Dementia communication tip: Say yes.

say-yes

In my role as an SLP and family educator, I often explain the importance of meeting people with dementia where they are. This usually leads to a conversation about lying to loved ones, which makes everyone uncomfortable at first. Even I am uncomfortable with the idea of “lying” to people with dementia. Treating someone with respect and dignity is telling and enforcing the truth, right?

When I began working with people with dementia, I had to reconsider the guilt I felt when I didn’t tell the complete truth. The more I examined the situations I was in, I realized when working with people with dementia (or other cognitive impairment) telling the truth can be self serving. If people no longer have the ability to rationalize, forcing the truth is drawing attention to their weaknesses (e.g. decreased memory, problem solving, etc.) and causing discomfort.

Your part in the story

We are part of a story, but the story isn’t about us. It is about the elders or loved ones in our life. Keep them the protagonist of the story, driving the action. Some people may find this concept similar to a Montessori approach.

But this can be a difficult concept to teach. Discussing lies and truth is emotionally charged, which is why I was overjoyed when I heard a recent podcast from This American Life (Magic Words, Act Two). The story follows two improv comedians, who discovered a popular “Yes, and…” improv technique worked really well with their family member with dementia.

In brief, “Yes, and…” asks comedians to always say “yes, and…” rather than “no, actually…” When you say “no” the conversation ends. So if a comedian enters the stage and their fellow comedian says, “Look at this amazing new cheese snack for cows!” If they say, “That doesn’t makes sense, cheese is made from cows milk” the conversation ends. But if they say, “Wow! How do they get the farmers to buy the cheese for the cows?” the conversation continues.

How to say “Yes, and…”

I love this way of looking at meeting people where they are. It’s not about lying. It’s about something positive – saying yes. What does this look like in communicating with those with dementia? Say yes. Acknowledge their thoughts and feelings. Then contribute. Here are some examples:

Situation – Just after lunch in the dining room.
Elder: I need to pay my bill. (Looks in pockets for wallet)
Me (saying “no, actually”): You don’t have to pay. It’s all included in your monthly bill.
Me (saying “yes, and”): You got the bill last time. Let me get it this time. Thank you for visiting with me at lunch.

Situation – One on one conversation prior to therapy
Elder: There are bananas in the bathroom.
Me (saying “no, actually”): We don’t keep bananas in the bathroom. We keep them in the kitchen.
Me (saying “yes, and”): Well let’s make a banana split! Where is the ice cream?

If we are trying to force the “truth” into the story, what are we missing or leaving out? How can you use “yes, and…” rather than “no, actually…” to increase the value of emotions and participation in the story?

A clarification: My thoughts on using the “yes, and…” technique and not forcing the truth are not meant to discourage informed consent or resident rights.

Research Tuesday Roundup – September 2014

Research Tuesday

Photos Versus PCS – Babies Weigh In
Carole Zangari is a professor of speech-language pathology with a focus on AAC for children and adults. She is past coordinator of ASHA’s AAC Special Interest Group and is co-editor of the book Practically Speaking: Language, Literacy, and Academic Development of Students with AAC Needs. She blogs at PrACCtical AAC.

Combining errorless learning and vanishing cues
Rachel Wynn, MS CCC-SLP is speech-language pathologist specializing in geriatric care. She blogs at Gray Matter Therapy, which strives to provide information about geriatric care including functional treatment ideas, recent research, and ethical care. Find her on Facebook, Twitter, or hiking with her dog in Boulder, CO.

Children’s Auditory Working Memory in Noisy Conditions
Kira Wright, MS, CCC-SLP is a speech-language pathologist and resource specialist for The Hello Foundation, a client-focused company that specializes in providing high-quality services in the public schools and via online therapy. In addition to her patchwork of professional projects, Kira enjoys the stretch of a new language, a new recipe, a new parenting dilemma, or a new DIY adventure! You can follow some of her ramblings at http://www.kirawright.com/ and at http://www.thehellofoundationschools.com/.

What’s in a label?
Mary Huston, MS, CCC-SLP is a school based SLP. Mary has authored iPad apps, presented on using iPads in therapy, and is a member of the Smarty Ears Advisory Board. Mary collaborates with SLPs internationally via Twitter, Facebook, and her blog.

Reading Picture Books using the Common Core Curriculum
Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her blog to create a resource for parents to help make mealtime an enriched learning experience . Find her on Facebook, Twitter, and Pinterest.

Pass the Sentence Level, Please! Reading Comp in Parkinson’s Disease
Jen Biener, MS is a recent graduate of New York Medical College. While in college, she studied psycholinguistics, German studies, and medical ethics before speech-Language Pathology hit her like a brick of destiny. She hopes to work with adults and their families in the future.

Which Came First – the Dysphagia or the PEG?
Kelley Babcock, MS CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee. She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country. For more information on FEES and dysphagia, follow Kelley on Twitter.

Combining errorless learning and vanishing cues

Errorless learning and vanishing cues

This blog post is a part of Research Tuesday, which encourages bloggers to write about recent research once a month. The goal is to read more research as well as share research with our readers to improve the EBP in the therapy community.

As many of you may know, I am quite the fan of errorless learning and vanishing cues. In my experience, I have found combining errorless learning and vanishing cues can lead to better patient outcomes. So when I came across the following article investigating the success of combining the two versus isolated methods, I wanted to take the opportunity to see what the research says compared to my experience.

Reference:
Haslam, C., Moss, Z., & Hodder, K. (2010). Are two methods better than one? Evaluating the effectiveness of combining errorless learning with vanishing cues. Journal of Clinical and Experimental Neuropsychology. 32(9), 973-985.

Two experiments

Experiment 1
Participants included were 60 healthy adults with the average age of 22 years. They were recruited from the university setting. Participants were asked to complete a dual task, requiring divided attention and utilization of implicit memory.

The primary task was learning a set of 16 greeble-surname associations. The secondary task was monitoring taps on the back of their hands. They were to press a foot pedal when they felt 3 consecutive taps on the same hand.

Three learning conditions were provided. First, errorless learning only. Second, vanishing cues only. And third, a combination of errorless learning and vanishing cues. Under the combined approach only the first trial was errorless, due to the nature of how they facilitated a vanishing cues method. (Their approach to vanishing cues combined with errorless learning is different than mine. See my explanation below.) Baseline measures were obtained for all participants using a trial and error learning method.

Experiment 1 results
Results for the standard task and dual task were very similar. Errorless learning was better than vanishing cues. Errorless learning was no different than errorless learning plus vanishing cues (using the Bonferroni correction for multiple comparisons). The authors concluded healthy adults do not benefit from a combined approach.

Experiment 2
Participants included 22 adults with Alzheimer’s disease and an average age of 73.5 years, who were recruited via a memory clinic. Their average MMSE score was 24 (SD=4), which is consistent with mild to moderate cognitive impairment. All participants were living at home. Sixteen of the participants were taking medication for cognitive complaints (e.g. donepezil and galantamine). A full assessment to determine cognitive profile was completed for each participant. Participants were asked to learn face-first name associations.

Four learning conditions were provided to each participant: trail and error, errorless learning only, vanishing cues only, and errorless learning combined with vanishing cues. Procedures were modeled after experiment 1 procedures; however, no dual tasks were provided.

Experiment 2 results
The authors found that errorless learning and vanishing cues in isolation provided greater results than trial and error. Combining the two methods was better than just vanishing cues; however, a combined approach was not better than errorless learning alone.

What does this mean for practice?

For me, not much. Errorless learning is still an excellent method for helping people with memory impairment. I was surprised by the authors’ approach to a combined errorless learning and vanishing cues method. The article explained their approach (in experiment 1) as, “Participants were presented with the complete greeble–surname association on the first trial, and letters were gradually removed on subsequent trials. In practice, on 70% of trials this entailed the removal of one letter at Trial 2, two letters at Trial 3, and three letters at Trial 4. However, if the correct name was not produced after 10 s on any trial, the next letters of the name were presented until the correct name was produced, and letters were removed on subsequent trials, as for the vanishing cues group.”

This is different from how I approach a combined method. I have no research-based evidence (only personal experience) to support my approach, but as I initially read research about combining the two, this is the way I interpreted the information to combine errorless learning and vanishing cues.

I think about errorless learning as targeting accuracy and fading cues as a way to improve independence. I provide as many cues a patient needs in order to consistently provide the targeted response. I usually do 4-5 trials before working on fading my cues. If the person is successful with the faded cues (and I fade very gradually considering tactile, visual, and verbal cues), then I do another 3-4 at that same level before fading again. At any point if they are unsuccessful with that level of cues, then I go backup to the prior level (where they were successful) and do another 4-5 trials before attempting to fade again.

Rather than only the first trial being errorless in the case of these experiments, I should have 3-4 trials that are correct responses. Then as I fade the cues, an opportunity for error does present, but I am quick to return to that errorless level of cues. Again, I do not have any research-based evidence to support this specific approach. This is what my brain came up with as I learned about errorless learning and vanishing cues and considered combining them.

Sometimes I add in spaced retrieval therapy. Rather than decreasing cues, I’ll increase time between trials. I don’t know that there is any specific cookbook type of approach that will work for all clinician-patient pairs, but this approach has been successful for me. Try combining several approaches together and see what it does for your patients’ success.

Want to learn more about errorless learning and vanishing cues?

What is errorless learning? on Gray Matter Therapy
Errorless learning for memory impairment on ADVANCE Outlook: OT
Vanishing cues for memory impairment on Gray Matter Therapy
Tips for using spaced retrieval therapy on ADVANCE Speech and Hearing Perspectives

New graduate’s perspective on finding a job in a SNF

new graduate perspective

Today I am pleased to feature a guest post from Megan Nosol, MS SLP-CF, who shares her perspective as a new graduate in the skilled nursing setting and what she did to find an ethical job.

Unrealistic productivity standards. Lack of supervision. Empty promises. Ethical dilemmas. No time to complete patient documentation. These are just a few of the stereotypes that I once associated with skilled nursing facilities. I had heard horror stories from new graduates who resigned a month into their CFYs. I had spoken with burnt-out SLPs who were jaded by the heartless politics within SNFs. I had read about the daily struggles of SLPs working in SNFs throughout the country in the ASHA Leader and on online forums. For these reasons, I purposefully requested a semester placement in a SNF for my first medical practicum. I wanted to see first-hand why clinicians were sometimes leery about working in SNFs.

My CF experience in a SNF

In the days leading up to beginning my SNF practicum, I prepared myself for the worst. I envisioned managers with whips in hand, pressuring SLPs to screen and treat all patients regardless of their diagnoses. Well, not exactly, but I worried that all of the rumors were true and that my first medical practicum experience would be a rough taste of reality. I lucked out.

My mentor, who had won “Mentor of the Year” awards twice from my university, was knowledgeable, encouraging, and treated patients as if they were her own family. The rehabilitation manager at the facility cared about her therapists, because she once was a physical therapist. Therefore, she understood why some patients are not appropriate for certain therapies and did not challenge the recommendation of therapists. This autonomy created a caring and collaborative work environment between the patients, therapists, co-workers, and managers—most of the time.

No facility is perfect, I learned. I witnessed a number of heated exchanges between therapists and nurses about the care (or lack of care) for patients. There was an ever-present tension between therapists and nursing staff regarding each side’s territory of skills. The facility had four physical therapists, two occupational therapists, and two speech-language pathologists and only two computers to record patient documentation.
Every day, my mentor had to wait her turn to type her notes on an old desktop PC, which often resulted in her extending her jam-packed 8-hour day by 2 hours. Due to her high caseload, she had no time during the day to record her notes, let alone eat lunch. At the end of my practicum, I felt confident in my bedside evaluation and swallowing therapy skills and I was grateful for the opportunity to get a glimpse one SLP’s work life in a SNF.

A desire to work in a SNF

I secretly knew I wanted to work in a SNF ever since my first medical practicum. Armed with lessons I learned during my SNF practicum and from other SLPs in that setting, I prioritized my career needs and deal-breakers. Ultimately, my goal was to find a CF placement that not only met my needs as a working mom, but also met standards of good business practice and patient centered-values. I set off to find the chupacabra of SNF clinical fellowships—one that went above and beyond the measly 4 supervision hours per month requirement, set fair productivity standards, allowed me an efficient way of systematically documenting patient activities, a collaborative work environment, and management that genuinely cared about me and their patients.

Before I was ready to hit “submit” on those job applications, I researched questions I should ask employers during the interview to ensure they met my criteria. I came across Gray Matter’s “Interviewing Tips for Finding Ethical SNFs” blog post and took Rachel’s advice to heart. My practicum experience in a SNF also gave me ideas about what to look for in terms of red flags and I developed questions based on those ideas.

Then, I reached out to my SLP network when I was ready to apply for jobs. I am the kind of person who likes recommendations for services from people I know and trust, so I asked for recommendations for reputable facilities, too. Two fellow classmates from my university SLP program, both a year ahead of me, told me about a CF opening in their facility. The key here was that I respected these classmates, Sherri and Kelly, for their integrity and passion for the profession and their patients. If they worked at this facility and loved it, then I felt obligated to check out the facility.

After several conversations, I learned that after three years of working in this facility, Sherri and Kelly were both still very happy with their facility, colleagues, and management team. Best of all, Sherri was mentored by the same mentor who would supervise the facility’s next CF. She had nothing but high praises for this mentor, whose main job was to provide mentorship. To this day, Sherri still considers her a mentor and friend. This next CF would fill Kelly’s spot since she was leaving the facility to work for the same company but in a different state—and that says a lot, too. She wanted to stay with the company.

Interviewing a rehab company and CF mentor

After doing more research of my own on the company, I completed the application online and received a call from the HR department the next day. When the HR representative asked me if I could come to the facility that Thursday, I told her there was one minor issue preventing me from doing that: I was living in Poland for another month. Thankfully, I had VOIP and a local number that allowed us to do a phone interview, but I still worried. Would they want to wait a month for me to start working? Since I could not meet them in person, would I still be in the running as a candidate? The rehabilitation manager called me a day later and was very understanding of my situation.

I asked her my list of questions and her answers met my criteria and then some. She told me that I would have an iPad to do patient documentation in between seeing patients throughout the day, which made the process seamless. My mentor would spend at least 100 hours with me during the course of my fellowship and that I could depend on her for guidance, since mentoring was the focal point of her job.

Later that night, I spent two hours talking to the mentor about our approaches to patients with dementia, aphasia, dysphagia, and head and neck cancer. We talked about typical work days, challenges of the position, personalities of the management, library of material in the therapy room, and a little bit about our personal lives. I felt an immediate connection to the mentor because she was a working mom and had such enthusiasm for her job and her patients. I accepted the job offer that day.

Advice from a CF and former teacher

What advice can I offer to other new graduates looking for a CF placement in a SNF that truly cares about their patients and their staff? Everyone’s situation is unique; I am a mother, so my deal-breakers and needs may be different than another new clinician. Yet, prioritizing your wants and needs in a facility and mentor is a must before you start the job hunt. Spend a couple weeks, if you can, asking for recommendations for facilities or mentors and thoroughly research them to determine if they meet your standards.

Prepare a list of questions that you will ask when being interviewed by the manager and your mentor. Keep in mind that the manager may not have SLP knowledge and expertise, so ask him or her questions related to the facility, the company’s values, and their expectations of SLPs. Design different questions for the mentor to decide if your approaches and personalities mesh, the quality and quantity of your supervision is sufficient, and expectations about patient-care are clear.

Although this is not my first career, I remember having romantic ideas about my first job as a teacher and how easy it was to be fooled by those who were more experienced in the workforce. I remember being disappointed with myself for not asking more difficult questions, doing more research on schools that met my needs and standards, and talking with other teachers about their experiences and advice. Perhaps if I would have not taken that teaching position that seemed too good to be true, I would still be teaching today.

Megan Nosol, MS SLP-CF is starting her clinical fellowship year in a skilled nursing facility. She graduated from the University of North Carolina at Chapel Hill. During her graduate studies, Megan published Love After a Stroke, a children’s book about aphasia and stroke. She is also co-authoring a book for SLPs working with laryngectomy patients. Her main interests are dysphagia, aphasia, and head and neck cancer. Megan has created a Speech Therapy Tool Box for patients and caregivers to provide them with a go-to resource for more information about speech-language disorders. She has two very active and adorable sons and lives in Raleigh, North Carolina.

Join us on October 2

October2
Join us on October 2, 2014 for an event organized by American Association of Rehabilitation Therapists (Janet Mahoney, PT) and Gray Matter Therapy (Rachel Wynn, SLP). Therapists across the country and of all disciplines will stand together to advocate for our patients and our professions. We will politely but firmly put patients first.

This might look different for everyone – educating colleagues and your company, providing care in a patient-centered manner versus profit-centered system, calling your company’s compliance hotline, reporting via the False Claims Act, or calling the Medicare fraud hotline – but for everyone the goal is the same. We need to act together if we are to affect bottom-up change.

Risk of civil resistance

Is there risk in acting together? Yes. But what is the risk if we don’t act?

Civil resistance works for countries. In fact, only 3.5% of people need to act in order to affect change. If it can work for countries, it can work for healthcare.

Request a FREE media kit

Media kits contain the following

  • Poster
  • Lapel buttons
  • Wrist bands
  • T-shirt
  • Supporting documentation

Contact Janet Mahoney with American Association of Rehabilitation Therapists to request media kits. Message her on Facebook or email Janet. This is a grassroots movement, without external funding. Please be conservative with your media kits request. Submit requests prior to September 15th. Digital packets will be available also.

Can you fail an MBSS?

fail mbss

This post was originally written for Eden Alternative as a guest post. The target audience was healthcare professionals, but not necessarily SLPs.

When someone has an x-ray of their leg or gets lab work to test cholesterol, we never say they failed the x-ray or lab work. We may report it was negative for this or positive for that, but the procedure is never passed or failed. Unfortunately, for some reason many people see an x-ray swallow study (MBSS) as pass or fail.

Here are some examples of comments I have heard from well-meaning healthcare professionals, family members, and administrators.

  • “Did you study?” (before the MBSS)
  • “Well, did you pass?”
  • “He failed the swallow test.”

Why is talking about passing and failing a problem?

“Passing” may not be the ultimate goal. For some people having a report of no aspiration isn’t the goal. The goal might be determining what can be done to reduce aspiration risk or even aspirate more comfortably.

A pass/fail mentality makes anything but a recommendation of regular food texture and thin liquids a failure. It’s not a failure. While I usually only recommend an altered diet as a last resort, the goal isn’t a specific diet. The goal should be about improve quality of life while reducing risk of medical compromise. If an altered diet helps achieve that goal, it’s a success.

It’s not a test.

When I order an MBSS, I am not testing someone. I need more information. The swallowing process is so complicated that palpation and listening often aren’t enough. Usually a diet recommendation is an outcome of an MBSS, but it’s not the only outcome. I learn which strategies work well and which strategies aren’t necessary.

With an MBSS, I am able to obtain the information I need in order to revise the plan of care. I also gather information that will help me discuss status, recommendations, and prognosis regarding swallow function, so elders and their families can make decisions that are right for them.

What should you say?

Maybe nothing. We wouldn’t talk about someone’s blood pressure in the dining room. Why are we talking about the MBSS? Sometimes a simple, “How is your day going?” is the best question. If they want to discuss the MBSS, then they will mention it. Then respond with, “How did that go?”

Don’t be surprise if they respond, “It went great!” and you read a report indicated they aspirated multiple times. That just means we got all the information we needed to determine the next steps.

Power of Observation for Students

SLP observation hours
Undergraduate and leveling students everywhere are trying to obtain their observation hours. ASHA requires 25 observation hours (Standard V-C). (AOTA and APTA also require observation hours.) While I was completing my leveling work, I was encouraged to complete observation hours in the clinic on campus. Observing in the clinic will help prepare you for treating clients in the graduate school clinic, but I have found those cases to be very different from anything I did during my internships or employment.

I recommend SLP students complete many of their observation hours outside of the graduate school clinic. This recommendation may not be popular, because it does complicate the documenting process. (The clinic supervisor had to approve each off-site observation in my case.) So if you wanted to simplify things you could always do more than 25 hours (which is a good idea anyway) and spent the bulk of your documented hours in the graduate school clinic.

Who should you observe?

First of all, variety is important. I have heard of some students doing all of their observation hours with one therapist or in one setting. I believe these students would benefit more if they varied the clinicians and the settings where they completed their observation hours. I recommend students observe across the scope of practice.

How to find observation sites

As a student it can be difficult to understand the scope of practice (which is why I want you to observe it), so how do you identify the scope?

  1. Go the website of a graduate program you are interested in. Let’s look at Texas State University – San Marcos, where I completed my graduate program.
  2. Find the list of courses required for the graduate program. Example here.
  3. Usually the courses are divided into parts of the clinician’s scope of practice. So from the courses in the example provided, we may determine that the scope consists of:
    • Stuttering/fluency in adults and children
    • Child language development(pre-elementary AND post-elementary)
    • Articulation disorders in children
    • Motor speech disorders in adults
    • Voice therapy in children and adults
    • Cognitive rehabilitation
    • Aphasia

    Each university will have slightly different course offerings, but this should give you an idea.

  4. Now use your undergraduate background or a little web research to determine what types of disorders, settings, and populations fall into each category. For example, motor speech disorders in adults may include ALS, Parkinson’s Disease, Huntington’s Disease, CVA, etc. People receive treatment on an inpatient, outpatient, skilled nursing facility, and home health basis for these disorders.
  5. Use the information you gleaned to complete web searches to find SLPs in your area to observe. For example, you may search for “Boulder”+”stroke”+”Speech Therapy” and find Boulder Community Hospital has nationally certified stroke care.
  6. Then email or call and ask to observe. I would recommend calling over emailing as people in our field do not spend time at a computer. (I check my work email 1-2x a week.)
  7. Say something like this. Hi, my name is ______. I am a student at ________. My goal is to understand the scope of practice better, so I would like to visit your office/clinic/hospital to observe the care you provide to ___________ (diagnosis, population, etc.).

Say thank you

At the end of your observation time, verbally say thank you to the therapist you observed. You might even want to add an “I had no idea…” or “It was neat to see…” statement. Therapists who love their profession want to know that you were actually learning rather than racking up hours. Also ask, do you mind if I contact you later if I have additional questions (and get their preferred contact information).

Then (within a few days) contact them via email/card to say thank you again.

Why is observing across the scope of practice important for students?

I found my observations across the scope of practice immensely helpful. When I was sitting in class learning about a specific disorder, I was able to visualize it due to my observation experiences. As someone who is highly visual and learned by experience, this was invaluable to me.

And you never know what you’ll discover. I thought I would focus my career on autism or AAC. I observed an autism clinic (where ABA, OT, and SLP were used together) and it was a really great experience. I observed an SLP that specialized in AAC and child language and that was fascinating. But when I observed adult cognitive rehabilitation at a day program at the local rehab hospital, I knew I had found my calling.

Please share your tips for finding observation sites and your experiences with observation sites below. We can learn together.

Research Tuesday Roundup – August 2014

Research Tuesday

Supporting Children with Severe and Profound Multiple Disabilities
Carole Zangari is a professor of speech-language pathology with a focus on AAC for children and adults. She is past coordinator of ASHA’s AAC Special Interest Group and is co-editor of the book Practically Speaking: Language, Literacy, and Academic Development of Students with AAC Needs. She blogs at PrACCtical AAC.

Alcohol Use in Mid-Life & Cognitive Impairment in Later Life
Rachel Wynn, MS CCC-SLP is speech-language pathologist specializing in geriatric care. She blogs at Gray Matter Therapy, which strives to provide information about geriatric care including functional treatment ideas, recent research, and ethical care. Find her on Facebook, Twitter, or hiking with her dog in Boulder, CO.

What is the best method when reading to your child?
Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her blog to create a resource for parents to help make mealtime an enriched learning experience . Find her on Facebook, Twitter, and Pinterest.

Obstructive Sleep Apnea and Dysphagia
Cynthia Williams Bowen, MS, CCC-SLP owns Bowen Speech-Language Therapy, LLC in Clearwater, FL. Cyndee provides quality, creative, collaborative treatment to adults and adolescents with communication, swallowing, Parkinson’s, and related disorders.

Remove the NG to see? No way.
Jen Biener, MS is a recent graduate of New York Medical College. While in college, she studied psycholinguistics, German studies, and medical ethics before speech-Language Pathology hit her like a brick of destiny. She hopes to work with adults and their families in the future.

Is Thicker Better for Dysphagia Treatment?
Kelley Babcock, MS CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee. She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country. For more information on FEES and dysphagia, follow Kelley on Twitter.

Why are we talking about Robin Williams?

Facebook and Twitter were full of posts about Robin Williams. It started with a slow trickle yesterday afternoon and then a burst. So many people were posting their favorite movies and sharing information about crisis hotlines.

Why were so many people talking about Robin Williams?

I offer my piecemeal thoughts. I wish they were more eloquent.

Celebrity
Robin Williams has been part of our lives via the silver screen for 36 years beginning with Mork and Mindy. (Mork lived in a house here in Boulder.) We feel like we know celebrities. It comes as quite a shock when someone commits suicide. How could we not know what they were facing? Could we have helped?

Grief
Being faced with the reality of suicide of a well loved celebrity, we may begin to think about family members or friends that have committed suicide. We are triggered to experience the emotions (disbelief, fear, sadness, frustration) that we experienced when we first learned of a loved one’s suicide. And then we grieve and seek to understand suicide. We may begin to question again if there was something we could do to prevent their suicide.

Low
We all have low moments. Sometimes very low. When faced with the reality of suicide, we may begin to wonder how far we are from that brink. Would we know if we are getting too close? Will the people who love us see that we are nearing the edge? Will things get better? Perhaps we are even triggered of our own personal struggles with suicidal ideation or attempts (currently or in the past).

Fear
We may begin to think of about someone we know that is going through a rough time. We can’t know exactly what they are feeling, so we experience a sudden panic of fear and wonder if we would know if their situation was getting bad enough to consider suicide. We don’t understand much about suicide, which makes it pretty scary.

In short, being faced with the reality of suicide fills us full of emotions that extend beyond the sadness of losing a celebrity. It feels very real and we are left with all these emotions and struggling to make sense of it all. So even if there were arguably more important things in the news yesterday, this had a big impact. It is important. We’re processing our thoughts together.

Last week I wrote about why I went to therapy. I have met some very gifted therapists. I would recommend it to anyone, even if you are just wondering if it might be helpful and if you’ve been once before and thought it wasn’t helpful. If you aren’t ready yet, check out The Happiness Trap. I have recommended this book to several people, all of which have told me, “This book was written for me.” The book radically changed how I handle negative thoughts.

As healthcare professionals, it is important for us to be aware of mental illness, so we can help our patients get the help they need. Many of my patients have a diagnosis of mental illness. I am so honored to be invited to be a part of a session at the ASHA 2014 convention, Clients at Risk for Suicide: Our Experience and Responsibilities (#1310) Friday 8-10. I hope you will consider joining us or finding appropriate training near you. NAMI is an excellent organization that offers training and has state chapters.

While writing this post Iron & Wine’s “Waitin’ for a Superman” song came up on my playlist.

“‘Cause it’s getting heavy
Well, I thought it was already as heavy as can be

Tell everybody waiting for Superman
That they should try to hold on the best they can
He hasn’t dropped them, forgot them or anything”

How can we as healthcare professionals (but not mental health professionals) best serve our patients with (diagnosed or undiagnosed) mental illness or those at risk for suicide?

Alcohol use in mid-life & cognitive impairment

Alcohol Use Memory

Last week my blog post, I went to therapy and you should too, focused on the importance of psychotherapy for healthcare professionals in stressful workplaces.

This week, for Research Tuesday, I’m writing about alcohol use disorders. While as rehabilitation specialists, we are not mental health or addiction professionals, I believe it is important for us to be aware of mental health and addiction disorders and how they impact our scope of practice. (For more about mental health, I hope you’ll check out one of my convention sessions “Clients at Risk for Suicide: Our Experiences and Responsibilities“.)

The study

This week I read “History of Alcohol Use Disorders and Risk of Severe Cognitive Impairment: A 19-year Prospective Cohort Study“. The paper defines alcohol use disorders (AUDs) as “alcohol dependence or alcohol abuse (recurrent alcohol use associated with a range of problems but not meeting criteria of dependence).”

While previous studies have been completed looking at alcohol use during mid-life and cognitive impairment, this is the first long-term study spanning 19 years. The study was completed with data from the RAND Center for the Study of Aging, including 8663 self respondents. All data is available online.

Baseline memory function was assed using immediate and delayed recall tasks (20 nouns). Abstract reasoning was assessed with a modified similarities test (Wechsler Adult Intelligence Scale – Revised). Follow-up assessment was completed via the Telephone Interview for Cognitive Status (mTICS) with is an adapted version of the MMSE.

In order to focus on the effects of personal history of alcohol consumption (rather than current consumption) participants consuming three or more drinks per day were excluded. With this consideration, findings would reflect the association of a history of heavy alcohol consumption and memory and cognitive function rather than current heavy consumption.

The authors did an admirable job teasing out variables, including but not limited to formal education, race, smoking status, obesity, physical exercise, hypertension, cardiovascular disease, and head injury.

The major limitation of the study was study participants self reported AUDs and people tend to underreport alcohol consumption. Also, those that engage in risky behavior are less likely to participate in survey.

AUD leads to increased risk for severe cognitive impairment

The authors found people with a history of AUDs developed severe memory impairment in later life with 1.84% odds compared to those without history of AUDs at 0.85% odds. While the percentages may seem low over all, AUDs more than doubled the odds of severe memory impairment.

The odds for severe cognitive impairment in later life were nearly doubled in those with a history of AUDs (1.86%) compared to those without a history of AUDs (1.06%).

The results of this study are consistent with previous studies, even though this study had a much larger sample and had follow up over the longer period of time.

How does alcohol impact the brain?

Alcohol use is suspected to be related to dementia as a result of brain damage from toxic effects of alcohol, metabolic brain changes, imbalanced neurotransmitters, and nutritional deficiencies.

Specifically alcohol dependence is linked to:

  • Volume reduction in white and gray matter, especially in the frontal lobes limbic system, and cerebellum
  • Reduced glucose metabolism in cortical and subcortical structures
  • Neurotransmitter imbalances impacting GABA, serotonin, dopamine, and opioid receptors
  • Head injuries
  • Liver cirrhosis
  • Nutritional deficiencies – Severe thiamine deficiency may result in Wernicke encephalopathy
  • Cardiovascular system changes including cardiomyopathy, arrhythmias, hypertension, and stroke

What can you do?

This study did not examine on cognitive rehabilitation treatment. The study was focused on building connections between mid-life alcohol use disorders and severe memory impairment in later life. This study offered no help in treating current patients. However, it may offer opportunities for prevention.

If you or someone you know is struggling with an alcohol use disorder, seek help. Alcoholics Anonymous is an excellent place to start. Visit this page to learn more about AA meetings near you. The National Institute for Alcohol Abuse and Alcoholism reported in 2012 approximately 17 million adults had an alcohol use disorder resulting in 5.1% of disability worldwide. Alcohol abuse is considered the fifth leading risk for premature death and disability.