Where There Is No SLP - Cognition Strategies (third in a series)

What can you do, if your home health patient doesn't have speech therapy - but isn't thinking well? Problems with thinking (cognition) skills can make a patient less independent, and even jeopardize her/his safety. Human cognition is a complex hierarchy of skills that we depend upon for living in the modern complex world. Preventing long - term effects of challenges to a patient's cognitive status is a worthy goal of home health intervention. Where there is no SLP, what can you do help the patient to function best to meet her/his cognitive needs? Remember that hearing impairment in adults is a major risk factor for development of cognitive impairment. Suggest the patient get a hearing screening, either through self - assessment or behavioral testing.

Effective communication with your patient during the visit will make thinking through your activities easier. For example, speak clearly with the patient, maintaining consistent eye contact. Regularly ask the patient to "teach back" what you have demonstrated or explained. Use the "WRAP" strategy (write down; repeat/routine; associations; picturing) to help the patient retain your information. Supply WRITTEN illustrations of home exercises when possible. If the patient does not easily initiate an action (e.g., picking up a utensil or taking a step), give a timing cue by modeling what you wish her/him to do.

Where There Is No SLP - Swallowing Strategies (second in a series)

What can you do, if your home health patient doesn't have speech therapy - but doesn't swallow well? Swallowing breakdown not only can challenge a patient's respiratory system, but also can be a serious barrier to general health. Swallowing problems (dysphagia) are such a high - risk problem, that they are often the first reason doctors refer their patients to SLP. Preventing long - term effects of challenges to a patient's nutrition/hydration is a worthy goal of home health intervention.

Where there is no SLP, you can still have a positive effect on the patient's oral health and hydration status. How does the patient maintain oral care? The mouth can be a portal to many bad things. Encourage the best possible oral care.

Dehydration is easily achieved, but sometimes not easily corrected. The clinical signs of dehydration you can easily see. Even sharing an ounce of water with the patient during a therapy visit can be a reminder: SIP VOLUMES OF BEVERAGES EACH MORNING TIL NIGHT.

Where There Is No SLP - Hearing Strategies (first in a series)

What can you do, if your home health patient doesn't have speech therapy - but doesn't hear well? Hearing loss is one of the strongest risk factors for cognitive impairment in older persons. Preventing long - term effects of challenges to a patient's hearing is a worthy goal of home health intervention.

Where there is no SLP referral, try to observe the following. Does the patient complain of changes in how the ear feels? Those signs may require a medical referral. Can your patient understand louder sounds best? Does she/he confuse words in conversation? Use strategies that help the patient understand your directions and your teaching. Strategies may include: constant eye contact when speaking; slower speech rate; stressing key words; gesturing; or writing down what you said.

To document the patient's perception of her/his hearing, complete: REVISED HEARING HANDICAP INVENTORY - SCREENING VERSION. THe patient can use the experience of communicating with use of strategies, as well as the self-perception of hearing function, to decide about possible hearing rehabilitation.

Will You Try It Once?

Hi! If you're not lost, welcome to hearing about a new way to look at human communication, cognition - or thinking - and swallowing. I'm a speech - language pathologist, a professional who helps people keep these skills. Relax, have a seat and - and I hope you're comfortable enough to tell me if or when I get off track. We need to take this journey together, so we all get to the end feeling good about our travel. Are you comfortable? Got enough room? Good, good, that's good! All right, let's talk about where we're going on this trip. We want to talk about people; people of all kinds - all sizes, shapes, all colors, ages, beliefs, constitutions and appetites. Their appetites then lead us to talking about all the foods that this big group of people might eat. They eat what they can afford, what they can find, grow, what they can stash away for when it's the best time to eat, or when they have to because Mama tells them, "eat!". You eat because you have to, it keeps you here with all the rest of us. It keeps you here, and it keeps you happy and wanting more: more food, more time, more life. So we have lots of people to talk about, and we have to consider all the foods these people need and crave. Seems pretty natural and easy to talk about people and food, right?

There're people, and all people communicate - some better than others. We need to do it, people do. It's part of our makeup, like walking on two feet and thinking about tomorrow. I want to communicate well, because my Mama said I HAVE to do it this way. I communicate because I want to stay emotionally close to people like my loved ones, friends; the people I know from work and my neighborhood. Those communication skills help me behave as my family, friends and neighbors expected - to follow the rules. Good communication also helps me to tell people what I'm thinking, seeing and feeling, and at a more basic level, I get what I need through what I can say, hear, read and write, and think. Even though we all have differencies in how our communication sounds or reads, we all yearn to connect by thinking about and playing the communication game.

Thinking is so closely linked to communicating, isn't it? You are awake and alert; you're focusing and concentrating, reasoning and classifying, planning and executing. From the time we're sleeping in a drawer, a bassinet or crib, we're plotting how to jump out and run the world. Developing as we do throughout life, we couple our thinking and talking skills with all the physical prowess that we should have. We learn to take care of ourselves, we learn what our parents and teachers share with us, and we learn from the big world with our increasing sophistication of our thinking brain. A healthy thinking brain, well protected and well fed, keeps us independent agents to confront our world each day.

Hang on, hang on! You look a little restless over there. We've almost got through the basics of what we can do - we still need to think about chewing and swallowing. Since we use many of the same muscles and nerves to swallow that we use to speak, my colleagues and I in SLP take on the responsibility of making sure we all can eat what is good for us, as well as simply what tastes good. We chew foods in a range from mashed peas to massive steaks over time. Getting the food we chew ready for swallowing ("when food is ready to swallow, it should be like MOTOR OIL; sticky and slippery!") is critical. Most of the time, we don't have to think about it. At times we all may have a momentary slip in our eating patterns, but the majority of us can manage those slips without any harm done.

We speech - language pathologists (SLP's) have to think about it for you. Swallowing is often the SLP intervention physicians call upon, when they send a referral our way to help someone. Thinking disorders are more prevalent among our referrals, with all the public's concerns about dementia. When speech, language and other communication problems are remediated well, we hear how skilled we are. Our professions are built upon bringing people back from the brink of disability, and now we're prepared to to serve our communities even more. Let's talk about how you can help prevent the effects of cardiovascular disease by eating well.

(Continued, part Two)

I Will Try It Once

You most likely recognize the name "Jacob Marley" from the Dickens story that is played on television at Christmas. Though Scrooge saw the damned spirit of Mr. Marley in the story as a warning to himself, you can imagine that things might have been different. What if Marley, transported to the 21st century, had also had opportunities to improve his fate, just like Ebenezer Scrooge in the Dickens story? The following story tells how Marley - and you – might avoid the burden of chronic disease that hurries death, that weighs down the life we want. Everyone should have an equal chance to live the best, longest life.

Young Jacob "Jake" Marleigh didn't think much at the beginning of his life about how to stay healthy. His parents did much of the thinking and doing for him on this issue. He had gotten good nutrition, good sleep, and good activity. Young Jake was the middle kid of five, and he had things to do, after being programmed by the eons of growth and adaptation by his ancestry, and getting ready to tackle the tasks of an everyday kid. From his entry into the world, Jake had a need to hold, grasp and claim things, so before he could say the word "MINE", his strong fingers spoke "MINE" for him. Just as many strong-willed infants had done to lure his parents into being adored, Jake had gripped his father's index finger one day with pudgy little fingers. MINE. Then as a headstrong toddler, he was given a pack to carry on his back, to carry all things that he considered, his important stuff. All the things he had collected, craved, earned.

There were mementoes of his first McDonald's french fries from age 2 - a soiled paper fry basket; from his first bottle of soft drink, the cap; and from his initial box of Good and Plenty candy, a few sweet cartridges rattling within the container. Jake's parents did their best, exposing him to mass - produced industrial Western foods only sporadically, but of course what his parents offered tasted SO GOOD when he was given any of those treats, and so Jake would always want more. Meals at home were dark and heavy, in comparison. There was pot roast almost every Monday. Meatloaf with (ICK) onions and English peas. When Jake had his first plate of spaghetti with meat sauce placed before him and he got a mouthful of the sweet, beefy viscosity, he thought - yeah! Something nice here....and then his older sister had to tell him the pasta beneath was "worms"! AUGHHHHHHHHHHHHHHHHHHH. Four years had passed before Jake once again put a forkful of spaghetti in his mouth.

Jake was a shy boy, though he was very assertive in the grade school classroom and on the playground at recess. He was so assertive that he got mixed up in a playground scrum, the weight of all those boys causing his wrist to snap beneath him as he crashed down on a sewer cover. But as soon as the cast was dry on Jake's forearm, he was blasting out of the classroom as soon as the recess bell rang. Back inside, he was soon labeled "teacher's pet". Our hero took to both battlegrounds with energy, especially since his cast alloweed him to stash some energy sources - Hydrox cookies, Jordan almonds he had stashed inside the plaster when at the movies, and even some bits of hamburger from last night's dinner. Boy, that cast really stank! But the stash kept him going, kept his neurons firing and kept that hand raised to answer EVERY QUESTION! Books and TV became Jake's life, even though he had plenty of encouragement from his parents and his few friends to play ball after school, or go to a Scouts meeting or to church. NO, was the boy's answer. Another potato chip from inside the backpack, before he went back to his books.

Jake was dusting himself off one day at the end of recess, and wanted to be on time because he had to read aloud to the class....but a tall, imposing adult beckoned him to come closer, at one corner of the school playground. The boy was certainly no dummy and looked around for support - no other adults were on the grounds, and he had to go! The adult prevailed though, and Jake was held tight to listen to the adult's entreaty: Young man, you work hard. I've been watching you. You play hard and I know you study hard.

The large man, who was dressed like a gym teacher but whom Jake had never seen IN HIS SHORT LIFE, went on: I have noticed that you don't have much energy as the day goes on, unless you have a little, er, pick-me-up? And then, the teacher guy leaned down and ACTUALLY PATTED DOWN the boy until he found in the shorts pockets: a pack of Clove gum, fresh from his granny's hand not two hours ago, and a peppermint wheel still within its plastic wrap....then as if he was hit by an electric shock, Jake glared angrily at the strange man, hissing in the scariest voice he could: STOP IT OR I'LL SCREAM. The man reared to upright himself, smiling as if to calm Jake's anxiety. Jake - you've got to stop this living to eat! Then, quickly lifting and blowing his gym teacher whistle - POOF!

It Should Be Very Simple

The idea didn't just come, but like most tantalizing ideas it was a Michelin - quality dish that started out using ingredients in my everyday cupboard. Years ago, I attended an American Speech - Language - Hearing (ASHA) national convention, and heard papers on "prevention" by Marge, Lubker, Antoniadis and others. Radical indeed: doing our best to make sure that we SLP's may not have customers! I loved the idea, and looked for a way to incorporate this widget for our profession into the daily slog. Over the years I wondered: were many people approaching speech-language pathology from this perspective??

A few papers appeared, on decreasing risk for child language impairments, as well as for increasing success in literacy and speech fluency. There's also been continued attention to screening the public for signs of impairments. Audiology, in addition, has devoted growth among its numbers for the study and practice of population health - which includes the idea of "primary prevention", or avoiding/lessening risk altogether. Now THAT, other than in the practice domains I've already named above, seems rare in SLP now. It takes too much time during training of master's students, I've heard. In the real world of patient care, how would you do it? Who would want to buy that kind of prevention, from a "speech therapist"? And, above all, who's going to pay you for that?

But, but, but - there's such a need! The 2023 report by the CDC on mortality in the US, reported that for 10 top causes of death, cardiovascular disease was (in)directly connected to 50% of them. Among the world's top seven industrialized nations, another report lists three of them as of 2021 as having cardiovascular disease the leading cause of death (US, Germany, Italy). Though Canada, France, Japan and the UK also listed cardiovascular disease as their leading cause of death in 1980, by 2021 the leading cause was cancer in all those nations. There is evidence that a government's change in public health policy might bring about significant improvement in citizens' wellness. For clinicians, researchers and institutional leaders in the communication sciences and disorders (CSD) professions, there's an opportunity to help the nation move the needle on cardiovascular risk in a positive direction.

As well - trained professionals with varying levels of experience in the healthcare system, we see the evidence of health behaviors that may lead to higher cardiovascular risk, after the fact. I've reviewed the variables encompassed in the "Life's Essential Eight" https://www.heart.org/en/healthy-living/healthy-lifestyle/lifes-essential-8 many times in this blog, so readers will have had some orientation to a framework for wellness that appears accepted by the medical establishment. Not only is this framework a guide to managing cardiovascular risk, but clinicians working in cancer treatment will also recognize these variables for better health. How can the CSD professionals relate to these data points, when what they do day - to - day is so far removed?

I can only defend my own actions, and advocate for this approach to primary prevention; in this case, I want to do primary prevention of cardiovascular disease, through addressing consumers' diet. The operative question is then - can well adults, not presenting with a referral to speech - language pathology for evaluation/treatment of a problem swallowing, learn and implement strategies for eating a diet for themselves?

On the Trail of Evil with DICK DARING, Speech Therapist

On that fateful day, he facepalmed to gather his wits and calm himself, stopping the walk down this long hallway in the building he knew intimately, to scrape the slightly clammy flesh down his face and reset his thoughts for the afternoon. A toddler who had come to the clinic some weeks ago, to play games – so he thought – was on the floor, so Dick Daring was on the floor, too! In the process of living his best life with the Fisher – Price doll house, - the wellworn plastic device giving off a slight chemical odor - the toddler noticed that Dick had his back to the window letting in morning sunlight. Brilliant beams cast an outline around the speech therapist’s ear, bearing the signs of middle – aged hirsutism: hair sprigs no more than a ¼ inch from top to bottom of Dick’s outer ear, and the child couldn’t repress his need walk over to the therapist, and play in it with a finger. The mother was tickled – or was she mortified?? DICK WAS MORTIFIED. Make it stop, please! The therapist took a deep breath after resetting and then moved down the hall to his next case.

The walk down this hall seemed to take forever, though. Daring had worked here so long; used all the rooms to see all kinds of people, young and old; talked to his colleagues and managers in their offices over all kinds of cases; - that he tended to get lost in thought. The room on his right he was just passing had the barest remnants of a drywall patch on the far side. Dick had even been a student therapist here, and after a rather contentious meeting with a case supervisor about a report – put his then powerful fist through the clinic room wall, to be followed by a shriek of pain that would have awakened the dead! As Dick paused at that room’s door, he felt the offending hand throb a bit – and he then heard the clinic director calmly speaking with him, a few hours after the incident. Dick had been quickly escorted to the Student Health Center; his hand X-rayed, cleaned and wrapped with an Ace bandage, before he had been plopped in an office chair to learn his fate. “I looked over that report”, she said. “You were right with your calculations. Don’t ever do that again”, she said in a businesslike voice that belied her skill at managing people. Dick felt himself smiling as he moved on. One victory there.

Yes, Daring had been doing what he’s doing for what seemed like forever. He looked on the field of communication sciences and disorders – what the “man in the street” called speech therapy - so much differently than most of his fellow therapists, that he scarcely felt he could talk with them. He actually could talk with them! He could recite data recently published on a journal website, that explained informed consent for an “at – risk” swallowing therapy approach. He could demonstrate to a family member, or to the consumer with family in the treatment room, how blowing bubbles through straws of differing diameters was very similar to using the EMST (expiratory muscle strength training) technology, so popular now. Cost of a package of straws? As little as $3 USD for 100 straws. Cost of an EMST 75 or 150 training kit? $55 USD. Daring moved on down the hall and entered the next room, the case file in a clear plastic bin mounted next to the door.

This 25-year-old woman had initially “presented”, like she was an unlucky invertebrate pinned to a display board with those colored pins, as a case of severe hoarseness – conversational speech marred by sudden “pitch breaks” where her voice just cut out; she was often breathless, and she was increasingly frustrated at work – an educational co-operative – because persons calling her office had trouble understanding her. Today, she reported that her primary care physician had prescribed a proton pump inhibitor, a drug that stifles stomach acid production that seems to be refluxing up into her throat. She went on to say that she had promised to cut down on her beer consumption. After she demonstrated how much clearer her voice was becoming, reading 25 10 – word sentences without a pitch break, Daring scheduled her for a final visit next week, then left to move on to the next case.

“Dick,” a woman passed him by as he moved on. “Hello, Mary”, Darling replied without pausing in his brisk walk to the next case. Mary had been a fellow graduate student with him, but had moved on to becoming a staff supervisor, occasionally managing a case with Dick. There had been that time, he remembered, when he and Mary might have had something – until they had met one day at the materials center on the third floor. You had to check out a toy, or a test, or some specialized equipment to use It during a therapy session. Mary had just procured her toys for use with a child with cleft palate and turned to progress down the hall to the child’s therapy room. KAPOW! Daring, in his style, is barreling down the same hallway but in the opposite direction, lost in thought and carrying his FIFTH cup of strong black coffee without a lid! STUPID. They called it, when people gossiped about the event, the “eruption of Mount Mary”. She publicly forgave Daring for the incident, but on another level, their interactions were that brusque. Hello, move on. Daring opened the door to the next case he had been assigned today, a bit weary for the late afternoon.

Name: _____; Age: 55; Diagnosis: Severe aphasia after left hemisphere stroke, right hemiplegia. The patient held his right arm crooked against his chest, waiting seated behind the table and smiling at Daring, the case file in hand. “One time”, he greeted the veteran therapist with a smile. “Hi, Mr. ____”, Daring replied, resting his well – worn Fedora at the corner of the table. “How is your day today?”, the therapist asked. “One time!”, the client answered with a woeful sound to his voice. “Did you see the game last night?", Daring inquired, knowing that the client’s favorite team had won – and BAM! The patient SLAMMED his strong left hand on the table and exclaimed “ONE! TIME!!”, smiling broadly and then – showed that he could sing a bit of the team’s fight song when Daring started the song. He could actually sing the actual lyrics - !! “Applause!”, Daring cried out with a broad smile and clapped to celebrate the client’s performance. Laughter came from the client’s side of the table: “ONEEEEEEEEEEEE TIMEEEEEEEEEEE!”. Daring wrote down the client’s next scheduled date and time for another singing lesson, what was called in the literature “Melodic Intonation Therapy”.

Fedora back on his head with a slight tug to get the brim just right, Daring gently closed the door of the treatment room. On to the next case – Boy, this corridor seems extra long today.