Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4523_Библиотеки_им_академика_М_И_Перельмана
.pdf
Interdisciplinary Collaboration for a Client with Alzheimer’s Disease
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
physical therapy staff, occupational therapy staff, ac tivities staff,
nursing, dietary aides, and housekeeping. To maximize functional carryover of communication strategies, the clinician
6
facilitated creation of reminiscing books
based on photos and
personal memorabilia items provided by JK’s spouse. Additional
high-interest items for discussion were introduced via the use
7
of technology items, such as the It’s Never 2 Late (iN2L)
Google Earth.
8
and
Signage was also created and placed at key touch points
within JK’s room to help prompt the completion of desired tasks
and to assist with memory of necessary appointments, relevant
safety precautions, etc. As accommodations were implemented
to address JK’s cognitive-linguistic deficits, his spouse and caregivers reported improved engagement and acceptance of care.
Functional communication strategies allowed for increased
socialization and participation in facility activities designed to
offer both cognitive stimulation and physical exercise. Prior to
completion of skilled speech-language pathology services, the
clinician provided final recommendations and strategies to
maximize functional ability in the form of a functional maintenance plan for JK’s caregivers and provided education on monitoring for future changes in functional communication and
other speech-language pathology–related areas as JK’s medical
condition progressed.
75.7 Key Points
●
Effective care plan development for individuals with Alzheimer’s disease and other forms of dementia requires both
informal and formal assessment of functional abilities to
ensure interventions will be meaningful to the individual and
translate into daily living.
●
Speech-language pathologists working with clients with
dementia must operate as part of a larger interdisciplinary
team that addresses functional concerns in a holistic manner
to maximize functional outcomes and carryover.
●
Technology and environmental modification can assist clinicians in creating environments that offer context and direction in the absence of direct communication partner cueing.
●
When addressing current functional deficits in the context of
progressive neurological disorders, the speech-language pathologist must also provide extensive education to caregivers
and offer insight regarding the future speech-language-swallowing needs as the underlying illness progresses.
Suggested Readings
[1] Brookshire RH, ed. Introduction to Neurogenic Communication Disorders.
8th Ed. St. Louis, MO: CV Mosby; 2015
[2] Giebel C, Challis D. Translating cognitive and everyday activity deficits into
cognitive interventions in mild dementia and mild cognitive impairment. Int
J Geriatr Psychiatry. 2015; 30(1):21–31
References
[1] Alzheimer’s Association. 2017 Alzheimer’s Disease: Facts and Figures 2017.
Available at: https://www.alz.org/documents_custom/2017-facts-and-figures.pdf. Last accessed January 14, 2018
[2] Mansbach WE, MacDougall EE, Rosenzweig AS. The Brief Cognitive Assess-
ment Tool (BCAT): a new test emphasizing contextual memory, executive
functions, attentional capacity, and the prediction of instrumental activities
of daily living. J Clin Exp Neuropsychol. 2012; 34(2):183–194
[3] Helm-Estabrooks N. Cognitive Linguistic Quick Test. San Antonio, TX: Psy-
chCorp; 2001
[4] World Health Organization. International Classification of Functioning, Dis-
ability and Health (ICF). Geneva: World Health Organization; 2001
[5] Murry L, Paek E. Behavioral/nonpharmacological approaches to addressing
cognitive-linguistic symptoms in individuals with dementia. Perspect ASHA
Spec Interest Groups. 2016; 1(15):12–25
[6] O’Shea E, Devane D, Cooney A, et al. The impact of reminiscence on the qual-
ity of life of residents with dementia in long-stay care. Int J Geriatr Psychiatry.
2014; 29(10):1062–1070
[7] It’s Never 2 Late (iN2L) [Adaptive engagement/rehab technology] 2017. Cen-
tennial, CO, www.iN2 L.com
[8] Google Earth [Computer program] Version 7.1.5.1557. Mountain View, CA:
Google; 2013
299
Efficacy of Transcranial Direct Current Stimulation in PTSD
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
76 Efficacy of Transcranial Direct Current Stimulation in
Posttraumatic Stress Disorder
Jyutika Mehta
76.1 Introduction
Posttraumatic stress disorder (PTSD) is a psychiatric disorder
that can develop after exposure to a traumatic event and affects
approximately 3.5% of the adult population in the United States,
and is recognized as global mental health concern.
working memory are observed in PTSD.
reduce the neurological resources available to PTSD patients
and can impact their ability to engage in and respond to
treatment with associated negative occupational and social
outcomes.
3,4
2
1
Deficits in
Memory problems
76.2 Clinical History and
Description
ZM, a 40-year-old male, is a military veteran and diagnosed
with combat-associated PTSD presented with memor y-related
deficits. His presenting concern was difficulty with word recall,
which often led to anxiety in social and professional situations.
A history of combat-related psychological counseling was
reported. There was no history of head injury with loss of consciousness, no neurological or psychiatric condition other than
PTSD, no presence of deep brain stimulator, no history of alcohol/drug dependence, or seizures. ZM was prescribed Zoloft
(50 mg/day) for anxiet y and for mild-to-moderate depression.
He was married and his wife reported episodes of difficulty
recalling names of familiar friends and family members as well
as appropriate words in conversations, which led to frequent
frustration and social disengagement.
depression symptoms. It is a self-administered, 21-item survey
that is scored on a scale of 0 to 3 in a list of four statements
arranged in increasing severity about a particular symptom of
depression. Quality of life measurement extends beyond measures of disease and pathology and captures important aspects
of survey participants’ daily social contexts. Primary and secondary outcome measures were administered 1 week prior to
transcranial direct current stimulation (tDCS) sessions and 1
week after the 12th treatment.
76.4 Questions and Answers for
the Reader
1. What is tDCS?
a) Transcranial direct current stimulation.
b) Transcranial direct cranium stimulation.
2
c) Transdermal direct current stimulation.
d) Transformational direct current solution.
Answer: a is correct. Transcranial direct current stimulation
(tDCS) is a noninvasive brain stimulation treatment that uses
direct electrical currents to stimulate specific parts of the brain.
b is incorrect. “c” in tDCS is current.
c is incorrect. “t” in tDCS is transcranial.
d is incorrect. “t” in tDCS is transcranial and “s” is stimula-
tion.
2. How does tDCS work?
a) By getting the neurons to fire.
b) By altering neuron polarity.
c) By changes in action potential.
76.3 Clinical Testing
The primary outcome measure was Wechsler Adult Intelligence
Scale (WAIS; Fourth Edition).
ces: Verbal Comprehension Index (VCI), Perceptual Reasoning
Index (PRI), Working Memory Index (WMI), and Processing
Speed Index (PSI). The VCI is designed to measure verbal reasoning and concept formation. The PRI is designed to measure
fluid reasoning in the perceptual domain with tasks that assess
nonverbal concept formation, visual perception and organization, visual-motor coordination, learning, and the abilit y to separate figure and ground in visual stimuli. The WMI measures
sustained attention, concentration, and executive functions,
while the PSI is an indication of the rapidity with which simple
or routine information is processed. All the indices were calculated as standard scores with a mean of 100 and standard deviation of 15. The secondary outcome measures were changes on
(1) Beck Depression Inventory-II (BDI-II)
Organization’s Quality of Life Questionnaire-Brief Version
(WHOQOL-BREF).
7
BDI-II is a screening instrument to quantify
5
The test scores provide four indi-
6
and World Health
Answer: b is correct. tDCS causes polarity-dependent alterations in cortical excitability and activity.
a is incorrect. tDCS does not get neurons to fire but may pos-
sibly increase their likelihood of fir ing.
c is incorrect. tDCS does not influence action potential, but
may bring about subthreshold modulation of resting membrane
potential.
3. What is working memory?
a) A type of memory used in procedural tasks.
b) A type of short-term memory.
c) A type of long-term memory.
Answer: b is correct. A part of short-term memory that is concerned with perceptual and linguistic processing.
a is incorrect. Working memory is primarily used in linguistic
tasks.
c is incorrect . Working memory is part of short-term memory.
4. What is 10–20 International EEG placement?
a) Recognized method to apply scalp electrodes.
300
Efficacy of Transcranial Direct Current Stimulation in PTSD
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
b) Recognized method to study EEG.
c) Recognized method to study neuronal topography.
Answer: a is correct. The International 10–20 system is a recog-
nized method to describe and apply the location of scalp electrodes. This method was developed to ensure standardized
reproducibility so that studies could be compared over time
and subjects.
b is incorrect. Although used to collect EEG, it is not necessa-
rily a method to study EEG.
c is incorrect. This method can be used to locate appropriate
underlying neuronal tissue based on scalp topography, but its
primary purpose is to determine electrode placement.
76.5 Description of Problem and
Recommended Treatment
A substantial proportion of individuals with PTSD show limited
benefit from pharmacological and/or behavioral therapy, and
this seems especially true for PTSD-related memory dysfunction. Moreover, pharmacological management often has serious
side effects and may lead to poor compliance. Studies have evaluated the efficacy of existing approaches in management of
PTSD, and these treatments may have better acceptability in
PTSD patients if fewer side effects were noted. In the present
case, no serious adverse effect was noted during or after application of tDCS and the patient exhibited improvement in memory measures and overall PTSD symptoms.
Clinical use of tDCS has been reported in the treatment of
psychiatric and neurological conditions and has demonstrated
Fig. 76.1 dLPFC corresponds to electrode F3 position on the 10–
20 International system of electrode placement.
facilitation of improvements in cognition and working mem-
8
tDCS involves application of weak direct electrical currents
ory.
to the scalp via sponge electrodes to polarize underlying neurons, which leads to changes in cortical excitability. It is theorized that this excitability extends beyond the period of stimulation. Through this polarity-dependent shift, low-intensity dc
current influences neuronal function by inducing neurochemical changes and influences nonneuronal cellular components of
the central nervous system.
For ZM, tDCS was applied thrice a week (MWF) for 4 weeks
for a total of 12 sessions. Anodal electrode was placed over the
left dorsolateral prefrontal cortex (dLPFC) and cathodal electrode was placed on contralateral (right) shoulder according to
the 10–20 EEG placement system (▶ Fig. 76.1). This electrode
montage was adopted because anodal tDCS of the dLPFC is
8
known to enhance working memory.
Precise positioning of
electrodes ensures that current is directed to appropriate neuronal tissue. Intensity of current was maintained at 2 mA for
30 minutes during each visit. ZM was monitored throughout
the session and asked to report any adverse effect like scalp
pain, tingling, itching, or any other discomfort. He did not
report any adverse event during the treatment. ZM continued
with counseling and medication regimen during the treatment
sessions.
76.6 Outcome
ZM showed remarkable response to tDCS treatment sessions.
Improvement in working memory as well as marked reduction
Table 76.1 Results of tDCS treatment sessions
Scale Preinter-
Verbal Comprehension Index
Perceptual Reasoning Index
Working Memory Index
Processing
Speed Index
BDI-II 19 (border-
BDI-II, Beck Depression Inventory-II.
a
Scores are standard scores with mean = 100 and SD = 15. Verbal
Comprehension Index and Perceptual Reasoning Index did not change
significantly, while Working Memory Index and Processing Speed Index
showed significant improvement. BDI scores improved depression
classification from borderline clinical depression to mild mood
disturbance.
vention
score
a
101
a
92
a
75
a
82
line clinical
depression)
Postintervention
score
a
105
a
95
a
98
a
95
12 (mild
mood disturbance)
Interpretation
Overall verbal comprehension scores
remain unchanged
Overall nonverbal
reasoning scores
remain unchanged
Improved significantly
Improved significantly
Improved significantly
301
Efficacy of Transcranial Direct Current Stimulation in PTSD
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
in anxiety and depression symptoms appears to have made significant positive impact on the patient’s quality of life. Results
were qualitatively analyzed and summarized in ▶ Table 76.1.
Overall, verbal comprehension and nonverbal processing did
not change as a result of tDCS. However, working memory and
processing speed showed significant improvement as a result of
tDCS intervention. Specifically, the WMI index improved by
over 20 points (over 1 SD), which can be considered a meaningful clinical gain. BDI-II scores were also lowered considerably,
resulting in a change of category from “borderline clinically
depressed” to “mild mood disturbance.” Further, ZM reported
increased interest in daily family and social routines, as well as
noticeably less difficulty with word recall. His wife reported
similar outcomes and stated that ZM appears to be happier and
“not as frustrated” leading to a “more harmonious” social interactions and relationships. WHOQOL-BREF responses showed
improvement across all domains and a marked reduction in
avoidance of social interaction.
76.7 Key Points
●
tDCS appears to have improved ZM’s ability to recall and
resulted in an increase in the rate and in the total amount of
recovery of memory functions.
●
Although the results in this case are based on single participant and should be interpreted with appropriate caution,
such findings can provide empirical evidence upon which a
larger clinical trial can be developed.
●
Novel approaches are needed to address concerns in the neurorehabilitation field. If noninvasive brain stimulation such as
tDCS, either singly or in combination with other therapeutics,
is found to accelerate rate and/or extent of neurocognitive
recovery, it will have wide-reaching application in both cost
of rehabilitation and quality of life.
Suggested Readings
[1] Baddeley A. Working memory: looking back and looking forward. Nat Rev
Neurosci. 2003; 4(10):829–839
[2] Jasper HH. Report of the committee on methods of clinical examination in
electroencephalography. Electroencephalogr Clin Neurophysiol. 1958; 10(2):
370–375
References
[1] Friedman MJ, Keane TM, Resick PA, Eds. Handbook of PTSD: Science and Prac-
tice. New York, NY: Guilford Press; 2015
[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013
[3] Wrocklage KM, Schweinsburg BC, Krystal JH, et al. Neuropsychological func-
tioning in veterans with posttraumatic stress disorder: Associations with performance validity, comorbidities, and functional outcomes. J Int Neuropsychol Soc. 2016; 22(4):399–411
[4] Geuze E, Vermetten E, de Kloet CS, Hijman R, Westenberg HG. Neuropsycholog-
ical performance is related to current social and occupational functioning in
veterans with posttraumatic stress disorder. Depress Anxiety. 2009; 26(1):7–15
[5] Wechsler D. Wechsler Adult Intelligence Scale. 4th ed. San Antonio, TX: Pear-
son; 2008
[6] Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II.
San Antonio, TX: Psychological Corporation; 1996
[7] The WHOQOL Group. Development of the World Health Organization WHO-
QOL-BREF quality of life assessment. Psychol Med. 1998; 28(3):551–558
[8] Fregni F, Boggio PS, Nitsche M, et al. Anodal transcranial direct current stimu-
lation of prefrontal cortex enhances working memory. Exp Brain Res. 2005;
166(1):23–30
302
77 Management of Patients at End of Life
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Joseph Murray
Management of Patients at End of Life
77.1 Introduction
The frail elder experiences physical decline and reduced
capacity to adapt to stressors. Those stressors may include multiple disease processes, iatrogenic effects of pharmaceutical
treatments for the medical problems as well as the intangible
effects of isolation, loss of a spouse, exhaustion of caregivers,
and difficulty in organizing and completing health care directives. In the elder with failure to thrive (FTT), the decline is frequently more dramatic than a single diagnosis and the synergy
of stressors may lead to unexplained weight loss, malnutrition,
and functional deficits.
77.2 Clinical History and
Description
FH was a 90-year-old man with a history of heart disease, mild
signs of Parkinson’s disease (PD), hypothyroidism, gastroesophageal reflux disease, severe esophageal dysmotility, cervical
spondylosis, and kyphosis. FH was in a normal state of health
and living alone until 1 year ago when he was seen at the emergency department on several occasions related to falls at home
resulting in chronic paraspinal and cervical muscular pain.
Shortly thereafter, FH was admitted following a fall at his home.
He was unable to right himself and was stationary for 2 days
until a neighbor found him. He was admitted to a local hospital
and underwent a short period of inpatient rehabilitation. Following discharge, FH moved in with his 88-year-old ex-wife
who served as his primary caregiver. She had her own health
concerns, including heart disease, chronic obstructive pulmonary disorder (COPD), and progressive dementia.
FH’s pharmacological management included medications for
heart disease and Sinemet for PD. Notably, he was prescribed
opioids for chronic pain for the cervical spondylitis and new
muscular and orthopedic pain from the recent fall. Several
months following discharge, he was readmitted for dyspnea and
suspected aspiration pneumonitis versus pneumonia following
witnessed aspiration during an emesis event and subsequent
difficulty handling oral secretions. He complained of increased
pain and increasing dysphagia. He underwent an extensive evaluation including computed tomography of the neck, laryngoscopy,
barium esophagram, esophagogastroduodenoscopy, and modified barium swallow (MBS). He was made NPO (nil per os, “nothingbymouth”) and percutaneous endoscopic gastrostomy (PEG)
feedings were initiated. He was discharged home after declining
placement in a rehabilitation facility.
Two months later, he was readmitted following a fall. He
was in severe pain related to the fall and pain management
was challenging (▶ Fig. 77.1). Although he received enteral
feeding at the designated rate and volume, he had lost weight
(▶ Fig. 77.2). His symptoms related to PD had progressed with
increased cogwheeling and rigidity. His Sinemet dose was
increased, and he again declined rehabilitation placement and
was discharged home. Several weeks later, his PEG tube became
dislodged. He was admitted for replacement of the PEG and was
severely dehydrated with moderate nutritional compromise
thought to be related to chronic diarrhea. His tube feeding was
adjusted and he was rehydrated following a short stay and was
discharged home. A synopsis of the course of his workup is provided in ▶ Table 77.1.
Fig. 77.1 Weight during period of decline.
303
Management of Patients at End of Life
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig. 77.2 Pain ratings recorded during period of
decline.
Table 77.1 Testing and results
Testing Result
Neck CT (3/28) No evidence of acute fracture or cortical disruption
Anterior osteophyte complex at C5–C6
Thickening of piriformis
Recommend ENT evaluation
Laryngoscopy
(3/28)
Visible stream of secretions being aspirated
Does not cough or respond to the secretions in any way
Distal pharyngeal soft-tissue fullness
Placed gastroenterology consult
Gastroenterology EGD (3/29)
Grade B esophagitis
Dilation with food in the entire esophagus
No apparent structural outlet obstruction, lesions, or
strictures
Recommended barium esophagram
Barium
esophagram
(3/30)
Severely limited examination secondary to patient
condition and kyphosis
Severe aspiration of contrast
Tertiary contractions and stasis of contrast with
severe dysmotility
Recommendation for dedicated speech pathology
oropharyngeal exam
Clinical swallowing evaluation (3/31)
Speech/voice
●
Hypophonia with wet dysphonic quality
●
No festination of speech
●
No dysarthria
Sensorimotor exam
●
Unable to produce volitional cough
●
Generalized weakness of oromotor systems
●
Sensory system normal
●
Increase in adventitious airway signs with ice chips/
water sips
●
Recommend modified barium swallow to confirm
findings
Modified
barium swallow (3/31)
Confirmation of anterior cervical osteophytes at C5–C6
Generalized weakness of propulsive components of
swallow
Moderate/severe postswallow retention
●
All bolus textures midpharynx
Table 77.1 continued
Testing Result
●
Without subsequent spontaneous clearing swallows
Silent gross aspiration of all boluses greater than 2–
3 mL in volume
●
Cued coughing ineffective in clearing aspirant
Recommendation for short-term NPO status with
enteral feeding until patient becomes more robust
with reassessment for readiness to initiate safe oral
feedings
Clinical swallowing evaluation (4/3)
Largely unchanged from previous assessment
Patient lethargic and not requesting oral intake
Recommend palliative care consult to evaluate goals
of care
Failing to thrive and in a state of terminal frailty
Family meeting is called
Patient is unable to participate in meeting due to
somnolence
Goals of care reviewed with family who decide that
full code and all life-sustaining efforts be enacted in
continued care for patient
EGD (4/4) Externally removable PEG placement successfully
completed
Clinical bedside
exam (7–21)
Somnolent but awake and interactive
Paucity of speech but requesting food and liquid
Speech/voice
●
Grossly hypophonic with severe wet dysphonic
quality
●
No festination of speech
●
No dysarthria
Sensorimotor exam
●
Unable to produce volitional cough
●
Generalized weakness of oromotor systems
●
Sensory system normal
Increase in adventitious airway signs with ice chips/
water sips
CT, computed tomography; EGD, esophagogastroduodenoscopy; ENT,
ear, nose, and tongue; NPO, nil per os, “nothing by mouth”; PEG,
percutaneous endoscopic gastrostomy.
304
Management of Patients at End of Life
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
77.3 Questions and Answers for
the Reader
1. PEG tube feeding in an adult with FTT is guaranteed to result
in the following:
a) Improved nutrition and hydration.
b) Direct delivery of nutrients into the enteral system
bypassing the oral route.
c) Increase in weight.
d) Pain and suffering on the part of the patient.
Answer: b is correct. Food and liquid are delivered via a tube
into the stomach bypassing the oral cavity. Although aspiration
of food and liquid may not occur, patients with enteral feeding
tubes can still aspirate oropharyngeal secretions and/or aspirate
refluxed materials. In some patients, including elders with
dementia, enteral feeding is not protective for aspiration pneumonia, reduced length of hospital stay, or mortality.
a is incorrect. This response is sometimes tr ue, but not guaranteed. Enteral feeding formulas may offer enough calories and
nutrients, but may not be processed in the same way food is.
Further, the anabolic systems that combine to convert nutrients
into glucose may become aberrant in patients with certain diseases leading to catabolic processes where the body preferentially converts stored fats and muscle into glucose instead of
nutrients that enter the alimentary system through the mouth
or even a feeding tube.
c is incorrect. Some patients may gain weight. Some patients
may lose weight as a result of diarrhea, which is a common side
effect of nonoral feeding.
d is incorrect. Although some patients find nasogastric tube
feeding and PEG placement unpleasant, others find that it is tolerable and preferred to the chronic discomfort associated with
aspiration events and/or fatigue that may occur during meals in
particularly weak patients.
2. In an adult patient, FTT is defined as:
a) An expected functional outcome from a primary disease
diagnosis such as lung cancer or diabetes.
b) Progressive debility after common and reversible causes
of frailty are detected and seemingly managed.
c) A state of socioeconomic poverty with an inability to pay
for expensive health care.
d) A state of diminished health resulting from noncompli-
ance with medical regimens.
Answer: b is correct. Frail elders frequently present with symptoms that are more severe than expected given existing, known
disease and/or other health conditions. Typically, their symptoms are outsized and not fully explained following seemingly
effective treatments.
a is incorrect. Typically, the decline of the patient and inability to recover from a reversible condition is out of line with the
presentation of a single disease.
c is incorrect. Socioeconomic stressors can contribute to and
amplify functional disability in a frail elder. It is not typically a
singular cause of FTT.
d is incorrect. Even patients who are closely managed and
monitored in modern health care systems can become frail and
suffer from intractable decline in physical function.
3. Short-term tube feeding may result in improved outcomes
for elderly subjects with acute but reversible health deficits.
a) True
b) False
Answer: a is correct. Some frail patients may “bounce back”
after a short period of improved nutrition and rehabilitation.
All efforts should be made to help the patient regain enough
functional reserve to return to baseline. It is important to communicate that enteral feedings are reversible and to be sure that
the patient and family are well informed regarding the intent of
short-term enteral nutrition.
b is incorrect. Although some patient populations (i.e.,
demented elders) have been shown to have worse outcomes
with enteral feeding, considerable evidence suggests that many
patients do well with the associated improved nutrition.
4. Decision making at the end of life …:
a) Can be guided by a well-constructed decision-making
chart.
b) Is based on the number of disease processes present and
the degree of debility of the patient.
c) Should be individually constructed and determined by the
patient and family after an informed discussion.
d) Should be left to the professional medical team.
Answer: c is correct. Sustaining autonomy and dignity at the
end of life are essential.
a is incorrect. Each patient should be treated as an individual
with unique value systems and requirements for sustaining dignity at the end of life. Some patients require complete
autonomy and direction to sustain dignity at the end of life.
Others may require the consensus of a family group. Principals
in making decisions may demonstrate resolve to engage in
complete life-sustaining treatment only to change their mind as
they reflect further and integrate information and witness the
burden of life-sustaining treatments.
b is incorrect. Projections of the timing and nature of death
are difficult to predict.
d is incorrect. Medical professionals should guide an
informed patient through treatment options and to deliver
those treatments and procedures in a way that sustains dignity.
77.4 Description of Disorder and
Recommended Treatment
MBS revealed generalized weakness of the propulsive components of the swallow resulting in retention of the bolus in the
pharynx (i.e., postswallow residue). An anterior cervical osteophyte complex obstructed bolus transit with reduced pharyngeal clearance. FH’s generally inefficient pharyngeal stage, likely
secondary to PD and the presence of cervical osteophytes, synergistically resulted in bolus retention. Both components were
evident and perceived by FH, but were not clinically significant
when he was stronger and possessed adequate functional
muscle reserve. In that context, he maintained his weight and
overall health. The immobility resulting from his recent fall,
pain, and iatrogenic effect of reduced sensorium related to the
opioid pain management likely contributed to reduced functional reserve and debility. Intervention in the form of enteral
305
Management of Patients at End of Life
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
feeding was appropriate initially. Some patients regain the
functional reserve necessary to sustain safe oral intake after a
short bout of enteral feeding during acute illness. Other patients
may continue to have trouble managing pain and/or may not be
capable of undergoing aggressive rehabilitation. These patients
may spiral into further loss of function and debility related to
the acute stressor (i.e., the fall), the baseline effect of multiple
comorbidities (i.e., a mild form of PD, cervical osteophytes, and
COPD), and iatrogenic effects of pharmaceutical management
for pain (i.e., reduction in sensorium and somnolence with
immobility).
77.5 Outcome
FH was readmitted shortly thereafter with a urinary tract infection, dyspnea, and suspected pneumonia. Although previously
ambulating with a walker, he was now nonambulatory at home.
His caregiver reported that she was unable to assist in his activities of daily living. He was identified as failing to thrive. FH was
somnolent, but when awake and interactive, he requested oral
intake at times and the family wished to comply with this
request. A clinical bedside examination of swallowing was performed with identical findings from previous visits. The issue of
pleasure feeds was initiated by the speech pathologist, which
led to further discussion with the palliative care team regarding
goals of care. A family meeting ensued and FH was subsequently admitted to a hospice care center where he expired
surrounded by family shortly after admission.
77.6 Key Points
●
Multiple, mild comorbidities and polypharmacy following an
unrelated acute event, such as a fall, may result in a functional
profile that is marked by greater impairment than would be
expected.
●
Patients and families may not agree when to initiate end-oflife care. The care team should be sensitive to these unique
perspectives and allow patients and families to make
informed choices.
●
Enteral feeding may have a favorable short-term effect in
some patients and allow for recovery of strength to allow for
rehabilitation.
●
Some patients may acquire aspiration pneumonia even when
NPO and receiving enteral feeding secondary to aspiration of
oropharyngeal secretions or aspiration of tube feeding secondary to dysmotility or reflux.
Suggested Readings
[1] Abraham RR, Girotra M, Wei JY, Azhar G. Is short-term percutaneous endo-
scopic gastrostomy tube placement beneficial in acutely ill cognitively intact
elderly patients? A proposed decision-making algorithm. Geriatr Gerontol
Int. 2015; 15(5):572–578
[2] Hwang TL, Lue MC, Nee YJ, Jan YY, Chen MF. The incidence of diarrhea in pa-
tients with hypoalbuminemia due to acute or chronic malnutrition during
enteral feeding. Am J Gastroenterol. 1994; 89(3):376–378
[3] Periyakoil VS. Frailty as a terminal illness. Am Fam Physician. 2013; 88(6):
363–368
306
Augmentative and Alternative Communication for a Client with Broca’s Aphasia
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
78 Augmentative and Alternative Communication for a
Client with Broca’s Aphasia
Amber Thiessen
78.1 Introduction
This case history focuses on the process of implementing augmentative and alternative communication (AAC) intervention
for improved functional communication and life participation
for EB, a woman with aphasia. Many people with aphasia experience chronic language deficits that affect their life participation. Often, these individuals benefit from the use of AAC
supports, including speech-generating devices, low-technology
communication books and boards, and various techniques and
strategies to maximize their communication.
78.2 Clinical History and
Description
EB was a 68-year-old woman who suffered left hemisphere cerebrovascular accident resulting in Broca’s aphasia. Approximately 10 months ago, EB was admitted to a local hospital presenting with right-sided weakness and difficulty speaking.
Computed tomography scan revealed an ischemic stroke in the
left middle cerebral artery. EB received appropriate medical
treatment and was later evaluated to determine the extent of
her deficits. Assessment revealed symptoms consistent with
Broca’s aphasia, including the production of short, agrammatic
utterances and difficulty with written expression. Her expressive language was significantly more affected than her receptive
language. In addition, EB presented with right-sided hemiplegia
resulting in an inability to use her right arm and difficulty
ambulating.
EB received inpatient therapy for 8 weeks focused on
improved language expression and physical functioning. During
this time, she regained function in her right leg; however, her
language deficits and hemiparesis of her right arm persisted.
She then transitioned back to her home with her husband,
a retired teacher. Prior to her stroke, EB was an active member
of her community. She regularly attended social outings with
her friends and enjoyed spending time with her t wo adult children and her grandchildren. Since retur ning home, EB had
become increasingly isolated. She spent most of her time at
home, but expressed a desire to return to her previous hobbies
and social schedule. As such, EB began receiving outpatient
speech therapy to address her ongoing communication deficits
and part icipation limitations.
78.3 Clinical Testing
EB underwent a comprehensive assessment including the
Aphasia Quotient portion of the Western Aphasia Battery-
1
Revised
achieved a 48.2 with characteristics consistent with her diagnosis of Broca’s aphasia. In addition to formal testing, informal
assessment was performed to determine which modes of com-
to determine the severity and type of aphasia. EB
munication EB spontaneously utilized to communicate. EB
relied most on verbal production; however, facial expressions
and gestures including referential pointing were also observed.
EB did not spontaneously attempt to draw to express herself,
and when prompted to do so, she was reluctant. Additional
informal assessments were completed to examine EB’s literacy
skills and ability to recognize objects depicted in images. EB
recognized sight words with 85% accuracy during a picture–
word matching test; however, she demonstrated more difficulty
when attempting to write common words (e.g., lamp, table).
EB and her husband were also interviewed to better understand her communication needs and the support network currently in place. Specific information gathered included important topics of conversation, hobbies and interests, and social
roles (e.g., parent, spouse, friend). In addition, EB and her husband were questioned about the people with which she communicated and the environments in which she frequented
before and after her stroke as well as communication situations
that were most challenging since the stroke.
78.4 Questions and Answers for
the Reader
1. What type of AAC intervention would be most appropriate
for EB?
a) Unaided AAC strategies only.
b) Low-technology AAC supports only.
c) High-technology AAC supports only.
d) A combination of unaided and high- and low-technology
AAC supports.
e) EB is not an appropriate candidate for AAC intervention.
Answer: d is correct. Like most people, EB communicates in
a variety of settings about a range of topics with communication partners ranging from strangers to family members. Creating an intervention plan that incorporates various aided and
unaided AAC techniques and supports will allow her to meet
her diverse communication needs more effectively. For example, for individuals who are more familiar with EB’s communication style, unaided strategies paired with existing speech may
be effective; however, for people who are less familiar with EB,
aided forms of AAC including high- and low-technology supports may be necessary. Having several options available will
allow EB to choose the most effective strategy to express herself
in a variety of situations.
a is incorrect. Unaided AAC st rategies include gestures, facial
expressions, and other methods of communication that do not
require external supports. Although unaided AAC methods
would benefit EB, this technique alone will be insufficient to
meet her needs.
b is incorrect. Low-technology AAC supports include communication books and boards and other nonelectronic communication aids. Although low-technology supports would be
307
Augmentative and Alternative Communication for a Client with Broca’s Aphasia
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
beneficial for EB, solely using these supports would not be sufficient to meet EB’s diverse communication needs.
c is incorrect. High-technology AAC supports, also referred to
as speech-generating devices, are electronic devices that produce synthesized speech output. The benefits of using hightechnology supports are numerous; however, there are times
when they may not be the most efficient or effective choice. For
example, EB may be able to produce a gesture or use a lowtechnology communication book more effectively in certain
instances than finding that information in a high-technology
AAC system. Having several options available will allow EB to
use the most effective communication strategy for each situation.
e is incorrect. EB still has some preserved natural speech;
however, she frequently experiences communication breakdowns that limit her ability to participate in everyday activities.
Because she cannot meet her functional communication needs
through natural speech alone, EB is a candidate for AAC intervention to augment her existing communication capabilities.
2. When is it appropriate to implement AAC strategies for
someone with aphasia?
a) Early in the recovery process.
b) Six months after stroke.
c) One year after stroke.
d) When the client asks for it.
e) It is never appropriate.
Answer: a is correct. AAC intervention is designed to support
the immediate and future needs of individuals with complex
communication disorders such as aphasia. As such, AAC should
not be considered a treatment of last resort. Instead, supports
should be identified early in the treatment process and should
be modified as the individual makes gains in therapy.
b and c are incorrect. Speech therapy for aphasia can be
broadly divided into restorative and compensatory treatment
approaches. The goal of restorative intervention is to reduce the
language impairment experienced by a person with aphasia by
restoring their level of functioning as closely to their prestroke
state as possible. The goal of compensatory intervention is to
compensate for the language deficits experienced by people
with aphasia. AAC is a compensatory treatment designed to
allow people to participate functionally in situations and environments that require communication. It is essential that clinicians focus both on restoring lost function and compensating
for current and future deficits to improve their clients’ function
and to give them a way to communicate with their language
deficits.
d is incorrect. Clinicians should consider their client’s wishes;
however, many clients are not aware that AAC is an option.
Hence, it is essential that clinicians provide their clients with
any and all appropriate treatment options to maximize recovery and well-being.
e is incorrect. AAC inter vention is appropriate for any client
who cannot meet his/her functional communication needs
through natural speech. For those with residual capabilities,
AAC can be used to augment current communication, and for
those with ver y little speech communication, AAC can be used
as an alternative communication method.
3. Why is it beneficial to have a family member or close friend
involved in the assessment and treatment process for someone with aphasia?
a) So they can be provided information about the vocabulary
and communication needs of the person with aphasia.
b) So they can learn how to modify their own communica-
tion style to more effectively communicate with the person with aphasia.
c) So they can learn how to maintain the AAC supports used
by the person with aphasia.
d) All of the above.
e) They should not be part of the assessment and treatment
process.
Answer: d is correct. Family members and close friends play a
critical and often multifaceted role in supporting the communication of people with aphasia. They have intimate knowledge of
vocabulary needs and can serve as informants regarding communication needs. Family members and friends also provide the
day-to-day support necessary for AAC system maintenance. In
addition to these roles, family members and close friends need to
learn how to modify their own communication style to ensure
that the personwith aphasia comprehends their messages.
a is partially correct. The family members and friends of people with aphasia can act as communication informants by
describing potential topics and environments/situations in
which the person with aphasia needs to be able to communicate. However, their role is not limited to providing this type of
information, so this answer is only partially correct.
b is partially correct. Many people with aphasia experience
deficits in receptive language. As such, communication partners
often must modify their own communication style to ensure
that the person with aphasia can comprehend their messages.
This requires training. Clinicians must provide family and
friends with training on ways to augment their communication
(e.g., writing key words, lowering speaking rate). Providing augmented input is only one reason why family and friends should
participate in the assessment and treatment process; therefore,
this answer is only partially correct.
c is partially correct. Formal therapy time is limited for
most people with aphasia. Hence, family members and friends
often are called upon to provide the support necessary to
maintain AAC systems (e.g., adding/removing photos and content, technical maintenance). Clinicians must train family
members and friends to assume this role, and being active
participants in the therapy process can be beneficial.
Although AAC system maintenance is an important function
served by family and friends, it is not their only role, so this
answer is only partially correct.
e is incorrect. The input of family members and friends is
tant for assessment and treatment planning. Their input
impor
can be beneficial when designing AAC support, and they might
be needed to assist in system maintenance once formal therapy
has ended.
308
Соседние файлы в папке Библиотека им академика М.И. Перельмана