Dysphagia in parkinsonian syndromes

Transcription

1 DYSPHAGIA IN PARKINSON S EARLY IDENTIFICATION AND TREATMENT OPTIONS modified for handout 11th Annual Meeting of the GEoPD Consortium / 3rd International Parkinson s Disease Symposium October 2016, University of Luxembourg Session 6: Multidisciplinary approach to PD care Dr. Janine Simons *Focus on life Dysphagia in parkinsonian syndromes aspiration Ø Highly relevant symptom, but still underestimated aspiration pneumonia dehydration Ø Negative predictor for remaining lifetime & quality of life malnutrion Enteral/parenteral nutrition Health threats Tracheal canulla Swallow related burden shame fatigue fear avoidance compensations / adaptations / dietary restrictions exclusion / isolation Prolonged time for eating less enjoyment On-off fluctuations 1

2 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 2

3 Demo web-app dpv Swallowing disorders German Society for Parkinson s Disease Dysphagia screening and quality of life 3

4 Clinical dysphagia assessments Ø Timed water swallow test (90/150 ml, max volume <20ml?) Ø Bedside examinations Ø Mealtime observations Ø Important, but also limitations! Instrumental dysphagia diagnostics Ø FEES (gold standard) Ø HRM olympus-europa Ø VFS/VFSS dysphagie-therapie MMSinternational Ø Combination of all 3 methods à analysis of oral, pharyngeal & esophageal dysphagia patterns! Ø No uniform / standardized Parkinson-specific examination protocols available! 4

5 no saliva/secretion accumulation Ó Dr. phil. Janine Simons steady movements of the vocal folds with sufficient glottal closure completely closure of the vocal folds possible forceful coughing (complete glottal and subglottal closure with glottal explosion) accumulation in valleculea hypopharyngeal accumulation reduced clamping force of the vocal folds / insufficient glottal closure glottis remains slightly open à supraglottal closure possible on request to hold breath and press (vocal/false cords contact + median anterior-position of arytenoids) moderate coughing (incomplete glottal and subglottal closure with reduced glottal explosion ) PARK-FEES Endoscopic standard for validation of the Munich Dysphagia Test laryngeal accumulation with penetration up to vocal folds subglottic accumulation with aspiration greatly diminished movement of the vocal folds glottal closure as well as supraglottal closure remain incomplete after attempts of holding breath and press forced expiration (very reduced activity of vocal/false cords without apparent glottal explosion) 1/2 Ó Dr. phil. Janine Simons info@janine-simons.de * Pill/tablet is offered with blue dyed water or with blue dyed fruit sauce / thickened drink, if necessary. compensatory strategies, others (e.g. semi-fluids, semi- Assessment of residues (0-3 a, b, c, d) Consistency typical value if applicable, maximum value (outliner) H2O (90 ml, dyed blue) Bread with crust+spread ( ½ slice, 8x7x1 cm) Butter cookie (1 piece, Ø 5 cm) 1 placebo pill (Hepa-Lichtenstein, uncoated, Ø 8mm)* 1 tablet (Pro Life Vita-Fit, uncoated, divisible, 19x8x7 mm)* Pharyngeal leakage of oral residues Assessment of leakage afterwards Consistency Rating scale: see bolus leakage severity scale (0-4 a, b) typical value if applicable, maximum value (outliner) H2O (90 ml, dyed blue) Bread with crust+spread ( ½ slice, 8x7x1 cm) Butter cookie (1 piece, Ø 5 cm) Penetration-aspiration scale (PAS) modified according to Rosenbek et al. (1996) Severity Level Charakteristika normal 1 Material does not enter the airway slight 2 Material enters the airway, remains above the vocal folds, and is rejected from the airway slight-mild 3 Material enters the airway, remains above the vocal folds, and is not rejected from the airway mild 4 Material enters the airway, contacts the vocal folds, and is rejected from the airway mild-moderate 5 Material enters the airway, contacts the vocal folds, and is not rejected from the airway moderate 6 Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway moderate-severe 7 Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort severe 8 Material enters the airway, passes below the vocal folds, and no effort is made to eject Additional assessment Assessment of P/A (1-8) Consistency if applicable, type of P/A if applicable, predeglutitive intradeglutitive postdeglutitive typical value maximum value (outliner) H2O (90 ml, dyed blue) Bread with crust+spread ( ½ slice, 8x7x1 cm) Butter cookie (1 piece, Ø 5 cm) OVERALL ASSESSMENT Clinical advices (e.g. nutrition/diet, Dysphagia-Severity Assessment Consistencies concerned Information indication of therapy, follow-up) No clinically relevant oropharyngeal dysphagia fluid (H2O) Slight oropgaryngeal symptoms without any risk of solid (bread with crust) penetration/aspiration Mild dysphagia with penetration (risk) and dry-crumbly (butter cookie) sufficient clearance effectiveness Moderate dysphagia with aspiration (risk) and Intake of pills/tablets (almost) sufficient clearance effectiveness Severe dysphagia with aspiration (risk) and insufficient clearance effectiveness solids, mixed consistencies, saliva) PARK-FEES Endoscopic standard for validation of the Munich Dysphagia Test 2/2 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 PARK-FEES - PARK-FEES - Parkinson s specific protocol for fiberoptic endoscopic evaluation of swallowing Parkinson s specific protocol for fiberoptic endoscopic evaluation of swallowing Patient name: Date: Patient name: Date: Examination procedure: Inspection of structure, sensory reflex analyses, functional exam à swallowing tests: 90ml spring water, ½ slice of bread with crust and spread, 1 butter cookie, 2 types of pills* If required, you can change the proposed sequence. Instructions for the patient: Please eat/drink as you usually do. (relevance to everyday condition) *If the patient is not capable to take/handle the bolus, please indicate so on the forms. If necessary, please offer bread without crust as well as drinks in a feeding cup / with a straw / thickened (please note all compensatory/adaptive strategies needed). Medication cycle Last intake of medication (levodopa, combination products) before (h/min) On Off during examination Evaluation Structure, functional exam Severity and characteristics (0-2/4) Secretion/saliva management Movement of vocal folds ([e:] phonation in middle register for a few seconds) Glottal closure (while holding breath) Arbitrary coughing normal (0) normal (0) normal (0) normal (0) mild (1) moderate (2) affected (1) affected (1) affected (1) severe (3) sorely affected (2) sorely affected (2) sorely affected (2) very severe (4) Sensing of residues with spontaneously and fully removal (via multiple swallowing, hawking/coughing) or although residues are denied when asked about, the patient is subsequently able to remove them easily Sensing of residues, but fully removal does not succeed (via water swallows or other cleansing mechanism) or no sensing of residues, no spontaneously reaction is initiated, but mostly cleansing possible on request (even though with some difficulties) No sensing of residues, no attempts to clear the throat are initiated spontaneously; even on request no sufficient cleansing possible Bolus leakage und predeglutitive penetration/aspiration Severity Rating scale Characteristics normal 0 No leakage slight 1 Leakage up to valleculae epiglottae (could be normal) 2 a Hypopharyngeal leakage (sinus piriformis, postcricoid region, lateral/posterior pharyngeal walls) mild 2 b or massive, non-differentiable leakage 3 a Leakage up to aditus laryngis with predeglutitive penetration (vocal folds) moderate 3 b or suspected unnoticed penetration (postdeglutitive assessment due to hidden view with massive leakage) 4 a Leakage with predeglutitive aspiration (subglottic) severe 4 b or suspected aspiration (postgeglutitive assessment due to hidden view with massive leakage) Assessment of leakage (0-4 a, b) Consistency typical value if applicable, maximum value (outliner) H2O (90 ml, dyed blue) Bread with crust+spread ( ½ slice, 8x7x1 cm) Butter cookie (1 piece, Ø 5 cm) Pharyngealeal residues and clearance effectiveness Severity Rating scale Nature and depths of residues normal 0 No residues mild b, Oropharyngeal 1 (a, c, d) residues (base of tongue, valleculea epiglottae) moderate 2 (a, b, c, d) Hypopharyngeal residues (top edge of epiglottis, sinus piriformis, postcricoid region, lateral/posterior pharyngeal walls) severe 3 (a, b, c, d) Residues in vestibulum laryngis Additional Severity Nature of clearance effectiveness (if necessary) assessment effective a moderate b Sensing of residues with fully removal only after several swallows of water or other continued cleansing mechanism weak c ineffective d J.A. Simons, S. von Clarmann, T. Warnecke. 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 5

6 Dysphagia treatment Ø Functional dysphagia therapy by SLTs Rehabilitative 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) disfagiabrasil EMST150 Dietary adaptations Normal diet 6

7 Dysphagia treatment chemicalparadigms Ø Dopaminergic medication (levodopa) x Ø FEES-Levodopa-Test Warnecke et al. 2014/2016 Ø DBS (i.e. STN, Gpi) x Ø NMES x Ø Future Directions Ø Corticobulbar rtms 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 ) 7

8 THANK YOU CBBM-uni-luebeck Contact CBBM-uni-luebeck 8