GEoPD 2016, JSimons session6 handout
Transcript of 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
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
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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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
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
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
Screening evaluation: Web application
Resulting categories: No dysphagia / noticeable oropharyngeal dysphagia /
dysphagia with risk of penetration/aspiration
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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
Demo web-app
www.mdt-parkinson.de © J. Simons
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
dPV – Swallowing disordersGerman Society for Parkinson‘s Disease– Dysphagia screening and quality of life
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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
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!
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
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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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
PARK-FEES-Parkinson’sspecificprotocolforfiberopticendoscopicevaluationofswallowing
Patientname: Date:
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:
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)
H2O(90ml,dyedblue) Breadwithcrust+spread(½slice,≈8x7x1cm) Buttercookie(1piece,Ø5cm)
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
H2O(90ml,dyedblue) Breadwithcrust+spread(½slice,≈8x7x1cm) Buttercookie(1piece,Ø5cm)
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
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
FEES video records in PD
© J. Simons
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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
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
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
Dietary adaptations
Normal diet
© J. Simons
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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
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
DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
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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DEPARTMENT OF NEUROLOGY | CENTER OF BRAIN, BEHAVIOUR AND METABOLISM
Multidisciplinary approach to PD care: Dysphagia – Early identification and treatment options
THANK YOU
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