June 2008

Laura Verdun, Speech-Language Pathologist, Otolaryngology Associates

I wrote up this summary using the handout that Laura provided. If you would like more information, please contact Laura at 703-573-7600 ext. 1414 or lpverdun@yahoo.com.

Introduction:
PD medications tend to be less helpful for speech and swallowing disorders. Difficulties with swallowing generally occur later in the course of the disease.
Drooling is not because of increased saliva but rather because of not swallowing as much, or difficulty managing the saliva.
Be aware and practice swallowing more, especially when speaking. Medications to reduce saliva are not very effective because they tend to dry everything out, making swallowing even more difficult.

Swallowing Evaluation:
It is best to seek treatment earlier rather than later. An evaluation will include medical, dietary, feeding and swallowing histories so it is helpful to come prepared with your observations and concerns.

The following are some common clinical questions you may be asked so you can think about them beforehand:
* Do you feel like you have to much or not enough saliva in your mouth?
* Do you still eat and drink what you want?
* Have you had to modify your diet, or change how you prepare foods?
* How long do meal times take? Longer or shorter?
* Do foods stick on the roof of your moth or in your cheeks?
* Are you having difficulty chewing?
* Do you cough or clear your throat when you drink water or other liquids?
* Do you cough or choke more during mealtimes than at other times of the day? (VIP question)
* Do you have any trouble taking medications? You may also undergo a videofluroscopic swallowing study (VFSS) which is a 10-15 minute x-ray video. It is important that when taking this test, you do things like you would at home such as sipping a drink instead of gulping it all.

What can you do to improve your ability to swallow?
The most important place to start is with oral hygiene:
* Maintain scrupulous dental care
* Avoid smoking, alcohol and caffeine
* Drink plenty of water throughout the day
* Minimize non-cooked dairy products (e.g. milk) as it can thicken secretions.
* Rinse out your mouth with water after meals.
* Club soda or sparkling water may help cut through secretions because they refresh the mouth and provide sensory feedback.
* Avoid gels and mouthwashes that contain alcohol or menthol. Hall’s lozenges also dry out the throat.
* Use a humidifier at night by your bed
* Suction machine (suction toothbrush)
* Make sure your dentures are clean and well fitting
* Consult with a dentist

Some links to check out for oral hygiene products:
Biotene products (non-prescription, for dry mouth)  www.biotene.com
Plac-Vac (suction toothbrush system)  www.trademarkmedical.com/personal/personal-oral.html

Meal-time strategies:
* Coordinate meal times with medication cycles
* Sit upright, preferably in a chair
* Minimize distractions (TV, radio, newspaper, etc.)
* Experiment with different plates and utensils (smaller eating utensils, plates with edges & bottom grip)
Maroon spoons www.proedinc.com
* Experiment with different cups, glasses and straws.
Flexi-cut cups www.alimed.com
Spillproof Flo Tumbler www.kcup.com
* Slow, steady rate of ingestion
* Supervision at mealtimes, preferably someone familiar with the Heimlich maneuver
* Consult with an occupational or physical therapist

Diet modifications:
* The goal is not to eliminate foods necessarily, but consider how they could be prepared differently to enhance ease and safety of swallowing.
* Thicken liquids to slow rate of transit, but be aware that this may contribute to inadequate fluid intake. Some suggestions are pre-thickened liquids, oatmeal, fruit purees, banana, potato flakes, silken tofu.
There are also commercial thickeners:
ThickenUp www.nestlenutrition.com
Hydra-Aid www.llinksmed.com/hydraaid.html
Simply thick www.simplythick.com
Thick & Easy www.www.hormelheathlabs.com/products.asp
* Avoid highly textured and dry foods such as red meats, rice, corn, firm breads, crackers, etc.
* Stick with moist and tender foods such as dark meat chicken, casseroles, cooked vegetables and canned fruit.
* Avoid multiple consistency items like fruit cocktail and broth based soups, because the body receives a mixed message about how to swallow them   (fast for liquid, slow for drier foods). It can help to blend them.
* Use condiments/gravies/sauces to lubricate foods
* Experiment with foods at different temperatures to see if warmer food is swallowed easier than cold food.
* Consider more frequent, smaller meals. Safer swallowing strategies:
* Clear away secretions prior to meals and medications
* Keep your chin level – avoid tilting your head and neck back
* Take small bites and small sips
* One bite/sip and swallow
* Alternate food and liquid swallows
* Use a teaspoon for liquids
* Cup vs. straw drinking. Experiment by pinching the straw to restrict the amount swallowed.
* Try taking medications with purees, yogurt or pudding because the pill will stay with the food which will lubricate the passageway.
* Avoid Jell-O®
* And keep practicing swallowing!

Speaking changes in speech include:
Dysarthria – related to mouth movement when there is difficulty in pronouncing sounds, and slurred or imprecise speech.
Dysphonia – related to the voice box when there is difficulty in generating sound
Also PD speech and voice are characterized by a soft voice, mumbled and accelerating speech and loss of facial expression (related to the rigidity of movement, slowness of movement and reduced amplitude of movement).

Strategies to improve speech:
* Drink water with all voice use
* Face your listener
* Keep sentences short
* Take a good breath before speaking because air helps to project the voice.
* Speak-up! and slowly
* Be deliberate with all speech sounds
* Repeat entire sentence when necessary, versus an isolated word
* Use gestures
* When talking on the phone, use a headphone with a microphone that rests in front of the mouth.
* Best way to practice talking is to keep talking and singing! Form a new habit and practice every day!

Strategies for the listener:
* Eliminate distractions and reduce background noise
* Listener should face the speaker
* Keep questions and comments brief
* Ask one question at a time, allowing time for a response
* Stick with one topic at a time
* Ask for the topic of the message to allow for use of context cues
* Ask for clarification, or ask “Did you say . . .?”
* Stick with familiar topics
* Provide choices to ease decision making, “Do you want coffee or tea?” vs. “What do you want to drink?”

In addition:
Lee Silverman Voice Treatment (LSVT) is proven to significantly improve voice quality of PD with a very specific, intensive treatment program   emphasizing “loud speech”. However, it is not effective with fluency difficulties (e.g. stuttering).

Alternative therapies:
* Personal voice amplifier – Chattervox  www.chattervox.com
* Vocal Fold Augmentation – as described by Dr. Patty Lee at our meeting in April
* Consult your physician and speech pathologist to tailor a program specific to your needs.

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