Guest Blog Post by Rachel Wynn, MS CCC-SLP
It has been about three years since I completed graduate school. As a student, I learned a lot in graduate school and during my leveling courses; however, I have learned far more in the three years following graduation. There isn’t space in this blog post to explain everything I’ve learned. So today, I’m going to share the three things I learned that made the biggest impact on how I deliver care in general.
1. People should come before profits. I remember the ethics lectures in graduate school. It seemed so common sense to me. I figured these ethical dilemmas would happen occasionally. I’ve got a good head on my shoulders and a strong desire to advocate for social justice. Of course, people come before profits.
Not all companies and facilities consistently act on the belief people come before profits. It’s a frequent complaint in the community of therapists working in healthcare that productivity expectations seem to be more important than patient outcomes.
I highly recommend joining some of the Facebook forums (Adult Rehab Speech Therapy and Slpeeps) and reading some of the discussions about ethics. Just search for “ethics” or “productivity” within the forum. Having this awareness going into your interviews and first positions will be very helpful.
Learn more: ASHA’s Employer Demands in Healthcare and Good Work Conditions for Therapists
2. You have to meet people with dementia where they are. Dementia is a progressive disease. Whether or not people and their families have insight into deficits or are living in denial, we have to meet them where they are. We meet them in their confusion and delusions.
Meeting people with dementia where they are sometimes involves lying, and that’s okay. I frequently talk to family members about lying versus rationalizing. Many people want to always tell the truth and rationalize with family members. When people say they want to go home, families may try to rationalize that they are home. They live here now, etc.
This is the wrong approach. A better approach is to validate the person’s concern then distract. “Let’s eat dinner before you go home.” Validation can be calming. We all want to heard. Then distraction can set in. The key is to communicate in a way that resolves the problems and concerns that people with dementia feel they are experiencing.
I had a patient that told me she had no time for my therapy tasks. She had too many things to do. She felt she needed to be productive. She was agitated by continued attempts, so I set up a calendar system with her and her personal caregiver and put speech therapy on her calendar.
The next day I arrived at my scheduled appointment and had specific tasks for us to do that weren’t standard therapy. She followed directions and completed problem solving in making holiday cards. Then we worked on walking safely with her walker when we delivered the cards. It worked wonderfully. I heard her, validated her concerns, and met her where she was.
Learn more: Eden Alternative Equals Better Care for Elders and An Amazing Village Designed Just for People With Dementia
3. People die. Death is the ultimate rite of passage. Many people fear death. People and their families need someone to tell them they have choices. SLPs have an expertise in dysphagia that can help families make choices. Death isn’t a prescribed process. Respecting patient and family wishes at end of life is the best thing we can go to help them experience a good death.
I’ve worked with people who are at end of life and their bodies and mind are beginning to shut down. Some families want to fight until the very last moment. Terminal cancer in a 90-year-old beginning to experience multi-organ failure is just a reason to fight harder. After seeing families go through this, I have clearly communicated to my family members that this is not what I want.
I had an end of life and quality of life talk with a family recently. Sometimes, I feel a bit like the Grimm Reaper, because I enjoy these conversations. (They used to make me uncomfortable.) Death is certain, but I feel like I can do my part to empower the family and patient to experience a good death.
If they don't want thickened liquids, I can provide recommendations to make them as comfortable as possible with thin liquids. My job isn't always to prevent illness and death, sometimes the only focus is improving quality of life. What an incredible honor!
Learn more: Check out ASHA’s Patient Rights and Patient Choices.
Special Thanks to Rachel Wynn for writing a great blog post with her perspective pertaining to the geriatric population!
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. Rachel’s projects include: Gray Matter Therapy Newsletter, Research Tuesday, and Patient and Family Education Handouts. Find her coaching new SLPs, on Facebook, on Twitter, or hiking with her dog in Boulder, CO.
Long Term Goal: Improve functional cognitive linguistic skills to maximize safety and community re-entry.
----Short Term Goal: The client will complete graphic attention/organization tasks with 80% accuracy and min cues.
Different Colored Tic Tacs, Pill Organizer, List of Client's Prescriptions, Empty Pill Bottles or Containers
Preparing for the Activity:
1. Look in the patient's chart for a list of their prescriptions. If you do not see a list you can make up some prescriptions for this activity, it just is more functional if you have the patient's actual list of prescriptions.
2. Write or type up a list with the prescription information, I would number the list so it is easy to read.
3. If the patient is taking three different types of medications then you will need 3 different colored tic tacs.
4. Pour the different colored tic tacs into the different empty pill bottles or containers.
Instructions for the Activity:
1. Explain the purpose and the instructions for the activity.
2. The patient will read each prescription carefully and then organize their medication for the week in the pill organizer.
3. For example if the prescription reads: Advil: Take 1 capsule twice a day x 5 days, then the patient would put two capsules in each section of the pill organizer for Monday through Friday.
4. Provide cues as needed throughout the activty.
5. Ask the patient if they are typically the one who organizes his/her medication each week.
This is a great activity that I used when I was in my internship in the Skilled Nursing Facility. My supervisor introduced me to this activity and I think it is very functional, especially if the patient is going to be re-entering the community and will be managing his/her medication independently.
1. Learner will gain familiarity with some possible strategies and techniques that an SLP may provide to patient when addressing specific areas.
2. Learner will be able to state 3 possible areas that an SLP may encompass in his/her treatment plan.
3. Learner will gain information regarding the role of an SLP when assisting with reduction of patient falls in the nursing home.
Attention and Concentration
Increasing maximal attention
*Goal: To maintain attention to structured tasks with less than 2 redirections.
*Activities: Making a grocery list, following map directions, sequencing tasks
*Possible Strategies/Techniques: Maintaining eye contact, speaking slowly, repeating information as needed, turn off the radio or television, closing the door during therapy to decrease distractions and background noise, complete only one task at a time.
Addressing short term and long term memory
*Goal: To increase recall of daily events and therapy details with minimum cues.
*Activities: Listening to a list of directions, presenting patient with pictures of different people and then have he/she recall the names of each person.
Safety Awareness and Reasoning
Due to cognitive deficits and lack of insight, patients may be at an increased risk for future falls.
*Goal: To increase safety awareness/problem solving skills to a maximal level for re-entry into the community.
*Possible Recommendations: Patient may need a room closer to the nurse's station so that they can be closely monitored, written reminders (i.e. "Do not get up unassisted!") reviewed and posted in room.
*Activities: Reviewing and reinforcing safety precautions (i.e. ringing red call button and waiting for assistance, locking wheelchair before standing), safety cards, written steps to carryout a task (e.g. transferring from bed to wheelchair).
Sometimes after a patient has a fall he/she may lack awareness of the time, place, existing situation, and identity
*Goal: To orient patient x 4
*Activities: Family can bring in pictures of family members and pets as visual reminders of familiar people and different areas in their life, using the calendar to orient to time, checking daily to see if patient is oriented to person, place, situation and time (re-orient as needed).
*Strategies/Techniques: List of medications, visitor log, memory book or day planner which includes: calendar, daily schedule, names and roles of therapists, doctors and nurses
Many of these strategies are great to help improve patient's short term and long term memory as well as orientation skills.
*One of the patient's that I worked with when I was doing my internship in the nursing home told me once, "Part of growing old is letting go of the things you love." I have never forgotten that quote till this day, which brings us to the next important area, counseling.
*Most adults that are seen on a daily basis for therapy have suffered traumatic events that have caused many changes in more than one area of their life. So as a speech language pathologist it is important to keep that in mind when working with this population. Some are having to adjust to a change in schedule, asking for help and waiting for help with a skill that they have been use to doing independently, and many other changes that they experience.
*ASHA's "Scope of Practice" states that we as SLPs can/should provide counseling for those individuals we see for therapy with communication/swallowing disorders.
*It is important to help the patient realize that "they are still the same person, but just with different pieces."
American Speech-Language-Hearing Association. (2007). Scope of Practice in Speech-Language Pathology [Scope of
Practice]. Available from www.asha.org/policy.
*The information above was from a PowerPoint for an Inservice project for my internship in a Skilled Nursing Facility (SNF). I hope you all enjoyed it, let me know what you think the role of the Speech Language Pathologist when pertaining to falls in the nursing home.