Counseling the Neurologically Impaired Client

1. Counseling the Neurologically Impaired Client Joanna Boettcher Speech Pathologist Kaiser Permanente – Sacramento

2. SPHP 219 • ** slides are not on the exam

3. 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. My background**

4. 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 - Home Health • Outpatient - Craniofacial Clinic

5. Practice Expansion** • 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

6. 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!

7. 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

8. Challenges of the Medical Environment • Hospital Environment • 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

9. 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.

10. 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

11. 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

12. 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

13. 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.

14. 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.

15. 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.