Parkinson’s and Dysphagia: What you need to know

When it comes to Parkinson’s Disease (PD), patients, families, and even medical practitioners often focus on the most visible symptoms…

1. The tremors

2. The slow movement

3. The shuffling gait

But what about dysphagia? 

If you look on the surface, you might find that about a third of all patients with PD experience subjective symptoms of difficulty swallowing. 1 out of 3 is no small number. But that’s just the tip of the iceberg. If we take a peek under the hood, you might find that 82% of patients are actually diagnosed with dysphagia. 

Patients often don’t feel the dysphagia until later in the disease process. When managing it becomes more difficult. If we aren’t hearing the patient complain, how do we know how to help? If you don’t know there’s a problem… How do you solve it?

Why do so many patients with PD have dysphagia?

Swallowing is a complex, fine motor activity involving the timed coordination of 26 pairs of muscles and 5 cranial nerves. It’s a massive neurological interplay of sensory and motor activity. In PD, the dopaminergic neural network dysfunction disrupts this delicate system, leading to 3 main issues: 

1. The Oral Stage: You’ll often see a lingual pumping or the repetitive movement of the tongue. This is a sign of rigidity that makes it hard to initiate a swallow, leading to "piecemeal" swallowing, where it takes multiple attempts to clear just one bite, let alone a full meal.

2. The Pharyngeal Stage: Reduced tongue base retraction and pharyngeal wall constriction are common. This leaves food residue in the throat (the valleculae and pyriform sinuses) after the swallow, which is a major predictor of aspiration.

3. Airway Protection: PD can lead to reduced pharyngeal and laryngeal sensitivity. This, combined with a weakened cough reflex, often results in "silent aspiration," in which food or liquid enters the lungs without the patient even realizing it. A hallmark risk for aspiration pneumonia.

Understanding the timeline

How fast might dysphagia appear in a patient with a PD diagnosis? It depends on a number of factors, but significant swallowing difficulty usually doesn’t arise until the middle to late stages of the disease process or several years after diagnosis. So, we have time. BUT there are exceptions to this rule. If a patient develops severe dysphagia within the very first year of motor symptoms appearing, it should raise a major red flag. In "Parkinson Plus" syndromes—like progressive supranuclear palsy (PSP) or multiple system atrophy (MSA)—dysphagia typically occurs much earlier and progresses more rapidly than in standard PD. Recognizing this difference is essential for accurate differential diagnosis and setting realistic expectations for the family. 

What can we do to help?

So, how do we best help these patients? The key is early detection through validated screening tools and instrumental swallowing evaluations.

Once we have a clear picture of the underlying physiology, we can move beyond fear-based restrictions and toward targeted rehabilitation that addresses those deficits and takes into account the patient's wants and needs. So, what works for patients with PD? Three things to consider…

1. Consider EMST: Incorporating expiratory muscle strength training (EMST) can improve the force of a voluntary cough, helping patients eject material from the airway if they do aspirate.

2. Voice-Swallow Connection: Programs like the Lee Silverman Voice Treatment (LSVT) have shown positive "crossover" effects, improving not just the voice but also pharyngeal swallowing function.

3. Pharmaceuticals: While dopaminergic medications like Levodopa are the standard for motor symptoms, their effect on swallowing is still controversial—some patients improve, while others do not. This highlights why an interdisciplinary approach is non-negotiable.

Conclusion

Dysphagia starts with swallowing but extends to many other areas of the patient: nutrition, respiratory health, and the simple joy of sharing a meal. If you have one takeaway from this article, it is to assess our patients objectively and early to get on top of their condition, empower them with the skills that truly make a difference in their lives, and support them as their condition changes over time. The goal? Maintain their dignity and quality of life for as long as possible.

What have you found to be most effective with patients with PD? Share below!

I was inspired to write this after reading this great article: Kwon, M., & Lee, J. H. (2019). Oro-pharyngeal dysphagia in Parkinson's disease and related movement disorders. Journal of Movement Disorders, 12(3), 152–160.