by Stephanie O’Silas
Should I Pick These Patients Up?
The skilled rehab setting provides speech-language pathologists with a healthy serving of critical thinking challenges in the management of cognitive-communication impairments—especially those that are not as obvious as an overt aphasia or dementia.
This experience is common for many SLPs, particularly those working in sub-acute inpatient rehab: You arrive at work and view the new admissions for the day. In your chart review, you notice that your patient’s primary admitting diagnosis during their recent hospitalization was, for instance, diabetic ketoacidosis (DKA). There is no “traditional” speech pathology-related diagnosis that you can find directly warranting our involvement such as a recent stroke documented in the chart. To evaluate or not to evaluate?
Most influential to your screen is your knowledge of certain medical conditions that directly or indirectly affect cognitive performance/mental status. Knowledge of this kind will help you better decide if cognitive intervention will be appropriate for your patient. A skillful approach when documenting can be to choose altered mental status secondary to DKA as the primary medical diagnosis, for instance.
I’ve found it crucial in my practice to not overlook certain medical conditions that can affect cognitive performance and swallowing function. Most common in the sub-acute setting are:
- Diabetic Ketoacidosis
- Congestive Heart Failure
- Acute Kidney Injury/Failure
From a holistic viewpoint, these conditions that persist upon admission into the SNF can actually affect progress in therapy, safety and judgment, reasoning during ADLs, swallowing function, and participation in functional and meaningful tasks.
As advocates first, it is important to determine cognitive baseline through testing in order to ensure that the patient’s cognitive status will not hinder their functional participation in therapy tasks or impact their swallowing function. The direction of your treatment may be to enhance and monitor cognitive performance to prevent further decline and to facilitate a full return to prior level of function.
Some useful treatment ideas when indicated are:
- Patient education regarding the condition and management of symptoms to help the patient identify symptoms on their own and to independently express medical needs
- Orientation Training
- Facilitating Safety and Problem Solving
- Functional ADL Sequencing
- Skilled Dysphagia Treatment
Listed below are the aforementioned conditions and their potential symptoms that will assist your clinical decision making during evaluation and treatment:
Diabetic Ketoacidosis (DKA):
“Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can’t produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. Untreated diabetic ketoacidosis can be fatal.”1
- Weakness and fatigue
- Shortness of breath
- Vomiting and inability to tolerate food or liquid
Hyperkalemia (High Potassium):
This condition is noted for unusually high levels of potassium in the blood. Your kidneys help control the balance of potassium in the blood and are suppose to filter out excess potassium from the bloodstream and body. “Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Having a blood potassium level higher than 7.0 mmol/L can be dangerous and requires immediate treatment. Causes may include, but not limited to Type 1 Diabetes, Acute Kidney Injury, Alcoholism, and Chronic Kidney Disease.” 2, 3
Congestive Heart Failure (CHF):
Occurs when the heart is not able to pump blood effectively to organs of the body. The less blood provided to oxygenate major organs and muscles makes one feel tired and weak. Less blood to the brain can cause dizziness or confusion.4
- Fatigue and weakness
- Poor activity tolerance
- “Slowing down”
- Impaired simple-complex problem solving
- Impaired thought organization
Insufficient filtering of nitrogen-containing compounds in the blood usually causes Azotemia. The kidneys are usually responsible for this function, filtering the blood as well as excretion of waste products through urine and stool. Examples of nitrogen-containing compounds include urea, creatinine, and various body waste compounds.5
- Reduced Alertness
- Weakness and fatigue
- Xerostomia (dry mouth)
- Tachychardia (rapid heart rate)
- Dysphagia secondary to impaired cognitive status
Commonly experienced by our profession, dehydration is the excessive loss of vital body fluids. Mostly water and small amounts of salts are lost.6
- Dry mouth and swollen tongue
- Weight loss
Acute Kidney Injury/Failure:
By now, it is clear that healthy kidney function is very important. The kidneys are vital for filtering out waste and filtering the blood stream in order for oxygen-rich blood to oxygenate major organs including the brain. AKI can lead to many of the previously mentioned conditions including metabolic acidosis and azotemia. Acute kidney injury and kidney failure should not be overlooked for its potential to indirectly cause cognitive decline if left untreated.7
Overall, being cognizant of these medical conditions and their potential impact on cognition and swallowing is paramount in our practice. Our services may be necessary in the clinical management of these “untraditional” medical conditions that are so commonly encountered by speech-language pathologists in skilled rehab settings.
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