Adapted from the HDSA
booklet:A Guide for Families by Lynn Rhodes, MS, CCC-SLP
Coping with Speech and Swallowing Difficulties in Huntington's Disease
|AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION Rockville, Maryland|
|The American Speech-Language-Hearing Association is the national
professional, scientific, and credentialing association for audiologists; speech-language pathologists; and speech, language,
and hearing scientists. As part of its mission, ASHA advocates that all people with speech, language, or hearing disabilities
have access to quality services to help them communicate more effectively. |
reader should consult an appropriate health care professional concerning any advice, treatment or therapy set forth in this
A speech-language pathologist (SLP) can have a profound
effect on quality of life for a person with Huntington's Disease (HD). I realized this one evening several years ago when,
after an in-service presentation to family members, a young woman approached me and said, "I never knew that there were so
many options available to my mother if her swallowing failed. I always thought she would automatically have to get a G-tube.
It is such a relief to know that you can try all of these other things...Thank you."
That woman's statement sums up the purpose of this booklet, which is to provide
families with information that will hopefully remove some of the struggle and fear associated with living with HD. This booklet
will focus on common communication and swallowing problems that occur in persons with HD, what you can do at home to help
manage these problems, and how an SLP, as well as other professionals, can be of service to you and your family.
Why Communication and Swallowing Symptoms Arise in HD
As brain cells become depleted in Huntington's Disease,
problems may develop in the following three areas: motor control (movement); cognition (thinking); and behavior. Speech and
swallowing problems arise when the centers of motor or cognitive control are affected, causing muscle weakness or discoordination,
chorea, and problems with memory, sequencing, new learning ability, reasoning, and problem solving.
Typically, speech and language functions are primarily controlled in the
left side of the brain and swallowing function is controlled in the brainstem (at the base of the brain). Cognitive function
is believed to be controlled in the right side of the brain. HD typically begins in the caudate nucleus and putamen, which
are located in the central part of the brain (core), and spreads to these other control centers, causing communication and
Problems with communication and cognition vary in nature
and severity from person to person. Although there are commonalities, no two people with HD are exactly alike, and as the
disease progresses, the variability continues. The following list summarizes problems that people with HD may experience at
different stages of the disease. In many cases, a person with HD will experience the same areas of difficulty throughout the
course of the disease, with severity varying from stage to stage.
- Dysarthria (muscular weakness, slowness, or incoordination of the lips,
tongue, throat, and jaw)
- Apraxia (disruption in programming and sequencing muscle movements for speech)
- Diminished rate control (talking too fast or too slowly)
- Poor voice quality (hoarse/harsh, breathy,volume too low or too high)
- Discoordination of breathing and voice
- Word finding difficulties
- Short length of utterance (person only responds with one or two words)
- Misarticulations (incorrect pronunciation of sounds)
- Lack of initiation (inability to initiate conversation)
- Perseveration (person gets "stuck" on certain words or phrases, repeating
them often and at inappropriate times)
- Echolalia (person keeps repeating back what you've just said)
- Difficulty with monitoring pragmatic skills (turn-taking in conversation;
reduced ability to maintain a topic or switch topics appropriately)
- Inability to speak
- Stuttering (difficulty beginning a word or sentence, with repetition of
- Difficulty understanding information
- Difficulty reading and writing
- Diminished memory, immediate and short-term (long-term memory usually remains
- Poor reasoning/judgment
- Reduced problem-solving ability
- Difficulty sequencing/organizing ideas
- Concentration problems/distractibility/short attention span
- New learning ability diminished
- Problems with numbers and mathematic computations
* It should be emphasized that most people with HD are receptively intact,
and that even during the end stages of the disease, they can understand what is being said to them.
How a speech-language pathologist can help
pathologist can be helpful at all stages of the disease. In the early stages, he/she can assist with problem solving and developing
strategies to help persons with HD compensate for some of the problems they might be experiencing. As the disease progresses,
the role of the SLP evolves into helping preserve and maintain the person's highest level of communication and swallowing.
Early intervention and involvement with therapeutic professionals is best because people can learn compensatory strategies
more successfully during the early stages of HD and can then apply them throughout the course of the disease.
The SLP can also evaluate a person's ability to use augmentative or alternative
communication devices and techniques, which can be as simple as a word/picture board, or more complex, such as an electronic
device that speaks for the person. After determining a person's level of ability for using such techniques, the SLP begins
to focus on personalizing the technique or method of communication.
For example, the SLP might work with a person with HD and his or her family
to create a word/picture board tailored to the person's environment (whether it be a nursing home or private residence) or
flexible enough to be carried around. Where an electronic device might be beneficial, the interest and motivation of the person
with HD to use it should be evaluated. If there is evident motivation, then the device should be made easily accessible.
Suggestions for improving communications
methods of communication are available, people with HD generally prefer to attempt verbal communication for as long as possible,
even if their speech becomes hard to understand. The SLP and family members can often help by encouraging the speaker to:
- Speak more slowly
- Say one word at a time
- Repeat the word or sentence when necessary
- Rephrase the sentence
- Exaggerate the sounds
- Speak louder (take deep breath before speaking)
- Describe what he/she is trying to say ifhe/she can't think of the word
- Indicate the first letter of the word
- Use gestures
- Keep sentences short
- As a supplement to speech, use alternative communication techniques such
as word boards, alphabet boards, picture boards, electronic devices
Some suggestions for the listener are:
- Eliminate distractions (TV's, radios, large groups of people)
- Keep questions/statements simple
- Ask one question at a time
- Use yes/no question format as much as possible
- Pay attention to gestures and facial expressions/changes
- If you do not understand what is being said, don't pretend that you do.
Ask for clarification, or repeat what you think was said in the form of a question, such as, "Did you say...?"
- Try to keep to familiar topics
- Encourage the speaker to use his/her specific compensatory strategies
- Allow enough time for the person to convey his/her message
- Most importantly, be patient with the speaker
People with HD should seek out an SLP at the point when communication with
others becomes frustrating and upsetting, or when the areas of memory, thought processing and organization of thought become
There are also compensatory strategies for cognitive problems that can be
implemented in the home. Some examples are:
|1) Poor orientation to time and place
- Keep a large calendar visible
- Display a large, visible clock
- Post signs on walls stating location
|2) Diminished memory
- Post a schedule of daily routine
- Establish routines for all activities, e.g., place keys or glasses
in same place daily.
- Label cabinets and drawers
- Keep a memory log book like a diary in which the person with HD can
write down and refer back to what he/she has done, with whom, and when.
- Keep an appointment book for social events, doctor's visits, and
other dates and occasions to be remembered.
|3) Reduced problem-solving ability
- The person with HD should discuss with a family member possible problems
that could occur in the home. Solutions or steps to be followed should be anticipated, written down, and kept in an obvious
- Follow these set guidelines for problem solving.
These are just a few examples of how a person experiencing cognitive problems
can make life easier at home. An SLP can provide assessment, guidance, and further suggestions on the use of compensatory
problems (also known as dysphagia) are common among people with HD. Statistics have repeatedly shown that the number one cause
of death among persons with HD is aspiration pneumonia. This can occur when food or liquid enters the airway rather than the
esophagus during eating or drinking, and then forms a collection in the lung that can become a pneumonia.
The involvement of an SLP can be helpful at all stages of the disease in
maintaining the highest possible level of swallowing function. This intervention will help to prolong the quality of life
and may lower the risk of death caused by pneumonia.
There are many steps that can be taken to preserve safe swallowing for as
long as possible. First, let's look at the problems that people with HD frequently encounter:
Swollowing Problems Associated with HD
- Impulsivity or difficulty controlling amount of food or liquid intake
- Difficulty controlling rate of food or liquid intake
- Difficulty chewing or manipulating food
- Delayed swallow reflex (doesn't kick in even when food moves to the back
of the throat)
- Holding food/liquid in mouth
- Difficulty initiating a swallow at all
- Inability to swallow
- Incomplete swallows where food or liquid is left in the mouth and/or throat
- Lack of coordination between swallowing process and breathing or speaking
- The need to swallow repeatedly for each bite/sip
- Chorea of the oral or pharyngeal muscles (tongue, lips, jaw, throat, esophagus)
- Drooling and/or spillage of food or liquid from mouth
The SLP can evaluate a person's swallowing function and make recommendations
that involve positioning issues, feeding techniques, diet consistency changes, and education of the person with HD, family
members, or caregivers. Special test ing known as videofluoroscopy (or a Modified Barium Swallow) can be done by a speech-language
pathologist and a radiologist to determine if a person is actually aspirating a particular consistency. This test provides
an inside view of a person in the act of swallowing food or liquid and can be a useful tool in developing strategies for safe
The following signs at mealtime may indicate swallowing
- Gurgly voice quality
- Wet sounding breathing
- Spillage of food or liquid from the mouth
- Frequent throat clearing
- Progressively slower rate of food intake
- Regurgitation of food after it has been swallowed*
- Food or liquid left in the mouth after swallow
- Difficulty manipulating food or liquid in the mouth
- Frequent congestion*
- Frequent temperatures*
- Consistent or significant weight loss*
Signs marked * could be indicative of a serious and possibly unrelated medical
condition and should be monitored by a physician. In general, if a person with FID experiences any one or a combination of
the above problems, he/she should contact a physician and seek out an SLP for evaluation.
1) Person was coughing and throat-clearing
frequently when drinking thin liquids such as juice or coffee.
2) He was observed to drink all liquids from a cup and
to throw his head back as the cup emptied.
3) Then he would cough hard.
Problems observed during evaluation
1) Suspected upper airway
penetration (liquid entering the airway instead of esophagus).
2) Rate of intake too fast.
3) Size of sips too big.
1) Person was given a straw. He took liquids with the
straw and his coughing and wet vocal quality stopped. He now drinks all liquids, including coffee, via straw.
keeps his head in a more forward position and helps to control the rate of intake (he tended to take big gulps with the cup).
3) He is given verbal reminders to take small sips.
4) Staff was educated about these strategies for safe swallowing.
1) Person holding food in mouth for
long periods of time.
2) Swallows were delayed and food was left in mouth after the swallow.
Problems observed during evaluation
I ) Chewing skills were observed
to be ineffective.
2) Mouthfuls were too big.
1) Person was placed on a finely chopped diet (regular
consistency too much for her to chew).
2) Cues were given to alternate sips with bites and to place less food on the utensil.
1) Person feeding self and experiencing
a lot of spillage of food/liquids from the mouth.
2) Significant weight loss.
Problems observed during evaluation
1) Severe dysarthria (muscles
of mouth and throat weak).
2) Person holding head down when trying to swallow (leaning far forward).
3) Person now
unable to chew.
4) Person not coordinated for self-feeding any more.
1) Person placed on pureed diet.
2) A slightly reclined
position in bed for mealtimes.
3) Feeding now done by staff.
4) Family allowed to bring soft favorites (candy, snack
Strategies for Safe Swallowing in the Home or Care Facility
- Provide small bites and sips.
- Alternate bites with sips to help wash down the food.
- Make sure that the person is sitting as upright as possible; place pillow
behind head/neck to prevent head tilting backwards.
- Control rate of intake, allowing enough time for previous bite/sip to be
cleared. Look for rise and fall of larynx (Adam's apple) or lightly place two fingers on the person's Adam's apple to feel
this rise and fall, which can signal the completion of a swallow.
- Person should swallow twice for every bite or sip to clear residuals from
- Use gravies, sauces and condiments with dry foods or solids whenever possible.
- Crush medications in applesauce if a person is on a pureed (blenderized)
- Avoid distractions during oral intake:
- No talking with
food in mouth
- No large crowds
- If the person is coughing a lot or showing other signs of swallowing problems
(see warning signs), begin giving thicker liquids such as nectars, shakes, and tomato juice. Also,
give blenderized food until person can be seen by the physician and/or speech language pathologist. Further recommendations
would follow a complete assessment.
- Produce a strong cough after each swallow (if voice sounds 'gurgly' or 'wet')
- Limit quantity of food placed on plate or liquid in cup at one time
As we have seen, there
are many interventions and strategies that can help to preserve safe swallowing - some very simple and easily implemented
at home. Others require evaluation and guidance from an MD or SLP. If all attempts fail, only then will it be necessary to
discuss alternative methods of feeding.
|Alternative Methods of Feeding|
Once this point has been reached, the task of deciding what is best can be
difficult and emotional. This issue typically arises when a person with HD is in the end stages of the disease, although it
may need to be addressed earlier in some cases. By the late stages of HD, the person is often unable to meet nutritional needs,
tends to become dehydrated, or aspirates all possible consistencies - often reflected by frequent bouts of pneumonia. The
eating process may have become unpleasant.
The following is a list of possible considerations involved in deciding whether
or not to proceed with G-tube placement:
- Are the person's wishes known or documented?
- Is he/she dehydrated?
- Is there severe weight loss?
- Is the person suffering from malnutrition, with possible subsequent skin
- I Does the person have frequent temperatures?
- I Does he/she have frequent bouts of pneumonia (especially aspiration pneumonia)?
- Is there decreased, or lack of, enjoyment at mealtime?
- Is the person unable to swallow without coughing/choking ?
- Does he/she have difficulty with respiration following oral intake?
- Are any other interventions/strategies available?
- How important is eating to the person? Is eating a rewarding experience?
The risk/benefit ratio of the enjoyment which eating brings versus the dangers of eating for this person should be carefully
A nasogastric tube is considered temporary and is inserted through the nose.
It goes down the back of the throat and into the stomach. A G-tube is considered more permanent but may be reversed. Placement
requires a minor surgical procedure with insertion directly into the stomach. Shake like feedings and medications are then
introduced via tube.
In both cases, if a person is able, he/she may continue eating and drinking
while the tube feed ing provides the consistent caloric intake needed for weight maintenance, or gain, if so desired.
The issue of alternative feeding is difficult because it may extend a person's
life span and thus prolong the disease. At the same time, families find it difficult to decide against alternative feeding
because the end may be hastened by their decision. There are no easy answers and it can be very hard to gauge a person's quality
of life at the time when this issue arises.
Ideally, family members should know in advance what the individual's wishes
are with regard to G-tube placement (see Planning Ahead). It is important to discuss the issue beforehand as, when the time comes to
implement the decision, the person may be unable to communicate his/her wishes or to provide a reliable yes/no response to
questions regarding the issue.
At this juncture, the role of support personnel is critical. Professionals
who can offer guidance and assist with this kind of decision-making include the:
These professionals can answer questions regarding the ramifications of placement,
or non-placement, of a tube. "What will happen if the tube is not placed and the person can no longer be fed?" "What will
happen when we continue to feed someone who we suspect is aspirating frequently?" "What are the benefits of tube placement,
and what are the possible complications?" "Does the person having the tube placement feel any pain? Does the person who does
not get a tube and doesn't eat any more feel any pain?"
These are common questions asked by families and answered as completely and
sincerely as possible by the professionals.
When grappling with this decision, support can come from other areas such
as clergy, or what is known as a biomedical ethics, or bioethics, committee. This group of professionals, which can include
physicians, nurses, and patient advocates, may be requested to assist with decision-making on the issue of alternative feeding.
Often, the committee makes decisions for a patient who is hospitalized and has no family involvement or other decision-makers
to act on his/her behalf, or if there is a conflict between the person's wishes and family concerns. The best scenario is
when a document can be produced that clearly indicates the person's wishes.
It is tough enough to face a diagnosis of HD and
to cope with early symptoms without having to look ahead, but the sooner these issues are discussed, the more control a person
with HD can exercise over these crucial decisions.
People in the early stages of HD and those at risk should complete a "Living
Will" or "Health Care Proxy." The Living Will is a clear statement of a person's wishes in terms of medical treatment and
life-support should they ever become unable to communicate or understand information. This includes placement of a G-tube
or nasogastric tube, as they are considered life-support. The Health Care Proxy enables a person to designate a third party
to make these kinds of decisions on the person's behalf in lieu of a written request, or to insure that a written request
is carried out.
Again, documentation and communication of these decisions are of paramount
importance. It is crucial that these issues be discussed early on, when thought processes and communication are not impeded
Huntington's Disease is a devastating illness that
affects every aspect of a person's life. Although no treatment yet exists to stop or reverse the course of HD, health professionals
of different disciplines can help to maximize quality of life for as long as possible.
In addition to speech-language-pathologists, physical and occupational therapists
can bring strategies and equipment to bear to make dealing with I ID a little easier. Social workers, recreational therapists,
dietitians, and others can all make important contributions. Most importantly, the sooner the person with HD arrives for evaluation,
the sooner the professional can implement a plan that will prolong independence and maintain the highest level of function
for the longest period of time.
How to Locate a Speech-Language Pathologist
- Physician referral.
- Phone book.
- Call any major hospital. They should have a rehabilitation department that
includes speech-language pathology.
- Call the Speech-Language-Hearing Association in your state.
- Contact the American Speech-Language-Hearing Association (ASHA) at the following
address or phone number:
10801 Rockville Pike,
Rockville, MD 20852 (800) 638-8255
Visit http://www.asha.org on the World Wide Web:
For Further Information
Additional publications about nutrition, communication, swallowing, and related
topics may be obtained from the Huntington's Disease Society of America, 140 West 22nd Street, 6th Floor, New York, NY 10011-2420,
(800) 345-HDSA, (212) 242-1968.
Visit http://hdsa.mgh.harvard.edu on the World Wide Web:
The following videotape is also available from HDSA for $10 including shipping
The Gift of Caring: A Practical Guide to Managing feeding and Swallowing
Difficulties Associated with Huntington's Disease
The Non-Chew Cookbook by J. Randi Wilson, 1985, 188 pages, which offers
easy recipes complete with caloric intakes, can be purchased for $23.95 from Wilson Publishing Inc., P.O. Box 2190, Glenwood
Springs, CO, 81602-2190, (800) 843-2409.
Tomorrow's Choices: Preparing Now For future Legal, financial and Health
Care Decisions is a free publication available from the American Association of Retired Persons (AARP), 601 E Street,
NW, Washington, DC 20049. Ask for publication #D13479.
(Speech-related terms are defined in communication section)
Assistive devices to aid
in communication, such as letter or word boards, picture boards, electronic devices, gestural systems.
Nutritional intake provided by something other
than oral feeding.
Areas of thought processing, including problem
solving, reasoning, judgment, sequencing, attention, memory, understanding of more complex information, concentration, and
new learning ability.
A technique that can help make up, or compensate,
for a particular loss of function or problem.
The disorder of swallowing that can be characterized
by problems within the oral cavity or the pharynx.
Modified Barium Swallow
Swallowing test conducted in the radiology
department in which barium is mixed with different food consistencies and presented under videofluoroscopy (X-ray).
Eating/Drinking Helpful Hints
At some point, a person with Huntington's Disease may have difficulty eating and drinking. Some of this difficulty is related
to the weakness of the and swallowing muscles. Other difficulties are a result of weakening hand, arm and shoulder muscles.
With chewing and swallowing weakness pHD's must make changes in their dietary consistency meaning they have to eat softer
foods and avoid thin liquids. This section deals with adaptive equipment that will help pHD's who are still able to eat and
drink on their own.
Finger and hand atrophy or weakness may make it difficult to hold a conventional knife, fork or spoon. Utensils
with built-up handles are much easier to use. There are several varieties on the market, but I prefer the ones called Good
Grips. Even when my fingers got weak enough that I could not hold items like a pencil or a regular fork, I could still use
my eating utensils with the built-up handles
Use plastic plates that
will not break when you drop them. Special plates with raised edges make it easier to eat. You can push the food against the
edge to make it easier to get it on your fork. Make sure any plates that you buy are microwave safe.
Cups or mugs with handles are easier for pHD's to grab. Plastic cups are the
best. The plastic travel mugs with lids work great. If you happen to tip over or drop one of these mugs, you end up spilling
a lot less liquid.Straws
are essential for pHD's when it becomes too difficult to lift a cup to your mouth. Straws are also helpful to drink with your
chin tucked down, which helps prevent aspiration and choking.
There are some straws with clear plastic tubing with a wider diameter opening
which requires less effort to drink more which are used by a hospital x-ray department for patients who had to swallow barium
prior to x-ray. Check with your local radiologist or hospital to see if you can obtain some of these straws or if they will
order some for you.
HandSpeaktm is the largest, fast-growing popular
visual language dictionary online.
http://www.handspeak.com/Sign Languages etc. showing you the actual position of
hands for the sign.
Baby Sign is a prevalent use in North America that babies can communicate basic needs
earlier than they can speak. It benefits the lingual development as well.
Fluent signers use International Sign to
communicate at ease with other foreign signers in foreign countries and at international gatherings.