Caregiver Questions in Alzheimer’s Disease – Research Tuesday

Caregiver Questions

This post is a part of Research Tuesday. I read “Do you remember? How caregivers question their spouses who have Alzheimer’s Disease and the impact on communication”.

In this article the researchers investigated the questions caregivers asked to their spouse with Alzheimer’s Disease during a 10-minute conversation sample on the topic of their choice. They investigated three types of questions and their demand on semantic and episodic memory.

  • Yes-No: Do you want rice for dinner? (semantic), Did we have rice for dinner last night? (semantic and episodic)
  • Choice: Would you like rice or potatoes? (semantic), Did we have rice or potatoes last night? (semantic and episodic)
  • Open: What would you like for dinner? (semantic), What did we have for dinner last night? (semantic and episodic)

Only one choice question was observed, so this article does not investigate choice questions further. Caregivers used open and yes-no questions equally. Questions requiring the use of episodic memory were used nearly twice as often as questions requiring semantic memory only.

The researchers hypothesized that participants with Alzheimer’s Disease would respond more successfully to yes-no questions requiring semantic memory than episodic memory. Their research found this to be true. Questions requiring the use of episodic memory resulted in more than twice the number of communication breakdowns.

In terms of open questions, researchers found that the majority (64%) of open questions requiring semantic memory were successful. However, open questions requiring the use of episodic memory were largely unsuccessful (71% breakdown).

When I read a journal article, I pay close attention to the participants as described in the methods section. This helps me determine how the article might apply to the population I work with. For example, here are some details about today’s article:

  • Participants reported normal (or corrected to normal) vision and hearing. – Many of my patients have sensory deficits such as macular degeneration and unaided hearing loss.
  • Participants MMSE score was 20.3. – My patients vary in severity of cognitive deficits.
  • The average of of participants was 72. – Many of my patients are 85-100 years old.

So with so much difference between their participants and my patients, is this article useful? I think so.

This article looks at yes-no versus open questions, which many articles have done before. However, unlike many of the previous articles, the researchers also investigate the type of memory required in yes-no and open ended questions. Both types of questions can require semantic memory only or both semantic and episodic.

Through reading this article, I gained another way to perform my own ‘case studies’ on my patients to determine how to best communicate with them (and train their caregivers – staff and family). This article is a reminder to educate caregivers about episodic versus semantic memory use.

Small, J.A. & Perry, J. (2005) Do you remember? How caregivers question their spouses who have Alzheimer’s Disease and the impact on communication. Journal of Speech and Hearing Research. 48:125-136.

UTI and Cognitive Rehabilitation: Is it Ethical?

UTI-cognitive-rehabilitation

I receive many questions about possible ethical dilemmas. One of the questions I frequently receive is in regard to providing cognitive treatment to people with UTIs.

Here is a recent question I received from an SLP (quoted with permission):

“My facility is pressuring me to evaluate a woman who came in with a UTI. They want me to evaluate her for cognition. I’m getting a lot of pressure to do this. But to me, it seems contraindicated to evaluate someone with a UTI for cognition. What do you think?”

There really isn’t an easy answer. Every patient is different. There should not be a blanket policy to evaluate and treat for cognitive dysfunction in patients with a UTI. Why? A diagnosis doesn’t indicate a need for evaluation or treatment.

When I review charts a diagnosis may contribute to the information I am gather and may lead me to ask other questions during an evaluation, but the need for evaluation and treatment is driven entirely by the patient’s need – not their diagnosis.

So this patient with a UTI, has she had a decline in attention that impacts her ability to feed herself? Is she having trouble communicating with caregivers and unable to communicate her wants, needs, etc? These are things we might address in cognitive treatment; however, not in a rehab approach. If we provide treatment it should be in a habilitation approach – or in other words modifying their environment and the people in it.

If we intervene would we be able to assess the patient’s strengths and weaknesses and modify the patient’s environment, so they are better able to engage in their environment with their current abilities?

But a UTI is treated with antibiotics?

A very important question frequently asked as we discuss whether to provide treatment when UTI is the cause of cognitive dysfunction is, “Why provide treatment when a disease will heal given antibiotics and time?” Perhaps a related question is, “Why provide pain medication to someone when the pain will resolve as their broken leg heals?”

Because it’s not just about the end result. It’s also about quality of life now. If we have unique skills that can help a person improve their quality of life we should use them. We are not treating the UTI. We are providing treatment to the person who is now unable to participate in their environment.

However, our plan of care should not consist of treatment six times a week for 30 days. With this habilitation approach we are assessing the situation, training caregivers, and discharging. It should be much shorter in duration and frequency.

As I mentioned at the beginning, there should not be a blanket policy. Every patient will not need cognitive intervention. In fact, we could have two patients with UTIs that share many characteristics (e.g. age, sex, co-morbidities, etc.), but one could benefit from intervention while the other may not. A blanket policy for evaluation and treatment based on diagnosis does not consider individual patient need, but it also belittles our clinical autonomy. Clinical autonomy is essential to providing skilled services.

There are some patients that I screen and determine they are doing okay in their environment given their cognitive decline secondary to the UTI. I keep them on follow-up. We have no formal process in my building. I keep a checklist and as I follow-up, I document in the notes section of our EMR. I might check in with OT, PT, or nursing in a few days to make sure things are resolving rather than worsening.

Once their course of antibiotics has been completed and their UA has come back negative, I may follow up again to make determine if an evaluation is warranted at that time. After all, the UTI may have been just a part of the change in cognition.

Bottom line: Base your decisions on patient need rather than diagnosis. Consider appropriateness of rehabilitation versus habilitation approach. Make clear, confident recommendations accordingly. You’ve got the clinical training to make the decision.

Orientation as a Goal

Orientation Goals

Confession

I used to write orientation goals for most of my patients. Before you gasp, hear me out. Knowing today’s date (within a day or two…) is an easy thing? Knowing where the heck you are and why you are here is essential. Right?

Many of the screeners and evaluations we conduct with our patients assess elements of orientation. Most of my clients either missed questions regarding orientation miserably or were off just a bit. Regardless of their cognitive and communication strengths and weaknesses, I wrote the same goal. Patient will communicate awareness of orientation to self, time, location, and purpose for three consecutive sessions given use of external aids.

Seems like a good goal, right? It’s specific. It’s measurable. It’s assignable. It’s realistic…

Is orientation an appropriate goal?

Okay, maybe an orientation goal is not realistic for some of our patients. Before I write an orientation goal, I ask myself,

  • Will being oriented to place/time/etc. improve this patient’s quality of life or independence?
  • Does this patient have the ability to be oriented?
  • Would spending extensive time on orientation detract from spending time on areas that would have a greater impact?
  • Does the patient care about being oriented?

As I asked these questions, I found my answers often weren’t in favor of addressing orientation as a goal. When my patients are pleasantly confused and don’t care about the day or time as long as nobody calls them late for dinner, I don’t make orientation a goal – even if they think it is 1968.

Yet there are patients for whom orientation is a very important goal. These are my patients who answer orientation questions close but not quite right. These are my patients who are bothered by not being able to accurately answer such a “simple” question. These patients have goals of managing their own schedule for which awareness of time and place is crucial.

External aids for temporal orientation

I have been hunting for the perfect calendar to hang in patients’ rooms and come up short. There are calendars with gorgeous pictures and tiny numbers. If by chance my patient has excellent vision and is able to read the date in the tiny text, they will have to contend with glare bouncing off the glossy paper. Tiny numbers. Glossy paper. Extra cartoons, quotes, etc to distract. I could not find a calendar that was suitable for someone with older eyes and impaired attention, who will likely view it from their bed. So I created one.

I also recommend buying a cube of 2″ Post-it sticky notes. Cut out the middle (just fold in half sticky-side out) and stick on today’s date. I like this method better than marking off days, because it focuses on what today is rather than what today isn’t. It is also much easier to see than a faint pen line marking out a day. Caregivers and family members can help with moving the sticky note (even if they don’t have a pen handy). This calendar works perfectly with 2″ Post-it note frames.

Teaching Ethical Decision Making to Students

teaching ethics
Session Title:
“Strategies for Ethics Education in Speech-Language Pathology: Clinical & Academic” #1434

Presenters and relationship to topic:
Carol L. Cannon, M.S., CCC-SLP, Jackson, MS Public Schools and Lauren E. Bland, Ph.D., CCCSLP, Western Kentucky University
They both are have served in a clinical supervisor role at the University level. Instruction and guidance in teaching and helping SLP graduate students hone ethical decision making skills.

What was the overall goal(s) of the session?

  • Identify the reasons that the ASHA code of ethics must be taught in graduate programs.
  • Describe at least one strategy that can be used when teaching ethical behavior in an academic context
  • Describe at least one strategy that can be used when teaching ethical behavior in a clinical training context

What did you learn from the session?
The audience was entirely made up of university supervisors, on-site school or hospital based supervising SLPs, and me, the newly minted SLP fresh from grad school. I sat listening to the ideas on how to help students interpret and apply the ASHA Code of Ethics to a variety of settings for future and current practice. Most of the research on teaching ethics comes from the medical and social work fields; however, it’s still relevant. The strategies I liked best include:

  • Negative practice – creating an unethical situation and practice reactions with Code of Ethics near-by
  • Special lecture – invite a panel of SLPs from the same or different fields and pose ethical questions, allow students to hear responses
  • Interview – students interview current supervisor or other SLP to identify ethical challenges that are prevalent in that setting; the SLPs will share strategies for successfully navigating the challenges

They mentioned others, but most programs incorporate ethics into each disorders class. For instance, as the disorder is being covered, the instructor can talk about where the ethical challenges occur and share possible solutions based on the code of ethics.
I liked all these ideas better than a professor saying, “Hey, read the code of ethics while you read this entire text book”. You can imagine how thorough that ‘read’ would be.

What’s next for you? What should we all do with this information?
I need to get better at checking the ASHA Code of Ethics when I have an ethical question. Usually, I ask an SLP colleague or twitter; while those are always a good reference, go to the source. For those working at a university setting, supervising an SLP graduate student, or mentoring a CF, don’t neglect a discussion on ethical decision making. I feel like half my job is making these decisions and trying to fall into my employer’s directions. It’s a delicate balance that needs attention, especially for newbies like myself. I’m new, still learning, and not always sure of myself. The ASHA Code of Ethics is a good starting point for reassurance and guidance to my next steps.

How can we continue the discussion?
Wouldn’t it be nice if ASHA had a curriculum of some sort to accompany the ASHA Code of Ethics? I think so. Otherwise, keep it bookmarked and read it as often as you check your phone. Ok…that’s intense. Maybe just keep it bookmarked for that rainy day next week when you think of this post. Enjoy.

Guest blogger bio:
Katie Millican, M.Ed., CCC-SLP, works in a K-2 elementary school in Alaska. She recently received her CCCs and enjoys blogging about graduate student interests, adventures of Alaska living, and daily happenings of SLP life. You can find her on Facebook, Twitter, Pinterest, Google+, and her blog!

How to Talk to Your Supervisor About Ethics Concerns

How to Talk to Your Supervisor About Ethics Concerns

I was pleased to share the stage with Janet Brown and Tim Nanof, both ASHA staff members to discuss Productivity Pressures in the SNF Setting: A Top Down and Bottom Up Approach. After Janet and Tim spoke about what ASHA is doing to address SLPs’ concerns, I spoke about what SLPs can do right now. Here are some notes from my portion of the session about talking to your supervisor about ethical and legal concerns. .

You should speak to your supervisor first about ethics and legal concerns. Of course, if your supervisor is participating in the activity of concern (e.g. billing for patients, they aren’t seeing), you might want to skip this step.

Otherwise, speak to your supervisor first. And acknowledge the pressure they are probably under too. While you may be frustrated, don’t enter the conversation with an “us versus them” attitude.

Pick a specific concern to address one at a time. Go for the low hanging fruit (something easily addressed) or something that impacts patient safety.

If you do not achieve desired results, move on to the next rung in the corporate ladder. Remember the definition of insanity – doing something over and over again and expecting different results.

Next in line is the regional director, but from speaking to many of you it may be uncomfortable to speak to the regional director, especially if you fear it being seen as going above your supervisor’s head.

The next person in your company to contact is the compliance hotline or department. They are very familiar with current regulations and want the company to run ethically. Complaints to the compliance department are protected from retaliation; after all it’s your job to report things that put the company at risk (like safety concerns, labor law violations, and fraud).

While you are preparing to speak to your supervisor (or another member of your company) about your concerns, I recommend that you start a journal. Document the when and where of your concerns, your response, and the result of your response. This information will be extremely helpful as your talk to the compliance department or report externally.

Is Evidence-Based Practice Misunderstood?

Is Evidence-Based Practice Misunderstood?

This week Gray Matter Therapy is bringing you guest blog posts covering ethics related sessions at the 2014 ASHA Convention. Thanks to Karen Sheffler for her guest post today (which I would have attended if I wasn’t scheduled to speak at the same time).

Session Reviewed:

Rosenbek, J. & Leslie, P. (2014, November). 1182: Ethics & Evidence in Practice. Session presented at the annual convention of the American Speech-Language-Hearing Association, Orlando, FL.

This session was developed by the American Board of Swallowing and Swallowing Disorders, and it was presented by Dr Paula Leslie of University of Pittsburg and Dr John (Jay) Rosenbek of the University of Florida. Rosenbek offers his 45 years of experience of “trying to be an ethical practitioner.”

Stated goal of the session:

“Clinicians who have evidence without acumen and knowledge of patient wants and needs are helpless to direct a patient’s treatment. Clinicians and patients need help to understand the other’s territory in order to come to a closer place in decision-making.”

Summary of what I learned:

Dr Leslie reminded us that when we are invested in our patients and families we should face emotionally troubling decisions and worry about them. This is difficult work, but Leslie shared what guides her:

  1. Values, morals and ethics
  2. Medical ethical principles
  3. Evidence-based practice

Let’s break these down further.

  1. Values, morals and ethics
    When there is a communication breakdown, we need to check our personal biases and think about the patient’s/family’s values and morals. Make sure you are working towards the least restrictive level of care, per Leslie.
    Values: personal principles of what is important in life. This is influenced by family and friends (who we hang out with).
    Morals: personal standard of behavior or belief concerning what is right and wrong. This is influenced by our society, community, culture, country, and even age group. There are significant cultural differences.
    Ethics: we are guided by our professional code of ethics from ASHA and those at our workplace.
  2. Medical ethical principles
    We have to balance the patient’s right to make decisions about his/her own body (autonomy) with the desire to take positive action for the patient (beneficence). The phrase: “do no harm” is paramount in bioethics (non-maleficence), as an intervention may do more harm than good. Tube-feeding placement in advanced dementia was an example given by the presenters.

    Potentially, the patient (or family) may think it is a “candy store,” and feels it is his right to “buy” the intervention if he wants it, per Leslie. However, Leslie also asked us why do we question our patients’ decision-making when they don’t agree with us, but we don’t question their decision-making when they do agree with us?

    Ultimately, what may diffuse the tension is justice. We see this with the conflict in Ferguson, Missouri and elsewhere. People need to know that treatment is fair and equitable.

    Leslie advised to: “Shut up and listen!” Communicating with the medical team is crucial, but even more importantly, go into the patient’s room listening, observing and “feeling the room.” The patient and family come first.

  3. Evidence-based practice (EBP)
    Dr Leslie challenged that EBP is one of the most misunderstood frameworks in our field. We have all seen the diagram of the three interlocking circles with the following three components:

    • Best research evidence
    • Clinical expertise
    • Patient values and preferences

    We may forget that these are three equal guiding principles, weighing research over the patient preferences and our own experience.

    Additionally, the evidence may be limited and of little clinical utility. There are gaps in care, per Rosenbek, when it may take up to 25 years of research to move from new idea to practice. The clinician may have a hard time finding her patients in the clean sample populations. For example, if the researchers excluded patients with advanced dementia, head and neck cancer and tracheostomy, then what do you do with the results when that is your patient population at a rehabilitation center.

    Rosenbek referred to Montgomery & Turkstra (2003) and Byiers et al (2012) when he discussed the “tyranny of the randomized-controlled trial (RCT).”
    “An overemphasis on RCTs may create radical skepticism when this standard is not attained, and this in turn may lead to therapeutic nihilism.”
    Rosenbek and Leslie were not suggesting to ignore evidence and throw out EBP. They were advocating for “equal consideration” of all three components. Rosenbek recommended Fleming & Demets (1996) in reference list below.

    “The informed clinician checks his/her knowledge against best available practice and against informed patient preferences,” per Dr Leslie.

    Key word is informed.

A bit about informed consent:
Dr Leslie noted that this is a process. Not a piece of paper. Not one event. Not a waiver form.

It is a dialogue.

The key components are

  • Intention: patient choosing or declining an intervention.
  • Capacity: we can document capacity in a moment in time, but we cannot evaluate for competence. To determine competence, the patient will need a formal psychological evaluation. We can say that the patient had capacity to make the decision at that moment as he was able to repeat back in his own words the risks, benefits, etc.
  • Voluntariness: We want the patient to have autonomy. Maybe the patient does not want to disappoint the clinician. Avoid coercion. For example, making the patient sign a waiver form is a method of coercion.

What should the SLP do with this information?

  1. Join your facility’s ethics committee.
  2. Rosenbek and Leslie recommended a biopsychosocial model from Engle (1978), as an oldie but goodie. Rosenbek noted that our biomedical model tends to minimize psychological, social, and environmental factors. The patient becomes a number, and suffering and lived experience are suppressed. Is the true clinical outcome relevant to the patient? Sometimes we cannot fix the problem, so are we helping the patient get to the least bad option for the best possible quality of life? Rosenbek agreed that shutting up and listening helps us with “humane care.”
  3. Document well. You are protected per ASHA if you can document that you had thorough discussions and performed the least restrictive practice.
  4. Always remember your patient is “more than bolus flow abnormalities.” “Your patient is more than mucous,” joked Rosenbek. Seriously, though, if we ignore everything else, than the patient may be reluctant and disregard clinical advice.
  5. Be comfortable in the zone of ambiguity and tension. There should be constant tension between data and your beliefs to make sure you are constantly growing and changing your practice. “All this is why we have frontal lobes.” Another great quote from Dr Jay Rosenbek!
  6. Check and double-check new information. Fortunately, research papers now contain enough detail to thoroughly analyze the design and data

Here is a funny double-checking example: Rosenbek in the session attributed this quote: “some of the things that count cannot be counted,” to Albert Einstein. I wanted to double check for accuracy. All over the internet this is attributed to Einstein, but one spot noted it was just a plaque in his office! Quoteinvestigator.com states the evidence is weak linking it to Einstein! Here is the full quote: “Not everything that can be counted counts, Not everything that counts can be counted.” The proper citation is: William Bruce Cameron (1963). It is an excerpt from his text: Informal Sociology: A Casual Introduction to Sociological Thinking.

Let’s continue this discussion.

I want to thank Gray Matter Therapy for initiating this ethics conversation with the help of ethics sessions at the annual convention of ASHA.

Guest blogger bio
Karen Sheffler, MS, CCC-SLP, BCS-S has almost 20 years of experience in the field of adult dysphagia, graduating from the University of Wisconsin-Madison in 1995. She was a member of the ethics committee at a hospital for 13 years. Currently, she still works in acute care, is a FEES/FEESST consultant through SEC Medical, and started her own website/blog.
You can also follow her on:
Twitter, Facebook, and Pinterest.

References provided by Jay Rosenbek and Paula Leslie:
American Speech-Language-Hearing Association. (2010r). Code of Ethics Retrieved September 29, 2012, from http://www.asha.org/policy/ET2010-00309/
Borrell-Carrio, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med, 2(6), 576-582.
Borrett, D. S. (2013). Heidegger, Gestell and rehabilitation of the biomedical model. J Eval Clin Pract, 19(3), 497-500.
Byiers, B. J., Reichle, J., & Symons, F. J. (2012). Single-subject experimental design for evidence-based practice. Am J Speech Lang Pathol, 21(4), 397-414.
Drummond, A., & Wade, D. (2014). National Institute for Health and Care Excellence stroke rehabilitation guidance – is it useful, usable, and based on best evidence? Clinical Rehabilitation, 28(6), 523-529.
Engel, G. L. (1978). The biopsychosocial model and the education of health professionals. Ann N Y Acad Sci, 310, 169-187.
Fleming, T. R., & DeMets, D. L. (1996). Surrogate end points in clinical trials: are we being misled? Ann Intern Med, 125(7), 605-613.
Greenhalgh, T. (2010). How to read a paper : the basics of evidence-based medicine (4th ed.). Chichester, West Sussex, UK ; Hoboken, NJ: Wiley-Blackwell.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? BMJ, 348.
Levy, A. G., & Hershey, J. C. (2006). Distorting the probability of treatment success to justify treatment decisions. Organizational Behavior and Human Decision Processes, 101(1), 52-58.
National Institutes for Health. Teaching Exploring Bioethics Retrieved 31st May, 2014, from http://science.education.nih.gov/supplements/nih9/bioethics/guide/teaching.htm
Ross, C. N., Zabawa, A., & Leslie-Pelecky, D. L. (2005). Helping students learn to question. American Journal of Primatology, 66, 166-166.
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312(7023), 71-72.
Seedhouse, D. (2009, 06.15.2009). Ethical Grid Retrieved 08.20.2009, from http://www.aut.ac.nz/study-at-aut/study-areas/health-sciences/research/national-centre-for- health-law-and-ethics/decision-making-tools/ethical-grid
Seedhouse, D. (2009). Ethics: The Heart of Healthcare (Third ed.). Chichester: John Wiley & Sons.
Sharp, H. M., & Shega, J. W. (2009). Feeding tube placement in patients with advanced dementia: the beliefs and practice patterns of speech-language pathologists. Am J Speech Lang Pathol, 18(3), 222-230.
Stark, M., & Fins, J. J. (2014). The ethical imperative to think about thinking. Cambridge Quarterly of Healthcare Ethics, 23(04), 386-396.
Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2011). Evidence-based medicine : how to practice and teach it (4th ed.). Edinburgh ; New York: Elsevier Churchill Livingstone.
Turkstra, L. S., & Kennedy, M. (2005). Evidence-based practice for cognitive-communication disorders after traumatic brain injury. Semin Speech Lang, 26(4), 213-214.

Doing the Right Thing: Learning the Power of Ethical Decision-Making in Practice

Doing the Right Thing

Today’s post is a follow-up to the 2014 ASHA Convention. I’m pleased to welcome guest blogger, Amna Fares.

The presenters Michele T. Kramer, M.A., CCC/SLP, Dana Tingley, M.S., CCC/SLP, Carol Ashdown, M.A. CCC/SLP RAC-CT are speech-language pathologists with extensive experience in optimizing patient care and compliance with Medicare guidelines. Their session titled Doing the Right Thing: Learning the Power of Ethical Decision-Making in Practice was presented at this year’s ASHA Convention, hosted in Orlando, Florida. Keeping with the Orlando theme, the topic of ethics was discussed with a touch of Disney.

When faced with a possible ethical dilemma one could ask “What would Jiminy do?” The moral conscious character is a good example of ethical behavior. In fact, many of the Disney protagonists can help remind us of our own Code of Ethics set by ASHA. The presenters lightheartedly reminded us of the Code of Ethics using some of the beloved Disney Princesses:

Cinderella

Principle of Ethics I
Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.

Cinderella spent much of her life in service. She faithfully and cheerfully served those around her, without the expectation of praise. She was kind, even though her stepsisters took her for granted. As clinicians, our efforts may sometimes go unnoticed by patients, families, or staff members. However, we should always keep our actions and intentions clear—our primary goal is the patient’s well being.

Belle

Principle of Ethics II
Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.

Belle’s love of reading and learning accentuate her natural beauty. As a clinician it is important to engage in continued lifelong learning. Whether it’s through approved CEUs or recreational reading, staying current with the latest developments in the field and beyond is essential.

Mulan

Principle of Ethics III
Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions, including the dissemination of research findings and scholarly activities, and the promotion, marketing, and advertising of products and services.

Although her intentions were good, Mulan’s misrepresentation of herself ultimately caused her to be expelled from service. As clinicians, it is essential that we do not misrepresent our services. It is our responsibility to build trust and understanding with other professionals and the public by providing services, as necessary, that are based on accurate information.

Rapunzel

Principle of Ethics I
Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.

Rapunzel was the victim of oppression and neglect by someone she trusted. As clinicians it is our duty to refrain from discrimination, harassment or bullying of others. Furthermore, engaging in sexual activity with clients, students, or research participants is forbidden. When referencing another professional’s ideas, research or products, it is necessary to reference the source.

A case study activity followed that was laced with possible violation of the Code of Ethics. The audience was invited to identify which code was violated, as well as provide ethical alternatives or solutions. The presenters wrapped up the session with a final quote from Jiminy Cricket, Let your conscience be your guide.

If you would like to learn more about the ASHA Code of Ethics, visit http://www.asha.org/about/ethics/. There you will find the complete list of the Principles of Ethics as well as detailed Rules of Ethics. There is even a printable poster. If you have questions about the Code of Ethics, contact ASHA’s Director of Ethics Heather Bupp, Esq., at 800-498-2071, or submit your questions via e-mail to ethics@asha.org.

Guest Blogger Bio:
Amna Fares, MS CCC-SLP has over 5-years of experience in clinical adult and pediatric settings. You can email her at hello@amnafares.com or visit her website.

Respiratory function and dysphagia, understanding the clinical relationship

Respiration Function and Dysphagia
Learning more about respiratory function is among my professional goals for 2015. This guest post is a great starting point for those of you with the same goals. Thanks to Debra for sharing!

What is a cough?

We all do it, but are we aware of the importance of a cough and its protective abilities for our lungs and health. It is responsible for clearing of particulate matter from the airway and to avoid aspiration.

When we cough, the initial phase, inspiratory, is triggered by deep inhalation. The greater the inhalation the greater the amount of pressure is generated for the cough. The second phase, compression, is initiated when the glottis (vocal folds) closes which maintains lung volume as pressure builds and promotes contraction of expiratory muscles. Once the glottis opens, the final phase, expiratory, of the cough ensues. A short blast of air through the opening glottis occurs, forcing the exhalation.

A productive cough can act as a defense mechanism for the lungs as it assists with clearing material from the airway. Sufficient subglottic pressure to achieve a productive cough is essential for patients with dysphagia who are at high risk for penetration and aspiration.

In addition, mucociliary clearance, the body’s process for removing foreign particles from the lungs, diminishes with age and therefore increases the risk for development of pneumonia.

Respiratory muscle strength training

Inspiratory muscle strength training (IMST) focuses on improving maximal inspiratory pressure (MIP or PImax) along with the diaphragm and muscles of inspiration.

Expiratory muscle strength training (EMST) focuses on improving maximal expiratory pressure (MEP or PEmax) along with the abdominal muscle and expiratory muscles (Sapienza & Troche, 2012). These training programs improve cough strength and subglottic pressure, associated with improvement of the coordination and accuracy of the swallow function, reducing the risk for penetration and aspiration.

Numerous clinical diagnoses encountered by medical SLPs require an understanding of the diagnosis’ impact on the respiratory system, the associated changes that occur and resultant implications for rehabilitation. Two examples follow:

  • Pitts et al. (2009) investigated cough strength and swallow function for individuals with Parkinson’s disease following four weeks of participation in EMST. Participants utilized an EMST 150 device to complete five sets of five breaths (twenty-five per day), five days a week. They found penetration/aspiration episodes decreased and volume acceleration of the cough increased therefore improving cough strength and subglottic pressure.
  • Ambrosino et al. (2011) stated that there is “physiological evidence that inspiratory muscle weakness is a clinical feature of COPD”, and that “There are physiological laboratory studies indicating that, if properly applied, IMT (Inspiratory Muscle Training) improves inspiratory muscle function, particularly in those patients with weak inspiratory muscles”.

Conclusion

A clear understanding of the oral, pharyngeal and respiratory systems ability to complete airway protection is essential. A modified barium swallow study is an objective assessment for safe consistencies swallowed, the need for compensatory swallow positions, maneuvers and techniques, and possible diet modifications such as thickened liquids and solid textural modifications.

Any or all of the above may be required as the patient receives effective interventions from the SLP, such as the above discussed IMST and EMST, with a comprehensive rehabilitation plan to improve the patients swallowing safety and the respiratory system for airway protection.

Want to learn more? Recommended Readings/CEUs

References:

  • McCool, F. D. (2006). Global physiology and pathophysiology of cough: Accp evidence-based clinical practice guidelines. Chest, 129(1), 48S-53S.
  • Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest, 135(5), 1301-1308.
  • Sapienza, C. M., & Troche, M. S. (2012). Respiratory muscle strength training. San Diego, CA: Plural Publishing, Inc.
  • Teramoto, S., Matsuse, T., & Ouchi, Y. (1999). Clinical significance of cough as a defense mechanism or a symptom in elderly patients with aspiration and diffuse aspiration bronchiolits. Chest, 115(2).

Guest blogger bio
Debra Tarakofsky, MS CCC-SLP, Jana Mitchell, MS CCC-SLP, and Michelle Kravatsky, MS CCC-SLP are employees of Swallowing Diagnostics Inc. (SDI), a mobile provider performing Modified Barium Swallow Studies throughout South Florida. SDI was started in January of 2000 by Debra Tarakofsky, a board-certified speech pathologist with a master’s degree from Nova University in speech and hearing science. She brings expertise in working with the geriatric population for over 20 years. She is an adjunct instructor at NovaSoutheastern University and has developed an online, interactive lab for students to enhance their understanding of anatomy and physiology of swallowing on modified barium swallow study and the identification of normal and abnormal swallowing disorders on videofluoroscopy. Collectively SDI staff has completed over 20,000 modified barium swallow studies. They are also certified to provide CEU’s, by ASHA, and are currently developing online MBS training courses.

Clinical Bedside Swallow Evaluation: What Does the “Big Picture” Tell Us in the Identification of Silent Aspiration?

Clinical Beside Swallow Eval

Thanks so much to Eric Blicker to writing another guest post for Gray Matter Therapy. You might remember his first post about his name mnemonic for clinical bedside swallow evaluations. If you are looking for dysphagia CEUs, check out his webinars.

A clinical bedside swallowing evaluation is often a puzzle and the speech language pathologist is often consulted to try and determine how the different puzzle pieces fit together, to try and form answers as to what is going on in the “big picture”. The SLP may be armed with their tools of the trade. Some clinicians use stethoscopes, pulse oximeters, and others may review lab and x-ray results to try and help augment the swallowing function findings with additional data. Most of us can agree on potential clinical signs of pharyngeal dysphagia and potential aspiration risk during oral intake: cough, choke, wet voice, throat clearing response. When trying to determine risk for aspiration in a patient with an impaired tracheal cough and clear response,the SLP needs to consider that silent aspiration symptoms are more difficult to pinpoint in a clinical exam, as they are less overt.

Conditions including, but not limited to: congestion during meal, repeat pneumonias, weight loss, malnutrition, low grade fevers, repeat infiltrate development on chest x-ray, reductions in oxygen saturation, and elevated white blood cell levels are all potential pieces to the puzzle when trying to determine the presence of silent aspiration. One element of the patient status that should be considered in this puzzle, is to to try and review patient laboratory results when possible.

White Blood Cell Lab Values and Dysphagia

Elevated white blood cell levels, often referred to as (WBC), is an increase in disease fighting cells (leukocytes) within the blood. Elevation in white blood cell count is leukocytosis. Typically, the threshold for elevated WBC count might be different, depending on facility standards. Regularly, a level of more than 11,000 leukocytes in a microliter of blood in adults is regarded a high white blood cell level count. For a patient who might be developing an infection like pneumonia from aspiration, recognizing the initial rise of WBC can a significant piece of the puzzle that the patient is having a potential change in status. This may be accompanied by fever for a patient with a developing infection such as pneumonia. Another area of focus in the patient work-up for determining potential silent aspiration risk should be the nutritional lab parameters.

Malnurishment and Dysphagia

According to the ASHA speech language pathology medical review guidelines from (2008), swallowing treatment is given, in part, to help reduce nutrition problems. Based on the ASHA document, patient assessment involves evaluation of the patient’s ability to eat safely and to sustain nutrition. Adequate nutrition is essential for the immune system function. (Harris, and Fraser, 2004). Malnutrition has now been found to be a condition in patients that are at risk for aspiration. Bouchard et al (2009) indicated that 80% of patients with aspiration pneumonia assessed also were malnourished. Clinical experience has shown that chronic silent aspirators can show malnourishment as the food will not have proper ingestion since it is entering the airway.

Pre-Albumin Lab Values and Dysphagia

One frequently used laboratory value used for monitoring nutrition is pre-albumin lab values. Pre-albumin levels measure the nutritional status of patients. Pre-albumin is a protein status indicator. This has a half life of approximately two days. As pre-albumin binds and transports protein, this is a sensitive and timely indicator of protein status (Collins, 2001). Pre-albumin levels of 10-15 mg/dL reflect mild visceral protein depletion. Pre-albumin levels of 5-10 mg/dL reflect moderate visceral protein depletion. Pre-albumin levels of <5 mg/dL reflect severe visceral protein depletion. These levels alone are not used by staff to determine nutritional depletion, but are part of a battery of exams and clinical data used to examine nutritional status. The management of malnutrition in the elderly should be an interdisciplinary and collaborative venture. In addition to the lab values listed above, another puzzle piece to assess for potential silent aspiration is understanding chest x-ray report findings.

Chest X-Rays and Dysphagia

The presence of an infiltrate on a chest X-ray may reflect the presence of aspiration pneumonia. When the radiologist refers to an infiltrate in their report, they are reporting a condition where there is filling of an airspace with fluid or cells in the lungs. These cells or fluid occupy a lung area or multiple areas at once. This is recognized by the lung as something foreign. There are some important “red-flags” that the SLP should be mindful of when reading the radiology reports. SLP should note whether infiltrates are new onset in their development or if they are chronic. When there is aspiration and the patient is in a reclined position the infiltrates will often show on the x-ray in the posterior segment of the upper lobes and superior segment of the lower lobes. When there is aspiration for a patient in an upright position, the infiltrate is more likely to involve right middle lobe (Kim et al 2008). As an extension of the chest X-ray results, one additional area in the assessment for potential silent aspiration would be auscultation of lung sounds.

Lung Auscultation and Dysphagia

Lung auscultation with a stethoscope can allow the SLP to hear the vibration of airflow in the airways transmitted to the body surface with a stethoscope. The presence of rhonchi or rales may be present in breath sounds during lung auscultation of silently aspirating patients. Rales or crackles are characterized as clicking or bubbling like sounds. These rales or crackles present at the end of the inspiratory breath phase may reflect pneumonia. Coarse crackles generally are represented by wet inspiratory sounds on lung auscultation. Rhonchi have a snoring or gurgling-like sound quality and may be present during inhalation or exhalation. Rhonchi can often clear with coughing. Clinical experience has shown that patients who cannot clear secretions or residual food/liquid bolus from the airway, can present with rhonchi. In conjunction with congestion to breath sounds, one additional area that should be considered in a potential silent aspiration would be a reduction in oxygen saturation during oral intake.

Pulse Oximetry and Dysphagia

A pulse oximeter, like a stethoscope, can be a valuable tool when treating patients that are at risk for aspiration. This is another key to assessing the clinical picture. The pulse oximeter can be placed on the patient’s finger and provides a reading that shows how well the oxygen is moving in the patient’s blood. The measurement used is (Sp02). There have been attempts in research to show a cause and effect scenario with a drop in Sp02 and the presence of aspiration. The process of aspiration into the pulmonary airways has been reported to result in bronchoconstriction which results in oxygen desaturation (Collins and Bakheit, 1997). Normal oxygen saturation levels may range from 95-100%, with values under 90% generally considered hypoxemia, or low oxygen levels in arterial blood. These numbers may vary depending on certain pulmonary conditions, including chronic obstructive pulmonary disease, where lower oxygen saturation levels may commonly be present. Additional research is needed to determine a definitive causal relationships between aspiration and reduction to oxygen saturation.

The SLP provides food and liquid consistencies in a clinical bedside swallow evaluation and monitors the patent for signs and symptoms of dysphagia and aspiration risk. Often, there may be dysphagia and aspiration risk behaviors that cannot be detected clinically, such as in silent aspiration. By reviewing lab findings, using pulse oximetry, and learning the art of lung auscultation, the SLP can augment and enhance the clinical exam in a non-invasive manner with some further information, that may raise some additional “red flags” in a potential silent aspiration risk patient. Taking all of these separate puzzle pieces and trying to place them together may help the SLP formulate the “big picture” when it comes to identification of potential silent aspirators.

References:

  1. http://www.asha.org/uploadedFiles/SLP-Medical-Review-Guidelines.pdf
  2. Bouchard, J. (2009). Association between aspiration pneumonia and malnutrition in patients from active geriatric units. Canadian Journal of dietetic practice and research, 70(3), 152-154.
  3. Harris et al (2004 )Malnutrition in the institutionalized elderly: the effects on wound healing. Ostomy Wound Management. Oct;50(10):54-63
  4. Collins (2001) The difference between albumin and pre-albumin. Journal for Prevention and Healing (14), 235-236,
  5. Kim M, Lee KY, Lee KW et-al. MDCT evaluation of foreign bodies and liquid aspiration pneumonia in adults. AJR Am J Roentgenol. 2008;190 (4): 907-15.
  6. Collins et al (1997). Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke, 28(9):1773-5.

Guest Blogger Bio:
Dr. Eric Blicker M.A. CCC-SLP.D BCS-S is a Board Certified Specialist in Swallowing Disorders from the American Board of Swallowing and Swallowing Disorders. Eric received his doctoral degree from Nova Southeastern University and was trained in Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) by Dr. Jonathan Aviv, the otolaryngologist who developed FEESST. Eric has started multiple Flexible Endoscopic Evaluation of Swallowing (FEES) programs in the south Florida area while training speech-language pathologists and physicians in the process. Dr. Blicker owns a portable FEES company that provides testing services throughout the state of Florida. He also created the website as an ASHA CE provider: www.ceualliedhealth.com, to provide courses online in medical speech-language pathology.

Service isn’t something that happens “over there”

dont just stand there

Merriam-Webster defines “service” as “the occupation or function of serving” or “the work performed by one that serves”.

By that definition, we could say speech-language pathology is a field of service. The work I do is not for me. It is for someone else.

Yet at one of the sessions I attended there were some negative comments about professors having to participate in service activities (or joy for not having to participate in service activities). It totally struck me and distracted me the rest of the session.

Before we move forward, let’s take a look at a definition of service. When people working in a university talk about service, they are usually talking about one of the following:

  • service of the profession – reviewing manuscripts, leadership in professional organizations, etc.
  • university service – committee participation, faculty senate, etc.
  • extracurricular university service – involvement in student groups

The common argument is service takes professors away from teaching and research, which I can understand. (These are general observations; not all professors are the same.) But as someone who formally worked in student affairs (which is service heavy), I can see the other side. Service is important to universities and our professions.

As a practicing SLP, I can see so many reasons to participate in service activities. For as long as I can remember, I have had involvement in multiple service activities in, around, and outside my profession. I have been in a far number of conversations with therapists who want “someone” to do “something”, but they don’t want to get involved (for various factors). We need to be involved.

So why is service important to clinical and academic SLPs?

  1. You benefit. I learn so much from my service outside of our profession. I am on the board of directors for a co-op insurance company and I am learning so much about insurance regulation and lack of medical resources in the rural areas of my state (just two examples). Participating in service is a great way to connect with people who are want to make things happen.
  2. You can influence change. This is huge. Many of us want changes to caseloads in the schools, when and if we receive referrals, physician understanding of language and swallowing disorders, or productivity pressures in healthcare. Getting involved in service can put you into a position where you have influence on an organization or association that will help you accomplish goals. Imagine the possibilities of working with other people with big ideas. Together, we’re unstoppable!
  3. Service helps resolve our public relations problem. How many of us have ever told someone we are an SLP and they immediately understand what we do? Few and far between, right? Service outside of or around (e.g. other health care professionals) our profession helps us share the wonderful world of SLP with other professionals and people of influence.

I encourage you to find a service opportunity. There are so many ways to get involved. Here are a few. You may want to look for opportunities with the following organizations:

  • ASHA – Call for nominations is currently open. There are also many ways to volunteer or participate in committees.
  • Your state association has many similar opportunities. Join and get involved.
  • Universities aren’t just for professors. Look for opportunities to get involved as an alum. Wish you had XYZ training in school, advocate for it, so the next generation does.
  • State, city, and county associations and associations (e.g. Alzheimer’s Association, County Agency on Aging, etc.) are great ways to provide service around and outside our profession. Look for ways to influence how we help underserved populations (rural, low income, etc.).
  • Look within your organization for opportunities on committees. Perhaps your building is going to be renovating soon; get involved so you can advocate for the environments that would help all patients. Join the falls committee. Make change from the inside.

Service isn’t something that happens “over there” by someone else. Service should happen wherever you are. It doesn’t have to be “big”; you just have to do it in a big way.

See other 2014 ASHA Convention related blog posts.