Swallowing Problems in Parkinson’s: Early Warning Signs, Risks, and Strategies for Safety

[00:00:00] In Parkinsons, swallowing is medically known as dysphagia. It's a critical concern because it affects both safety and long-term health. Patients with Parkinsons, we always associate tremors, walking issues, but it also is very important to understand that the muscles of the throat, there's risk factors as well. The risk of aspiration pneumonia can occur with food or liquid. These particles of food or liquid into the lungs instead of the esophagus. So we're concerned about patients getting what's called silent aspirations or lung infections and then a pneumonia.

[00:00:47] Welcome back to The Caring Neurologist. Today's episode focuses on something that doesn't get talked about nearly enough, swallowing problems in Parkinson's. There's just not an uncomfortable or inconvenient issue that can actually be quite dangerous and life-threatening, especially if missed. I'm Dr. Sandeep Takar and I'm here to explain why swallowing issues do happen, how to spot them early as a warning sign, and what patients and families can do to prevent problems and emergencies.

[00:01:15] Dr. Takar, when people think of Parkinson's, they think of tremors or stiffness, not swallowing. Why is swallowing such an important issue in Parkinson's disease? Dr. So in Parkinson's, swallowing is medically known as dysphagia, and that's the medical term we'll use here and there during this podcast. But it's a critical concern because it affects both safety and long-term health.

[00:01:39] Patients with Parkinson's, we always associate tremors, walking issues, involuntary movements of the coordinated hand muscles, right, of the leg muscles. But it also is very important to understand that the muscles of the throat that require food and liquid to pass from the mouth to the stomach are important for nutrition purposes. So there's risk factors as well. The risk of aspiration pneumonia can occur with food or liquid, and even the saliva. And we can get these particles of food or liquid or saliva into the lungs instead of the esophagus.

[00:02:09] And so we're concerned about patients getting what's called silent aspirations or lung infections and then pneumonia. And we need to address the mechanics of swallowing because it's quite complex. And there's 50 pairs of muscles at least in multiple cranial nerves that are involved in Parkinson's. But it's again disruptive of the speed of the tongue movements, there's disruption of the throat muscles that make it harder for us to get that food into a bolus to get in the back of the throat

[00:02:38] that then actually can get into the stomach. So we see in Parkinson's that there's coordination issues along with not just again of the hands or legs or walking, but actually these fine motor control muscles for the for the swallowing. And we need to coordinate better and we need to talk about these situations because it does lead into hospitalizations.

[00:03:00] And there's stiffness of these muscles that again make it harder for patients to clear their throat properly and it leaves debris in their mouth and it can be inhaled even later on, which then puts them at risk for aspiration pneumonia. So this is again a really important topic. And it does lead to even life modifications and patients do become a little bit subdued and not want to be in social settings or they may not go to the typical restaurants that they enjoy.

[00:03:29] And as time goes on, it becomes more of a problem with malnutrition as well. And that can exist because when you're not eating or not feeling safe to eat, you then start losing the muscle mass, the muscle tone, the weight drops off. And then we see a lot of fatigue as well. So there's a lot of key factors important in Parkinson's and it's more than just the tremors and stiffness and slowness of the hands or legs. And what does swallowing dysfunction actually look like in real life?

[00:03:57] What are patients and families missing? Well, swallowing dysfunction in real life can be multiple things. So we'll start with first thing is when you're not moving your mouth well and the coordination of the lips are not as good as the tongue. We may even see the mouth hang a little bit forward in Parkinson's and we can actually get drooling or saliva that pools. So we can actually drool or we can also have swallowing of the saliva that sneaks back in the back of the throat and causes like this post nasal drip. And then patients can cough on the saliva as well.

[00:04:26] But other real life issues of dysphagia or the swallowing problems in Parkinson's isn't so like a movie where you're just dramatically choking and having this fit and someone needs a Heimlich maneuver. It actually manifests in multiple other ways. First and foremost, the changes during mealtime. So usually a meal that may take 20 minutes might now start taking an hour. And so we need to look at why is it taking so long for someone to eat? Are they pocketing the food and it's getting stuck in their cheeks or the roof of the mouth?

[00:04:53] And a lot of patients with Parkinson's complain or dry mouth. So we may start hearing these type of situations. We also see that they have to swallow multiple times just to get something to as far as like a small bite of food to clear the throat. And they may even develop kind of like this wet voice. So after drinking or eating, the person's voice may sound gurgly or kind of damp and we kind of hear like the food and liquids is stuck in the back of the throat.

[00:05:20] So that may be a sign that liquids getting or sitting at the top of the vocal cords rather than actually getting down to the esophagus. The other physical warnings of swallowing and or red flags that we think about is the frequent clearing of the throat. And it's kind of the constant need to clear the pipes during or immediately after the meal. Some patients may experience watery eyes or runny nose. And that's interestingly when food and any drinks touches a sensitive lining of the airway.

[00:05:51] You know, even in a person who doesn't cough, it may feel like there's this reaction that's being developed. And so we do see that it's kind of a secondary reflex. And in the effortful swallowing, you might see a person's neck muscles also straining. And it feels like kind of like the head of a bird, like is in motion and moving. And you see the spreading of these muscles. So these are types of things that may come across in other patients with Parkinson's.

[00:06:19] And then in another component of it, maybe in the real world, we may see patients have issues with mixed consistencies like food, like cereal, chunky soup, salad, for instance. Those are mixed consistencies that makes it hard to eat. So when they're trying to chew on certain things, the softer consistency foods may sneak back or the liquidy component of the consistencies may sneak back and patients can cough on those. Also crumbly foods can make someone cough.

[00:06:48] So if you're seeing these patterns, that's also a concern. Or if someone's sipping on water or thin liquids, you may start seeing that they want to intermittently cough or clear their throat. That's also another kind of start of issues that may come in Parkinson's. And Dr. Takar, I don't know if this is touching on a different subject, but because Parkinson's disease is a movement disorder, right?

[00:07:12] So it affects the muscles, movement in the throat, but it doesn't affect the chewing, which is also mechanic and movement. It can. A lot of patients, what ends up happening is they chew slowly and they don't chew enough, actually. And so when they chew, they may get tired or fatigued. So then the food doesn't really get softened in their mouth. And then they're swallowing like a larger bolus of food and it wasn't chewed down or softened.

[00:07:41] And so then you see that that's when they could put patients at risk of coughing on. But what they also complain about because they're not moving their mouth much and they're not softening the food is it feels like it's getting stuck in the back of the throat. They feel like something's still there and it does irritate the lining of the throat. So that's a great question. Good point. And why are swallowing problems so commonly dismissed or missed? Yeah, exactly. I think not only are swallowing problems just commonly missed or dismissed, it comes in two perspectives.

[00:08:11] One is, is the patient even aware of it to be a problem? And is it even related to the Parkinson's? That's what they may think. So swallowing problems in Parkinson's often refer to as silent symptoms because they don't always give you those medical emergencies. Again, as I commented, it's not like every time they eat that someone's having like a Heimlich maneuver that's needed. So there's a lot of what we call silent aspiration.

[00:08:33] And it's a phenomenon in patients that, you know, there's, it's like food is going down the wrong pipe, but slightly and slowly. And then there's a sensory loss in the back of the throat in patients with Parkinson's. And those nerves don't detect food or liquids in the airway and they become what's called desensitized to it. So the result is that the food and, and liquid enters the lungs without triggering a major cough reflex. And there's no like outward sign of the distress.

[00:09:02] And so those are called silent aspirations. So even family members aren't aware that that's happening. The other component would be maybe normalization of aging. Many people include healthcare professionals may mistakenly think that they view the slow eating or occasional coughing as a normal part of getting older. And that's not true. And we see that with a lot of neurological issues and mechanical issues of the throat and the, and the muscles of the mouth and tongue.

[00:09:27] We always focus right on big symptoms, the classic tremor, the stiffness, the balance issues, and the things that can lead to someone to falling. But, you know, that's why we miss the speech and swallowing. So we always concerned by things we can see and not necessarily the swallowing. And then patients, they may compensate. They may adapt. They do a good job subconsciously of adapting to discomfort. They may themselves take smaller bites. They may cut out certain foods that are harder to eat. A lot of our patients complain of it's harder to chew meats.

[00:09:56] So they may not eat steak and they may switch over to another type of food or consistency of food. They may drink or wash down their food with a little bit of water after each bite. So they kind of realize it. And a lot of these changes themselves happen over months and years. So you don't really realize that it's happening. And that's why it's, in my opinion, easily dismissed or missed. So, yeah, again, it's numerous factors.

[00:10:24] And also the gold standard of trying to figure this out and treating and diagnosing. Sometimes it's a little bit of work and extra testing that we only think it has to be serious enough that they're constantly coughing or choking on food that we would need to get testing. So sometimes we screen too late. Now, is this a symptom that develops over time as the disease progresses usually? Or can this be one of the first symptoms?

[00:10:51] Yeah, usually swallowing issues and aspiration on food and liquids is usually more of an advanced symptom of Parkinson's. You may see this more later on. But the interesting thing is I've seen many patients who lived a long life with Parkinson's, but their first actually motor or non-motor symptom is the sensation of not being able to swallow well. And they get this like million dollar workup, like why are they coughing, why are they clearing their throat?

[00:11:17] In fact, probably once every two weeks or so, I have a patient who comes in as a consult who's saying like they've been clearing their throat a lot and that's been one of the biggest problems for them. And they've seen a pulmonologist or they've seen an ENT and it just feels like there's this lot of like runny nose and a lot of excessive saliva. They're not necessarily drooling. They feel like they have to clear their throat or they have to randomly cough even if they're not eating.

[00:11:44] So we do see this come about early on, but it's typically the actual mechanism of swallowing problems is more advanced. And how do Parkinson's medications affect swallowing? Do they affect swallowing? How do the medications specifically affect swallowing? Yeah, well, number one is a medication efficacy situation here. Parkinson's symptoms are largely managed by our oral medications like levodopa.

[00:12:09] And if a patient cannot swallow the pills effectively, then the timing and absorption of the meds will become inconsistent. This can lead to like more of our what we call off periods where the motor symptoms worsen, more stiffness, more slowness. And it creates these cycles where the muscle rigidity is even worse and not just the hands like muscles. So it is key for the timing of the medicines to be taken. We always talk about with patients, you want to optimize any physical activity with the meds being taken first.

[00:12:38] And then maybe after 20, 30 minutes when the meds kick in, you want to do that activity. And that may include eating. And so you may want to take the pill, not just with food, but actually well before food so it can absorb. And as we've talked about on numerous episodes of these podcasts, that protein can also block the absorption or other foods can delay the absorption of the medication. So you want to take it on an empty stomach.

[00:13:00] And then when the medicines kick in, it may be easier for someone to eat and swallow and move their mouth or talk louder and then even create a stronger reflex to clear anything that's in the back of their throat. So a lot of the muscle rigidity would be less if they take their meds on time. And then there's also the fatigue factor. A lot of patients fatigue if they haven't gotten their meds.

[00:13:23] So we also want to make sure that when patients are eating, they want to not eat within a fatigued state where their voice is soft or they're like getting sleepy or drowsy. Oh, and before I ask the next question, the same medications that help with the rest of the symptoms are the ones that help the swelling to make the swelling better?

[00:13:46] They may. Certain medicines like, again, our levodopas or dopamine agonists, they may help in certain aspects of swelling. And then as the disease is actually progressing, it may be sometimes not as effective as it used to be. So that's when we have to really curtail to techniques and other unique kind of training that we get from our speech and language pathologists or speech therapists.

[00:14:12] So there's certain techniques that we'll get to talk about that will need to be used on top of the fact that if the meds are working or not working well enough for swallowing. And how does swallowing difficulty lead to aspiration pneumonia? So aspiration pneumonia is something aspirating into the lungs to create an infection in the lungs. And that's the pneumonia part. So it's a progression from simple swallowing, sips, or sorry, let's start that again.

[00:14:40] So the swallowing difficulty that leads to aspiration pneumonia, right? So aspiration meaning that something's getting into the lungs and the pneumonia is an actual infection of lungs. That progression from a simple swallowing slip to a full-blown lung infection is a cascade of biological issues going on.

[00:15:01] And so that also incorporates the defense of the immune system not working as well and the ability of the respiratory system and digestive tracts to also fail. So first and foremost is the infiltration of the food. In Parkinson's, the epiglottis or the cartilage flap or the lid that's supposed to close over the windpipes or the trachea, it may close too slowly. And then so they get penetration of food or liquids that enter the top of the airways and then stays above the vocal cords.

[00:15:29] And that material will then fall into levels of the vocal cord, which again enters into the lungs. So then we have this loss of cough guard or this reflex. And so in Parkinson's, muscles are also involved in coughing. The diaphragm itself and abdominal muscles are weakened. And then we see that they're not strong enough to create that strong appropriate cough reflex to kick out the intruder that's hitting into the airways. So the nerves of the throat may not be sensing the food.

[00:15:59] And that's what may lead to these silent aspirations where the lungs getting invaded by these particles of food or even the saliva that has bacteria in there. And then there's also the anatomy of the lung. So we see the right lung actually is very different from the shape of where the left lung is. And the heart kind of takes up a lot of the space of the left lung, whereas it's a right straight path into the right lung. And so sometimes food or liquids can actually lead right into the right lung.

[00:16:26] And that's how we know we're dealing with maybe an aspiration pneumonia because food and particles will work down the gravity path down that area. The other component that makes an aspiration pneumonia is that bacteria in our mouth, bacteria in the food that is still lingering there, that can build up. And then that poor oral hygiene that may be there and commonly seen in Parkinson's may again concentrate. And then that becomes harmful and harder to fight against.

[00:16:53] So we colonize in the saliva and that creates that heavy bacteria that, again, is harder for the antibiotics to get to. And then it's the chemical irritation in the lungs, issues of breathing that may occur. Sometimes patients have this hyaluronid hernia. They can have reflux. They have a lot of constipation already. So the gastric acids can also irritate and get into the lungs. And we can see that being a significant chemical irritation. So there's a lot of buildup that creates an aspiration pneumonia.

[00:17:21] And again, we would assume this to be more advanced stages, but we don't want to assume that's only the case. So when should someone request a formal swallow evaluation and how do you do a swallow evaluation? So a formal swallow evaluation should be requested as soon as there's any noticeable changes in eating habits or physical comfort during eating. So a lot of patients may complain of pain or discomfort in the chest or in the throat with eating certain foods.

[00:17:49] Because the brain often compensates for such issues, as I talked about subconsciously, you know, patients may start taking smaller bites. They may be mindful of maybe what consistency foods they want to eat. So we really want to request the test as soon as we can. And so if a patient or caregiver even notices one of the falling red flags as consistently happening, then it's time for a professional referral. So first and foremost is we would do the signs.

[00:18:17] The red flag signs are again coughing or choking with food, a wet voice with a gurgly liquid sound of the voice, recurrent pneumonias or bronchitis, multiple like chest infections. And that may be a sign again of the silent aspiration or chronic throat clearing like and then this kind of even having to randomly cough if they're not eating. That could be even the saliva sneaking back or patients feel like a sense of a lump in their throat. That would be a good reason to get a swallow evaluation.

[00:18:45] And if there's behavioral shifts, these are the subtle signs where patients are avoiding hard to chew foods, the fear of actually eating or drinking. There's associated weight loss that's going on. That may be another sign that they're not eating appropriately in this unintentional weight loss. And then again, I've like commented drooling or saliva or excessive secretions. Those are getting the red flags.

[00:19:07] So what we want to do with these types of tests, again, is a modified barium swallow or some form of fiber optic endoscopy. And those are again done where we would send a patient to the radiology department. And what interventions actually help reduce aspiration risk? So the actually, you know what I'm going to comment on is I want to I should be a little bit more clear on the swallow studies.

[00:19:34] And what we should do is actually we should talk about what may happen during these tests, because I think that that's another thing that patients have a fear of and they're not aware of these tests. So it's really common for patients to feel a bit of pressure anxiety or procedure anxiety when it comes to swallow studies. So a doctor like myself or even the primary care doctor would send a patient for a modified barium swallow.

[00:19:58] And that modified barium swallow test is done either with a radiologist or a speech pathologist. And what ends up happening is that these are again, non-invasive tests. They're generally very quick. And there's two main versions. But the first one we'll talk about is a modified barium swallow. And it's essentially an x-ray or a moving x-ray or fluoroscopy. And it takes place in a radiology suite.

[00:20:24] The process is typically that a patient may sit down or stand next to the x-ray machine. And the speech language pathologist or radiologist will give them food or liquids ranging from thin water to like thickened pudding or crackers. And it's mixed with barium. And that barium is a little bit chalky. It's a substance that's used that we can see on the x-ray. And it doesn't really taste like much. But usually it's flavored with some fruit or chocolate.

[00:20:49] And so what ends up happening, we can actually see how and the levels of where the barium and the food consistency are going down. So we can see where the issues are. And that information then is used by a speech therapist to work on certain mechanisms of which muscles are weaker. Or if the food is pocketing somewhere, what they can do as a technique. The second type of fiber optic endoscopy evaluation. And that usually is a test like a tiny camera rather than an x-ray. And it can be done at the bedside.

[00:21:19] But that process is done with a very thin flexible tube or endoscope. And it's passed through the nose or positioned just above the throat. And it doesn't necessarily go down the swallow pipe itself. And it doesn't actually interfere with eating. But it's looking to see the mechanisms of how the muscles are working and coordinating. So the food, in the context of this test, the patient eats or drinks regular foods usually.

[00:21:46] And it's dyed a little green or a little blue. So then you can actually see the difference against the pink tissue of the throat. And then that way we get a bird's eye view of the larynx. So the food or liquid is pooling in the throat or anywhere else. What interventions actually help reduce aspiration risk? So first and foremost, it's best to get a speech therapist. Get a swallow evaluation. Those are very, very key.

[00:22:13] I really depend on our physical therapist for balance training. I really depend on our speech therapist for swallowing and improving one's speech. So the interventions to reduce aspiration risk generally fall into three categories. It's the postural changes. It's the diet modifications. And then there's compensatory maneuvers. So while thickening liquids is the most well-known, modern evidence suggests that positioning and oral hygiene is also very critical to reduce the complications of developing a pneumonia.

[00:22:43] What we do with postural and positional interventions, a patient would need to make sure that they're sitting upright, that gravity plays a role in helping them with certain foods. But you don't want to be laying back and eating or you don't want to be eating forward. You want to have a proper 90 degree rule of sitting upright, a bit of the head up. And we don't want to be leaning back in any degrees that's off 90 degrees. We also, in my opinion, is you don't want to eat for too long.

[00:23:09] You want to have a quick meal, eat properly in the context of have the food cut up for you, have a good amount of energy. If someone's dozing off easily with eating, then you want to have a quick 5-10 minute meal and then come back to food again maybe 10-15 minutes later. But we don't want to be eating for 60 minutes having a tough time. But you also want to remain elevated for at least 30 to 60 minutes after you've eaten to prevent the reflux related to aspiration. The other part of the posture is the chin tuck rule.

[00:23:37] So it's a classic maneuver that we use and we tell patients where the patient brings their chin towards their chest while they're actually swallowing. This physically narrows the opening of the airway and widens the space at the back of the throat. That makes it harder for the food to fall back into the lung. And then head rotation. For instance, some patients, they have weakness on one side and that's really common more so like with a stroke.

[00:24:01] But if you turn the head towards a weaker side, it closes off that side of the throat and it forces the food down the stronger, safer side. And with Parkinson's, we may actually see that some of the vocal cords or like the vocal folds, that the muscles are not really as strong. And so we see again with Parkinson's, like one side is always a little bit more affected as well. And so that makes a big difference on that turning of the head. The second modification is actual dietary.

[00:24:27] And the goal here is to make the bolus that they're eating easier to use a chunky soup or the salads, as I commented before. It's often helpful if things are a little bit more pureed. You mix up the textures in a bowl. That's again, not too thin of liquids. And you want it a little bit more viscous. But you also may want the food to be maybe temperature wise, either cold or a little bit warm, not burning hot. When the temperature is just room temperature, maybe it's also not really waking up the senses of the mouth.

[00:24:57] So we kind of see that that makes a big difference. And then there's compensatory swallowing maneuvers that are taught by the speech therapist. And one of them is called a supraglottal swallow. And that's when the patient takes breath and holds it, swallows, and the cough clears it out before you take the next breath and eat. And there's the effortful swallow, which simply is swallowing hard.

[00:25:20] And that's an increase in the pressure used by the tongue and the throat muscles to clear the bolus completely, leaving no types of residue behind to be aspirated later. And then there's another maneuver called the mendensal. And that involves manually holding the larynx, kind of like the Adam's apple and elevating it. And you hold it there for a few seconds during the swallowing to keep the esophagus more open. And that, again, is something that's maybe more in advanced stages of Parkinson's.

[00:25:49] But some people have really found that to be helpful. But even online, there's a lot of tongue exercises to strengthen the tongue muscles. And some speech pathologist holds their tongue in and tries to swallow while holding that kind of strengthens these muscles. So I'll give a demonstration where it's like this. So it's actually you hold your tongue between your teeth and you try to swallow it. It actually strengthens these muscles. So if you're doing these exercises regularly, that really helps. And what practical changes can families make immediately?

[00:26:18] Yeah, the families need to be aware that there's an actual swallowing issue. As I commented, you really want to make sure that upright position is important. Make sure that the social dynamics is the families around the table, proper chairs, not necessarily that the patient is isolated in the bedroom. And if someone is eating, making sure that we're watching them eat to make sure that things are going stable. Small bites, sipping in between, avoid distractants during the meals.

[00:26:46] Always tell people, again, TV should be off. You should be focusing on one task at a time. And even when someone is eating, you shouldn't be talking, eating. And again, we get into these habits that that's, you know, eating is a social setting. And so it's easy to be wanting to talk or say something that's on what happened during the day. But again, we really want to focus on swallowing and chewing. And then again, being very meticulous when swallowing is becoming a problem.

[00:27:13] Also, just family members need to monitor when the patient's fatigued or very tired. And again, be aware of timing of the medicines. Making sure that we got the meds in earlier so that it's kicking in and so that we're able to coordinate better. And I always tell patients and family members that if there's a swallowing issue, let's go over the timing of the medicine so we can rearrange something along the lines so that we don't get into trouble when it's mealtime. And how do you help patients maintain dignity and joy around eating?

[00:27:42] Well, that's, again, the whole thing. You know, there's a lot of important things that we all want to be around. We want to be there for weddings. We want to be there around different ceremonies and anniversaries. And a lot of enjoyment in general socially is around the meal. And, you know, if you're going for a graduation party, you know, there may be a meal and someone wants to toast. So there's so much enjoyment that comes with eating that we want to maintain that the patient is there to enjoy the social aspects of everyone.

[00:28:12] And so I do believe that we don't want to make any physical limitations. But choose restaurants, number one, that are easy to get to, easy to enter, where it's not like it's so crowded. You want to also, you know, have a balance of what's safe, right? So when you're having meals, make sure that you're specifically ordering certain foods and it's easy to eat. And don't get into the trap of, well, oh, I really like this one thing and I haven't had this in a long time, but I'm going to, I could cough on it.

[00:28:39] So try to be smart in social settings that you don't put yourself in a vulnerable state. Some of our patients, they even bring their food to certain, you know, other families' homes just because they don't want to be at home and miss the entire meal. They want to actually be around others, but they'll eat something safely. So we don't want to like limit people or put an ostracize at anyone.

[00:29:05] But again, it's very important that we enjoy the company of everyone who has Parkinson's, but do it in a safe way. So the presentation obviously is a big part. We call it the first bite. We eat with our eyes first. We look at what we're eating. And again, sometimes the food is pureed. It doesn't look so good. So maybe you want to garnish it. Maybe it's a color contrast. Maybe nice plates, maybe nice cups and glasses that are there that makes it more enjoyable. You kind of feel like if you have a chalice, you know, you want to drink more water.

[00:29:34] So I think it's just kind of one of those things. But the aroma of the food can also take over, even if the texture of the food doesn't look that good. But certain soups can have different creams on there. Or again, you know, you can garnish it differently. And so I think that's one important thing. The autonomy and the choice, you know, the order of operations we speak of is, you know, we always offer the food first to the patient. Would you like to try this first? And would you like to sip on the water now?

[00:30:03] And then again, making sure that we're mindful of what's safe to eat. And then we empower the person who's having swallowing issues to make sure that they're eating. But still, again, in the context that we haven't forgotten that we have to maintain good discipline during the meal. You want to have proper tools. You know, a lot of our patients who have problems with swallowing, we don't want to give them a big tablespoon.

[00:30:24] Sometimes even teaspoons are better because a smaller amount of food that's on the spoon will allow them to eat and chew through it properly. And when we are in a social setting, sometimes as a caregiver, you may forget to be mindful of every time that the patient's eating. And sometimes finger foods, you know, maybe it's hard to use utensils and maybe it's better to have finger foods, small sandwiches, steamed veggies, certain fruit slices.

[00:30:51] And that can then allow for independence for the patient to be around there and avoid maybe the bib phenomenon, right? We want to protect our clothes. So maybe sometimes we put patients in a situation that they feel like they're a baby and like, why do I have to wear a bib? And that can also make it uncomfortable for them. Sitting at eye level makes a big difference as well.

[00:31:14] And I would also say that being Indian, we know we're all about our spices, but flavor beyond just the salt and the sugar. And make sure that we have a flavor hit, make sure that there's different seasoning. And it's not about just adding salt or sugar because, you know, certain oils, certain sauces, certain powder spices, they bring out also a lot of antioxidants as well.

[00:31:40] But I think that there's something emotional about having certain flavors that kick in and you don't want to have something too spicy as well because patients may even cough on it and that can lead to a lingering cough while they're at the table. But respect the no. And what I mean by that is when someone doesn't want to eat and we should say, it's okay, we don't have to eat right now. We can maybe wait. And just because we're in the setting of eating, it doesn't mean that the patient has to eat. Maybe they can wait till later to eat as well.

[00:32:07] So, Dr. Takar, we've reached the end of our episode. Is there anything else that you would like to leave our listeners with today? Well, that was hopefully a lot of information. And, you know, the unique thing about this topic when we talk about eating is it comes about safety. And I'm a huge believer about the safety component of it. There are two things that get people in the hospital and it's aspiration pneumonia and they're false. So, this is a really important topic.

[00:32:35] I really hope that we're able to simplify what goes on when it comes to eating and in the ways that we need to objectify it and what we need to do about getting speech therapy involved. We never want to minimize that aspect with neurological care. Thank you so much, Dr. Takar. Swallowing problems in Parkinson's are common, manageable, and too often ignored.

[00:32:57] If this episode helped you recognize early signs or feel more confident asking questions, please share with someone who needs it. Prevention starts with awareness and awareness starts with conversation. Thank you for listening to The Caring Neurologist. Thank you. Thank you.