Parkinson's disease: speech and swallowing
The clinical features of tremor and rigidity seen in Parkinson's disease (PD) may precipitate swallowing and speech difficulties.
Speech difficulties
About half of all people with PD are likely to develop difficulty with speech. Much research has gone into the causes, effects and relief of speech difficulties, and as a result there is a large amount of information and help available. The speech changes that occur are due to inco-ordination and reduced activity of muscles that control the speech mechanism.
The main difficulties experienced are:
- loss of volume, pitch, range and intonation in the voice;
- rate of speech being either too fast or too slow;
- uncontrolled repetitions of sounds, words or phrases;
- slurred speech;
- difficulty initiating speech;
- reduced facial expression and natural gesture; and
- a harsh, breathy voice.
Guidelines for better speech
The first step towards improving speech is to establish a conscious awareness of the way you speak. Family members may be able to help by pointing out weaknesses in your voice, as sometimes you may not be able to detect subtle changes. An individual evaluation by a speech pathologist will also be useful to determine particular difficulties and to assess functioning of the respiratory system, the larynx, the pharyngeal muscles and the muscles involved in articulation. Most clinicians favour a burst of intensive therapy, with follow-up to reinforce techniques and help transfer these skills to everyday conversation.
Once there is awareness of particular issues, then it is time to try some exercises.
- Be aware of your breathing. Breathe in deeply before you speak so you don't run out of breath before the end of a sentence.
- Concentrate on your rate of speech, working at keeping it slow and even.
- Pretend your listener cannot hear and has to read your lips. Force your lips and jaw to work hard as you articulate words. Face your listener as much as possible.
- Concentrate on finishing the sound of each word before starting the next.
- Encourage your family and friends to let you know when your voice drops. Acknowledge the problem with family and friends. These reminders can prompt you to improve yourself.
- Reduce background noise.
- Talk for yourself, even if it takes longer. Don't let others talk for you.
- It is sometimes helpful to have someone talk for you, for example when you are tired, but you be the judge of when.
- On the phone, hold your head up straight and speak directly into the mouthpiece. Practise a few words aloud before dialling or answering, so that your voice can 'warm up'.
- Clear your mouth of saliva regularly whilst talking.
- Daily deep breathing and relaxation exercises are helpful for head, neck and shoulders.
- Most of all, RELAX.
Swallowing problems
The major reason for eating and swallowing difficulties (i.e. dysphagia) in PD is the loss of the ability to swallow quickly because of reduced ability to use particular muscles in the mouth and throat. The severity of the movement disorder probably does not correlate with the severity of the dysphagia. The movements that are involved in swallowing are mostly under automatic or involuntary control. The gradual loss of control over these muscles makes it increasingly difficult for the person to clear the mouth of saliva and to swallow instinctively. Eating becomes slow, hesitant and more of an effort and drooling may become an embarrassing problem.
Food may collect within the mouth and at the back of the throat. Trying to eat too quickly may result in choking, as swallowing may not keep pace with the placement of food into the mouth. Coughing just after swallowing is common, especially after liquids, as clearing each mouthful may not be complete with a single swallow.
Suggestions for relief
- Posture is important; keep the back as straight as possible. Keeping the head slightly forward may assist further. Do not throw the head back to try to help food slide down the throat, as this may lead to saliva or food falling into the windpipe (aspiration) and cause choking.
- Think through the steps involved before you swallow; close the lips and jaw; collect the food together, breathe in through your nose, lift your tongue up, then back, then swallow strongly. Breathe out and relax.
- You can reduce food collecting in the back of the throat, by taking small mouthfuls. Chew on one side first and then push food to the opposite side with your tongue. This is useful as an exercise, even if it is not used when eating.
- You may need to swallow twice to clear each mouthful.
- Take time to eat. Be sure to swallow each mouthful before taking the next.
- If you do cough, stop and rest from eating and drinking. If it happens regularly, contact your speech pathologist.
- Sit upright for at least half an hour after a meal.
- Tablets may be difficult to swallow. Crushing medications may be appropriate.
Dribbling
Most people produce about a litre of saliva a day which is usually swallowed automatically. This automatic mechanism is disrupted in PD, so other methods are needed to get rid of the saliva. Recent research has shown that if these do not work and dribbling becomes a significant problem, it is possible that radiotherapy to the salivary glands may help.
- Swallow saliva often. Make a conscious effort to swallow saliva before eating or talking.
- Close your lips firmly, slurp the saliva to the back of your throat and swallow. (Remember to think: UP-BACK-SWALLOW.)
- Drink more frequently if dribbling is frequent. Reducing milk intake has been found to reduce dribbling.
- Try to keep your head in an upright position so that saliva will collect in the back of your throat and facilitate automatic swallowing.
Choking
What should you do if a person starts to choke?
- Reassure the person. Give them a tissue to cough any debris into and lean them forward in their chair.
- Do NOT pat the person on the back.
- Apply pressure with the flat of the hand just below the sternum, in time with the person's attempts to cough.
- Remove any residue of food from the mouth and pharynx.
- Having recovered the situation, spend a few moments analysing why the choking occurred: Was the posture wrong? Is the person tired? Were they hurrying? This may help reduce choking in future. Advice from the speech pathologist or physiotherapist should be sought if the person experiences choking frequently.
Dry mouth
Many people with PD suffer from this frustrating and damaging problem. Saliva is produced by 3 sets of salivary glands to provide a natural barrier against the bacteria that invade our mouths. Xerostomia is the clinical term used by dentists and doctors to describe 'dry mouth' (the lack of saliva in the mouth). Dry mouth in PD is frequently related to anti-cholinergic medication. Dry mouth may be compounded by mouth breathing overnight. Some people alternate between drooling and dry mouth.
People may complain of a sore, sticky, dry or rough throat and it may be difficult to talk as they feel hoarse all the time. Dentures may be difficult to wear as the mouth becomes sore. Fluids need to be taken often and food may stick to the roof of the mouth, some foods proving impossible to eat.
It has been found that people with dry mouth not only suffer more cavities, but are also prone to tooth sensitivity, as the tissues of the mouth become dry and sometimes painful.
Coping with a dry mouth
- Sipping water frequently throughout the day, sucking on an ice cube or spraying a mist of water from an atomiser to lubricate the mouth, will help.
- Restrict caffeine intake and try to avoid soft drinks, alcohol, tobacco, peppermints, cinnamon and candy as these will only dry the mouth more.
- To temporarily increase saliva production, chew sugarless gum or lemon drops.
- For dry lips, K-Y jelly, surgical lubricant or hydrous lanolin are recommended. Avoid Vaseline or other petroleum products.
Consult your dentist, who is trained to deal with the specific problems of the mouth and can advise on the best ways to relieve discomfort. Also ask your dentist about toothpaste for sensitive teeth and gums. Keeping the mouth clean will reduce plaque and therefore cavities.
Last Reviewed: 22 July 2002
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