Current Series: Management of Sialorrhea in Parkinson Disease

Stuart Isaacson, MD: When we think about sialorrhea, it seems to be common. It’s common in surveys, but why do you think people don’t recognize it so much? Do you think it’s because the patients don’t bring it up, or doctors and nurses don’t query about it enough because of time or other constraints?

Richard M. Trosch, MD: I think that’s part of it. I think it’s time. The average neurological recheck for Parkinson patients isn’t long enough to address all these questions. And if you don’t ask, the patients don’t necessarily volunteer it. So if the patient is in your office and they’re obviously drooling, and you see a constant stream coming out, it’s easy to pick up. But a lot of physicians don’t ask about sialorrhea. You have to ask, “When you wake up, is the pillow wet? Are you finding you have excessive saliva in your mouth? Are you having to wipe your mouth frequently? Is your speech gurgling at times? Are you coughing at night in bed?” These are all questions that can cue you. Some patients have no anterior drooling; it’s all posterior drooling. Maybe they’ve had a history of aspiration pneumonia. Maybe they just cough at night in bed, and those are the only clues you’ll have.

Stuart Isaacson, MD: When do you start asking about sialorrhea? Is this a question we should ask from the diagnosis forward, or do we wait until they’re having motor fluctuations? Who are the Parkinson patients in whom we’re most likely to have a return on asking that question then?

Richard M. Trosch, MD: Obviously, it’s more common as the disease progresses, and people who are early and mild, they’re probably not having problems. But I’ve seen the exception. I’ve seen patients who are relatively mild and early, yet they have sialorrhea. Part of my clinical exam, at least once a year I go through the UPDRS [Unified Parkinson’s Disease Rating Scale] part 2 with patients, and that 1 of the questions is you ask, “Are you drooling?” And then you try to quantify it. It’s part of my routine exam, and every patient is asked it at least once a year; if I see them every 6 months I do every other visit. But I understand that most physicians don’t do a full UPDRS as part of their exam. At some point, it should be important to ask the patient about drooling, particularly if there’s a history of swallowing or past history of pneumonia.

Stuart Isaacson, MD: Are there 1 or 2 screening questions that we could suggest to people listening and wanting to learn more about sialorrhea that may capture most of the patients? Because they may not have time to ask all the list.

Richard M. Trosch, MD: I guess I would ask, “Is the pillow wet when you wake up?” That could pick up fairly earlier sialorrhea.  

Stuart Isaacson, MD: Are there any scales, or tools, or ways that people can follow this over time, especially when you’re thinking about treating it, to know if the treatment is effective or not?

Richard M. Trosch, MD: There are quite a few scales that have been developed, but a lot of them were developed for a pediatric population, because drooling is also very common in children with intellectual disabilities, and children with cerebral palsy see it. A lot of these apply more to kids. For adults there are a few scales, but I actually like the 1 for Parkinson. The questions in the UPDRS part 2: no drooling, excessive saliva in the mouth, is the pillow wet at night, is there drooling during the day, and then is the clothing becoming wet. I use that as my 4-point scale.

Stuart Isaacson, MD: Not just for patients. We have to ask their caregivers and families as well because sometimes a patient may not even be so aware that the saliva is evident, and maybe the family or the caregivers who are seeing it and know how frequent it is.

Richard M. Trosch, MD: You have that all the time. You ask the patient, “Are you drooling?” And they say, “No,” and the caregiver is next to them and they’re shaking their head yes.