 At this crucial time in history there are a lot of events shifting our lives. This week especially we watched Baltimore tear itself down and it’s citizens come together to clean it right back up. We cheered on a mother for pulling her son from the riots and figuratively and literally slapping some sense into him repeatedly on live television. But for young woman across the country, this week caused a stir in our lives and our hearts for another reason. That being the untimely and brutal death of Dr. Derek Shepherd also known as McDreamy on Grey’s Anatomy. Young girls and women everywhere were heard crying as they were shocked to see their favorite character of the television series killed off the show. The following day I read article after article and watched several news reports almost poking fun at the disapproval of the shows creator’s choice to kill Patrick Dempsey’s character. Fans immediately went to social media to post about their anguish and inability to comprehend and accept Dr. Derek Shepherd’s television death by auto accident (audible sigh of relief from husbands and boyfriends everywhere). I had a little bit of a different reaction to the death of McDreamy.
No one really talked about the raw reality that the show illustrated about physician error and the dying process. One of which I thought was very rare for the show and should be noted. After all, McDreamy did survive a plane crash and being shot during a mass murder. What goes through a person’s mind while they lay there, helpless and in agony, unable to speak or communicate. Any of us who has ever been in the hospital, as Dr. Shepherd so eloquently played, unable to communicate his wants and needs, can attest to the show’s authenticity. I can. As a patient and a clinician. “I’m going to die because these people haven’t been properly trained”. That’s the line that stayed with me as I was just discharged yet again from another hospital stay only one day ago. Every time I go to a MD I enter with some version of that sentence in the back of my mind because I am always a threat to doctors and I know that the majority of them are not trained to deal with me. I scare them. None of them know what to do with me because I have such a rare disease all normal evaluations and treatments do not apply to me. I’m used to being ignored. So I in turn often ignore my symptoms until they get so bad that they are in fact an emergency because when you tell an MD “I have a pain” they often reply with “It’s probably muscular” or my favorite “Well you’ve been laying here for a while” instead of taking my complaints seriously and probably preventing said emergency. I’ve always had to find a physician that can think outside of the box or even better who knows and understands what my disease is. Both are a rarity. This has been my routine for the past 12(ish) years. Derek knew he needed a CT scan (he plays a Neuro-surgeon and it is… TV!). But he also had aphasia due to traumatic brain injury and lost all expressive language so he had no way to advocate for himself and had to rely only on the treating Dr’s abilities to recognize the fact that he couldn’t speak and most likely had a brain injury. He was silenced. He was ignored. If I had been completely ignored, I would have died 10 years ago, the first time I went to the ER. “I’m going to die because these people haven’t been properly trained”. August 2004 I slept through my alarm for the first time in four years and awoke to my phone ringing. I answered to my boss on the other end saying he was about to call the cops and have them come to my apartment he was nervous something happened. I immediately hung up the phone, jumped in a cab and went to work. Half of my face felt frozen and was swollen to the size of a watermelon, but it was already noon and I had to get to work. I knew something was very wrong as the day continued, but I pressed through and got through the day. The following morning I awoke and my face only got bigger. My mouth felt like I had gotten a Novocain shot and was throbbing. I felt that doom feeling we all hear about. Physically I had no idea what was happening to me. Until then I’d only dealt with the flu and chronic sinus infections. I took myself to Manhattan Eye and Ear’s Hospital at the recommendation of one of my MD’s and after waiting for what felt like an entire day, I was brought into an old room with an even older MD who barely looked at me. I sat in what looked like a dentists chair as this awful man poked around in my mouth with a tongue depressor and I cried because it hurt so much. I remember it being a Friday afternoon because I was supposed to call my friend to let her know if I was going to make it out to our Hamptons house that weekend or not. The MD gave me a prescription for some antibiotics and sent me on my way. I begged him saying, I don’t know what’s wrong, but I do know it’s Friday, and whatever it is, I need more than antibiotics. He refused. As I walked into the hallway, my mother had just gotten there and we went to the nurses station for our follow up report. I pleaded with the nurse knowing that if I had gone home with a simple antibiotic I could die. Lucky for me, she heard me. She heard me because I could speak for myself. And she was willing to listen. She called Lennox Hill Hospital ER just around the corner and told them to expect me. I was admitted to Lennox Hill by midnight and stayed through the weekend. I had an oral abscess that was clearly severe and needed to be drained and on IV antibiotics or my brain could have been infected and I could have died. This is just one example of many times I have been misdiagnosed, mistreated, maltreated, neglected by physicians. But it comes with a caveat. Maybe I was not communicating my illness/symptoms/etc. efficiently and maybe the MD’s were not listening effectively. Communication is a two way street with a speaker and a listener. For communication to be effective, both must be willing and functional. Medicine is a tricky business. MD’s, clinicians, therapists, are not miracle healers. Every once in a while they can be. I certainly am proof of that as I am a survivor of a coma. However, for treatment to be effective, and most prolific both the patient and the clinician must advocate and communicate their wants and needs with each other and the caregivers in a successful professional and helpful manner. Maybe if someone was there advocating for McDreamy, he'd still be alive???? Wishful thinking I guess! Taking a family trip with a special needs child in tow can be difficult but, with proper planning, it can be done. Kutest Kids Early Intervention, is well aware of the potential issues and would like to offer some practical advice for making the trip memorable and exciting for the whole family.
TIP #1 Scope out your vacation. Any family with a special needs child will tell you that planning well in advance of the family trip is crucial for a fun trip for everyone. This is true for all family trips and even more so when a special needs child is involved. Accessibility should be a top priority when considering a location. Having access to restroom facilities along the way and once you arrive at your destination needs to be thoroughly investigated beforehand. Any other specifications, like wheelchair accessibility should be discussed with the motel customer service rep or the person in charge of whatever other accomodation you may have booked. If they do not offer the amenities that your family requires, do not hesitate to ask them to refer another location that does. You never know; they may be motivated to incorporate these features into their own facility in the future because of your request and a lost customer. TIP #2 Pack lightly (if possible). Over packing can contribute to unnecessary stress when you are trying to help your child feel safe and entertained while at the same time being weighed down with loads of carry-on bags, garment bags and shopping bags. It is important to plan out your list of necessities and stick to it. This should include; clothing, diapers, electronic devices (and don’t forget the chargers!), snack, your child's favorite toys and, last but not least, any and all medications. You don’t want to be stuck without the basics either, so don’t leave anything out. Alternatively, you can make sure that your vacation area has all the products you may need to buy in case you run out of anything. TIP #3 Consult with your child's doctor. A large part of the stress associated with traveling with a special needs child is the medical considerations that must be taken into account. Consult with your child's physician to help you put together a list of necessities for your child. This will probably include necessary medical documentation, medicine refills, a detailed list of prescriptions that your child is taking, medical referrals to a physician in the area and numbers of medical supply stores, etc. Your travel will be that much calmer once you have all of that out of the way. TIP #4 Be ready for a meltdown. Understandably, parents of a special needs child are anxious about their child's behavior and fear a potential outburst in a public area. Don’t let this troubling thought stop you from making this family trip and creating memories for the family. The first step is to try and avoid all situations that may be stressful for your child. Special needs children tend to fall into a routine and anything outside of that routine will overwhelm them, which is a meltdown waiting to happen. If your child is used to having a snack at a given time, try to stick with it. Try to avoid unpredictability. The same goes to avoiding situations that will be stressful for YOU as a parent. Know your limits and work around them. Make sure that you pack lunch or a snack for yourself while taking care of everyone else. This will help you keep your sanity and make the trip more enjoyable for everyone else. TIP #5 Here’s a quick packing checklist before you hit the road: o ID Cards o Display notification cards o Comfortable Clothes o Sweatshirt o Pajamas o Umbrella o Blanket and pillow o Coat, hat, gloves, and boots (if applicable) o Bibs (if applicable) o Favorite Foods o Snack Foods o Books o Fidget Toys o Doodles and other drawing boards o Card Games o Paper and pencils o iPod, DVDs, CDs, etc. o Headphones o Orthopedic equipment o Feeding equipment o Oxygen (if needed) o Emergency contact information o General medical supplies o Medication o Wipes Be Brave! Just remember that you're not alone and that traveling with a special needs child can be challenging, but it can be done, with proper planning and foresight. For more information on Kutest Kids Intervention click here: http://www.earlyinterventionpa.com/ One of the many questions I often get asked is if I can provide templates of in patient or out patient Evals, SOAPS and/or progress notes for work in SNF's, Long Term Care Facilities, Rehabs and/or acute/sub acute care. I've been down in Florida visiting family now for a while. As a New Yorker, I've been through and seen a lot, but let's just say I think a lot of things need major fixing down here in Florida. 
Very saddened to hear of the passing of Dr. Jeri Logemann this week. She lead the field in speech language pathology. Her work was ground breaking in the area of Dysphagia and she lead the way for us to practice & study swallowing today. Her book is my bible & her literature clinically significant. She will be missed.  Jaw Opening Exercise This exercise has been studied for years and has finally been published. The authors described the Jaw opening exercise in the paper as active "jaw lowering. The jaw-opening exercise was carried out as follows. First, subjects opened their jaws to the maximum extent and maintained this position for 10 seconds. During the exercise, each patient was made aware that the suprahyoid muscles were strongly contracted. Your patient should feel the stretch right above the level of the vocal folds. This open-and-hold exercise was repeated 4 more times after 10 seconds of rest, which constituted 1 set. Subjects were instructed to perform 2 sets of the exercise daily." (Wada et al., 2012) Wada et al, 2012 states that the most widely used exercise for UES is thought to put strain on the sternocleidomastoid muscles rather than the targeted hyoid muscle group. The jaw Opening Exercise is able to implement a less straining exercise targeting intended muscle groups i.e., mylohyoid, digastric muscles, and the geniohyoid muscle. When these muscles are innervated, they act together to move the hyoid in an upward and forward fashion. In turn, opening the UES. Not very fancy but these exercises focus the effort solely on mandibular elevators without the need to lie down or do any other acrobatics. If you are interested in exercise as a means to strengthen muscles, some of the other citations below explain the rationale behind strengthening exercise which is very different from "oral motor exercise". You can download a patient handout for this exercise by CLICKING HERE or buy it along with other dysphagia patient handouts in our SPEECH STORE! References Hara, K., Tohara, H., Wada, S., Iida, T., Ueda, K., & Ansai, T. (2014). Jaw-opening force test to screen for Dysphagia: preliminary results. Arch Phys Med Rehabil, 95(5), 867-874. doi: 10.1016/j.apmr.2013.09.005 Robbins, J. A., Gangnon, R. E., Theis, S. M., Kays, S. A., Hewitt, A. L., & Hind, J. A. (2005)The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53(9), 1483-1489. Robbins, J. A., Kays, S. A., Gangnon, R. E., Hind, J. A., Hewitt, A. L., Gentry, L. R., & Taylor, A. J. (2007). The effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 88(2), 150-158. YOU SHOULD BE ABLE TO GET IT HERE: http://www.archives-pmr.org/article/S0003-9993(06)01457-2/pdf Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw-opening exercise for insufficient opening of upper esophageal sphincter. Arch Phys Med Rehabil, 93(11), 1995-1999. doi: 10.1016/j.apmr.2012.04.025 YOU SHOULD BE ABLE TO GET IT HERE:http://www.archives-pmr.org/article/S0003-9993(12)00322-X/pdf Yoshida, M., Groher, M. E., Crary, M. A., Mann, G. C., & Akagawa, Y. (2007). Comparison of surface electromyographic (sEMG) activity of submental muscles between the head lift and tongue press exercises as a therapeutic exercise for pharyngeal dysphagia. Gerodontology, 24(2), 111-116. Other good stuff to read on exercise: Kent-Braun, J. A., Ng, A. V., Doyle, J. W., & Towse, T. F. (2002). Human skeletal muscle responses vary with age and gender during fatigue due to incremental isometric exercise. Journal of Applied Physiology, 93(5), 1813-1823. Portero, P., Bigard, A. X., Gamet, D., Flageat, J. R., & Guezennec, C. Y. (2001). Effects of resistance training in humans on neck muscle performance, and electromyogram power spectrum changes. European Journal of Applied Physiology, 84(6), 540-546. Thompson, D. J., Throckmorton, G. S., & Buschang, P. H. (2001). The effects of isometric exercise on maximum voluntary bite forces and jaw muscle strength and endurance. Journal of Oral Rehabilitation, 28(10), 909-917. Yeates, E. M., Molfenter, S. M., & Steele, C. M. (2008). Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports. Clinical Interventions In Aging, 3(4), 735-747. Hello fellow SLPs,
Below is the 2014 ASHA CEUs brochure for Dysphagia Seminars offered in Morristown, NJ. These evidence-based seminars on Pediatric/NICU Swallowing and Pediatric Video Swallow Studies have been well-received coast to coast.
Conference Location: Morristown Medical Center Conference will be Auditorium A-B in Jefferson Building Level B Start/End Times: Registration: 745-820 am Seminars: 830-430pm
I am trying to get the word out to SLPs, as this is much needed and sought after information for the infants and children you may serve or hope to serve in the future.
Thank you for sharing this information with your colleagues!
I hope you can join us!
Sincerely,
Catherine Catherine S. Shaker, MS/CCC-SLP, BRS-S Pediatric Speech-Language Pathologist ASHA Board Recognized Specialist – Swallowing and Swallowing Disorders ASHA CE Provider www.Shaker4SwallowingandFeeding.com
WE ARE SO PROUD TO HAVE OUR NEWEST COURSE GOING "LIVE" RIGHT NOW. Speech Language Pathology CEU Course Information: "The iPad: Technology Tool for Communication and Language" Course Presenter: PLEASE VISIT: CEUALLIEDHEALTH.COM FOR DETAILS OR CONTACT CEUCUSTOMERCARE@GMAIL.COM How is it that we come to understand a child’s challenging behaviors? In addressing a typical child’s challenging behaviors we do not jump to implement an ABA program, although one could ask; “Why not?” With typical children and typical “challenging behaviors” the clinical approach utilizes a psycho-dynamic understanding. We examine the history of the child’s emotional world and come to understand his behavior in the context of that world. That is in the context of; who the parentsare and how they address or fail to address the child’s needs is examined. How the child with the challenging behaviors views his parents is examined, understood and addressed in therapy. A great many interventions also include behavioral interventionssuch as changing parent to child interactions and/or the environment. I have spoken with hundreds of administrators and clinicians over the years and when we talk about a child’s challenging behaviors we refer to the interactions between themselves and the child along with their feelings and what we think the child isfeeling. The dialogue invariably includes the impact pro and con of the parents and how they contribute to the child’s behavior, albeit unaware and unintentionally. We understand the parents’ contributions of a child’s behavior in large part based on our understanding of the emotional world of the child. Thisemotional world includes all significant adults and siblings. Yet, this emotional world is not addressed frequently enough in the world of child who has special needs and who is receivingservices via, early intervention, CPSE and CSE. When working with children we address the developmental delays most often with interventions consistent with Applied Behavior Analysis. When a special needs child is demonstrating Challenging Behaviors we have many issues to sort out. We have to considerhow much of the behavior can be assign to; •the biological disability, i.e., Autism, PDD, SID, ADD, ADHD developmental delays and so on? •other potential underlying developmental issues? •the child's feelings. What feeling is the child trying to communicate? •the child’s thoughts? •the dynamics between all significant others? •the physical and social environment? •the child identifying with either parent and being like the parent? Based on our understanding of the primary contributors of any given challenging behavior we begin to intervene in a systemic manner addressing the causes of the challenging behaviors. Inthe world of typical children the approach is psychodynamicverses the world of children with special needs, the approach is behavioral. Dare I ask; “Is the educational system discriminating? Where is the therapy, psychodynamic intervention for the child with special needs? If you have a child in your practice who is demonstrating challenging behaviors and need help understanding the behavior and how to intervene please consider the emotional communication of the behaviors. Parents too have to be willing to examine what the challenging behaviors are about beyond the manifest diagnosis their child has been given. As always I am available for consultation. Adam J. Holstein, P.D., L.P. Psychoanalyst/Behavior Therapist Cell: 516.297.5705
SWALLOW ASSESSMENT IN THE LONG TERM ACUTE CARE HOSPITAL: MORE THAN JUST AN EVALUATION FOR ASPIRATION
Within the long term acute care hospital (LTACH) setting, the SLP has a role as specialist for helping determine aspiration risk in dysphagia patients. There is a large portion of SLP training and clinical practice which addresses assessment and treatment of aspiration risk. Clinical experience has shown that assessment of dysphagia spans beyond the evaluation of aspiration risk. Within the LTACH setting, proper assessment of malnutrition risk and dehydration risk are of paramount importance in the medically fragile LTACH patient. It is critical to provide an examination that addresses more than whether a patient is aspirating or not.
Within the LTACH, there is a greater length of average patient stay than typical acute care and the patients still require medically intensive care. Many of these patients are tracheostomy and ventilator dependent and have wounds and pressure ulcers. It is a complex patient population to manage. The staff relies on the recommendations from the SLP to help guide patient treatment regarding oral intake and non-oral intake. These medically fragile patients require a team approach concept to ensure resolution of their deficits. The feeding recommendations from the SLP can impact the patient’s nutrition and hydration status, as well as their aspiration risk.
According to the ASHA speech language pathology medical review guidelines from swallowing, treatment is provided to help prevent nutrition and hydration problems. This involves, according to these guidelines, patient assessment of the ability to eat safely and to sustain nutrition and hydration. The SLP should consider that thepresence of malnutrition can be an aspiration risk predictor.Research has been conducted to determine the characteristics of patients that are at risk to aspirate. One trait that has been correlated frequently with aspiration risk is neurological disease. In addition to neurological disease, the presence of malnutrition has now been found to be a trait in patients that are at risk to aspirate. Bouchard et al (2009) reported that among patients with aspiration pneumonia assessed, 80% of these patients with aspiration pneumonia were also malnourished as determined by a dietitian. The presence of malnutrition may be a risk predictor for developing pneumonia in elderly patients.
In the LTACH, patients in a weakened and malnourished state can become prone to having reduced resistance for battling infection rendering then immunosuppressed. The patients typically present with a common appearance in these scenarios. The patient’s develop oral bacteria and generally maintain an open mouth posture at rest with a visible reduced frequency of spontaneous saliva swallows. As these malnourished patients become weaker, there is often an impact to awareness and wakefulness. Then these patients develop retained airway secretions, as the ability to mobilize secretions becomes more impaired with further decline in cough ability and airway clearance. There may be audible rhonchi in these situations. Extra focus in the LTACH must be given to maintaining good oral hygiene and the monitoring of patient’s temperature, lung, dietary, and weight status.
ASHA addresses the SLP’s role in the nutritional management of the dysphagia patient. The Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders: Technical Report indicates several SLP responsibilities in reference to not only aspiration risk, but also regarding nutritional issues. The ASHA report requires the SLP to consider the patient’s endurance and meal length as conditions that should be involved in the SLP decision-making process for feeding recommendations. ASHA’s report also describes SLP’s role in recommending non-oral intake support in relation to the patient maintaining optimal nutrition and hydration. ASHA indicates in this report that the SLP is part of the decision making team for nutrition should help determine whether non-oral intake support is temporary or more long term. There are several measures taken in the LTACH to monitor and maintain nutrition levels in dysphagia patients.
One of the methods used by the LTACH staff to track oral intake patterns is through the use of a calorie count. This is a method to document the portion of meals consumed for the patients at risk for malnutrition, with dysphagia. Calorie counts are monitored by physicians, nursing, SLP, and the dietitian. Calorie count sheets are generally filled in at the time of the meal by the nurse, nursing assistant, therapist, or family members assisting in the patient’s meal. The calorie count is not the only determining factor used for measuring oral intake levels. These calorie counts tend to be more subjective and are not always entirely accurate measures. Based on clinical experience, these calorie counts can be applied as one tool in a battery of exams when assessing the malnourished patient. It is important to have SLP involvement in the calorie count, as there may be need for dietary consistency modification and training for safe feeding measures and aspiration precautions. Another measure used in the LTACH setting are appetite stimulants.
The most frequent appetite stimulant used in this clinician’s facilities is Megace. This can help avert or rectify weight loss in the malnourished patient. Oxandrin is another separate medication used during the management of the malnourished patient. This medication can be used to help with weight gain in malnourished patients with pressure ulcers who have endured weight loss. Clinical experience has shown that the physicians mayprovide these types of medications to malnourished patientsduring times of reduced oral intake. These orally routed medicinal interventions are typically attempted by the physicians prior to non-oral intake measures being implemented. This includes oral nutritional supplementation.
Beneprotein is a protein powder and can be used with oral feeding patients who are malnourished in the LTACH. This powder can generally be combined with foods and liquids. This contains 6 grams of protein, has 25 calories and is 99% Whey protein. Magic cup is a frequently used nutritional supplement in the LTACH with malnourished patients that have dysphagia. This is an ice cream cup 4 oz with 290 calories and 9 grams of protein. This is a high calorie supplement that can be instrumental improving the nutritional parameters of malnourished patients. This ice cream can be consumed when frozen and does not melt to thin liquid. Instead, it becomes pudding and can be used with most dysphagia patients. BOOST pudding is a frequently used nutritional supplement in the LTACH setting. The pudding consistency is often used for dysphagia patients that cannot tolerate thin liquids. This 5 oz supplement has 240 calories and 7 grams of protein.
Data suggests that the route of nutrient administration influences the body’s response to injury (Pompeo, 2009). Patients with pressure ulcers and other complex problems are particularly prone to nutritional deficits (Salva et al., 2009). Study data indicate that the challenge to achieve an optimal nutritional status in these patients is significant (Pompeo, 2009). In the presence of a functioning gastrointestinal tract, patients who are unable to meet their nutritional needs orally may require enteral tube feeding. Access to the gastrointestinal system is via naso-gastric, naso-intestinal, percutaneous endoscopic gastrostomy or jejunostomy. Percutaneous Endoscopic Gastrostomy (PEG) is the preferred method when long-term feeding is needed (Fergunson et al 2000).
Naso-gastric tube is passed through the nose, through the pharynx, through the esophagus and into the stomach.These are not meant to be used for long term needs.Percutaneous endoscopic gastrostomy (PEG) is a surgically placed feeding tube in the stomach which can be used forlong term needs if necessary. Percutaneous endoscopic jejunostomy is similar to PEG placement except the tube is placed directly into the middle portion of the small intestine (jejunum). The nasojejunal tube is passed the same route as the naso-gastric but enters the jejunum. The nasoduodenal tube is also passed the same route as ng tube but enters the duodenum, the first part of the small intestine. These all use enteral feeding for nutrition via the gastro-intestinal tract.
TPN is total parenteral nutrition. This is used in the patients who are not having oral intake and cannot have tube feeding for other medical reasons. This is done through a central venus catheter which delivers liquid nutritional support through a central vein. TPN can be used for long term use if needed. It is combination of proteins, vitamins, and other nutritional requirements. PPN is partial parenteral nutrition. This is used for more short term needs, with some patients who can take some oral nutrition but not enough for sufficient intake.
Dehydration is common in malnourished patients with pressure ulcers (Fergunson et al 2000). Dehydration reduces the amount of oxygen, nutrients and cell-building substances to the wound because of its effect on blood volume and circulation, (Campbell et al. 1997). The age-related decrease in total-body water (relative and absolute) makes elderly persons markedly susceptible to stresses in water balance (Kugler et al. 2000). Fluid is an essential nutrient for the normal functioning of cells and is especially important for older adults because of their increased risk for dehydration. A number of factors increase the risk of dehydration in the elderly. These include inadequate intake, poor appetite, compounded by chronic illnesses such as diabetes (Mayo Clinic, 2009). It is critical for the SLP to be aware of the consequences of inadequate fluid intake to assist in the prevention of pressure ulcers. DYSPHAGIA ASSESSMENT IN LONG TERM ACUTE CARE: MORE THAN JUST EVALUATING FOR ASPIRATION RISK
Many elderly patients have aspiration risk and require thickener in the liquid as an anti-aspiration measure. Many of these same patients are also unable to take the liquids independently and are completely reliant on others forfeeding assistance. Clinical experience has shown that these patients may refuse thick liquids because of taste, which can impact hydration. Some patients may also take longer to consume liquids with a need for slower feeding to avoid aspiration. This too can impact total liquid consumed.Patients who are receiving thickened liquids should begiven routine re-assessment to determine if they still require the liquid thickener. Patients may require intravenous fluids at times, should oral hydration intake by insufficient. There are times when patients will take thin liquid despite the known aspiration risk they may have. In this instance, the SLP and physician consults with the patient and the family if indicated, to explain the aspiration risk. This allows patients and their families to make informed decisions about patient care.
The SLP has a unique role in the LTACH. The SLP, along with the physicians, nurses, and nutritionists work closely together to monitor nutrition and hydration status of patients. The patients have an average length of stay of 25-30 days in the LTACH, based on national averages, which is typically longer than the acute care stay. As a member of the nutritional team for these patients, the SLP must have a fine balance between restoring and managing patient dysphagia function. Therapeutic exercise and skilled mealtime interventions are typically both required. The most frequent obstacle encountered in terms of maintaining patient nutrition and hydration is generally reduced patient endurance and subsequent fatigue with meals. This situation may require smaller, more frequent meals during the day.
SLP may need to assess the effect of nutritional supplementation consistencies on dietary intake in critically ill elderly patients. This may be happening while the patient is simultaneously being monitored for their ability to sustain a compensatory posture in order to consume sufficient quantities of the nutritional supplement. Another large part of the LTACH treatment is family education, as many of the families stay at the facility and maintain a role as primary caregiver during meals. Their role in understanding patient’s nutritional and hydration needs as well as compensatory swallowing strategies is critical.Equally important to the family education is the education of the nursing staff. SLP will rely on the nursing observations in terms of dietary consistency tolerance, nutritional pattern changes in patients, and changes in aspiration risk behaviors. Ongoing communication with the nursing staff is critical to track patient’s oral intake needs.
Given that the speech language pathologist in medical dysphagia care has frequent recommendations that can impact nutrition and hydration, it is critical that the SLP becomes aware of the potential impact of their recommendations, beyond assessing aspiration risk.
http://www.asha.org/policy/TR2001-00150/
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.
(Speech-language pathology medical review guidelines published by the American Speech Language Hearing Association, September 15, 2008).
Salva, A. et al. (2009). Nutritional assessment of residents in long-term care facilities (LTCFS): Recommendations of the task force on nutrition and aging. The Journal of Nutrition, Health and Aging, 13(6), 475-483.
Pompeo, M. (2009) Misconceptions about protein requirements for wound healing: Results of a prospective study. Ostomy Wound Management, 53(8). www.o-wm.com.
Fergunson, M. et al (2000). Pressure ulcer management: The importance of nutrition. Med surge Nursing, 9(4), 163-177.
Campbell, S. M. et al. (1997). Enteral Nutrition Handbook. Columbus, OH: Ross Products Division, Abbott Laborator.
Kugler, J. et al. (2000) Impact of aging on water metabolism. The American Academy of Family Physician. Retrieved October 4, 2009 from www.aafp.org.
Mayo Clinic (2009). Dehydration. Retrieved July 14, 2009, from www.MayoClinic.com
WRITTEN BY: Dr Eric Blicker MA CCC-SLP.D BCS-S
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Amy Reinstein, M.S., CCC - SLP
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