Retail Therapy. We've all heard of it, right? It can be fun to shop, and newspaper advertisements, flyers, and catalogs can make great therapy materials. All you need to do is find a newspaper, advertisement insert, or catalog and read through it. Have the patient:
Search for and write down or name items in a category, like foods, clothing, cleaning products, gifts.
Make a grocery list for a holiday meal and search for coupons.
Find holiday decorations.
Find the best deal on items from a list of wants or needs.
Pick out gifts for a variety of people: family, friends, children, co-workers, etc.
Start with a budget and plan several days of meals, holiday shopping, etc.
Divide items into categories such as wants or needs, healthy and less healthy foods' expensive and inexpensive, holiday and year-round items, etc.
Organize catalog items toys, electronics, music and other items that they are familiar with and those that are new or unfamiliar.
Discuss new or unfamiliar products that the patient may want to try.
Make a holiday gift list and explain why they would purchase items for specific people.
Give opinions about why they would or would not purchase certain items.
Fill out an order form, or role play ordering an item by phone or computer.
Act out customer service scenarios, including complaints, making returns, etc.
Name pictures of items.
Find pictures of items based on descriptions.
Describe items using at least three different adjectives or attributes.
Plan a dinner and find coupons and sale items.
Estimate the cost of specific items and use the advertisements to verify if estimates are high or low.
Make a wish list of items they might want to receive as gifts.
Discuss who advertisements are targeting. Are advertisements effective? How have ads changed over the years?
Discuss how shopping has changed. Are stores too big? Is online shopping easier? How can someone shop if they cannot drive?
I'm sure that you can think of more!
All cognitive-linguistic assessments that I use have questions about orientation, and a quick chart review or screening will usually provide some insight into whether or not a patient is oriented. Often patients have had several changes happen before they are admitted to a nursing facility or before they are referred to therapy for cognitive-linguistic deficits. This might include a fall or illness, followed by a hospitalization, an admission to an acute rehabilitation, followed by a return home or to an assisted living facility with home health care, or possibly placement in long-term care.
Many patients are simply disoriented due to a combination of medical events and diseases, effects of medications or anesthesia, changes in location and routine, and fatigue. Others may have always had deficits in orientation, which can vary throughout the day depending on their particular diagnosis and behaviors such as sundowning. Addressing orientation is important, but identifying patients who will benefit from orientation goals versus those who may not is also important.
Why address orientation?
- To increase safety and independence in the discharge environment.
- To increase the ability to communicate effectively.
- To decrease anxiety, fear, agitation, etc.
- To maximize the patient's feeling of control and belonging.
- To increase the patient's ability to participate in long-term planning.
Who is appropriate for reorientation?
- Patients with acute changes in cognitive skills following surgery, illness, or other medical events.
- Patients with no history of disorientation but who are recently more confused.
- Patients in the early stages of dementia who can use compensatory strategies and understand therapy goals.
- Patients who are aware of deficits in orientation and who voice a desire to improve.
- Patients who can use memory strategies and respond well to memory techniques such as spaced retrieval.
Who may not benefit from reorientation goals?
- Patients in the later stages of dementia.
- Patients who become upset, agitated, angry, sad, or emotionally labile when reoriented to place, time, situation, and family.
- Patients who do not benefit from use of strategies such as spaced retrieval and visual aids for recall of information.
- Patient who have no awareness of their deficits, or deny all deficits.
What if I cannot reorient my patient?
- Try validation techniques to decrease anxiety, anger, sadness, etc.
- If orientation questions result in negative reactions, try to address orientation indirectly by discussing upcoming holidays, reading the paper, discussing current events, looking through mail for current addresses, making a family tree, looking at family photographs, etc.
- Educate staff and family not to confront the patient with orientation tasks or argue if the patient does not reorient.
- Allow for some spontaneous improvement. The patient might feel anxious when directly questioned about orientation, but also may use his own strategies to reorient as he improves in cognitive-linguistic skills
- Reevaluate the patient periodically if appropriate. Some patients will respond better once they become accustomed to new medications or when the effects of anesthesia dissipate.
- Give patients time to grieve or work through emotions when they have experienced a change in living arrangements, physical ability, or communication skills.
Thanksgiving is only a couple of weeks away and I know that many of us try to bring a little holiday cheer into therapy tasks. Thanksgiving is one of the most loved holidays, when family and friends gather together and enjoy food and company. While it can be difficult for patients to miss out on a traditional celebration, many people will enjoy sharing holiday memories and traditions, and taking part in holiday-themed activities.
Here are some Thanksgiving therapy ideas and resources;
● Thanksgiving Trivia for language and memory activities.
● Ask patients to recall favorite foods, recipes and traditions.
● Discuss the pros and cons of commercialization of the holiday season.
● Discuss challenges for people with communication disorders at the holidays. How will the patient cope with large groups of people? What word-finding or speech intelligibility strategies will the patient use?
● Try an online Thanksgiving memory match/ concentration game.
● Name words in given holiday categories: foods, family members, traditions, holidays.
● Write in holiday dates on a blank calendar.
● Ask the patient to sequence steps for completing Thanksgiving preparation tasks, recipes, clean-up, or for how the organize Thanksgiving day from morning to night..
● Practice words, phrases, and sentences that will help a patient communicate on Thanksgiving.
● With the patient's help, write important information that their loved ones will need to know about what helps the patient communicate, swallow, etc. Find one or two family members who can come to a therapy session and learn what strategies can help the patient, and are willing to train other family members. Also teach the caregivers and family what is not helpful to the patient, including speaking for her, or finishing her sentence, or repeating a questions loudly when a patient does not respond.
● Help patients and families plan meals that are easy to chew and swallow for Thanksgiving.
● Prepare patient with dementia, brain injury, etc., for changes in schedules, what the holiday will entail, who will be at the gathering, and so on. If able, talk about stressors that might arise and ways to reduce stress, including sticking to sleep schedules and familiar routines as much as possible.
● Problem solve for holiday mishaps. What should you do if your turkey isn't cooked thoroughly or if you don't have all of the ingredients for a recipe? What if you get lost or have car trouble on the way to your families house? How about if more guests than you expected arrive?
● Practice setting the table for holiday meals. Create a seating arrangement based on who is coming.
As with all holiday-centered activities, be aware that not all patients enjoy or celebrate every holiday. Some patients may have no interest in holiday-themed tasks, so be prepared to move on when necessary.
Many of us are feeling the effects of Daylight Saving Time when we "Fall Back" one hour. As much as we might appreciate the extra hour of sleep, many people notice that it can take days to really adjust, which means waking up and realizing that our alarm won't go off for another hour, not feeling hungry when it's time for a lunchbreak, or not feeling sleepy at bedtime. We all adjust in time, but for seniors a change in schedule can be much more complicated.
In the SNF setting, or even at home when a schedule is followed by caregivers, the geriatric patient might present with a decline in meal consumption, refusal to follow a schedule, restlessness at night, or awakening early. Toileting schedules can be affected, as the patient has physically become used to toileting after so many hours, but caregivers often follow the clock and wait for the "right" time to take a patient to the bathroom.
As we assess new patients using tests such as the Brief Cognitive Rating Scale, Montreal Cognitive Assessment, or Mini-Mental State exam, we should take into consideration that a patient's estimate of time of day might be affected.
How we can help our patients adjust to Daylight Saving Time:
- Remind caregivers and staff that patients might "refuse" toileting, meals, activities, and so on because their internal clock has not adjusted to the new time.
- Advise patients to limit caffeine later in the day. encourage caregivers to help patients relax and prepare for sleep in advance.
- Watch for patients who might attempt to get out of bed at the time their body has become used to.
- Talk to patients about the time change and use reorientation strategies with those who can understand and participate.
- Remember that patients have the right to choose when they go to bed, eat, or get up in the morning, even if the clock says it's time to do something.
- Watch for effects of sleep changes on safety. Disoriented patients are at a greater risk for falls and accidents.
- Do not argue with patients who do not want to eat because they are not hungry at the regular meal time. Offer snacks until the patient adjusts, and encourage the patient to participate in meals in their usual location so that they can become accustomed to eating at the same time.
Speech therapists have conversations about food textures and liquid consistencies on a daily basis with everyone from patients to other therapists to family members and staff. I think that many of us relate to feeling like we are either repeating the same information over and over, and perhaps not really being "heard," or to feeling like everyone wants an easy answer.
Swallowing is quite complicated, right? Just like no two patients always need the exact same medication dosage or type and size of wheelchair, what patients can and should consume for both safety and nutrition/hydration should be more patient-centered, and less of a "one size fits all" approach.
Have you ever worked in a building where anyone with any type of swallowing or feeding difficulty was placed on a pureed diet with thickened liquids for "safety?" Have you worked with staff that believe that any patient who coughs, ever, needs thickened liquids? How about family members who insist that diet textures cannot be upgraded because the patient "failed" a swallow study, or because "this is what the doctor ordered?"
I remember a patient on nectar thick liquids who wanted to use a straw due to positioning and decreased ability to pick up and drink from a cup. He had once had a swallow study in which he aspirated thin liquids via both a cup and a straw, but not nectar thick liquids; however, the SLP conducting the swallow study did not test nectar thick liquids via a straw. Because the nectar thick liquids were not tested with a straw, the family was sure that straws were unsafe with any consistency, and became quite upset that the patient was trying nectar liquids with a straw, and some of staff worried as well. Eventually, the patient gave up on trying straws because it entailed constantly educating staff and family, and was just too much trouble.
We SLPs know that swallow function is a bit different with a straw, and that thin liquids via a straw can move too quickly, causing coughing and increased risk of aspiration, but at some point, it seems to have become commonly accepted that nectar thick liquids cannot be taken via straw, ever. Sometimes they cannot ... but sometimes they can. I have more than one discussion with staff and families about this.
Taking a blanket or cookie-cutter approach to swallowing therapy and diet changes has, in my opinion, led to an epidemic of "one size fits all" treatment and diet modifications. Yes, safety is a big concern, and we so want to avoid aspiration, choking and other risks. Quality of life, food intake, and hydration are also very important, and if a patient can safely drink nectar thick liquids through a straw, why not allow him that? Sometimes, I think we make decisions based on fear of what could happen or of litigation, rather than on what the patient truly wants or on what the patient can do with patient-specific feeding and swallow protocols in place. Patient-centered protocols are definitely extra work and more time-consuming for staff, and might also include adaptive equipment.
We can never remove any risk of choking or aspiration from all patients; young, healthy people have choking incidents as well as do frail people who have dysphagia. Risks are inherent with any intake, and of course we try to reduce those risks through modifications. I would love to hear from other therapists about their decision-making process in diet modifications. Does your facility have a "blanket" policy on diet modifications for aptients with dysphagia? Are staff willing to accept patient specific recommendations? Do you have a Free Water Protocol in place?
I have several patients who are planning to return home, some sooner, and others later. As I update their short-term goals for language and cognition, I start to incorporate more everyday community or home activities and also to use less of the workbook activities. While I do find that many patients enjoy the challenge of logic puzzles and word games, and I see the benefit of practicing cheque writing and budget balancing skills, most of our patients are going to return to a routine that is familiar to them, and may or may not continues with workbooks and puzzles.
This week, I have collected several mail order catalogs, which gives me use for them before they are recycled! I thought of several ways to use them in therapy, including:
Problem-Solving and Reasoning Skills:
● Using a budget to determine which items you can afford.
● Identifying which items are useful or practical, and which items are luxury items.
● Reading the descriptions carefully in order to identify hyperbole in the copy, or possible false claims.
● Generating alternatives to an expensive item, such as what common items can be used for the same purpose without buying something new.
● Finding return policies, discussing the credit offers that sometimes accompany catalogs, determining how to remove oneself from a mailing list, etc.
● Discuss how to handle complaints about a product you might order, shipping errors, lost shipments, and damaged goods.
● Practice placing online order, telephone orders, and mail orders.
● Discuss the pros and cons of buying locally at a small store, buying at a large chain store or mall, and buying from catalogs.
Language and Speech
● Practice reading descriptions carefully.
● Practice writing by making copies of order form for patients to complete.
● Error awareness: write an order form with errors and have the patient find them. (This also works for mathematical calculations).
● Have the patient categorize items into gift ideas, items they would like to own, items they feel are frivolous or not useful, etc.
● Practice speech intelligibility by asking the patient questions about the catalog or by having the patient read item descriptions to you.
● Ask questions targeting written comprehension. If the patient has difficulty reading the text, let them look at the photographs of items while you read descriptions, and then ask comprehension questions.
● Read a description aloud, and have the patient guess which item you are describing. If needed, copy pictures from the catalog for the patient to look at, or give the patient a choice between two or three items you might be describing.
As most of us know, October is National Breast Cancer Awareness Month. During this month, many people focus on spreading information about risks, screenings and treatments. We honor survivors - men and women - and remember those who died from breast cancer. Some people raise money or donate to organizations that support research to develop a cure for breast cancer.
When we remember those who have battled or are now fighting breast cancer, we often think of co-workers, family, friends. Working in geriatrics, we do not often treat patients with a current diagnosis of breast cancer, but according to PubMed.gov, "As the mean age of the global population increases, breast cancer in older individuals will be increasingly encountered in clinical practice," and another article PubMed article states that "Cancer is an age-associated disease, and 55% of newly diagnosed cases and 67% of cancer deaths are in those above 65 years. There has recently been increasing interest in geriatric oncology, and more of the elderly are being screened for early cancer detection. Elderly cancer patients present problems not only because of their primary disease, but also because of comorbidity, reduced functional reserve, and diminished social support. Because of this combination of factors many of them need the specially skilled nursing care available in special units."
Elderly breast cancer patients may be facing challenges such as end-of-life decisions, such as choosing between hospice or long-term care, making decisions about treatment options, and even age-based treatment discrimination. Surely a stressful event in any person's life, cancer in the geriatric population may co-exist with other unrelated diagnoses, such as stroke, dysphagia, and dysarthria, that might be the speech-language pathologist's primary treatment diagnosis. In other words, we might be providing cognitive-linguistic, speech-language, and/or swallowing therapy to an individual due to an accident or disease process, during or after treatment for cancer, which of course will impact the treatment of swallowing and communication disorders. In addition, there is evidence to support description of memory, concentration and other cognitive deficits that correlate with cancer treatment, which must be taken into account.
What do we do as SLPs to help elderly breast cancer patients?
● Understand the emotional and psychological toll of a breast cancer diagnosis, and use our counseling skills that we have developed as professionals. Linguisystems offers a free resource to counseling as an SLP.
● Involve the patient and family in the plan of care to determine what goals are important to that patient during and after breast cancer treatment.
● Refer to other professionals - social workers, counselors, etc., - as needed to address counseling needs that fall outside of our scope of practice.
● Educate ourselves about treatment side effects and take them into account in the plan of care.
● As always, treat patients with caring and respect, and understand that breast cancer affects a patient both emotionally and physically. Understand fatigue, physical effects, and feelings of sadness, fear, and even anger.
● While we might be targeting speech intelligibility or word-finding skills, the patient may have greater concerns that communication. Alternatively, focusing on communication and swallowing skills may just allow the patient to concentrate on something besides cancer for a while.
Football plays a large part in the lives of many people around this time of year. Collegiate and professional teams alike draw fans in person and through television broadcasts. In some of the SNFs where I work, there is a game playing in almost every room on game day, and often a resident is surrounded by family and friends during the game, or several residents will gather together in a common area to watch a game. If you live in a "big" football town, the game seems to take over, and whether you are a die-hard fan or a more casual one, the topic is sure to come up.
Many of my patients enjoy watching football games, and whether or not they attended the local university, they root for the "home team." I have learned to use timely and interesting topics such as football as therapy tools in several ways:
1. Reminisce about college days, seasons past, or watching sports as a family pastime.
2. Discuss the pros and cons of college or professional sports. At what age should children be allowed to play sports such as football? Should college athletes be paid? Is professional football dangerous? How does the patient feel about the salaries of athletes?
3. Naming: Have the patient name categories such as college teams, professional teams, best all-time quarterbacks, or best coaches; have the patient name a team from specific cities, or produce a city that a team plays for; have the patient try to name all of the positions on a football team.
4. Describing: Ask the patient to describe the rules of the game for you before a game. After the game, if you know a patient has watched it, discuss specific plays, controversial calls, etc..
5. Gather newspaper or online articles about the game. Have the patient read articles and ask her comprehension questions, memory questions, etc.. Target speech intelligibility during oral reading tasks, as well as prosody, rate, vocal intensity, and so on.
6. Problem-solving: Discuss how to plan a football party. Plan a menu, talk about who to invite, etc. If possible, you could actually plan a football party for residents in the facility.
7. Make a snack for game day. Options might include popcorn, trail mix, nachos, cookies, layered dip. In the South, boiled peanuts are a good option for patients who are restricted from roasted peanuts or chips due to dysphagia diets. If possible, actually make the snack (you could collaborate with other therapists) and use the snack in dysphagia therapy.
8. Attention and orientation: If a patient is interested in watching a game, use some time in therapy to review when the game will be televised and where the patient will watch the game. Let nursing or activities personnel know that watching the game is something that the patient wants to do so that they can help him remember to turn on the TV or go to a common area. If you are working during a game, spend some time with a patient during the game to target attention to the game and immediate or delayed recall of the action.
Have you ever had a family member talk a patient out of participating in therapy? At times, we encounter skeptical family members. They might distrust all or most medical professionals, or perhaps they have misunderstood what a doctor, nurse, or another therapist explained to them. Now, they insist that whatever information you give to them is not correct, and that whatever therapy you are providing might somehow put the patient at risk.
I'll contrast two scenarios.
Patient A is admitted to a SNF after falling at home. On admission, he is already drinking nectar thick liquids per MD orders, and had been receiving dysphagia therapy as an outpatient prior to his fall. He is compliant with all strategies and precautions. His family is usually present during therapy, and the SLP educated everyone concerning liquid consistency options, oral care, strategies, and the benefits and risks of trials of thin water. Although they were initially worried about aspiration, the family realized that the patient had indeed been having trials of thin liquids in outpatient therapy and that the current SLP, who was aware of his progress with his previous therapist, had developed a detailed plan of care and protocol for PO trials of thin liquids. After a few sessions, the patient and the family express how having trials of thin liquids has improved the patient's quality of life.
Patient B has also had a fall at home. Her diet texture and liquids were downgraded to pureed foods and nectar thick liquids due to a choking incident while in the hospital. After a thorough evaluation, the SLP determines that the patient is an excellent candidate for a diet texture upgrade, and initiates trials of mechanical soft foods and thin liquids. Patient B's husband and daughter arrive during a trial of mechanical soft foods, and become quite anxious, insisting that the patient will choke. Even though the SLP thoroughly explains the evaluation results and the treatment plan, the husband states that he does not want the patient to have the upgraded diet texture. The patient, who was in agreement with the plan of care and verbalized wanting the diet texture upgrade, now says that she will wait until her family thinks that it is safe.
Why are some families open to education while others are not? Often, it is fear that their loved one will be harmed in some way. At other times, they overgeneralize what they were told in a specific situation, and conclude that the patient will never safely eat or drink certain foods or liquids again. Other families might find the very specific feeding and swallowing strategies too bothersome, and think that pureed foods will just be "easier" or that thickened liquids will compensate for not wanting to have the patient upright and out of bed for PO intake.
If family members are not open to education and training by the SLP, the patient can, of course, make his own decisions in many cases. If the family members make medical decisions for the patient, they can refuse any diet modifications. At times, the patient is responsible for their own medical decisions, but will acquiesce to the wishes of a spouse or child.
In either scenario, patient and family education is vital. If the patient or family does not support or agree with the plan of care, the SLP should find out what the family's goals are,and what the patient wants to achieve in therapy. It may also help to ask another SLP to treat the patient and educate the patient.
The doctor and nursing staff should be made aware of the family's opinions, and can help to educate families about the benefits of therapy. The SLP can explain that the patient may not be able to continue skilled therapy if the family is not in agreement with the goals that need to be addressed, and that of course the patient does have the right to refuse therapy. Although this tends to rare, some patients remain on a dysphagia diet due to the family's insistence.
I was surprised to see "Communication Disorders Sciences" listed in NPR's Planet Money blog as one of the least lucrative college majors. I realized, on second glance, that they were reporting on salaries for a person with a bachelor's degree; this is not the entry level degree for our field. A person with a bachelor's degree most likely would not be employed as an SLP, except for positions in some public school systems. I feel like this is misleading to potential students, and does not represent the training that our profession requires.
Admittedly, there is a wide salary range across geographical locations and settings, and most SLPs I have met do not mention salary as their primary reason for choosing our field. The demands of the education and the job certainly do weed out most people who would not pursue this career except for a paycheck. What concerns me is that one misleading report might scare away potential students from a challenging, enjoyable, and rewarding career, and a career in which you can see the results of what you do on a daily basis.
The fact is, we need students to choose our field who are dedicated, intelligent, and talented, and who are willing to devote themselves to ongoing training and professional development throughout their career. We need to stand up for our profession not only by letting people know that it is a profession in which you can earn a good living, but one that can be creative, personally rewarding, challenging, and flexible. I love my work in long-term care, and the range of part-time, full-time, and PRN options in medical, school-based, and private practice settings are truly exceptional. There is also the ability to travel with some companies.
I do not want our field to be seen as unworthy of pursuing for any reason other than the work we do does not interest a particular student. We have always been included on lists of the best careers, including by U.S. News and CNN Money. Today I am going to my job, and I am looking forward to it. I will hopefully improve the quality of life for my patients by improving their communication and swallowing skills. I will surely evaluate a new patient, and create goals that reflect the wants and needs of the resident and their families and caregivers. I will document progress for many patients, and re-evaluate and adjust goals for those that are not progressing as anticipated. I will examine my own therapy techniques and use clinical decision-making skills to determine what activities and exercises will help a patient to progress. I will educate and counsel patients and families on a wide range of communication, cognitive-linguistic, and swallowing disorders. I probably will not think once about how much money I earned today, or what my next paycheck will be. I am secure in knowing that I am well compensated for my work, which is steady and rewarding.
I'm taking a break from my series on dealing with families, caregivers, and friends of patients, and dealing with the challenges that arise as a result of personalities and interpersonal relationships in healthcare settings to address a question that my dear husband posed.
This week, I am going to talk about Hodor.
Yes, that Hodor, from a Game of Thrones.
Why? Because my husband asked me to.
I'm behind on the series, due to my admittedly sporadic television viewing habits, but my husband (who is currently a nursing student) was curious about my take on Hodor's receptive/expressive language skills.
By the way, I don't think that "Hodor" is actually this character's name; it's just what he says. And I apologize to hardcore GoT fans; I haven't read all of the books and I am behind in the episodes, so maybe this is addressed.
I've read/heard that Hodor is "simpleminded." But why, and how?
Ok, he cannot communicate well verbally, but I can understand what he's thinking/ feeling in the episodes.
He follows directions and understands consequences. I would trust him. Other characters certainly do.
TBI in battle?
Severe expressive aphasia?
Severe dysfluency/ stuttering?
Or maybe a case of the need for us to target what he CAN do instead of what he cannot. Maybe it doesn't matter what "Hodor," or anyone else, is diagnosed with, as long as we recognize their strengths, welcome their contributions, and respect them as part of our human experience.
Maybe that's it. As a nursing student, and a Sci-Fi/Fantasy fan, my husband wanted to know ...
How would YOU communicate with and support a Hodor in your life?
The overhelpful family member or family friend who wants to do everything for the patient, including feeding the patient who can feed herself, or speaking for the patient who is having trouble formulating a sentence. Instead of allowing the SLP to conduct a thorough evaluation, this person needs to let you know that he already knows everything about what the patient can and cannot do, and what type (if any) therapy is working.
Commonly, this person wants the evaluating or treating SLP to jump from pureed foods to a regular diet, or magically have a severely aphasic person speaking in conversation without a hitch in a matter of days. This person cherry picks recommendations from previous therapists at hospitals and SNFs, and demands to know why therapy is not progressing more quickly,why you are not taking XYZ approach, why the patient cannot have a certain food or liquid because "I gave him a hamburger yesterday and he was just fine. I mean, he coughed, and he ate too quickly, and he had to spit half of it out, but he did just fine with what he ate."
I prefer to approach a situation like this with the understanding that the family member is acting out of love and concern,and sometimes with a need to whitewash deficits in order to look at the the bright side, so to speak. Denial of deficits is often seen in friends and family as well as in patients. Some caregivers are very verbal about their doubts concerning communication and swallowing deficits because they are not ready to accept the gravity of a situation.
Another common source for this behavior is family or interpersonal dynamics. At times, a specific family member will set themselves up as the person in charge. This person might see an opportunity to outshine siblings, control the situation, win favor, be the friend who does the most, etc. There is not much an SLP can do to change family or interpersonal history and dynamics.
A third possibility is that the loved one wants the patient to be able to return home, and therefore is trying to minimize any deficits and talk everyone around the patient into agreeing that the patient can return to her prior level of performance with minimal or no assistance. I find that this situation often arises from concern about financial issues involved with long-term therapy, home health care and assistance in the community environment. It can also stem from the patient putting pressure on family and friends to take them home as soon as possible, whether or not they have met goals and demonstrated the ability to function in their home environment.
So, what to do?
- Always, always know if the patient is their own responsible party, and if not, who is.
- Clearly define your role in the rehabilitation process. Use clear, concise explanations and give concrete examples of deficits and goals that you have identified for the patient, and explain why these goals are important.
- Let family, caregivers and patients know that you respect their role in the patient's recovery.
- Understand that sometimes therapists become a sounding board or, worse, a scapegoat for families, friends and patients during trying and emotional times. Use your counseling skills, maintain a professional attitude and try to remain positive and focused on the patient's goals.
- Communicate with your supervisor, other therapists, nursing staff and administrators about any family or interpersonal dynamics that interfere with therapy or that concern you.
- Document skilled caregiver education and the caregivers' responses daily.
Family and even friends of patients can be great allies in the treatment process. They might give valuable history about the patient if the patient is unable to communicate that information clearly. They can support therapy goals and motivate the patient to practice exercises and use compensatory strategies. They can monitor and cue the patient during meals to ensure safety, and encourage compliance with dietary recommendations.
At times, therapists meet family and friends of a patient who are hindering more than they are helping in the rehab process. There can be many reasons for this, and sometimes they involve complex interpersonal relationships that we, as SLPs, are not in control of but nevertheless must circumvent if we want to patient to progress. Some types of interference that I have witnessed include:
● The overhelpful family member/ friend who wants to do everything for the patient, including feeding the patient who can feed herself, or speaking for the patient who is having trouble formulating a sentence.
● The controlling family member who wants to show everyone - family, friends, and staff - that he knows what is best and no one else can help the patient like he can.
● The enabling family member, who brings the patient with dysphagia food and drink that are not recommended by the SLP.
● The family member who is seeking some sort of control, whether financially or emotionally, over the patient for their own benefit.
● The skeptical family member, who distrusts anything the therapists, doctors, and nurses recommend.
While most family members and friends who visit only want to help the patient in their recovery, the SLP and other therapists should pay attention to interpersonal dynamics and how they affect the patient's ability to progress in therapy. Family and friends are often visiting daily, sometimes even for hours at a time or several times in the same day. While visitors can keep a patient optimistic and motivated during a short-term stay, long visits or crowds of people can exhaust a patient mentally and physically, which in turn is detrimental to participation in therapeutic tasks.
As therapists, we should be sharing information only with family and friends who have been granted the legal right to access the patient's information. If the patient is their own responsible party (RP), the SLP should simply ask the patient if he wishes family or friends to be present. The SLP can also explain to the patient and family that some therapy tasks are better suited to one-to-one treatment sessions, while others will be more suited to including family and friends. It is also a good idea to discuss the involvement of family and friends during interviews and therapy sessions when you are alone with the patient, so that the patient can speak freely without concern about hurting anyone's feelings. Many patients are actually relieved when they have a reason to get a break from visitors!
If the patient is not their own responsible party, is confused, or cannot communicate her wants and needs, it is important to establish exactly who is responsible for medical and financial decisions on behalf of the patient, and limit communication to that person, who can then pass information along as they see fit. Never assume that a person who is introduced as the patient's family member, or even as their spouse, is actually that patient's RP or has permission to hear medical information. The specific responsible party should be documented in the medical chart and reviewed before you enter the patient's room for the first time.
Although specific regulations vary from state to state, a mandated reporter is a professional working with children, senior citizens, disabled persons, or others who belong to vulnerable populations. As speech-language pathologists, we are required to report verbal, physical, emotional, or any other type of abuse, and can be held liable by law. In fact, most healthcare facilities, hospitals, and home health agencies require employees to complete annual training regarding abuse and reporting of abuse. We are also required to report neglect.
Of course, we should all know the obvious signs of abuse: bruises, broken bones, weight loss, fearful reactions, depression, dehydration, malnutrition, and so on. Neglect can include refusal to assist patient with hygiene and grooming tasks, not complying with toileting or positioning schedules, refusal or negligence in providing the patient with a diet that complies with physician's orders, or refusal to provide the patient with clothing that is suitable for the season and situation. Neglect can also include ignoring a patient's requests to leave a situation or to intervene in the occurrence of a catastrophic reaction to a situation, and refusal to report instances of abuse. The National Adult Protective Services Association has clear information and guidelines identifying and reporting abuse.
Although we often think of only the most overt signs and symptoms when we discuss elder abuse, there are types of abuse that might go unreported, particularly if the observer is concerned about being believed or being retaliated against.
When any abuse is suspected, the professional should intervene to stop the abusive action and report it to her supervisor, who should follow up on the report. If the supervisor is unresponsive or dismissive, the abuse should be reported to the next supervisor in the chain, or to a state agency. A state agency might be the first resort if an employee fears retaliation or has experienced supervisors who disregard or cover up reports of abuse- "Are you sure that your heard/saw that?" "Did anyone else see or hear it?" "I know you do not like so-and-so, but you can't accuse them of abuse!"
Next week, let's look at specific scenarios that might go unreported.
Therapists often work with patients on managing medications before the patient is discharged home, and this functional task is well-suited for both speech therapy and occupational therapy goals. Recently, I have worked in collaboration with an OT to address how patients will manage medications at home. We used empty prescription and over-the-counter pill bottles filled with beads and buttons of various shapes and sizes, along with a choice of several types of daily, weekly, and monthly medication organizers. Our procedure went like this:
- The OT introduced the patient to various pill organizers and targeted opening/closing the organizers and pill bottles and organizing the pills. This was repeated over a few sessions to determine which pill organizer was most suited to the the patient, and if the task was appropriate to the patient's fine motor and cognitive skills.
- The OT and ST discussed which, if any, language or cognitive deficits impacted the patient's ability to use the preferred organizer. We also decided who would target which deficits, and the ST assessed the patient's understanding of the prescription directions, the patient's ability to carry over use of the pill organizer, and other skills such as attention to the task, error awareness, and problem solving during and after the task.
- The ST followed up in a later session to maximize the patient's ability to understand the use of the pill organizer, problem solve for potential errors, such as spilling some pills or confusing pills that look similar, who to ask for help if needed, and recall important steps in the process of organizing medications for a day, week, or sometimes a month at time.
- The OT and ST repeated the steps as needed and documented the patient's progress. At times, one therapist would initiate the task, and the other therapist would continue during her session with the patient, allowing the patient to participate in the medication management task without any pressure to finish in a set amount of time, and also allowing performance in the task to be assessed according to each therapist's stated goals.
Of course, the order each therapist takes in the progression of the tasks can be changed around, and OTs or STs can target the task individually as needed or as appropriate.
At the end of several sessions, it should be evident if the patient is likely to achieve independence with medication management, or will require set-up, supervision, or even more assistance from family or caregivers. One important step is to have the patient "teach" the therapist to use the pill organizer. Visual acuity and compensatory strategies, such as color-coding bottles with tape or permanent marker, should also be considered. The patient may also benefit from written, step-by-step directions for medication management, in large print if necessary. The patient should also be able to state who he would call for assistance if he thought he took too much of a medication, was running out of a presciption, or was experiencing side effects. And, last but not least, it is of course vital for the patient to be able to identify pills by name and state what the medication is prescribed for.