GEoPD 2016, JSimons session6 handout

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DYSPHAGIA IN PARKINSON‘S –EARLY IDENTIFICATION AND TREATMENT OPTIONS

11th Annual Meeting of the GEoPD Consortium / 3rd International Parkinson´s Disease Symposium05 – 08 October 2016, University of LuxembourgSession 6: Multidisciplinary approach to PD care

Dr. Janine Simons

DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM

*Focus on life

modified for handout


Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options

Dysphagia in parkinsonian syndromes

Ø Highly relevant symptom,but still

underestimated

Ø Negative predictor forremaining lifetime &

quality of life

dehydration

aspiration

Enteral/parenteral nutrition

malnutrion

Tracheal canulla

Swallow related burdenshame

On-off fluctuations

fear

avoidance

Prolonged time for eating

fatigue

less enjoyment

compensations / adaptations / dietary restrictions

exclusion / isolation

Health threats

aspiration pneumonia

© J. Simons

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Dysphagia screenings

Ø Early identification§ MDT-PD ✓§ SDQ (x)§ NMS-Quest, quest 1, 3, 11 (x)§ MDS-UPDRS II, quest 9, 10 (x)Ø Screening necessity incorporated in German

guidelines for Parkinsonian syndromes, 2016

Ø Quality of life assessments§ SWAL-QoL (✓x)§ PDQ-39 (✓x)

Ø Clinical predictors§ Hoehn & Yahr stage >3§ Relevant weight loss / BMI <20§ Reduced oral bolus control /

drooling / sialorhea§ Dementia§ High UPDRSIII value§ (Disease duration >10 years)§ (Dysarthria)

Coeho et al. 2010, Lam et al. 2007, Norbrega et al. 2008, Cereda et al. 2014, Warnecke et al. 2010, Simons 2012



Screening evaluation: Web application

Resulting categories: No dysphagia / noticeable oropharyngeal dysphagia /

dysphagia with risk of penetration/aspiration

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Demo web-app

www.mdt-parkinson.de © J. Simons



dPV – Swallowing disordersGerman Society for Parkinson‘s Disease– Dysphagia screening and quality of life

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Clinical dysphagia assessments

Ø Timed water swallow test (90/150 ml, max volume <20ml?)

Ø “Bedside examinations“Ø Mealtime observations

© J. Simons

Ø Important, but also limitations!



Instrumental dysphagia diagnosticsØ FEES (gold standard)

Ø VFS/VFSS

© olympus-europa

© J. Simons

Ø Combination of all 3 methods àanalysis of oral, pharyngeal & esophageal dysphagia patterns!

Ø No uniform / standardized Parkinson-specific examination protocols available!

© MMSinternational

© dysphagie-therapie

Ø HRM

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PARK-FEES-Parkinson’sspecificprotocolforfiberopticendoscopicevaluationofswallowing

Patientname: Date:

Ó[email protected]

PARK-FEES–Endoscopicstandardforvalidationofthe

MunichDysphagiaTest

1/2

Examinationprocedure:Inspectionofstructure,sensory–reflex–analyses,functionalexamàswallowingtests:90mlspringwater,½sliceofbreadwithcrustandspread,1buttercookie,2typesofpills*–Ifrequired,youcanchangetheproposedsequence.Instructionsforthepatient:“Pleaseeat/drinkasyouusuallydo.”(relevancetoeverydaycondition)*Ifthepatientisnotcapabletotake/handlethebolus,pleaseindicatesoontheforms.Ifnecessary,pleaseofferbreadwithoutcrustaswellasdrinksinafeedingcup/withastraw/thickened(pleasenoteallcompensatory/adaptivestrategiesneeded).

Medicationcycleduringexamination On Off Lastintakeofmedication(levodopa,combinationproducts)before(h/min)

Structure,functionalexam Severityandcharacteristics Evaluation(0-2/4)

Secretion/salivamanagement normal(0)nosaliva/secretion

accumulation

mild(1)accumulationin

valleculea

moderate(2)hypopharyngealaccumulation

severe(3)laryngealaccumulationwithpenetrationuptovocalfolds

verysevere(4)subglotticaccumulation

withaspiration

Movementofvocalfolds([e:]phonationinmiddleregister

forafewseconds)

normal(0)steadymovementsofthevocalfoldswithsufficientglottal

closure

affected(1)reducedclampingforceofthevocalfolds/

insufficientglottalclosuresorelyaffected(2)

greatlydiminishedmovementofthevocalfolds

Glottalclosure(whileholdingbreath)

normal(0)completelyclosureofthevocal

foldspossible

affected(1)glottisremainsslightlyopenà

supraglottalclosurepossibleonrequesttoholdbreathandpress(vocal/falsecordscontact

+mediananterior-positionofarytenoids)

sorelyaffected(2)glottalclosureaswellassupraglottalclosure

remainincompleteafterattemptsofholdingbreathandpress

Arbitrarycoughingnormal(0)

forcefulcoughing(completeglottalandsubglottalclosurewithglottalexplosion)

affected(1)moderatecoughing

(incompleteglottalandsubglottalclosurewithreducedglottalexplosion)

sorelyaffected(2)forcedexpiration

(veryreducedactivityofvocal/falsecordswithoutapparentglottalexplosion)

Bolusleakageundpredeglutitivepenetration/aspirationSeverity Ratingscale Characteristicsnormal 0 Noleakageslight 1 Leakageuptovalleculaeepiglottae(couldbenormal)

mild 2a2b

Hypopharyngealleakage(sinuspiriformis,postcricoidregion,lateral/posteriorpharyngealwalls)ormassive,non-differentiableleakage

moderate 3a3b

Leakageuptoadituslaryngiswithpredeglutitivepenetration(vocalfolds)orsuspectedunnoticedpenetration(postdeglutitiveassessmentduetohiddenviewwithmassiveleakage)

severe 4a4b

Leakagewithpredeglutitiveaspiration(subglottic)orsuspectedaspiration(postgeglutitiveassessmentduetohiddenviewwithmassiveleakage)

Consistency Assessmentofleakage(0-4a,b)typicalvalue ifapplicable,maximumvalue(outliner)

H2O(90ml,dyedblue) Breadwithcrust+spread(½slice,≈8x7x1cm) Buttercookie(1piece,Ø5cm)

Pharyngealealresiduesandclearanceeffectiveness

Severity Ratingscale Natureanddepthsofresiduesnormal 0 Noresiduesmild 1(a,b,c,d) Oropharyngealresidues(baseoftongue,valleculeaepiglottae)

moderate 2(a,b,c,d) Hypopharyngealresidues(topedgeofepiglottis,sinuspiriformis,postcricoidregion,lateral/posteriorpharyngealwalls)severe 3(a,b,c,d) Residuesinvestibulumlaryngis

Severity Additionalassessment Natureofclearanceeffectiveness(ifnecessary)

effective a Sensingofresidueswithspontaneouslyandfullyremoval(viamultipleswallowing,hawking/coughing)oralthoughresiduesaredeniedwhenaskedabout,thepatientissubsequentlyabletoremovethemeasily

moderate b Sensingofresidueswithfullyremovalonlyafterseveralswallowsofwaterorothercontinuedcleansingmechanism

weak c Sensingofresidues,butfullyremovaldoesnotsucceed(viawaterswallowsorothercleansingmechanism)ornosensingofresidues,nospontaneouslyreactionisinitiated,butmostlycleansingpossibleonrequest(eventhoughwithsomedifficulties)

ineffective d Nosensingofresidues,noattemptstoclearthethroatareinitiatedspontaneously;evenonrequestnosufficientcleansingpossible

PARK-FEES-Parkinson’sspecificprotocolforfiberopticendoscopicevaluationofswallowing

Patientname: Date:

Ó[email protected]

PARK-FEES–Endoscopicstandardforvalidationofthe

MunichDysphagiaTest

2/2

Consistency Assessmentofresidues(0-3a,b,c,d)typicalvalue ifapplicable,maximumvalue(outliner)

H2O(90ml,dyedblue) Breadwithcrust+spread(½slice,≈8x7x1cm) Buttercookie(1piece,Ø5cm) 1placebopill(Hepa-Lichtenstein,uncoated,Ø8mm)* 1tablet(ProLifeVita-Fit,uncoated,divisible,≈19x8x7mm)* *Pill/tabletisofferedwithbluedyedwaterorwithbluedyedfruitsauce/thickeneddrink,ifnecessary.

Pharyngealleakageoforalresidues

ConsistencyAssessmentofleakageafterwards–

Ratingscale:seebolusleakageseverityscale(0-4a,b)typicalvalue ifapplicable,maximumvalue(outliner)


Penetration-aspirationscale(PAS)modifiedaccordingtoRosenbeketal.(1996)

Severity Level Charakteristika

normal 1 Materialdoesnotentertheairwayslight 2 Materialenterstheairway,remainsabovethevocalfolds,andisrejectedfromtheairway

slight-mild 3 Materialenterstheairway,remainsabovethevocalfolds,andisnotrejectedfromtheairwaymild 4 Materialenterstheairway,contactsthevocalfolds,andisrejectedfromtheairway

mild-moderate 5 Materialenterstheairway,contactsthevocalfolds,andisnotrejectedfromtheairwaymoderate 6 Materialenterstheairway,passesbelowthevocalfolds,andisejectedintothelarynxoroutoftheairway

moderate-severe 7 Materialenterstheairway,passesbelowthevocalfolds,andisnotejectedfromthetracheadespiteeffortsevere 8 Materialenterstheairway,passesbelowthevocalfolds,andnoeffortismadetoeject

Consistency

AssessmentofP/A(1-8) Additionalassessmentifapplicable,typeofP/A

typicalvalueifapplicable,maximumvalue(outliner)

predeglutitive intradeglutitive postdeglutitive


OVERALLASSESSMENT

Dysphagia-Severity Assessment Consistenciesconcerned InformationClinicaladvices(e.g.nutrition/diet,

compensatorystrategies,indicationoftherapy,follow-up)

Noclinicallyrelevantoropharyngealdysphagia fluid(H2O)

Slightoropgaryngealsymptomswithoutanyriskofpenetration/aspiration

solid(breadwithcrust)

Milddysphagiawithpenetration(risk)andsufficientclearanceeffectiveness

dry-crumbly(buttercookie)

Moderatedysphagiawithaspiration(risk)and(almost)sufficientclearanceeffectiveness

Intakeofpills/tablets

Severedysphagiawithaspiration(risk)andinsufficientclearanceeffectiveness

others(e.g.semi-fluids,semi-solids,mixedconsistencies,saliva)

Offi cial Journal of the International Parkinson and Movement Disorder Society

Volume 31 | Issue S2 | June 2016

Abstracts of the Twentieth International Congress of Parkinson’s Disease

and Movement Disorders

J.A. Simons, S. von Clarmann, T. W arnecke. Reliability of a newly developed protocol for fiberoptic endoscopic evaluation of swallowing in Parkinson’s patients (PARK-FEES). Mov Disord. 2016;31(Suppl.2):1574



FEES video records in PD

© J. Simons

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Dysphagia treatment

Ø Functional dysphagia therapy by SLTsRehabilitative trainings, compensation maneuvers (rare studies, little evidence)

§ EMST ✓ (Troche et al., 2010/2014)

§ VAST ✓ (Manor et al., 2013)

§ LSVT– LOUD® x (El Sharkawi et al. 2002)

©EMST150

©disfagiabrasil



Dietary adaptations

Normal diet

© J. Simons

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Dysphagia treatment

Ø Dopaminergic medication (levodopa) ✓xØ FEES-Levodopa-Test Warnecke et al. 2014/2016

Ø DBS (i.e. STN, Gpi) xØ NMES x

Ø Future DirectionsØ Corticobulbar rTMS

©chemicalparadigms

©NIH



Summary - THM

ü Dysphagia management is a multidisciplinary challenge

ü Screening for dysphagia in Parkinson’s patients is highly recommended

ü Comprehensive set of diagnostics should be performed when screened dysphagia-positive using standardized protocols

ü Treatment should be selected symptom-orientated on individual needs

ü Therapy should focus on clinical relevance (QOL⬆, pneumonia rates ⬇)

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THANK YOU

[email protected] ©CBBM-uni-luebeck

©CBBM-uni-luebeck

Documents

GEoPD 2016, JSimons session6 handout