Cognitive Aspects of Communication
This semester is the first time in my graduate education I’ve had the opportunity to work with clients who are facing cognitive deficits. Working in acute care at Spartanburg Medical Center has been eye opening for me. I now have a clearer picture about the reason ASHA expects speech-language pathologists to exhibit competence assessing and treating deficits of attention, memory, problem solving and executive functioning (ASHA, 2016). These are often the result of stroke, traumatic brain injury or dementia, much of which we see in acute care. I have been able to build my skills not just by watching my supervisor work and planning assessment and treatment activities myself, but also by jumping in to lead as we build patient rapport and strive to create the best possible patient-centered plan.
Each day as we enter a patient’s room, we informally assess cognition, gleaning information through conversation and orientation questions. However, there are times when a more formal screening or assessment might be warranted. Stroke work-ups, at least with my current supervisor, always include a cognitive screen, speech (and possibly language) assessment and a bedside swallow evaluation. When a cognitive deficit has not already been noted in patient records, we often use the Brief Interview of Mental Status to aid in determining whether or not a patient needs a formal cognitive evaluation. If so, we proceed the next day with administration of the Montreal Cognitive Assessment (MOCA) or the St. Louis University Mental Status (SLUMS). We often use the SLUMS if it seems a patient might not be able to make it through the entire MOCA because of fatigue. It can be quite helpful to have a formal, objective cognitive assessment, as patients have varying levels of cognitive deficits and some may exhibit milder deficits during conversation than during a formal assessment, concealing their true level of function.
Based on testing results, we then create a plan to utilize during their hospital stay. It is possible for some cognitive impairments to resolve with time. Therefore, we may see a level of spontaneous resolution without speech intervention, especially given that mental status may be altered by acute illness or medication. At the hospital, we take this into consideration in making recommendations. For those who continue to struggle with cognitive deficits, we include brief cognitive treatment into our visits. This has been an interesting experience for me. I’ve had to think hard about what treatment strategies are truly most appropriate for our patients. For example, in addressing attention goals, some of what we’ve done has been workbook oriented. However, this seems very decontextualized to me, and I think it would be best to incorporate more functional environmental modifications like reducing distractions, taking frequent breaks when overwhelmed, avoiding interruptions, and asking for help. Given the brief period of time we are with patients in acute care, it seems wisest to focus on functional strategies and allow the therapist at the next level of care to practice using less contextualized material if that seems appropriate for their patient’s needs.
I’ve also struggled with treatment of reasoning and problem-solving utilizing worksheets. It’s my understanding that there is little empirical evidence that workbooks and paper-pencil tasks are beneficial for our patients. Therefore, to me, the best option would likely be to collaborate with the patient/family, medical team and other rehab specialists, like OT and PT, to determine situations and problems the patient may face upon discharge. Then goals could be created that address those possible scenarios. In the event there is time, a “Goal-Plan-Predict-Do-Review” framework could be utilized to rehearse task-specific activities, allowing the patient to practice appropriately participating in activities of daily living.
As in any other area, family engagement in cognitive assessment and treatment is invaluable. This has been true even in the acute care setting, as I’ve been able to talk to family about patients’ prior level of function and get context from their historical narrative. Though I’ve not had the opportunity yet to plan specific memory enhancing strategies with family members, I believe that this would be helpful in supporting a patient’s ability to remember things at a certain time using external strategies like handwritten notes, calendars, checklists, electronic organizers, cell phones, alarm watches. As family will often be the ones helping the patient implement these strategies, it is best to make them a part of the decision process.
Though I haven't worked long-term with those that have cognitive deficits or disorders, I did create plans for a variety of case studies. The first included a 24-year-old male with a closed head injury who fell from a ladder onto a cement floor. His CT scans revealed multiple cerebral hematomas in the left frontal lobe, right temporal-parietal region and right occipital lobe. As he emerged from a coma, he was said to be in Rancho Los Amigos Level II. My partner and I create a plan of care extending through RLAS level VII that systematically addressed strategies for his possible recovery. This included initial utilization of sensory stimulation. Subsequently, orientation strategies were introduced to increase his awareness of person, time, place and situation including binders with maps and pictures, scripts for family to utilize, posters and signs on pertinent areas, and consistent scheduling. In addition, attention was targeted using compensation strategies such as reducing distractions, avoiding crowds, taking breaks when necessary, avoiding interruptions, and asking for help when needed. External strategies were suggested to enhance prospective memory. Ultimately, once the client made it to RLAS VII, we primarily targeted social skills in order to prepare him for a return to work. We utilized scripts with productive feedback and education in order to allow him to more fluidly return to regular communication with others in a work setting. Generalization was addressed, along with data collection, at this stage, with the help of family members. In addition to this case, I’ve also created behavior plans for a patient with dementia and a child returning to school after a traumatic brain injury (see other artifacts).
Though I’ve not had a consistent opportunity to work long-term in the area of cognition, I believe that our Cognitive Communication course prepared me well and left me with a toolbag of resources from which to pull when needed. I think the fact that I questioned simply utilizing worksheets for treatment is a testament to the learning I experienced in that course. One of my best takeaways is that whatever we do in treatment, we need to ensure that it’s functional – something that can be utilized and generalized outside of the treatment room. Otherwise, what are we really doing for the patient?
References
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.
Each day as we enter a patient’s room, we informally assess cognition, gleaning information through conversation and orientation questions. However, there are times when a more formal screening or assessment might be warranted. Stroke work-ups, at least with my current supervisor, always include a cognitive screen, speech (and possibly language) assessment and a bedside swallow evaluation. When a cognitive deficit has not already been noted in patient records, we often use the Brief Interview of Mental Status to aid in determining whether or not a patient needs a formal cognitive evaluation. If so, we proceed the next day with administration of the Montreal Cognitive Assessment (MOCA) or the St. Louis University Mental Status (SLUMS). We often use the SLUMS if it seems a patient might not be able to make it through the entire MOCA because of fatigue. It can be quite helpful to have a formal, objective cognitive assessment, as patients have varying levels of cognitive deficits and some may exhibit milder deficits during conversation than during a formal assessment, concealing their true level of function.
Based on testing results, we then create a plan to utilize during their hospital stay. It is possible for some cognitive impairments to resolve with time. Therefore, we may see a level of spontaneous resolution without speech intervention, especially given that mental status may be altered by acute illness or medication. At the hospital, we take this into consideration in making recommendations. For those who continue to struggle with cognitive deficits, we include brief cognitive treatment into our visits. This has been an interesting experience for me. I’ve had to think hard about what treatment strategies are truly most appropriate for our patients. For example, in addressing attention goals, some of what we’ve done has been workbook oriented. However, this seems very decontextualized to me, and I think it would be best to incorporate more functional environmental modifications like reducing distractions, taking frequent breaks when overwhelmed, avoiding interruptions, and asking for help. Given the brief period of time we are with patients in acute care, it seems wisest to focus on functional strategies and allow the therapist at the next level of care to practice using less contextualized material if that seems appropriate for their patient’s needs.
I’ve also struggled with treatment of reasoning and problem-solving utilizing worksheets. It’s my understanding that there is little empirical evidence that workbooks and paper-pencil tasks are beneficial for our patients. Therefore, to me, the best option would likely be to collaborate with the patient/family, medical team and other rehab specialists, like OT and PT, to determine situations and problems the patient may face upon discharge. Then goals could be created that address those possible scenarios. In the event there is time, a “Goal-Plan-Predict-Do-Review” framework could be utilized to rehearse task-specific activities, allowing the patient to practice appropriately participating in activities of daily living.
As in any other area, family engagement in cognitive assessment and treatment is invaluable. This has been true even in the acute care setting, as I’ve been able to talk to family about patients’ prior level of function and get context from their historical narrative. Though I’ve not had the opportunity yet to plan specific memory enhancing strategies with family members, I believe that this would be helpful in supporting a patient’s ability to remember things at a certain time using external strategies like handwritten notes, calendars, checklists, electronic organizers, cell phones, alarm watches. As family will often be the ones helping the patient implement these strategies, it is best to make them a part of the decision process.
Though I haven't worked long-term with those that have cognitive deficits or disorders, I did create plans for a variety of case studies. The first included a 24-year-old male with a closed head injury who fell from a ladder onto a cement floor. His CT scans revealed multiple cerebral hematomas in the left frontal lobe, right temporal-parietal region and right occipital lobe. As he emerged from a coma, he was said to be in Rancho Los Amigos Level II. My partner and I create a plan of care extending through RLAS level VII that systematically addressed strategies for his possible recovery. This included initial utilization of sensory stimulation. Subsequently, orientation strategies were introduced to increase his awareness of person, time, place and situation including binders with maps and pictures, scripts for family to utilize, posters and signs on pertinent areas, and consistent scheduling. In addition, attention was targeted using compensation strategies such as reducing distractions, avoiding crowds, taking breaks when necessary, avoiding interruptions, and asking for help when needed. External strategies were suggested to enhance prospective memory. Ultimately, once the client made it to RLAS VII, we primarily targeted social skills in order to prepare him for a return to work. We utilized scripts with productive feedback and education in order to allow him to more fluidly return to regular communication with others in a work setting. Generalization was addressed, along with data collection, at this stage, with the help of family members. In addition to this case, I’ve also created behavior plans for a patient with dementia and a child returning to school after a traumatic brain injury (see other artifacts).
Though I’ve not had a consistent opportunity to work long-term in the area of cognition, I believe that our Cognitive Communication course prepared me well and left me with a toolbag of resources from which to pull when needed. I think the fact that I questioned simply utilizing worksheets for treatment is a testament to the learning I experienced in that course. One of my best takeaways is that whatever we do in treatment, we need to ensure that it’s functional – something that can be utilized and generalized outside of the treatment room. Otherwise, what are we really doing for the patient?
References
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.
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