Speech and Swallowing in Parkinsons & Dementia Ms Sally Pittendrigh

Sally Pittendrigh, an experienced speech pathologist specializing in adult dysphagia, neurological and communication disorders, and head and neck cancer treatment, presents a comprehensive talk on the challenges of speech and swallowing associated with Parkinson's disease and dementia. With over a decade of involvement in the MND clinic, Pittendrigh's focus lies on understanding the nuances of speech pathology and their interventions across these neurodegenerative conditions.

The podcast begins with an overview of the complex nature of swallowing, defining it as a neuromuscular process that ages and changes over time due to various physiological factors. Pittendrigh contrasts normal swallowing with abnormal swallowing patterns observed in clinical settings, particularly emphasizing the risks of aspiration that can lead to severe morbidity. She addresses the different manifestations of dysphagia in dementia and Parkinson's, noting that while dysphagia tends to be more pronounced in dementia, it can present early in Parkinson's, often complicating both feeding independence and nutritional intake.

Shifting the focus to language and speech, Pittendrigh outlines how age-related changes impact communication, with particular attention to how these changes manifest in individuals with Parkinson's and dementia. She describes the early emergence of dysarthria in Parkinson's patients characterized by a soft, breathy voice and reduced facial expression, which significantly hinder social communication. In contrast, speech deficits in dementia appear later and are heavily influenced by cognitive dysfunction, which complicates both comprehension and verbal expression.

The talk proceeds to discuss various interventions that speech pathologists employ to mitigate the impacts of these communication and swallowing disorders. Pittendrigh emphasizes the importance of early intervention, highlighting that capturing patients at earlier stages allows for better long-term outcomes. She outlines a range of strategies that include compensatory methods such as texture modification and positioning adjustments during meals to enhance safety during swallowing. The conversation also covers rehabilitative approaches aimed at strengthening the muscles involved in swallowing and optimizing voice production through high-intensity vocal training programs, which are central to maintaining communicative efficacy.

Pittendrigh highlights the value of caregiver involvement throughout the therapeutic process, advocating for collaborative approaches to ensure that caregivers are equipped to support patients effectively. She discusses the significance of tailored communication strategies, including the use of communication passports that document personal interests and vital information, making interactions smoother for individuals with cognitive impairments who may require assistance in unfamiliar environments.

The potential of technology in speech pathology also emerges as a key theme in the discussion. Pittendrigh showcases how advancements in voice banking and AI can revolutionize communication for individuals with progressive voice loss, empowering them to retain their identity through voice recordings. These technological tools can be integrated within therapeutic practices to enhance both verbal and non-verbal communication.

The lecture concludes with a practical guide on how to access speech pathology services, underlining the importance of addressing concerns related to swallowing and communication early on. Pittendrigh encourages continuous contact between speech pathologists and patients, asserting that even sporadic check-ins can make a significant difference over time, especially as symptoms progress. She stresses the value of resources like Speech Pathology Australia in connecting patients with appropriate services, ensuring that individuals receive the necessary support tailored to their unique needs. Through her presentation, Pittendrigh emphasizes a proactive approach to intervention in speech and swallowing disorders, showcasing the transformative capacity of early and informed speech pathology care.

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Our next speaker is Sally Pittendree. Am I saying that correctly?

I sweated over it. So Sally's a speech pathologist here who specializes in adult

dysphagia, neurological and communication disorder rehabilitation,

and head and neck cancer treatment.

So she's been involved with the MND clinic for more than a decade.

And today she's going to give us a talk on speech and swallowing the hidden

challenges in Parkinson's and dementia. So thank you, Sally. Thank you.

All right. Yes. So I've worked at Macquarie University for about 15 years and

also in the private sector.

And my personal professional interests lie with our neurodegenerative population.

So it's lovely to be here today.

So we're talking about speech pathology and parkinson's how we might approach

it in assessment more probably interestingly is looking at how we approach intervention

and then how do you find us,

so speech pathologists by description

look at communication and swallowing changes across a lifespan,

and they're broken down into those categories there as sort of different domains of communication.

But swallowing, a really complex neuromuscular process,

and I've got a VFSS here to show a normal swallow, contrasting with an abnormal

swallow where the bolus enters into the trachea and has penetrated below the

level of the true vocal folds into the airway.

It's historically divided into phases, but it's a continuous process and it

is a significant measure of airway risk and this contributes to significant

morbidity and mortality.

But our swallowing ages. It ages for different reasons and the physiological

changes are there described.

But basically what we end up with is a swallow that's slower and poorly timed,

with changes to the way our body employs natural airway protection mechanisms.

And then we move into the dysphagia of a dementia and a Parkinson's.

Now, classically in dementia, dysphagia, the literature and perhaps true clinical

practice says it's moderate to severe, but I would challenge it.

I see it emerge quite early.

It is continuing and progressive in nature as it is with Parkinson's.

The contrast with Parkinson's is that we see it quite early in the disease process.

Dementia, it is embedded in cognitive dysfunction and the behavioural challenges

to feeding and transitioning from being someone who's an independent feeder

to being dependent for feeding.

And then in Parkinson's, we have those motor impairments that change the physiology of the swallow.

So what we end up with is a delayed or absent swallow,

poulpharyngeal clearance, so food and fluids sitting above the airway that can

then penetrate the airway, the presence of cough with food and fluid intake,

but we can also have silent aspiration, So the airway of material into the airway

that people don't detect and cough in response to.

And that obviously the history of a recurrent chest infection.

It also looks as excess oral saliva. So a delayed swallow and a changing frequency

of swallow means people do tend to present with scylaria.

Moving quite quickly through this topic, so we're going straight into speech and voice.

So age-related changes to speech and voice. We have physiological changes that

impact the way we generate speech and voice.

How that looks like is more reduced precise, imprecise articulation and formation of sounds.

We change our speech rate. We slow down.

Our pitch changes, and for men and women, that's slightly different.

Our voice volume drops, and we become a bit softer, and the duration of our

speech and how much we say on a breath changes also, and our voice quality changes.

The older we get, it's a little bit more hoarse and raspy, and that's,

in part, there is a normative component to that as a process of age.

But then we move into dementia and Parkinson's.

So dysarthria and dysphonia are very early and common in Parkinson's,

and it's primarily a hyperkinetic dysarthria.

There's an asterisk there because there can be a little bit of a variation of

how we might describe it, but that is a breathy, weak, hoarse,

soft voice. It's monotone.

It has reduced prosody, and we have people who have hypomimia or that reduced

facial expression and effect, which impact upon their social communication.

And then in our dementia, we have, it tends to emerge later,

these features of speech, but it does depend on the dementia subtype,

which has been discussed a bit already this morning.

So it can look a little bit more variable and largely affected by cognition and language.

So we have a later stage presentation of speech in dimension,

it might be a little bit more mumbled and coherent, more apraxic features and

definitely that softer volume.

Then we have language and its component or how it manifests in dementia and Parkinson's.

In Parkinson's, it can be a little bit later and it tends to be also with that

comorbidity overlap of a dementia profiling in Parkinson's.

But we have executive functioning changes that look at their planning,

organising, sequencing, those high, high-level cognitive communication skills.

But classically, it's word retrieval changes and that verbal fluency.

So we have that tip of the tongue phenomena that emerges in their speech.

Their speech doesn't contain as much or their language doesn't contain as much information.

And they have changes in the way they follow those complex instructions.

Whereas in dementia, it's a bit trickier. We have a really obviously clear disruption to language.

So we've had a bit of a discussion about the PPA variants.

But more characteristically, it does look like word retrieval changes.

So PPA is the more isolated disruption of word and semantic knowledge.

But our dementia subtype, our classical dementia clients, typically it's fluent.

So they say a lot, but they don't say much when they say a lot.

And it progresses to largely non-functional language output for them.

What do we do?

So, clients walk into my space and as Dom alluded to, I love families coming into,

they're the historians for me, they're the people that sit and do shake their

head to the questions and that's incredibly valuable because people often deny

dysphagia, not surprisingly,

or deny changes to how effective they are as communicators.

Our goal is to aim to preserve where possible and maintain and preserve function.

And speech pathologists are getting much better at researching what they do

in this domain and are developing more robust evidence about how they do it.

Our goal is to enhance access to communication and safety with mealtimes,

not for the actual purpose of doing them, but because they contribute so highly

to people's social and emotional well-being.

We don't eat in isolation.

We talk to people.

It's really important we maintain links to those sorts of domains.

And then we support others to support them. So our clients, caregivers become our clients.

Their families become our clients. and we look at ways to help them maintain

their roles that they perform in the community to the best of their ability,

and be active participants in the way that they would like to participate.

And then we plan for the future. And that's easy to do when we have some really

clear diagnostic profiles like PPA.

We really can prepare people for the changes that are coming towards them.

And the same with Parkinson's. It is more tricky with Alzheimer's disease and

other dementia types. What do we do?

I guess classically when people think of speech pathologists and swallowing,

you think of texture modification and thickened fluids. and that's my last resort.

That's never my place to start. That's my place to finish if absolutely necessary

and if my client wants it and if they don't want it, I have to work with them

around what they want and how we make it work.

And embedded in those compensatory strategies, we have swallowing maneuvers

and we have positional modifications that can make people more safe with swallowing.

But it does require a bit of a cognitive load. So you have to be able to do

it and you have to be able to do it consistently. And that's a challenge.

And then we have multidisciplinary teams. And that's me picking up my phone

at the phone to my colleagues who are dieticians and occupational therapists,

behavioural management support professionals who can help me manipulate the

environment for swallowing as well as the utensils they might use.

So simply enough, it can be just substituting a dessert spoon for a teaspoon

to support rate control.

Then we look at rehabilitative and that's where speech pathology evidence is getting stronger.

We have lots of pharyngeal stage, show strengthening the throat and the muscles

of the pharynx to support a much more coordinated stripping process where the

bolus is more likely to enter into the esophagus.

We have oromotor exercises. The evidence there is not as strong.

We have respiratory muscle strength training coming into the literature, both for and against.

And I think when we consider expiratory muscle strength training,

which is a little bit of the flavor of the month in speech pathology,

we cannot ignore inspiratory muscle strength training also.

In Parkinson's, there is a strong rehabilitative process for speech.

It's high-intensity vocal, high vocal-intensity programs that you might recognise

as like the Lee Silverman voice therapy approach or another program called Speak Out.

The principles of those interventions are also to maintain and preserve swallow

function. So we do apply speech-based and voice-based training with the aim

to support and maintain swallow function also.

And then we look at education. If someone, I need someone to be safe,

I need to minimise their risk of aspiration.

I also need them to understand if they are aspirators, how to minimise the infection

control aspect of that aspiration. So we look really carefully at oral hygiene.

In communication, I've talked a little bit about high effort voice therapy for

LSVT speak out, which I would apply for Parkinson's, some types of MSA, some types of PSP.

But carefully, and I have other therapeutic approaches for some of those other different phenotypes.

We look at augmentative and alternative communication. How can I help you to

be a successful communicator when your speech system is impaired.

So we can use voice amplifiers, a little bit like this looks like,

some low-tech devices. I do encourage this with all my dementia subtypes.

Having a communication passport. Who are you? What are your interests? What do you like about?

Who are your important people to you? Your person-specific vocabulary.

A little bit about your occupational history, where you're from, what your hobbies are.

It helps us facilitate communication.

It can reduce agitation with communication and it makes communication way more successful.

It's also really important when we have people that move into the acute care space with a dementia,

having some knowledge of that person on paper really supports them in a foreign

environment, which is highly agitating

when there's lots of door knocking people coming in to do testing,

lights are on, they can get quite agitated by that environment.

So having really nice clinical information about who this person is really helps

them in that foreign environment.

We look at communication training, partner training, helping people's caregivers

make them, help them to be successful with their communication and whatever

environment they occupy.

So that might be within their home or it might be in a residential aged care facility.

We've mentioned support groups and there's Parkinson's, so there's online choirs

and there are in-person choirs around Sydney for people with Parkinson's.

The biggest shift for speech pathology in recent times is voice banking and

the AI role in voice banking.

So we can bank someone's voice.

We can use a speech sample from their voice before it became impaired by whatever

disease process they're experiencing and bank retrospectively their voice.

We don't need, we used to need five to six hours of voice recordings. We need 15 minutes now.

It's a huge shift in technology and it's powerful.

We can embed those voices on text-to-speech based applications,

on iPhones and iPads or whatever applications that people might use and they

can communicate via text if they have preserved word, semantic and lexical knowledge.

Now that is the challenge here, but that's why early speech pathology intervention

is so powerful because we've got capacity to teach new learning and get them

on board with technology.

If they've not been a technology consumer, some people are huge technology consumers, some are low.

Our low tech consumers may not choose this pathway and that is okay, but they should be open.

They should have that offered to them as an opportunity.

And as I've mentioned, we do through therapy, impairment-based therapy.

We look at verbal fluency and word retrieval.

We look at word retrieval very much on person-specific vocab.

I don't need you to tell me that an African animal is a tiger.

I need you to tell me what's really important to you and maintain that language.

And I need to be able to collaborate with other clinicians to help you use your

language effectively in the environment to tell us when you're sick and something's

wrong and you're distressed, and then how can we help you?

And as I mentioned, high effort, voice therapy.

Both those programs have an

intense protocol of intervention followed by a maintenance group therapy.

It would be not surprising to any of you that all of those groups are done via telehealth.

I run a group for ladies on Tuesday morning and I do a weather check because

someone's from Port Macquarie, someone's from Armadale, someone's from Cooma,

someone's from Sydney and I go, tell me ladies, what's the weather?

And with their nice strong voices, they tell me.

How do you get to see a speech pathologist? Own referrals. So some interventions

are better early, and I hope I've advocated for that, that I can do a lot when

I capture people early and I can help them navigate some of these disease posts.

And we can future plan and look at preferences around how they would like to communicate.

We can use compensatory strategies to be preventative.

And if we get people early, as I said, we can build good habits that help when

they cognition really does start to decline.

We've got some entrenched communication supports in place that really we can

continue to use in the situations where cognition is deteriorating.

There's a different side there for dysphagia. Obviously, if you are concerned

that someone has a swallowing problem, using those descriptors, please refer.

But people are terrible at telling you they have swallowing problems,

but they lose weight, they don't seem to be interested in eating anymore,

they don't like going out socially for meals like they used to,

they've become fussy eaters,

they're constipated.

All of those things tell me sometimes that someone swallowing is also impaired

and it's worth analysing that and understanding what's happening.

So we don't need a medical referral unless required, unless they're using a CDM.

And that probably takes us to the next slide is how do you find a speech pathologist?

Speech Pathology Australia has a beautiful website to help you find one.

You can use by location and you can pop in your location or a postcode and it

will give you a snapshot.

In Sydney, our public hospitals, by and large, have an acute adult speech pathologist

in their staff, and most of them still have an adult outpatient speech pathologist.

Those speech pathologists, less and less, are people who can attend people's

private homes in the community.

And our clients are less and less the people who can come into clinics and see us.

So we are finding that we are having to transition to the private sector more

and more for some of these client populations.

Maddie beautifully brought to our attention the shifting that's occurring to my age care.

And that's excellent for accessing a speech pathologist or an occupational therapist

because suddenly we have access to a variety of providers in the community where

people can find someone that meets their needs specifically.

And that's really good. Rather than seeing a paediatric speech pathologist for

an adult swallowing disorder and not getting that same structured input or support.

So that's an excellent website as a reference point. Key takeaways,

it's early for us. The earlier, the better.

We don't want to, we're not seeing these people every week unless we're doing

an intensive program with them, but we maintain contact over a lifetime or,

you know, to a point where we are no longer able to intervene in their clinical

circumstance, in which case we might transition to a palliative care service

that has a speech pathologist attached or an aged care facility.

It's watching out for signs of dysphagia and not simply relying on,

overt signs of dysphagia as the true measure of its presence or absence.

And then obviously how to find one.

And Speech Pathology Australia has made an incredible resource for us in that space. Thank you.