Ana Caline Nóbrega

Silent saliva aspiration in Parkinson's disease

Background: Silent laryngeal penetration and silent aspiration (SLP/SA) are common manifestations in Parkinsons disease (PD) patients and are frequently associated with dysphagia. However, little is known about saliva aspiration in this population. Objective: We investigated the frequency and characteristics of saliva SLP/SA in PD patients with daily drooling (Group A) and in individuals without PD or daily drooling (Group B). Method: Both groups were evaluated by fiberoptic endoscopic evaluation of swallowing (FEES) after dyeing the oral cavity with blue dye. The oropharynx was assessed for the presence of the stasis of saliva, and sensitivity was tested by direct tactile stimuli. Results: PD patients (n = 28) and controls (n = 18) were evaluated. We observed silent aspiration of saliva in 10.7% and silent laryngeal penetration of saliva near the vocal folds in 28.6% of Group A; however, none of these events was observed in Group B. Sensitivity in the epiglottis and posterior wall of the hypopharynx was decreased in 89.2% of Group A and in 33.3% of Group B, whereas in the aryepiglottic folds and interarytenoid area, a decrease in sensitivity was observed in 92.8% and in 44.4% of Groups A and B, respectively. Conclusion: Silent aspiration and laryngeal penetration of saliva are common features in PD patients with daily drooling. The presence of hypoesthesia of the laryngeal structures and the lack of protective reflexes in such patients may play a major role in the mechanisms of SLP/SA.

Is silent aspiration a risk factor for respiratory infection in Parkinson's disease patients?

OBJECTIVE To assess if silent aspiration is a risk factor for respiratory infection in patients with Parkinsons disease (PD). METHOD From February 2006 to June 2006, 19 PD patients with diurnal sialorrhea were evaluated by swallow videofluoroscopy (VF). Two patients moved away and contact with them was lost. The other patients were divided into two groups according to the presence or absence of penetration/aspiration and were followed up for 1 year. During this period, patients were assessed for airway infections, hospital admissions, weight loss, use of nasoenteral or gastric tube and to detect cases of death. RESULTS Silent laryngeal penetration or silent aspiration (SLP/SA) was observed in four patients. During the follow up period, three of the four patients with SLP/SA developed respiratory infection, and one of the 13 patients who did not show SLP/SA had airway infection (RR=9.75, 95% CI: 1.36-69.65). Two patients with SLP/SA developed airway infection and died, and there were two deaths in the group who had not been diagnosed for SLP/SA, one due to cardiac arrest and the other related to pancreatic cancer. CONCLUSION The results suggest that patients with Parkinsons disease with diurnal sialorrhea and SLP/SA have an increased risk of respiratory infections, which is the main cause of death in PD patients. The data support a greater emphasis on preventive interventions for silent aspirations and silent penetration to improve survival in patients with Parkinsons disease.

Swallowing impairment and pulmonary dysfunction in Parkinson's disease: The silent threats

INTRODUCTION Swallowing disorders and respiratory impairment are frequent in Parkinsons disease (PD) patients, and aspiration pneumonia remains the leading cause of death among these subjects. OBJECTIVE The objective of this study was to investigate whether there is an association between pulmonary impairment and swallowing dysfunction in PD patients. METHODS A cross-sectional study with a comparison group was conducted with PD patients. Subjects were submitted to demographic questionnaires and underwent spirometric and videofluorographic assessments. Significance level was considered at 95% (p<0.05). RESULTS Among 35 PD patients, 40% presented with swallowing complaints. However, 22% of the clinically asymptomatic patients presented airway food penetration when submitted to videofluoroscopy. In 20% of PD patients material entered the airways and there was contact with the vocal folds in 7%. However, there was an efficient cleaning with residue deglutition in almost all patients. No penetration/aspiration was detected among the controls. Respiratory parameters were below the normal predicted values in PD patients when compared to the healthy controls. CONCLUSION These data suggest an association between pulmonary dysfunction and swallowing impairment in PD patients; even in patients without swallowing complaints, impaired pulmonary function can be detected.

Does botulinum toxin decrease frequency and severity of sialorrhea in Parkinson's disease?

This study analysed if botulinum toxin type A (BTX-A) decreases drooling in 21 Parkinsons disease patients. BTX-A injections were given in the parotid glands. The severity of drooling decreased in 18 (86%) patients, while frequency was reduced in 8 (38%). In 11(52%) patients, the frequency of drooling remained constant, which may reflect more difficulties in swallowing, compared to the group that presented such improvement. Future trials assessing the level of swallowing dysfunction may be important to establish a prognosis for patients who keep the frequency of drooling in spite of decreased severity after BTX injection.

Silent aspiration in Parkinson's disease patients with diurnal sialorrhea

OBJECTIVE We studied the frequency of silent laryngeal penetration or silent aspiration (SLP/SA) in Parkinsons disease (PD) patients with diurnal sialorrhea. PATIENTS AND METHODS In 19 consecutive PD patients with diurnal sialorrhea, swallow was evaluated using the videofluoroscopy analysis. Data were analysed to determine the frequency of aspiration and its relationship with the severity of sialorrhea. RESULTS All patients were classified in the Hoehn and Yahr stages between 2 and 5. SLP/SA was observed in 21% of patients and the score of sialorrhea in the group with SLP/SA was 8.0+/-0.81, while in the group with no SLP/SA was 6.46+/-1.06 (p=0.02). CONCLUSION SLP/SA is a frequent morbidity in PD patients, its risk is higher in later stages of disease and in those patients with severe sialorrhea. However, prospective and controlled studies of follow up will be necessary to determine the prognosis and management in this group of patients.

Do swallowing exercises improve swallowing dynamic and quality of life in Parkinson's disease?

OBJECTIVE To investigate the effect of motor swallowing exercises on swallowing dynamic, quality of life and swallowing complaints in Parkinsons disease (PD). DESIGN A before-after trial. SETTING University Medical Center. PARTICIPANTS Parkinsons disease patients with dysphagia complaints. INTERVENTIONS Motor swallowing exercises designed to increase the strength and range of motion of the mouth, larynx and pharyngeal structures, coordination between breathing and swallowing, and airway protection. Patients should perform the exercises twice a day, five days a week, for five weeks. MAIN OUTCOME MEASURE(S) The primary outcome was the difference before and after the intervention in number of swallowing videofluoroscopic events (Swallowing Score). The secondary outcomes were quality of life (QOL) and swallowing complaints. RESULTS Fifteen patients concluded the study (10 man/5 woman; mean age 59.2 ± 9.17). The videofluoroscopic events with greater improvement were loss of bolus control (P < 0.03), piecemeal swallow (P = 0.05) and residue on the tongue (P < 0.01), valleculae (P = 0.01) and pyriform sinuses (P = 0.05). Lingual pumping and dental absence were interfering factors associated with treatment failure (beta standardized coefficient = -16.6, 26.2; P = 0.02, 0.002, respectively). The domains with greater improvements in QOL were fear (P = 0.02) and symptom frequency (P = 0.05). Regarding swallowing complaints, patients reported to have reduced mainly their difficulty in moving food in the mouth when chewing (P = 0.02). Reduction in swallowing disorders was not related with QOL improvement (cor = 0.13, [95% CI, 0.6-0.4], P = 0.63). CONCLUSIONS Motor swallowing exercises may reduce swallowing disorders in PD patients without lingual pumping and dental absence and impact positively QOL and swallowing complaints in individuals with PD.

Swallowing Disorders in Parkinson's Disease: Impact of Lingual Pumping.

BACKGROUND Lingual pumping (LP) is a repetitive, involuntary, anteroposterior movement of the tongue on the soft palate that is executed prior to transferring the food bolus to the pharynx, but we also observed LP when multiple swallows were taken. LP may be associated with rigidity and bradykinesia in patients with Parkinsons disease (PD). This phenomenon tends to be more prevalent in dysphagic PD patients, and its impact on swallowing dynamics remains poorly understood. OBJECTIVE To evaluate how LP interferes with the oral and pharyngeal phases of the swallowing of foods of different consistencies and volumes. METHODS We used videofluoroscopy to study the swallowing of 69 PD patients performing 10 swallows of barium mixed with foods of different consistencies and volumes. RESULTS LP was associated with the unstable intra-oral organization of the bolus, the loss of bolus control, the pharyngeal retention of food and food entering the airway. This abnormal movement was also associated with a shorter oral transit time and was found to be more prevalent with food of thicker consistencies. CONCLUSIONS LP is associated with swallowing incoordination and with food entering the airway. Preventive measures to minimise the pulmonary or nutritional consequences of this behaviour are necessary.

Delayed latencies of auditory evoked potential P300 are associated with the severity of Parkinson's disease in older patients

UNLABELLED Electrophysiological methods could provide important information about the neurophysiological status in Parkinsons disease (PD). OBJECTIVE To investigate the prolonged auditory P300 latency in PD and its association with the disease clinical stage. METHOD Clinical profiles of 44 patients were evaluated and those in initial and advanced stages of PD were identified. The frequency of altered latencies, median of latencies in each stage, and correlation between latencies and motor and non-motor clinical features were analyzed. Latencies were considered altered when they were more than two standard deviations from the mean of controls, per age group. RESULTS It was verified 10% of alterations in initial stages and 31% in advanced. There was correlation between latencies and non-motor clinical features. Subjects older than 65, in advanced stages, presented a significant increase of latencies. CONCLUSION There was an association between PD severity and P300 prolonged latencies among subjects 65 years old or older.

Wet Voice as a Sign of Penetration/Aspiration in Parkinson’s Disease: Does Testing Material Matter?

Wet voice is a perceptual vocal quality that is commonly used as an indicator of penetration and/or aspiration in clinical swallowing assessments and bedside screening tests. Our aim was to describe the clinimetric characteristics of this clinical sign using various fluid materials and one solid food in the Parkinson’s disease (PD) population. Consecutive PD individuals were submitted for simultaneous fiberoptic endoscopic evaluation of swallowing (FEES) and voice recording. Speech therapists rated the presence or absence of wetness and other voice abnormalities. Two binary endpoints of FEES were selected for comparison with an index test: low penetration (LP) and low penetration and/or aspiration (LP/ASP). The accuracy of wet voice changed according to the testing material in PD patients. Overall, the specificity of this indicator was better than its sensitivity, and the wafer cookie and yogurt drink yielded the best indices. Our data show that wet voice is clearly indicative of LP or LP/ASP in PD patients in case of positive test. However, in the case of a negative result, the wet voice test should be repeated or combined with other clinical tests to include or exclude the risk of LP or LP/ASP.

Depression in elderly assisted in Basic Health Units

Objective: to identify the prevalence of elderly in the Family Health Strategy with signs and symptoms of depression, characterizing them. Method: documental, quantitative and descriptive research, with the sample of 376 elderly and data collection done by applying the demographic questionnaire and the Geriatric Depression Scale. Data analysis was performed by Microsoft Excel, after approval of the research project by the Committee of Ethics in Research, Protocol No. 20100712-051. Results: 41% with suspected depression, 24% of antidepressive users. Of these, 42.9% aged 60-69 years old, 84% living in urban areas and 16% in rural areas, 49.3% were married and 33.8% widowed, 41.6% practiced home activities and 31.2 % farmers. Conclusion: become necessary specific actions to elderly health, detection of depression in this age group, emphasizing prevention and health promotion. Descriptors: Elderly; Disorder Adaptation; Primary Health Care. RESUMEN Objetivo: verificar la prevalencia de adultos mayores en la Estrategia Salud de la Familia con signos y síntomas de depresión, caracterizándolos. Método: investigación documental, descriptiva y cuantitativa con 376 adultos mayores y recolección de datos mediante la aplicación de un cuestionario sociodemográfico y la Escala de Depresión Geriátrica. El análisis de datos fue realizado con el software Microsoft Excel, después de la aprobación del proyecto de investigación por el Comité de Ética de la Investigación, Protocolo N° 20100712-051. Resultados: Hubo 41% con sospecha de depresión, siendo 24% usuarios de antidepresivos. De estos, 42,9% tenían edad de 60 a 69 años; 84% eran residentes en zonas urbanas y 16% en zonas rurales; 49.3% eran casados y 33,8% viudos; 41,6% realizaban actividades domésticas y 31,2% eran agricultores. Conclusión: son necesarias acciones específicas encaminadas a la salud de los adultos mayores y detección de casos de depresión en este grupo de edad, dando prioridad a la prevención y promoción de la salud. Descriptores: Adultos mayores; Trastorno de adaptación; Atención Primaria de la Salud. Enfermeira, Mestranda em Neurociência Cognitiva e Comportamento/Universidade Federal da Paraíba/UFPB. João Pessoa (PB), Brasil. Email: perla07figueredo@gmail.com; Enfermeira, Professora Doutora em Enfermagem, Unidade Acadêmica Ciências da Vida, Universidade Federal de Campina Grande – Campus Cajazeiras. Cajazeiras (PB), Brasil. E-mail: oliveirafb@uol.com.br; Educadora Física, Doutoranda em Medicina e Saúde, Universidade Federal da Bahia/UFBA. Docente, Unidade Acadêmica de Letras Universidade Federal de Campina Grande – Campus Cajazeiras. Cajazeiras (PB), Brasil. E-mail: lana-ff@bol.com.br; Enfermeira, Doutoranda em Enfermagem, Universidade Federal da Paraíba/UFPB. Servidora Técnica administrativa, Universidade Federal de Campina Grande – Campus Cajazeiras. Cajazeiras (PB), Brasil. E-mail: elianeleitesousa@yahoo.com.br; Psicólogo, Doutorando em Medicina e Saúde, Universidade Federal da Bahia/UFBA. Docente da Unidade Acadêmica de Educação, Universidade Federal de Campina Grande – Campus Cajazeiras. Cajazeiras (PB), Brasil. Email: zedezefinha@bol.com.br; Fonoaudióloga, Doutora em Medicina e Saúde, Docente do Departamento de Fonoaudiologia e do Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia/UFBA. Salvador (BA), Brasil. E-mail: anacaline@uol.com.br ARTIGO ORIGINAL Soares PFC, Oliveira FB de, Freitas EAF de et al. Depressão em idosos assistidos nas Unidades... Português/Inglês Rev enferm UFPE on line., Recife, 7(9):5453-9, set., 2013 5454 DOI: 10.5205/reuol.3529-29105-1-SM.0709201312 ISSN: 1981-8963 Dentre os diversos transtornos psíquicos que afetam os idosos, tem-se a depressão que merece especial atenção por parte dos profissionais da saúde, uma vez que apresenta frequência elevada e consequências negativas para a qualidade de vida. Essa doença é prevalente na terceira idade e constitui grave problema de saúde pública, gerando repercussões sociais e econômicas. A depressão apresenta-se como distúrbio da área afetiva ou do humor, com impacto funcional em qualquer faixa etária. Na velhice, a depressão envolve os aspectos biológicos (fragilidade na saúde decorrente de doenças crônicas), psicológicos (viuvez, falta de atividades sociais e mudanças de papeis) e sociais (pobreza, escolaridade, solidão e modificações no suporte social). É uma doença psiquiátrica e está associada ao maior risco de morbidade e mortalidade, ao aumento na utilização dos serviços de saúde, à negligência no autocuidado, à adesão reduzida aos regimes terapêuticos e maiores risco de suicídio. A depressão é subdiagnosticada e ignorada entre os idosos, uma vez que, frequentemente, profissionais de saúde tratam os sintomas depressivos como manifestações normais decorrentes do processo do envelhecimento e não tomam as atitudes necessárias. Enquanto sintoma, a depressão pode apresentar os mais variados quadros clínicos, dentre os quais: transtorno de estresse póstraumático, demência, esquizofrenia e doenças clínicas. Pode ocorrer, ainda, resposta às situações estressantes ou as circunstâncias sociais e econômicas adversas. Entretanto, a presença desses sintomas pode ser responsável por perda de capacidade funcional, autonomia e agravamento dos quadros de enfermidades preexistentes. Diante da relevância do cuidado com a saúde dos gerontes, a Política Nacional de Saúde da Pessoa Idosa define que a atenção à saúde dessa população terá como porta de entrada a Atenção Básica, por meio da Estratégia Saúde da Família-ESF, tendo como referência a rede de serviços especializada de média e alta complexidade; é a equipe de saúde da família a responsável pelo acolhimento, pelo tratamento e pela promoção da saúde mental do idoso. Diante do contexto, ressalta-se a importância dos profissionais que atuam na Atenção Básica de estarem renovando conhecimentos no campo da saúde do idoso, especialmente, sobre transtornos mentais como forma de possibilitar a detecção de sinais e sintomas da depressão, favorecendo diagnóstico precoce e tratamento adequados. Além disso, deve-se buscar rápida intervenção, bem como medidas de reabilitação, todos esses cuidados são fundamentais para a melhoria da qualidade de vida das pessoas que vivenciam a terceira idade. O desafio que se segue é a reestruturação do modelo assistencial para contemplar o segmento idoso de forma integral, de modo que este consiga viver com a máxima qualidade possível. A promoção da saúde é capaz de responder a tal proposta, visto que promoção da saúde pode ser entendida como processo de capacitação da comunidade para atuar na melhoria da qualidade de vida e saúde. Frente ao exposto, este estudo tem como objetivo:  Identificar prevalência de idosos na Estratégia Saúde da Família com sinais e sintomas de depressão, caracterizando-os. Este estudo é parte de pesquisa interinstitucional da Universidade Federal da Bahia e da Universidade Federal de Campina Grande << Fatores Associados à Independência Funcional dos Idosos >>. Trata-se de pesquisa documental, descritiva e quantitativa. A pesquisa documental utiliza-se de instrumentos que ainda não receberam tratamento analítico, de tal forma que possam ser reelaborados, de acordo com o objeto da pesquisa, não necessitando do contato direto do pesquisador com os sujeitos investigados. Os sujeitos deste estudo foram idosos, com 60 anos de idade ou mais, não institucionalizados que compunham a classe idosa assistida pela ESF, de Cajazeiras-PB, Brasil. Existem nesse município 7.539 pessoas acima de 60 anos, destes 3.221 eram homens e 4.318 mulheres. Foram excluídos do estudo aqueles que não tiveram condições físicas e cognitivas de responder aos instrumentos de coleta de dados. O cálculo amostral foi realizado pelo programa “sample.exe” do pacote estatístico PEPI, versão 4, utilizando nível de significância de 0,05, resultando em uma amostragem de 376 sujeitos. Os dados foram coletados por meio de dois instrumentos: questionário sociodemográfico e Escala de Depressão Geriátrica, versão reduzida – EDG. No questionário, foram avaliadas características da população amostral estudada, a EDG foi utilizada para MÉTODO INTRODUÇÃO Soares PFC, Oliveira FB de, Freitas EAF de et al. Depressão em idosos assistidos nas Unidades... Português/Inglês Rev enferm UFPE on line., Recife, 7(9):5453-9, set., 2013 5455 DOI: 10.5205/reuol.3529-29105-1-SM.0709201312 ISSN: 1981-8963 identificar o índice de prevalência de características indicativas de depressão. A EDG é um instrumento valioso, composto de 15 questões em sua versão reduzida, utilizado com frequência para identificação do quadro depressivo em idosos. Após sorteio dos sujeitos de forma aleatória virtual, realizou-se visita domiciliar e assinatura do Termo de Consentimento Livre e Esclarecido (TCLE) pelos participantes, para então dar início à aplicação dos instrumentos de pesquisa. Primeiramente, foram analisados os dados coletados, observando a possível omissão de alguma informação considerável, avaliando estatisticamente o percentual do que fora coletado. Tal avaliação efetuou-se com auxílio do software Microsoft Office Excel, apresentando-os tabelas. A participação dos sujeitos fora aceita mediante a assinatura do TCLE, havendo pela pesquisa o parecer favorável, conforme no 20100712-051, junto ao Comitê de Ética em Pesquisa, da Universidade Federal de Campina Grande UFCG, Hospital Universitário Alcidades CarneiroHUAC, em 2011, conforme doravante preconiza a Resolução 466/2012, do Conselho Nacional de Saúde que regulamenta a pesquisa com seres humanos no Brasil. Foram encontrados 41% dos idosos com suspeita de depressão (Tabela 1). Tabela 1. Casos de depressão entre idosos. Cajazeiras-PB, Brasil. 2011 A amostra foi composta em sua maioria por mulheres. Referindo-se aos idosos com suspeita de depressão, 77,3% eram do sexo feminino e 22,7% do masculino. Os idosos com depressão leve a moderada e depressão grave também foram maioria, 75,5% e 100%, res