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In this episode, Kali talks with Lydia, CCC-SLP, who shares with us the vital role speech therapy plays in helping patients get back to their lives. She explains how awake and walking enables patients to resume eating sooner and preserves cognition. The utilization of speech therapy is explained and applied in ways that the ICU world has never understood before.
Episode Transcription
Kali Dayton
Today I have with me, Lydia, she is a speech therapist, an expert in all things, speech therapy, and cognition in the ICU.
Lydia
I enjoy it, but I’m not an expert.
Kali Dayton
Well, I think you’re an expert, and we use a lot of your expertise. So I’m excited to have Lydia with us to share with us her practice and her role in the ICU. Thanks for coming, Lydia.
Lydia
Thanks for having me. I really appreciate the opportunity.
Kali Dayton
So tell me a little bit about your role in getting patients home from the ICU and how are you able to do that differently here?
Lydia
Being a speech language pathologist in the ICU gives you a lot of awesome opportunities to work with patients who really need our services. One of the interesting things about speech pathology that I enjoy on a daily basis for just diversity in my work day. It’s also a piece of the profession that a lot of people aren’t aware of in regards to the fact that there are a lot of components to our scope of practice.
So if we’re looking specifically at ICU patients, we think about all the things that are involved with intubation. So if you have a patient that spends any period of time intubated, you’re going to have a period of time where the musculature that is responsible for speech, communication, and swallowing is not being utilized naturally. And just like with any other system in our body, if you have a period of time where the musculature and the neurological framework can be utilized in the functional way that it needs to be, you’re going to have patients with deficits. And really, we don’t use speech pathology in hospitals as often as we should.
And it’s a huge area of new research that’s being pursued to try and increase the utilization of speech to look at all of these areas of language and cognitive communication disorders that again, come along with those critical illnesses and situations that we see with patients in the ICU. So it’s a diverse range of things that we get the opportunity to work with patients on.
Kali Dayton
And what factors from the ICU contribute to the swallowing deficits? Or what makes them worse? Do you see such a variety of impairments and patients? How do you feel like sedation cessation and mobility affect your practice?
Lydia
Absolutely, Kaylee, those are great questions. Specific to the ICU. Again, if we think about the types of patients that are sick enough to spend a period of time in the ICU, oftentimes these patients are, whether they’re awake or were unconscious, they’re oftentimes not able to eat and drink normally. So again, you’re having this period of time where all of this normal anatomy and musculature can’t be utilized.
And when you compare swallowing deficits in patients that spend, let’s say, two to three days on a medicine floor for some kind of medical issue that requires a stay in the hospital, compared to someone who’s in the ICU for three weeks to two months, there’s going to be a huge difference in the amount of disability that can occur over a period of time where a patient is so limited in their ability to either eat or to speak again, you know, we think about the vocal folds as tissue that helps us speak and that vibrate to give us the ability to communicate.
And if you have an intubation tube down your throat, those vocal folds are not able to do their job, they’re not able to, to work the way they need to to not only facilitate communication, in a way that you would have been able to utilize it before your decline and your your intubation period.
Kali Dayton
So Lydia, how does this awake and walking culture impact your practice and patient outcomes, but then your focus?
Lydia
That’s another great question, Kaylee. So as a speech pathologist who’s focusing on swallowing, communication, and cognition, having a patient who is spending the days that they’re in the ICU as alert and interactive as possible, is absolutely crucial for helping patients return to function faster and it also makes a huge difference in helping patients to be aware of their surroundings, receiving communicative information from the caregivers around on them a patient’s who who is awake is going to be spoken to by care providers, by nurses by family members. They’re going to be receiving that receptive language, information that will in turn keep their brains moving. It provides better opportunities for those patients to be involved in their care. Because a patient who is awake can answer questions about how they’re feeling, what they need, what their preferences are.
As far as the awakened walking goes, when it comes to swallowing a piece of of swallow rehabilitation, that oftentimes we don’t think about until it’s almost too late is the idea that dysphasia and aspiration risk can sometimes almost prophylactically be avoided to a certain extent if, if the whole patient is taken to into account as we’re attempting to provide them interventions in the ICU.
What I mean by that is, if you have a patient who is awake enough to participate with physical therapy, sit at the edge of the bed, do exercises potentially get up and emulate. These patients are inflating their lungs, they’re using their diaphragms, they are incorporating all of those muscular systems that also are required to preserve calf strength and preserve the ability to clear the airway and help reduce the risk for aspiration when people are able to start those swallowing trials.
So while an intubated patient who is not sedated and up and working with physical therapy can’t necessarily do functional swallowing exercises, there’s a lot that can be done with speech pathology, to maintain the integrity of the oral mucosa. And while all of our nursing staff is educated and trained and performing oral cares, there are pieces of providing oral care that can be uniquely difficult in our intubated ICU patient population, especially when we’re talking about patients who are dealing with some confusion or issues with orientation.
Oral aversion is something that can be an acquired problem after being in the ICU, where, if during a period of time where you were confused, you had no control over the speed of, of someone approaching your mouth or entering your mouth with a swab or a toothbrush, or allowing you breathing breaks between scrubbing attempts in the oral cavity, we can have patients who come out of the ICU with a fear of being touched on the mouth or, or anxiety related to having their face touched and, and having a speech pathologist come in and help you evaluate where that patient is in regards to being able to participate, being able to follow some simple commands and be as as independent as possible.
Those tasks not only reduces the risks for, you know, the buildup of that really nasty anaerobic bacteria that we see populate patients mouth when they’re not able to eat or drink. But it also helps again, the patient have some control over their situation and avoid some of those those instances that I mentioned, where you can get people who end up really hypersensitive and traumatized over the oral care that was provided to them. Even if it was provided with the idea of, of, you know, doing a good job and caring for the patient of speech therapist can really help with putting together a program with nursing staff to make that as patient focused and specific as possible.
Kali Dayton
Do you see that aversion increase when patients have been delirious?
Lydia
Absolutely, absolutely. So anything that with delirium, making it difficult for patients to reason why things are being done to them. You know, we’ve talked to patients who, you know, who come out of periods of being lethargic, and you know, state the scary things they saw or thought they saw or things that were done to them that felt so real.
You can really aggravate the risk of those types of situations occurring. When anytime you’re dealing with someone’s mouth. If we think about it, obviously, we’re not used to people helping us with oral care as adults, but on top of that your mouth is the gateway to your lungs and your breathing. And anytime someone else has control over foreign objects in your mouth, including your endotracheal tube, you know, moving that around to do oral care, a lot of caring communication needs to be taken during during those times to make sure that we’re providing more benefit to the patient than harm. Interesting.
Kali Dayton
Yeah, I’d never thought of it that way. So I think speech therapy is really well known for helping people talk but especially in the ICU, for swallowing. So you’re kind of a gateway to being able to eat again. We get that. Something that I did not understand and am still discovering…. is what a role you can play in cognition, evaluation and therapy. Will you please tell us about that? Because I’m really excited about it.
Lydia
Absolutely. Absolutely. I’m so glad you’re asking. One of the difficulties with being a speech language pathologists, that’s my official title is our scope of practice really includes a wide range of items. And we’ve touched on a few of those here already with swallowing and communication and cognition. But the cognitive piece for our scope of practice, oftentimes people aren’t aware is even a part of what we can help with.
And one of the ways to help, I think, bring it into focus in regards to how we’re able to be utilized with these patients in the ICU, who are at risk for delirium is if you think about how the anatomy you know, going from the, from the black and white anatomy of the body, the mouth, the throat, all this anatomy we use to speak and to communicate any and drink cognitive processes, such as remembering things, being able to sustain your attention to a task or a conversation with your doctor, where you have a physician trying to explain to you the the serious implications of your current medical situation.
Cognition is almost inextricably linked with communication in that to practice our cognitive abilities with memory and with sustained attention and problem solving. And those more high level executive functioning. Abilities that are required to take multiple pieces of information and weigh them and make a decision. All of these features of cognition are required for us to be able to interact in our world and make decisions related to our lives. And when you’re intubated, and you’re in the ICU, your ability to have stimulation that can continue promoting those skills, and keep them fresh, for lack of a better word, oftentimes, those opportunities are limited.
And what we’ve been trying to do in the system that I’ve been working in, is, again, limit sedation as much as possible for these ICU patients so that we can facilitate their minds being awake and active and actively participating in their care. And, again, you know, you think of a very sick ICU patient who is intubated, and you think, well, they really can’t do much.
But if you are aware, if you have a patient who’s awake and you’re aware of what their deficits are, because you’ve had a speech pathologists come in, do a communication assessment, see what the patient has to utilize as, tools whether they’re able to write on a pad of paper, or use an iPad to communicate using a text to speech program, or we have patients who are unable to use their hands for writing or for pointing, and you can use something called an eye gaze board with a which allows for options to be placed in the patient’s visual field.
Caregivers can be trained to stand in a correct position to be able to determine what the patient is choosing just with the direction of their eyes. Anytime a patient is awake and alert enough to participate in interventions with physical therapy, it’s a good indication that as a care provider, you should consider speech language pathology assessment. Because the likelihood is if they can participate with physical therapy, there’s going to be a huge benefit in you having speech pathology come in, do that initial communication assessment, determine the best method for helping a patient communicate.
And then with having determined where their specific deficits are, again, whether it’s memory or sustained attention or problem solving, you can start functionally using tasks that are functional within the patient’s day to day life, to target these areas, and work on improving function, so that when the patient is extubated, and coming out of the ICU and more stabilized, they’re not faced with this huge decline in their ability to participate in those activities of daily life that really do require some cognitive functioning.
A few examples would be again, managing and organizing medications, making an appointment with a physician and making sure that you’ve contacted the insurance company to have the pre authorization you need. These are all very complex tasks. And if you’ve been in the ICU for six weeks, you haven’t had the stimulation that you need to be able to dive back into those tasks of daily life and a speech pathologist in conjunction with Physical Therapy and Occupational Therapy can be very useful in helping you determine where those goals should be targeted for that patient, and how not only family and care providers, but the patient themselves can work on improving these areas of cognitive functioning.
Kali Dayton
And you have brought me so much insight on my patients on numerous occasions. There are patients that can tell you where they’re at what day it is kind of the context. But we all have had those patients where it feels like there’s something off that you can’t put your finger on it. So we’ve asked you to do MOCHA scores. What is that test? What is it like? And what does it tell us?
Lydia
Good question. So the MOCHA is the acronym that stands for the Montreal Cognitive Assessment. And it’s one of many cognitive screenings that are frequently used in the hospital system to assess cognitive functioning. Now, just as a caveat here, I need to just make a quick comparison between a a more brief cognitive assessment that would be completed in the ICU.
The Moca is a perfect example of that, compared to more thorough diagnostic cognitive assessments, which are oftentimes very appropriate and can help facilitate a more thorough look into a patient’s cognitive status. These exams are usually done when the patient is out of the ICU. Often, they can be done as an inpatient, or as an outpatient with a speech pathologist or neuro psychologist.
And the rationale behind doing a shorter cognitive assessment. In the ICU is again, the patient’s attention span is going to be somewhat more limited compared to some of these more diagnostic examinations, which can take three to four hours at a time to complete. That’s just not an amount of time, you can expect a lot of these ICU patients to be able to attend functionally to a diagnostic assessment and the Mocha is a great option to utilize.
That doesn’t give us as much information as those more thorough diagnostic assessments but still does a great job in giving you a general idea of where your patient lies on a standardized bell curve of performance of a variety of patients. And the standardization data for the Moca is great because it allows us to have some good objective information to compares the patient progresses through their stay in the hospital and beyond. Another benefit to the Mocha is that it is a free source, cognitive assessment, at least it has been there, I think they’re going to make it so that you have to be certified to utilize it soon, because they’re trying to be more consistent with the training that is required for the exam.
But as of now, it’s still open source. It’s available in multiple different languages. And there are multiple versions of the examination. One of the things that I’m sure you know, you mentioned a moment ago are our patients in the ICU oftentimes will have variability to their cognitive presentation, you’ll have someone who’s getting more stable, getting sharper, and then something will happen. And you’ll notice for a few days, they’re not doing as well.
Or you know, you’ll have someone who’s had a very prolonged period of recovery. And let’s say you did a cognitive assessment when the patient was initially able to participate in that. But then after two or three weeks, the patient is still hospitalized, but you need an updated look at their cognitive functioning. The Mocha is nice, because the alternate versions that they have provided are different enough, but still under the umbrella of standardization that you can reassess the patient’s cognition without worrying about some of the retesting effects that are seen when you try to complete the same assessment on a patient more than once.
So the Moca has been a very commonly used tool within the speech pathology profession, there’s always, you know, a bit of conversation and agreement and disagreement about what protocols are most appropriate for which patients and again, I think we have to come back to this idea that each one of the settings we work in, we’re going to have a slightly different patient population and you really have to just go on what is most appropriate for your patients and for us, the Moca has worked very well. There’s a sub test on executive functioning, sub test on attention, immediate memory, delayed memory, recall, reasoning, orientation, and language and it allows for you to just again to determine briefly some areas where the patient either is within what would be considered normal cognitive functioning or outside of those boundaries in a way that they could benefit from skilled services. Have you heard of the John Hopkins adapted cognitive assessment for ICU patients?
Kali Dayton
I haven’t.
Lydia
That’s an assessment that we are starting to use in the facility that I work in that was put together specifically by some wonderful people at John Hopkins. And the idea of this assessment is is that it allows for earlier cognitive assessment specifically of ICU patients who are intubated. And the reason why this exam could be beneficial, in comparison to the Mocha is for the Mocha to be completed. Ideally, you want the patient to be able to hold a pen and draw some lines, there’s a clock drawing task.
And for a lot of our intubated patients, that’s not something that’s easy for them to do. And on top of that, for the Mocha, there is a sub test that requires the patient repeat back a few sentences, you have an endotracheal tube, and that’s a much harder task to accomplish. But it’s a very important part of the cognitive assessments, because oftentimes, if we’ve had cognitive declines, those are are visible when assessing the patient’s ability to comprehend language, retain language in the mind, and then repeat language in the form of a sentence repetition.
And that’s not something that an intubated patient is able to do. So the John Hopkins adapted cognitive exam is set up in a way that the patient is asked questions, they are given the options for the potential answers for the questions, they’re given the options a few times and it’s put together in a way that the patient just needs to be awake and to be able to signal to you basically a yes or no, whether that’s with blinking or a thumbs up or thumbs down, or pointing. And it’s really enabled us to have a good tool to look closer at cognition in these patients who are intubated. And in historically, in a lot of systems.
Even today, you know, this is all newer research that you’re embarking on with ICU, delirium. A lot of systems cognition is not touched until the patient has either left the ICU and is on the acute care floors. Or I would say, in more cases, cognition is not touched at all, or isn’t touched until the patient is an outpatient. And oftentimes, the argument for that is, well, you know, the patients in the hospital, we need to target medically pertinent conditions and concerns and other things can be targeted when the patient is no longer an inpatient.
But I think this population of, of patients that we’re discussing who are at such high risk for ICU delirium, this is the perfect opportunity for more research to be done and more focused to be put on the idea that if we could start these interventions with these patients, when they’re alert and oriented enough to their, their surroundings, to participate in physical therapy, that they should be starting with cognitive interventions that are appropriate to their level of function, and can continue that process of stimulation and reduce the number of days that that cognitive decline is allowed to continue occurring.
Kali Dayton
Yeah, that is such a strong point. Because I mean, really, all of this is completely irrelevant if patients are on sedation. When that is still our standard practice around the country and even world then cognitive function is something that has to be cleaned up later.
So what does it mean to you and your practice, and I don’t know, your fulfillment and your career, to be able to work with patients during their acute and critical illness? What does it mean to be able to do these kinds of therapies during that? And what kind of impact does it have on their outcomes?
Lydia
I think the benefit that speech pathologist interventions can provide to these ICU patients in improving their outcomes is absolutely a crucial service that is starting to get more volume in regards to the benefit it provides, but absolutely needs more awareness brought to it because again, you know, we, we talked about how these patients in the ICU are so ill, that they’re not able to participate in normal human interactions that we would have on a day to day basis, a normal conversation, you know, follow along with a joke that’s pertinent to the situation at hand.
And that, in and of itself, takes away a lot of someone’s humanity. When you cannot functionally communicate your wants and your needs with the people around you and have a semblance of orientation to where you are and why you’re doing what you’re doing. It’s easy to lose yourself and it’s easy to feel like you don’t have a part to play in not only your life but you’re your recovery. And the more we can identify these cognitive deficits and these breaks in ability to communicat wants and needs, the more we can help patients maintain their individuality and their humanity, and keep them involved in the process of getting better as a human being, and not just another piece of equipment in the hospital room that is looked over. You know, as people come in and out and do their jobs.
There’s a lot of job satisfaction that I get out of feeling like getting into these interventions with patients and utilizing external strategies. Let’s say just even a little memory book or a planner that a patient can use to write down the activities of the day, or take a peek at the calendar a few times and mark off which days have occurred and write down some important events in that person’s life that are occurring, that month, birthdays, anniversaries, things that don’t have anything to do with the patient, being sick in the hospital. These are the ties to our lives, that help us remember why we like to be alive, and who we are as a human.
And I think that not only patients in the ICU can can become out of touch with that when they’ve been sick for so long. But as care providers, it’s easy for us to get out of touch with the fact that the people we’re taking care of are just that they’re people and making it a priority to capitalize on this important time in the ICU, where we can be of use and we can be of help for these patients providing physical therapy and occupational therapy and cognitive and swallow interventions, communication interventions that are all aimed at improving functional ability and quality of life and control over one situation.
You know, as I say that out loud, how could it be anything other than the way things should be? We should be promoting this in every hospital all over the world.
Kali Dayton
I’m so excited to see our sedation practices change so that your field, your expertis, can be used more because we have such a need to keepour patients human like you said, you said it so beautifully. So thank you for caring about their brains, caring about their swallows, keeping them comfortable keeping them progressing and about their lives. It’s honored to work with you and your whole field. We love what you do in the ICU and we’ll keep using you.
Lydia
Kali, I’m absolutely honored to be a part of this discussion and it’s my pleasure and joy to work with these patients.
Transcribed by https://otter.ai
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