Transcript Counseling the Neurologically Impaired Client

Counseling the Neurologically
Impaired Client
Joanna Boettcher
Speech Pathologist
Kaiser Permanente –
Sacramento
SPHP 219
• ** slides are not on the exam
My background**
SF State for BA and MS
degrees
• Internship and Veteran’s
Administration SF
• Graduated Jan 1988
• What Education
provided:
– Confidence and tools to
solve problems
What Education did not
provide: everything that I
needed to know about
every disorder.
Working experience
• InSpeech, Inc. and
/NovaCare, Inc.
- Skilled Nursing
Facilities, Home Health
agencies, Inpatient
Rehab facilities.
- Kaiser Permanente
contract for services in
outpatient, home care as
well as inpatient care.
Kaiser Permanente**
• How I transitioned to KP; getting started
under supervision of Physical Therapy
• How we grew the department from 1-7
staff
• Diversity of the treatment settings and
disorders treated in each setting
– Inpatient
– Outpatient
- Home Health
- Craniofacial Clinic
Practice Expansion**
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Modified barium swallow studies
Tracheo-esophageal prosthesis placement
Treatment for Parkinson disease - LSVT
Pediatric care for cranio-facial disorders,
swallowing/feeding disorders, vocal
disorders (VCD, habit cough), ASD.
• AAC for children and adults
• Laryngo-video-stroboscopic Evaluations
Administrative Support for Growth**
• Added space, staff and equipment over the
years.
• Hired staff members with a diverse set of talents.
• Now divide disorders and specialties among
ourselves, each specializing in several disorders
but none of us being a specialist in all the
disorders. In a pinch anyone can do anything.
• Difficult period when we had only 3-4 staff; we
felt we had to be experts in everything!
My Expertise**
• Left ,Right and Brainstem CVA impairments
• Traumatic Brain Injury – (TBI) severe to mild
• Oral and laryngeal cancer treatment
– including placement of voice prostheses
• Physiological and Functional voice disorders
- polyps, nodules, post radiation, paresis, tremor,
paralysis, Spasmodic Dysphonia (SD); Botox
• Swallowing disorders for adults – not mbss
• Other Neurological disorders
Challenges of the Medical
Environment
• Hospital Environment
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Busy, unpredictable schedule and caseloads
Pressure to work and think quickly, concisely
Work in noise and distraction
Work closely with other professionals
Standing and walking all day; constantly changing environment
Very ill and medically unstable patients
Families in crisis (confusion, fear, shock)
Health risks from exposure to disease causing organisms
Lots of rules and regulations to understand and follow
Mostly initial diagnostics with informal measures, little long-term
treatment
– Lots of dysphagia evaluation and some treatment
Challenges of the Medical
Environment
• Outpatient Environment
– Slower pace, more predictable schedule; set schedule and patient list,
but can change on short notice
– Clients usually healthier, more medically stable and more able to
cooperate
– Family not in immediate crisis but dealing with long-term issues
– Better work environment; sitting in a quiet treatment room, less
interruption, more materials at hand
– More time dedicated to treatment plan and provision of ongoing therapy
– Less in-person interaction with other professionals; talk on phone,
electronic chart and email to exchange information
– Less exposure to disease causing agents although risk still present
– Lots of rules and regulations to follow - Medi-Care guidelines (Big sigh!)
– More formalized testing, planning and carrying out longer-term
treatment.
– More client-family-clinician relationship building, counseling regarding
long-term outcomes and limitations, decisions to end treatment.
Counseling Challenges
• Left CVA
– Dysarthria, aphasia, apraxia, dysphagia,
hemiparesis, emotional lability, depression,
visual impairment, memory
– Loss of job, income, driving ability mobility,
social connection, independence, changed
self-image, personality changes
• Case:
– 50 yo woman (Regina), L CVA
Counseling Challenges
• Right CVA
– Awareness of deficits, motivation to improve,
dysarthria, dysphagia, hemiparesis, decreased social
perception, judgment, reasoning, problems solving,
visual perception, Left neglect, orientation, abstract
language.
– Loss of job, income, driving ability, mobility, social
connection, independence, changed self-image,
personality changes
• Cases:
– 64 yo male (Melvin) – atypical R CVA deficits mixed
– 63 yo female (Kate) – benign brain tumor resection
Counseling Challenges
• Traumatic Brain Injury
– Usually but not always younger people
• May never achieve their potential
• May be forever dependent on family or institutions
– Awareness of deficits, motivation to improve, executive
functions, attention, sensory deficits, short- and long-term
memory, orientation, problem solving, language, emotional
control, speech of processing, dysarthria, aphasia.
– Likely loss of job or educational opportunity, changed
appearance and self image, behavior, mobility, independence,
social interaction, personality changes.
• Case:
– 16 yo female (Marissa) anoxic brain injury post heart stoppage
Counseling Challenges
• Progressive Neurological Disorders
– Parkinson disease, Multiple Sclerosis, ALS, Primary Progressive
Aphasia
– Mostly middle age people or older, but not always
– Sometimes difficult to diagnose, late to receive diagnosis or start
treatment
– Dysarthria, aphasia, dysphagia, cognitive decline
– Likely loss of job, driving ability mobility, independence, social
connection
– Never will get “well”, in fact will get worse
– More time to plan for lifestyle and neurological changes
– Anxiety about changes and effect on life going forward.
– Effect on family members
• Case:
– 58 yo female (Linda) – presented as mild Primary Progressive Aphasia
although her diagnosis was Alzheimer’s.
What Can We Do?
• What the speech therapist can do:
– Establish rapport
– Be personable and honest; void over-optimism and
over-cheerfulness
– Be a good listener for the primary concerns
– Address the concerns as stated (driving!)
– Education about the disorder and symptoms
– Discuss plan of treatment to address primary
complaints; ask for client & family agreement with
problem priorities and plans
– The family has a life change; help patient and family
adjust to the new normal; patient focus, but DO treat
the family communication issue.
Helpful Resources**
• Brain Injury Survival Kit , 365 Tips, Tools and
Tricks to Deal with Cognitive Function Loss, by
Cheryle Sullivan, MD.
• A physician who had a traumatic brain injury
shares her tools for functioning after TBI.
• One Hundred Names for Love, by Diane
Ackerman.
• An established author writes about about her
husband, author Paul West, rehabilitating after a
significant Left CVA.