coping strategies: bending forward to help swallow
- Don’t tilt your head back when eating, as this makes swallowing more difficult
- Try not to eat meals when you are ‘off’ as eating will be more difficult and choking more likely. Time medications to allow good swallow function at mealtimes.
- Try not to eat when you are tired.
- Keep distractions to a minimum at mealtimes – turn off the television.
- Only take more food when you have swallowed the previous mouthful. Double swallow if food did not all go down first time.
- Make sure that any dentures are a good fit and not uncomfortable when chewing.
- Brush your teeth at least three times a day, checking for leftover food in the sides of the mouth.
- Involve your friends and family – make sure they are aware of the problems you experience and the need for you to take your time.
- If eating out, check the menu in advance. Book a secluded table if you want some privacy and remember to take any special eating aids you use.
Alternative feeding methods
In some situations, if eating and swallowing are no longer possible, an alternative feeding method will need to be used. There are two main kinds:
A tube is inserted through the nose and into the stomach and liquid foods are passed through it. This is generally used as a short-term solution to a persistent problem.
A small tube is inserted directly into the stomach and liquid foods are passed through it, sometimes with a dietary supplement. This may be used as a longer-term method of feeding. The most common form is called PEG (percutaneous endoscopic gastrostomy). Gastrostomy feeding can help in many ways, reducing your anxieties about eating and also the risk of infection. Your energy levels should increase and your general health improve.
It may be possible for you to still eat small amounts of food – ask your doctor or speech and language therapist.
Dental care is still important when alternative feeding methods are used. Teeth should still be brushed at least three times a day and a mouth rinse can help to avoid a build-up of plaque and stale breath. Oral care is important to avoid oral and chest infections.
Of course, you should still take your medications when using alternative feeding methods, but how they are taken may need to be adjusted. Some may be injected or fed in liquid or solution form through a tube. Your doctor will advise.
Articles from Parkinson's Life online magazine
Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information:
Eating, Swallowing and Saliva Control in Parkinson's.