, Volume 33, Issue 6, pp 809–817 | Cite as

Drooling in Parkinson’s Disease: Evidence of a Role for Divided Attention

  • Hannah ReynoldsEmail author
  • Nick Miller
  • Richard Walker
Original Article


Drooling is a frequently reported symptom in Parkinson’s Disease (PD) with significant psychosocial impact and negative health consequences including silent aspiration of saliva with the associated risk of respiratory infections. It is suggested that in PD drooling is associated with inefficient oropharyngeal swallowing which reduces the effective clearance of saliva rather than hyper-salivation. This is compounded by unintended mouth opening and flexed posture increasing anterior loss of saliva. It is reported to occur most frequently during cognitively distracting concurrent tasks suggesting an impact from divided attention in a dual-task situation. However, this supposition has not been systematically examined. This study assessed whether frequency of saliva swallows reduced, and drooling severity and frequency increased, when people with PD engaged in a cognitively distracting task. 18 patients with idiopathic PD reporting daytime drooling on the Unified Parkinson’s Disease Rating Scale (UPDRS) were recruited. They completed the Radboud Oral Motor Inventory for PD saliva questionnaire and the Montreal Cognitive Assessment. UPDRS drooling score, disease stage, duration, gender, and age were recorded. Swallow frequency and drooling severity and frequency were measured at rest and during a distracting computer-based language task. There was no significant difference between drooling severity at rest and during distraction (Wilcoxon signed rank test z = − 1.724, p = 0.085). There was a significant difference between at rest and distraction conditions for both drooling frequency (Wilcoxon signed rank test z = − 2.041, p = 0.041) and swallow frequency (Wilcoxon signed rank test z = − 3.054, p = 0.002). Participants swallowed less frequently and drooled more often during the distraction task. The frequency of saliva swallows and drooling are affected by divided attention in a dual-task paradigm. Further studies are needed to explore the exact role of attention in saliva management and the clinical applications in assessment and treatment.


Drooling Dysphagia Parkinson’s Dual task Divided attention 



Grateful thanks are due to Keith Gray for his support with the study statistics and to the clinical teams and their patients who supported the project.


No funding was received for the research itself; however, the project was completed as part of a Masters in Clinical Research by the primary author with funding from a Masters Studentship from the Royal College of Speech and Language Therapists.

Compliance with Ethical Standards

Conflict of interest

There are no known conflicts of interest.


  1. 1.
    Kalf JG, Bloem BR, Munneke M. Diurnal and nocturnal drooling in Parkinson’s disease. J Neurol. 2012;259(1):119–23.CrossRefGoogle Scholar
  2. 2.
    Srivanitchapoom P, Pandey S, Hallett M. Drooling in Parkinson’s disease: a review. Parkinsonism Relat Disord. 2014;20(11):1109–18.CrossRefGoogle Scholar
  3. 3.
    Kalf J, Smit A, Bloem B, Zwarts M, Munneke M. Impact of drooling in Parkinson’s disease. J Neurol. 2007;2007(254):1227–32.CrossRefGoogle Scholar
  4. 4.
    Leibner J, Ramjit A, Sedig L, Dai Y, Wu SS, Jacobson C, Okun MS, Rodriguez RL, Malaty IA, Fernandez HH. The impact of and the factors associated with drooling in Parkinson’s disease. Parkinsonism Relat Disord. 2010;16(7):475–7.CrossRefGoogle Scholar
  5. 5.
    Nobrega AC, Rodrigues B, Melo A. Is silent aspiration a risk factor for respiratory infection in Parkinson’s disease patients? Parkinsonism Relat Disord. 2008;14:643–8.Google Scholar
  6. 6.
    Rajaei A, Ashtari F, Azargoon SA, Chitsaz A, Nilforoush MH, Taheri M, Sadeghi S. The association between saliva control, silent saliva penetration, aspiration, and videofluoroscopic findings in Parkinson’s disease patients. Adv Biomed Res. 2015. Scholar
  7. 7.
    Kalf JG, Munneke M, van den Engel-Hoek L, de Swart BJ, Borm GF, Bloem BR, Zwarts MJ. Pathophysiology of diurnal drooling in Parkinson’s disease. Mov Disord. 2011;26(9):1670–6.CrossRefGoogle Scholar
  8. 8.
    Evatt ML, Chaudhuri K, Chou KL, Cubo E, Hinson V, Kompoliti K, Yang C, Poewe W, Rascol O, Sampaio C, Stebbins GT. Dysautonomia rating scales in Parkinson’s disease: sialorrhea, dysphagia, and constipation—critique and recommendations by movement disorders task force on rating scales for Parkinson’s disease. Mov Disord. 2009;24(5):635–46.CrossRefGoogle Scholar
  9. 9.
    Kalf JG, Borm GF, de Swart BJ, Bloem BR, Zwarts MJ, Munneke M. Reproducibility and validity of patient-rated assessment of speech, swallowing, and saliva control in Parkinson’s disease. Arch Phys Med Rehabil. 2011;92(7):1152–8.CrossRefGoogle Scholar
  10. 10.
    Pehlivan M, Yüceyar N, Ertekin C, Çelebi G, Ertaş M, Kalayci T, Aydoğdu I. An electronic device measuring the frequency of spontaneous swallowing: digital phagometer. Dysphagia. 1996;11(4):259–64.CrossRefGoogle Scholar
  11. 11.
    Hyson HC, Johnson AM, Jog MS. Sublingual atropine for sialorrhea secondary to Parkinsonism: a pilot study. Mov Disord. 2002;17(6):1318–20.CrossRefGoogle Scholar
  12. 12.
    Arbouw M, Movig K, Koopmann M, Poels P, Guchelaar H, Egberts T, Neef C, van Vugt J. Glycopyrrolate for sialorrhea in Parkinson disease; a randomized, double-blind, crossover trial. Neurology. 2010;74:1203–7.CrossRefGoogle Scholar
  13. 13.
    Perez-Lloret S, Nègre-Pagès L, Ojero-Senard A, Damier P, Destee A, Tison F, Merello M, Rascol O. Oro-buccal symptoms (dysphagia, dysarthria, and sialorrhea) in patients with Parkinson’s disease: preliminary analysis from the French COPARK cohort. Eur J Neurol. 2012;19(1):28–37.CrossRefGoogle Scholar
  14. 14.
    Marks L, Turner K, O’Sullivan J, Deighton B, Lees A. Drooling in Parkinson’s disease: a novel speech and language therapy intervention. Int J Lang Commun Disord. 2001;36:282–7.CrossRefGoogle Scholar
  15. 15.
    McNaney R, Lindsay S, Ladha K, Ladha C, Schofield G, Ploetz T, Hammerla N, Jackson D, Walker R, Miller N, Olivier P. Cueing for drooling in Parkinson’s disease. In: Proceedings of the SIGCHI conference on Human Factors in Computing Systems. ACM; 2011. pp. 619–622.Google Scholar
  16. 16.
    South AR, Somers SM, Jog MS. Gum chewing improves swallow frequency and latency in Parkinson patients: a preliminary study. Neurology. 2010;74(15):1198–202.CrossRefGoogle Scholar
  17. 17.
    Sarra N, Siderowf A, Duda J, Ten Have T, Colcher A, Horn S, Moberg P, Wilkinson JR, Hurtig HI, Stern MB, Weintraub D. Montreal cognitive assessment performance in patients with Parkinson’s Disease with “Normal” global cognition according to mini mental state examination score. J Am Geriatr Soc. 2009;57(2):304–8.CrossRefGoogle Scholar
  18. 18.
    Kudlicka A, Clare L, Hindle JV. Pattern of executive impairment in mild to moderate Parkinson’s disease. Dement Geriatr Cogn Disord. 2013;36(1–2):50–66.CrossRefGoogle Scholar
  19. 19.
    Stojmenovic GM, Stefanova E, Stojkovic T, Tomic A, Markovic V, Lukic MJ, Kresojevic N, Stankovic I, Kostic V. Attentional flexibility deficits in Parkinson’s disease patients with freezing of gait. Mov Disord. 2014;29:S354–5.Google Scholar
  20. 20.
    Dromey C, Jarvis E, Sondrup S, Nissen S, Foreman KB, Dibble LE. Bidirectional interference between speech and postural stability in individuals with Parkinson’s disease. Int J Speech Lang Pathol. 2010;12(5):446–54.CrossRefGoogle Scholar
  21. 21.
    Yogev-Seligmann G, Hausdorff JM, Giladi N. The role of executive function and attention in gait. Mov Disord. 2008;23(3):329–42.CrossRefGoogle Scholar
  22. 22.
    Muralidharan V, Balasubramani PP, Chakravarthy S, Gilat M, Lewis SJ, Moustafa AA. A neurocomputational model of the effect of cognitive load on freezing of gait in parkinson’s disease. Front Hum Neurosci. 2016;10:649.PubMedGoogle Scholar
  23. 23.
    Brodsky MB, Abbott KV, McNeil MR, Palmer CV, Grayhack JP, Martin-Harris B. Effects of divided attention on swallowing in persons with idiopathic Parkinson’s disease. Dysphagia. 2012;27(3):390–400.CrossRefGoogle Scholar
  24. 24.
    Troche MS, Okun MS, Rosenbek JC, Altmann LJ, Sapienza CM. Attentional resource allocation and swallowing safety in Parkinson’s disease: a dual task study. Parkinsonism Relat Disord. 2014;20(4):439–43.CrossRefGoogle Scholar
  25. 25.
    Rana A, Khondker S, Kabir A, Owalia A, Emre M. Impact of cognitive dysfunction on drooling in Parkinson’s disease. Eur J Neurol. 2013;70(1–2):42–5.CrossRefGoogle Scholar
  26. 26.
    Goetz CG, Tilley BC, Shaftman SR, Stebbins GT, Fahn S, Martinez-Martin P, Poewe W, Sampaio C, Stern MB, Dodel R, Dubois B. Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord. 2008;23(15):2129–70.CrossRefGoogle Scholar
  27. 27.
    Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992;55(3):181–4.CrossRefGoogle Scholar
  28. 28.
    Hoehn M, Yahr M. Parkinsonism: onset, progression and mortality. Neurology. 1967;17:427–42.CrossRefGoogle Scholar
  29. 29.
    Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9.CrossRefGoogle Scholar
  30. 30.
    Gernsbacher MA, Faust ME. The mechanism of suppression: a component of general comprehension skill. J Exp Psychol Learn Mem Cogn. 1991;17:245.CrossRefGoogle Scholar
  31. 31.
    Thomas-Stonell N, Greenberg J. Three treatment approaches and clinical factors in the reduction of drooling. Dysphagia. 1988;3(2):73–8.CrossRefGoogle Scholar
  32. 32.
    Banerjee KJ, Glasson C, O’Flaherty SJ. Parotid and submandibular botulinum toxin A injections for sialorrhoea in children with cerebral palsy. Dev Med Child Neurol. 2006;48(11):883–7.CrossRefGoogle Scholar
  33. 33.
    Mancini F, Zangaglia R, Cristina S, Sommaruga MG, Martignoni E, Nappi G, Pacchetti C. Double-blind, placebo-controlled study to evaluate the efficacy and safety of botulinum toxin type A in the treatment of drooling in Parkinsonism. Mov Disord. 2003;18(6):685–8.CrossRefGoogle Scholar
  34. 34.
    Ondo WG, Hunter C, Moore W. A double-blind placebo-controlled trial of botulinum toxin B for sialorrhea in Parkinson’s disease. Neurology. 2004;62(1):37–40.CrossRefGoogle Scholar
  35. 35.
    Boersma P, Weenink D. Praat: doing phonetics by computer [Computer program]. Version 6.0.19; 2016. Accessed 13 June 2016.
  36. 36.
    Santamato A, Panza F, Solfrizzi V, Russo A, Frisardi V, Megna M, Ranieri M, Fiore P. Acoustic analysis of swallowing sounds: a new technique for assessing dysphagia. J Rehabil Med. 2009;41(8):639–45.CrossRefGoogle Scholar
  37. 37.
    Norman DA, Shallice T. Attention to action. In: Consciousness and self-regulation. Springer, Berlin; 1986. pp. 1–18.Google Scholar
  38. 38.
    Wu T, Liu J, Zhang H, Hallett M, Zheng Z, Chan P. Attention to automatic movements in Parkinson’s disease: modified automatic mode in the striatum. Cereb Cortex. 2015;25(10):3330–42.CrossRefGoogle Scholar
  39. 39.
    LaPointe LL, Stierwalt JA, Maitland CG. Talking while walking: cognitive loading and injurious falls in Parkinson’s disease. Int J Speech Lang Pathol. 2010;12(5):455–9.CrossRefGoogle Scholar
  40. 40.
    Nieuwhof F, Bloem BR, Reelick MF, Aarts E, Maidan I, Mirelman A, Hausdorff JM, Toni I, Helmich RC. Impaired dual tasking in Parkinson’s disease is associated with reduced focusing of cortico-striatal activity. Brain. 2017;140(5):1384–98.CrossRefGoogle Scholar
  41. 41.
    Clark JP, Adams SG, Dykstra AD, Moodie S, Jog M. Loudness perception and speech intensity control in Parkinson’s disease. J Commun Disord. 2014;51:1–12.CrossRefGoogle Scholar
  42. 42.
    Parveen S. Comparison of self and proxy ratings for motor performance of individuals with Parkinson disease. Brain Cogn. 2016;103:62–9.CrossRefGoogle Scholar
  43. 43.
    Noble E, Jones D, Miller N. Patient reported changes to swallowing in Parkinson’s disease. Int J Ther Rehabil. 2015;22(12):573–81.CrossRefGoogle Scholar
  44. 44.
    Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG. Awareness of dysphagia by patients following stroke predicts swallowing performance. Dysphagia. 2004;19(1):28–35.CrossRefGoogle Scholar
  45. 45.
    De Lau LM, Breteler MM. Epidemiology of Parkinson’s disease. Lancet Neurol. 2006;5(6):525–35.CrossRefGoogle Scholar
  46. 46.
    Jenkinson C, Fitzpatrick RAY, Peto VIV, Greenhall R, Hyman N. The Parkinson’s disease Questionnaire (PDQ-39): development and validation of a Parkinson’s disease summary index score. Age Ageing. 1997;26(5):353–7.CrossRefGoogle Scholar
  47. 47.
    McCaig CM, Adams SG, Dykstra AD, Jog M. Effect of concurrent walking and interlocutor distance on conversational speech intensity and rate in Parkinson’s disease. Gait Posture. 2016;43:132–6.CrossRefGoogle Scholar
  48. 48.
    Heinzel S, Maechtel M, Hasmann SE, Hobert MA, Heger T, Berg D, Maetzler W. Motor dual-tasking deficits predict falls in Parkinson’s disease: a prospective study. Parkinsonism Relat Disord. 2016;26:73–7.CrossRefGoogle Scholar
  49. 49.
    Strouwen C, Molenaar EA, Keus SH, Münks L, Heremans E, Vandenberghe W, Bloem BR, Nieuwboer A. Are factors related to dual-task performance in people with Parkinson’s disease dependent on the type of dual task? Parkinsonism Relat Disord. 2016;23:23–30.CrossRefGoogle Scholar
  50. 50.
    Kelly VE, Eusterbrock AJ, Shumway-Cook A. A review of dual-task walking deficits in people with Parkinson’s disease: motor and cognitive contributions, mechanisms, and clinical implications. Parkinson’s Dis. 2012. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.South Tyneside NHS Foundation Trust, Department of Speech and Language TherapyQueen Elizabeth HospitalSheriff HillUK
  2. 2.Newcastle University Institute for AgeingNewcastle UniversityNewcastle upon TyneUK
  3. 3.Northumbria Health NHS Foundation Trust, North Tyneside District HospitalNorth ShieldsUK
  4. 4.Institute of Health and SocietyNewcastle UniversityNewcastle upon TyneUK

Personalised recommendations