Anxiety, depression and swallowing disorders in patients with Parkinson's disease

Abstract

Swallowing disturbances (SDs), anxiety and depression are commonly present in Parkinson's disease (PD) patients. We hypothesized that there is an association between the presence of SDs and the PD affective state. Sixty-nine PD patients were assessed for the presence of SDs by undergoing cognitive screening with the Mini Mental State Examination (MMSE), completing three inventories: a swallowing disturbance questionnaire (SDQ), the Spielberger manual for the trait anxiety and Beck depression inventories. All patients underwent clinical swallowing evaluations by a speech and language pathologist (SLP). Patients diagnosed with SDs were also assessed by fiberoptic endoscopic evaluation of swallowing (FEES) performed by an ENT and SLP. Thirty-eight patients experienced SDs, the other 31 did not. The clinical characteristics of the two groups were matched. Patients with SDs experienced increased anxiety and depression compared to patients without SDs. Comparisons between patients who scored in the two opposite ends of the anxiety and depression ranges demonstrated that the most anxious and depressed patients reported more swallowing difficulties (SDQ scores) compared with the least anxious and depressed ones. In addition, the most anxious patients had significantly increased disease severity and decreased MMSE scores compared with the least anxious patients. Disease severity was also increased in the most depressed patients compared with the least depressed ones. Advanced disease emerged as being associated with high anxiety levels and greater numbers of SDs. The contribution of anxiety or depression to the development or worsening of SDs and their role in treatment strategy warrant further investigation.

Introduction

Dysphagia (swallowing disturbances, SDs) affects the most cardinal aspect of human functions, the ability to take in nourishment by eating and drinking. Malnutrition, dehydration, weight loss, difficulties in handling oral medications and the high incidence of aspiration pneumonia as a cause of death attest to the clinical importance of this problem [1]. It is well recognized that swallowing problems are associated with distressing psychological responses, such as anxiety, shame, depression, embarrassment, fear, and reduced self-esteem [2]. Emotional factors are believed to cause disturbances of appetite and eating, swallowing and digestive functions [3]. These factors are frequently observed in patients with esophageal disorders [4], such as disturbances of esophageal motility. Globus hystericus, or the sensation of a lump in the throat, has also been associated with panic disorders and depression [3]. Alternatively, these symptoms can also elicit anxiety and fear of eating which might lead to depression and reduced quality of life [5], [6], [7].

Parkinson's disease (PD) is a neurodegenerative disease that affects 1.4% of the population over the age of 55 years and 4.3% of the population 85 years of age and older [8]. SDs comprise a common complication (up to 95%) of patients with PD and are considered to be the major cause of death [9]. In patients with PD, SDs affect all three stages of swallowing, oral, pharyngeal and esophageal [10], [11].

Patients with PD develop behavioral characteristics which frequently complicate the disease picture. These traits are attributed to a number of factors, including disease processes, medication effects, and psychological reactions to the illness. Up to two-thirds of patients with PD have persistent affective disturbances, specifically, high levels of depression and anxiety [12]. The interrelationship between mood, behavior and swallowing disturbances has not been investigated in the PD population. Although the traditional goal of swallowing therapy is the prevention of aspiration pneumonia, behavioral symptoms play an important role as well. We tested the hypothesis that the presence of dysphagia among patients with PD is associated with mood and behavioral disturbances. We sought to determine whether PD patients with SDs are more depressed and anxious than PD patients without SDs and if PD patients who score high on the anxiety [13] and depression [14] inventories report more frequent and severe SDs than those who do not.