Norman A. Leopold

Pharyngo-esophageal dysphagia in Parkinson's disease.

Abstract. The radiologic characteristics of pharyngo-esophageal (PE) dysfunction in Parkinsons disease (PD) are not well established, partly because most previous studies have examined only small numbers of patients. We administered a dynamic videofluoroscopic swallowing function study to 71 patients with idiopathic PD. Using the Hoehn and Yahr disease severity scale, patients were subdivided into those with mild/moderate disease, subgroup I (n = 38), and advanced PD disease, subgroup II (n = 33). From pharyngeal ingestion to gastric emptying, bolus transport was normal in only 2 patients. The most common abnormalities occurring during pharyngeal ingestion included impaired motility, vallecular and pyriform sinus stasis, supraglottic and glottic aspiration, and deficient epiglottic positioning and range of motion. Esophageal abnormalities were multiple but most commonly included delayed transport, stasis, bolus redirection, and tertiary contractions. Typical aberrations of lower esophageal sphincter (LES) function included an open or delayed opening of the LES and gastro-esophageal reflux. A pathogenesis linking PE with the pathology of PD is proposed.

Prepharyngeal dysphagia in Parkinson's disease

Dysphagia in patients with Parkinsons disease (PD) is most often atributed to pharyngeoesophageal motor abnormalities. In our study of patients with idiopathic PD, attention was focused on prepharyngeal symptoms and motor functions. Using the Hoehn and Yahr disease severity scale, patients were grouped into those with mild/moderate disease [subgroup I (n=38)] and those with advanced disease [subgroup II (n=34)]. Dysphagia symptoms were present in 82% of all patients, but subgroup I patients voiced significantly more complaints. Conversely, many prepharyngeal abnormalities of ingestion, including jaw rigidity, impaired head and neck posture during meals, upper extremity dysmotility, impulsive feeding behavior, impaired amount regulation, and lingual transfer movements were statistically more frequent in subgroup II patients. Impaired mastication and oral preparatory lingual movements were the most common aberrations observed during dynamic videofluoroscopy (48/71), with most patients being concordant for both. The motor disturbances of ingestion reported herein reflect the disintegration of volitional and automatic movements caused by PD-related akinesia, bradykinesia, and rigidity.Dysphagia in patients with Parkinsons disease (PD) is most often atributed to pharyngeoesophageal motor abnormalities. In our study of patients with idiopathic PD, attention was focused on prepharyngeal symptoms and motor functions. Using the Hoehn and Yahr disease severity scale, patients were grouped into those with mild/moderate disease [subgroup I (n=38)] and those with advanced disease [subgroup II (n=34)]. Dysphagia symptoms were present in 82% of all patients, but subgroup I patients voiced significantly more complaints. Conversely, many prepharyngeal abnormalities of ingestion, including jaw rigidity, impaired head and neck posture during meals, upper extremity dysmotility, impulsive feeding behavior, impaired amount regulation, and lingual transfer movements were statistically more frequent in subgroup II patients. Impaired mastication and oral preparatory lingual movements were the most common aberrations observed during dynamic videofluoroscopy (48/71), with most patients being concordant for both. The motor disturbances of ingestion reported herein reflect the disintegration of volitional and automatic movements caused by PD-related akinesia, bradykinesia, and rigidity.

Dysphagia--ingestion or deglutition?: a proposed paradigm.

Abstract. The current classifications of dysphagia are based on local structural or central nervous system pathology causing dysfunction of the aerodigestive tract. The result is a clinical science grounded in the analysis of the swallow with its lingual, pharyngeal, and esophageal stages. Adding bolus preparation to the swallowing paradigm improves but still constrains the study of dysphagia and treatment of the dysphagic patient. Those pre-oral facets of mealtime behavior that may evoke or exacerbate dysphagia remain beyond the existing classification boundaries imposed by the conceptual swallow and anatomic aerodigestive tract. We offer a more inclusive strategy for investigating dysphagia based on a five-stage process of ingestion: pre-oral (anticipatory), preparatory, lingual, pharyngeal, and esophageal. The first stage considers the interaction of pre-oral motor, cognitive, psychosocial, and somataesthetic elements engendered by the meal. The limited literature regarding the interaction of the pre-oral stage with other ingestion stages, in both normal subjects and patients with cortical, basal ganglia, and psychogenic diseases, is reviewed. The neurophysiologic and clinical justifications for embracing a pre-oral stage, and thus for the paradigm shift from deglutition to ingestion, are presented.

Errors Produced on the Mini-Mental State Examination and Neuropsychological Test Performance in Alzheimer's Disease, Ischemic Vascular Dementia, and Parkinson's Disease

The authors investigated whether MMSE indices designed to measure temporal and physical orientation, declarative memory, language, working memory, and motor/constructional function could differentiate patients with different dementia diagnoses: Alzheimers disease (AD), ischemic vascular dementia (IVD), or Parkinsons disease (PD). MMSE summary scores did not differ (AD, 21.4; IVD, 21.1; PD, 22.3). The AD group scored lower than IVD or PD on temporal orientation and declarative memory, IVD lower than AD on motor/ constructional and working memory. The IVD and PD groups made more errors in writing a sentence and copying intersecting pentagons. Significant correlations were found between the orientation indices and neuropsychological tests of naming and memory, and between the working memory and motor/constructional indices and tests of executive control. Such analyses of MMSE performance could assist in formulating referral questions for cognitive assessment and in tracking the course of dementing illnesses.

Risperidone treatment of drug‐related psychosis in patients with parkinsonism

Risperidone, a novel neuroleptic with approximately equal D2 and 5HT2A receptor blocking properties, has been used to treat drug‐related hallucinations in patients with Parkinsons disease. However, the results of only small numbers of patients have been reported with the drug demonstrating limited usefulness. We report our experience with this drug in 39 patients (25 women and 19 men) with parkinsonism. Monitored clinical data included duration of disease, Hoehn and Yahr score, Mini‐Mental State Score, Unified Parkinsons Disease Rating Scale (UPDRS) prior to drug administration and after 3 and 6 months of treatment, and response to treatment. Twenty‐three patients with Parkinsons disease had either complete or near‐complete resolution of hallucinations whereas an unsatisfactory response (N = 6) or worsening of parkinsonism (N = 6) was noted in 12 patients, only six of whom had Parkinsons disease. Excluding patients with diffuse Lewy body disease, there was no significant worsening of the UPDRS scores after either 3 or 6 months of treatment. The presence of dementia did not predict response to treatment. Our results suggest that risperidone is a useful treatment for hallucinations in patients with parkinsonism.

Supranuclear Control of Swallowing

Swallowing is an act requiring complex sensorimotor integration. Using a variety of methods first used to study limb physiology, initial efforts to study swallowing have yielded information that multiple cortical and subcortical regions are active participants. Not surprisingly, the regions activated appear to overlap those involved in both oral and nonoral motor behaviors. This review offers a perspective that considers the supranuclear control of swallowing in light of these physiological similarities.

Dysphagia in Progressive Supranuclear Palsy: Radiologic Features

Abstract. Progressive supranuclear palsy (PSP) is a progressive degenerative extrapyramidal disease that often masquerades as Parkinsons disease (PD). Similar to PD, dysphagia frequently complicates the course of PSP. Because there is only one published report characterizing dysphagia in PSP, we reviewed the neurologic features and dynamic videofluoroscopic swallowing function study results in 10 dysphagic PSP patients. Abnormalities during multiple stages of ingestion were recorded in each patient. Uncoordinated lingual movements, absent velar retraction or elevation, impaired posterior lingual displacement, and copious pharyngeal secretions were noted in all patients. Tongue-assisted mastication, noncohesive lingual transfer, excessive oral bolus lingual leakage to the pharynx prior to active transfer, vallecular bolus retention, abnormal epiglottic positioning, and hiatal hernias were noted in at least half of the cohort. Although ingestion abnormalities in PSP are similar to those previously reported in PD, the number of studied patients and observed differences were too few to clearly differentiate the two diseases.

Dysphagia in drug-induced parkinsonism: a case report.

Dysphagia complicates both idiopathic Parkinsons disease (IPD) and drug-induced parkinsonism (DIP). Although parkinsonism of DIP and IPD are often clinically indistinguishable, there is no assurance that their abnormalities of swallowing will be similar. We evaluated a patient with DIP who complained of difficulty chewing and swallow initiation. The dysphagia evaluation demonstrated abnormalities during all stages of ingestion. However, the prepharyngeal stages were disproportionately affected when compared with patients with IPD and similar levels of parkinsonian functional disability. This case gives additional support for a significant basal ganglia influence on motor deglutitive functions.Dysphagia complicates both idiopathic Parkinsons disease (IPD) and drug-induced parkinsonism (DIP). Although parkinsonism of DIP and IPD are often clinically indistinguishable, there is no assurance that their abnormalities of swallowing will be similar. We evaluated a patient with DIP who complained of difficulty chewing and swallow initiation. The dysphagia evaluation demonstrated abnormalities during all stages of ingestion. However, the prepharyngeal stages were disproportionately affected when compared with patients with IPD and similar levels of parkinsonian functional disability. This case gives additional support for a significant basal ganglia influence on motor deglutitive functions.

Is arterial spin labeling a potential biomarker for early stage lewy body spectrum diseases

Background: Hypoperfusion/hypometabolism in parietal-occipital regions has been consistently reported in Lewy Body Spectrum Diseases (LBSD) using Arterial Spin Labeling (ASL-MRI) and FDGPET respectively regardless of the severity of cognitive or motor impairment. Herewe use optimally-discriminative voxel-based analysis (ODVBA) to identifydifferences incerebral bloodflood (CBF) in patients with Mild Cognitive Impairment (MoCAMean Score1⁄4 24) and Hahn & Yahr Stage II motor symptoms) versus controls to determine whether ASL may be a suitable biomarker for early stage LBSD.Methods: 22 healthy controls (HC) (15 F; 7366 years) and 16 LBSD patients (5 F; 7068 years) were scanned on at 3T using a 32channel head array. Anatomical images were acquired, followed by resting-state ASL consisting of 80 label-control pairs acquired with pseudo-continuous labeling, background suppression and singleshot 3D RARE stack-of-spirals readout. CBF maps were computed using a modified one-compartment model, normalizing absolute mapswith each subject’smean graymatter value to generate relative CBF maps, then normalizing to MNI space using SPM8 DARTEL toolbox and smoothed with FWHM1⁄48mm for group analysis. Linear correlations between whole-brain mean CBF and age and sex were evaluated and mean relative CBF differences between patients and controls were assessed using ODVBA; P value was set to p< 0.001, uncorrected. Results:Whole brain mean CBF was negatively associated with increasing age (p1⁄40.055) and positively associated with female sex p1⁄40.004. LBSD patients demonstrated decreased relative CBF compared to controls in the left parieto-occipital area (Fig.1A) including superior and inferior parietal gyrus, middle occipital gyrus, and angular gyrus; in more lateral regions left (Fig.1B) and right (Fig.1C) inferior occipital gyrus, and in the prefrontal region right middle frontal gyrus (Fig. 1D). LBSD group