Assess, diagnose and manage any difficulties in the areas of;

• Speech
• Language
• Voice
• Swallowing
• This can involve; formal diagnosis using standardised tests, subjective assessment and/ or
  diagnostic therapy

Please note, all of the below do not affect all clients or to the same level or at the same stage post
diagnosis.

• Mumbled, imprecise or unclear words (dysarthria).
• Reduced rate of speech
• Rapid rate of speech.
• Stammering and stuttering (dysfluency or palilalia).
• Reduced facial expression.
• Reduced volume of voice (hypo-phonia).
• Difficulty word-finding or structuring sentences.

• Dysarthria occurs when the muscles you use for speech are weak or you have difficulty controlling them.
• Dysarthria often causes slurred or slow speech that can be difficult to understand.
• Dysarthria in Parkinson’s disease can be characterised by
  • monotony of pitch and loudness,
  • reduced stress,
  • variable rate,
  • imprecise consonants,
  • a breathy and harsh voice.
  • This is articulatory and phonatory impairment.
  • SLT will assess
  • the muscle function
  • Perform a perceptual speech assessment
  • Gain the client’s and next-of-kin’s perception of their speech

Be aware of how you sound. Monitor the clarity of your speech.

• When do you sound better or worse? Is it fatigue or medication related?
• Eliminate background noise when engaging in conversation (turn off the television, radio etc).
• Use a loud, clear voice.
• Over-articulate your words.
• Reduce your rate of speech.

• It is a speech disorder that can resemble neurogenic stuttering/ stammering.
• Associated with PD and other Parkinsonian conditions, palilalia presents as an involuntary repetition of
  syllables, words or phrases with increased speed and decreased volume and clarity.
• Often similar to tremor, this can be exacerbated when nervous, in new environment and/ or timing of
  medications.

• Pacing- subtle taping of finger or hand to regulate your speed of speaking. A pacing board may be
  used.
• Controling breath support- taking slow, calm, relaxed breaths and making sure you have enough breath
  for speaking.
• Reducing rate of speech- this is the most effective strategy in improving all areas of speech.

• Speech and voice impairments are common among those living with Parkinson’s. As many as 90% of
  people with Parkinson’s experience difficulties such as “hypophonia” (soft speech) or a more monotone,
  raspy or breathy voice (Duffy, 2005).
• One reason is directly related to the disordered motor system that accompanies PD, including rigidity,
  slowness of movement and tremor. For example, the poor muscle activation that leads to bradykinesia
  (slow movement) and hypokinesia (small movements) in the limbs can translate to the muscles involved
  in speech. These problems with muscle activation can result in reduced movements of the respiratory
  system (reduced breath support), larynx (reduced vocal loudness) and articulation (reduced clarity of
  speech).
• Another cause of speech and voice impairment in PD is a change in sensory processing that is related to
  speech. It is believed that people with PD may not be aware that their speech is getting softer and more
  difficult to understand. When people in this situation are asked to bring their voice to normal loudness,
  they often feel as though they are shouting, even though they are perceived by listeners to be speaking
  normally.

• Keep your vocal chords moist and lubricated. Sip plenty water throughout the day.
• Do not shout.
• Avoid making sound effects with your voice.
• Do not cough and clear your throat, instead swallow and take a drink of water.
• Have periods of voice rest, particularly if demand on your voice is high.
• Avoid environments with smoke, fumes, strong odours or chemicals.
• Avoid cough sweets and lozenges.
• Slow down, speak, clearly and slowly (see slide on dysarthria).
• *Amplifier- may be used in loud environments (e.g.- public speaking, teaching etc)

• Lee Silverman Voice Treatment.
• TARGET: Vocal Loudness (amplitude) These strategies are consistent with the most effective, evidence-based strategies for learning and
  neuroplasticity (the brain’s ability to change).
• MODE: Intensive Dosage and High Effort.
• Intensive and high-effort treatment that encourages people to achieve more by always working harder
  (e.g., “louder, longer”). Sessions are delivered one-on-one and tailored to your individual communication
  goals.
• CALIBRATION: Generalization
  •  “Recalibrating” sensory feedback so people recognize their new, louder voices are within normal limits.
    This increases the likelihood that people with PD will feel comfortable with and use their louder voice at
    home, work and play.
• 1 session per day 45-60mins.
• 4 sessions per week 
• 4 weeks 
• Home-work and carry-over activities.
• Hierarchy-
  • Loud, clear ‘Ah’.
  • Word lists.
  • Phrase lists.
  • Personally relevant phrases.
  • Paragraph reading
  • Generalise to conversation.

    

Cognition is a general term that refers to the mental abilities that we use to process information and apply
knowledge. These mental processes allow us to perform daily functions such as paying attention, solving problems,
and remembering where items are and how to do certain tasks. When people typically talk about cognition, they
often focus on “memory,” but “memory” is only one aspect of cognition.

1. Attention and working memory:
   •  Attention is the ability to selectively focus on a particular aspect of one’s environment, often while ignoring competing stimuli. In PD,
     people may find it difficult to concentrate on a conversation or reading a book. It may be challenging to talk to someone while
     walking and maintaining balance.
   • Working memory refers to the memory process of temporarily storing information in one’s mind and manipulating it over a short
     period. Mental arithmetic is one example of working memory function. These cognitive processes are often linked to alertness.
     Sleepiness and sedating medications can impair attention and working memory function.
   • These cognitive processes involve the frontal and parietal lobes in the brain. Working memory also involves the basal ganglia and
     dorsolateral prefrontal cortex, regions affected in PD.
2. . Executive function:
   • Executive function includes the ability to plan, organize, initiate, and regulate goal-directed behaviour. These activities may include
     multitasking, solving problems, starting new tasks, and switching tasks. Executive function involves the prefrontal cortex of the brain
     and the dopamine system, which are affected in PD. Executive dysfunction is one of the most common cognitive changes reported
     in PD.
3. Memory: invokes learning and remembering information. Memory can be classified into different processes and
   types.
   • immediate (seconds-minutes),
   • short-term (minutes-days)
   • long-term memory (days-years).
   • There also is memory for facts, concepts, or events (called declarative memory).
   • Memory for how to do certain tasks like tie our shoes or ride a bicycle (called procedural memory) as well as working memory
     (described earlier).
   • Declarative memory typically involves the hippocampus or temporal lobe of the brain, whereas procedural memory often involves the
     frontal areas and basal ganglia.
4. Language:
   • Language abilities include naming objects, generating words, comprehension, and verbal concepts. The most common language
     problem in Parkinson’s Disease is finding the “right” words. People with Parkinson’s disease also tend to speak less overall (in addition to
     softer voice) and use simpler speech.
5. Visuospatial function:
   • These abilities tell us where things are around us in space, give us a spatial map of our environment, and involve our sense of direction.
     Visuospatial functions allow us to estimate distance and depth perception, use mental imagery, copy drawings, or construct objects
     or shapes. Examples include being able to give someone directions to your house by tracing the route in your mind, avoiding
     obstacles in one’s path, and putting together a puzzle. These abilities rely on the parietal lobe of the brain.

• Maintenance Tasks and Activities:
• Cross words 
• Word searches
• Reading books, magazines and newspapers.
• Brain-storming 
• Maintenance Tasks and Activities:
• Cross words
• Word searches
• Reading books, magazines and newspapers
• Brain-storming
• Word association games and puzzles
• Writing lists, notes, letters and emails
• Word association games and puzzles
• Writing lists, notes, letters and emails

1. Dysphagia is a term which means any interference to food, drink or saliva as it travels from the mouth to 
   the stomach.
2. Aspiration is where diet, fluid or saliva particles enter the airway (trachea).
3. It is usually marked by a cough (overt aspiration) or can be silent.
4. Dysphagia occurs in Parkinson’s due to reduced oral muscle function and reduced oral and pharyngeal
   (throat) sensation.
5. Poor postural and breath support can worsen the situation.

Signs of dysphagia: Contact your local SLT.

• Difficulty chewing certain foods
  ◦ Avoidance of foods you once loved
  ◦ Coughing or choking during or immediately after mealtimes
  ◦ Eye-tearing or discomfort when eating or drinking
  ◦ Wet and gurgly breathing or voice when eating or drinking.

• Slow rate of intake of all diet and fluid.
• Good supportive posture when eating or drinking.
• No speaking when eating or drinking.
• Avoid distractions at mealtimes.
• Do not over-stuff your mouth.
• Following seeing a SLT, you may be prescribed a modified diet or fluid.
• Complete regular, careful oral hygiene to reduce oral infection and risk of aspirating this bacteria or
  fungus (oral thrush). 
• A drink to accompany all diet.
• Do not lie down immediately after eating or drinking. Remain upright approx. 20minutes following a
  meal.
• Weighted cutlery or cups/ mugs may help regarding tremor at mealtimes.

1. HSE- via your local Primary Care Team. Your GP, Public Health Nurse,
   Clinical Nurse Specialist or Consultant may refer to your local service.
   This is a free service and waiting times vary throughout the country.
2. Private Speech and Language Therapy- make sure the therapist you
   choose is registered and familiar with working with Parkinson’s Disease. 
3. In acute setting when having a neurological review or as an inpatient.
   ◦ Associations and support groups- local groups often hire SLTs to
   complete therapy activities with their members.

Progressive neurological conditions can cause weakness of the muscles used for speech. Some people’s speech clarity can reduce over time to a point where it becomes difficult to understand. In this case, people with PD might think about using an electronic communication device. Message banking and voice banking are two different ways to record speech while it is still clear.  These recordings can then be built into an electronic communication system in the future should one ever be needed.

Please see more information on Message & Voice Banking – Research Motor Neurone (rmn.ie). The Irish Message Banking Toolkit Initiative is proudly supported by Research Motor Neurone (RMN) and the Irish Association of Speech and Language Therapists (IASLT). The Irish Message Banking Toolkit provide information for Speech & Language Therapists and people who are thinking about doing message banking. The documents focus mainly on message banking but some voice banking information is also included as it would usually be thought about at the same time as message banking.