Speech Therapy in nursing homes

It goes without saying that the ability to communicate is important. However, communication for seniors in long-term care, expressing oneself is critical. Being able to communicate simple thoughts, like pain, hunger, thirst, or other desires can be life-saving. This is why speech therapy is critical. On this week’s episode, nursing home abuse attorneys Rob Schenk and Schenk Firm welcome Sena Crutchley, MA, CCC-SLP of the University of North Carolina Greensboro to discuss how speech therapy plays into nursing home care.

Schenk: Hello out there and welcome back. Hope you are springing into spring. My name is Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: And we are your hosts for this episode of the Nursing Home Abuse Podcast. We get calls a lot. I don’t want to say we get calls a lot. I don’t even know why I said that. I think sometimes I just have autopilot on. But oftentimes in our job, we are required to comb through medical records and in those medical records, you’ll see all kinds of things – medications, activities of daily living, etc. One of the things we see a lot are speech language pathology, dysphagia, thickened liquids, and some of these things are head scratchers. So we wanted to have an episode dedicated to what speech therapy is, what speech language pathology is, and how it actually affects the overall health and care of nursing home residents.

Smith: Yeah, it’s one of the most important aspects of their assessment is the speech language pathology session, because that tells us what they can swallow, how they can swallow it, how they can communicate, and these types of things can prevent dehydration, malnutrition and aspiration pneumonia, which are three major problems in nursing homes.

Schenk: At a minimum.

Smith: Yeah.

Schenk: But we’re not going to have this conversation with you alone. We’re going to have an extra special guest, Sena Crutchley, and Will, can you tell us a little bit about Sena?

Smith: Sure. So Sena Crutchley, she is an SLP, which is a speech language pathologist, which means she has a master’s and a certificate of clinical competency. She’s currently an AP, associate professor, and clinical educator in the Department of Communication Services in Disorders at the University of North Carolina at Greensboro, and she has served as the speech language pathologist and interim rehab director in skilled nursing facilities in North Carolina from 2012 through last year, 2019.

She transitioned to working in the skilled nursing setting after working as an SLP for 13 years in a variety of other settings. Ms. Crutchley has presented at the state and national levels about documentation, supervision and Medicare related speech language pathology in the skilled nursing setting, and we are very honored to have such a knowledgeable guest on today.

Schenk: Sena, welcome to the show.

Sena: Thank you.

Schenk: All right. Well Sena, we thought it would be important to have you on the show because oftentimes we have clients who come in due to neglect or abuse and we’re looking through the records, and through the records, we see speech therapy. We see ST.

Smith: And I think speech therapy is one of those professions that everyone is confused about and we’re ignorant about it in the beginning, because I remember the first time that I saw speech therapy, I was thinking like are you trying to teach this person how to talk correctly? And I didn’t realize the full brunt of everything that was involved in that and just how important it is. And it encompasses a lot, doesn’t it?

Sena: Right, it does.

Schenk: And so I felt like, Will and I, we’re pretty close to being laymen and I think that’s something that family members of nursing home residents probably feel too – they’re confused about what speech therapy is, so we’re glad that you’re on and we’re glad that you’re here to educate us.

Sena: Thank you.

Schenk: So that’s really the first question is in a nursing home setting, what is speech therapy?

What is speech therapy in nursing homes?

Sena: Well I appreciate this opportunity because the term, the phrase “speech therapy” is a bit misleading. Before I went into speech therapy, I really had no idea what speech pathologists did. So I’m going to use the acronym SLP sometimes for speech language pathologist just to simplify it.

Schenk: Okay.

Sena: So we evaluate and treat patients who have speech difficulty, language difficulty and swallowing difficulty. We work with patients to help them either in their short-term care at a skilled nursing facility, to help them get back to their prior level of function, so how they were before, whatever illness occurred, or at least as close as we can to get them to their prior level of function. If we have a long-term resident, then the goal is typically to help improve their safety, their quality of life, and we do this by evaluating the patients and then we collaborate with other members in interdisciplinary teams, and those team members are of course the patient, the resident, but also the other therapy disciplines like PT and OT. We work closely of course with the nursing staff, the physician. Because we work with people with swallowing disorders, we also work closely with the dietary staff. Social worker is an important part of the team. And then of course the resident’s family and friends.

We educate the staff to help identify other people in the facility who may need help, because even sometimes someone who works in the kitchen, someone in dietary may recognize someone in the dining room who coughs often while they’re eating or drinking, so it’s good to have eyes throughout the facility to help us identify people who might need our help.

Schenk: Right. I was going to say it seems like you guys are part of the team there, so to speak, in the nursing home, but in terms of what SLPs are doing, one of them is honing in on trying to evaluate and then treat swallowing or feeding disorders as opposed to something along the lines of communication disorders. So we’ll start with the swallowing and feeding disorders.

What are disorders treated by speech therapy in nursing homes?

Sena: Okay.

Schenk: What are the broad categories that we’re talking about that would affect a nursing home resident’s ability to swallow?

Sena: So there is a pretty broad range of difficulty that someone might have. So swallowing occurs at different stages, different phases, so we may have someone who may only have difficulty with chewing or maybe they had a stroke and they’re numb or very weak on one side, so they have trouble moving the food or the drink to their mouth. The muscles may be weak throughout the swallowing system, so mouth, throat, even the muscles necessary for being able to cough hard enough if something goes down the wrong pipe, which is aspiration.

So we first would identify the area of difficulty or areas of difficulty and then determine the best way to treat that difficulty, and sometimes the treatment involves therapy – therapy which is intended to restore function, so maybe improving the muscle strength, improving sensation. Sometimes it’s just in addition to compensatory strategy, so someone may need to slow down when they’re eating and may need to take a sip after each bite to help the food get down safely and efficiently. So again, we identify the area that is impacted by the swallowing deficit and then decide what’s the safest way to improve the swallowing but also keeping in mind the residents’ requests in terms of quality of life, because sometimes the strategy might be that they’re safer with thickened liquids, but the patient may refuse thickened liquids, so we always have to work with the resident to help improve safety but also make sure that their quality of life and wishes are respected.

Schenk: So can you kind of elaborate on – you used the term “thickened liquids.” What does that mean and how does that play into treating a swallowing disorder?

What does thickened liquids mean in a nursing home setting?

Sena: Okay. So if someone has trouble swallowing liquids, because liquids move very quickly, like you picture your think and you’ve got the water going down the sink, it moves quickly, so for some people, if their swallowing system is slowed, if there’s a bit of a delay, they may not be able to swallow quick enough to catch that liquid as it moves down into the throat and into the esophagus, so one way to slow the liquids down is to add some thickener.

So some places will add a thickener to the liquid. Some places are providing pre-thickened liquids of certain texture, certain viscosity so some people will be okay if the liquids are thickened to a nectar consistency, like tomato juice, but some people may really need the liquids to be thicker to move extra slow, so more like a honey consistency. And again, it helps to counteract this delay in the swallowing system. And again, if you picture your thick, if you’ve got a thicker liquid like a gravy moving down, it’s going to move slower and so it gives the person time to swallow it.

But it depends on the person. Some people do better with thickened liquids. Some people do better with thin liquids. Again, we have to identify what that particular person needs.

Schenk: That makes sense. And Sena, would you might going back – you were talking about how you want to appropriately assess a resident with a swallowing disorder, and then based on that assessment, you might do different therapies or exercises or interventions. Can you talk about what are some of the common interventions that you encounter or you would use for somebody who has a swallowing or feeding disorder?

What are common interventions for nursing home residents with swallowing disorders?

Sena: Okay, so like besides the compensatory strategies like altering the diet, really we first would look at are there strengthening exercises that we could do and that could look like a regiment that somebody would get with PT. So it’s swallowing exercises but it’s designed to strengthen the muscles of the mouth and the throat, so it might be exercises that we may add certain things like something very sour or something very salty or we may add certain things to enhance sensation if someone has some numbness after a stroke or if someone has dementia and due to the dementia, they’re not really recognizing the food or drink in their mouth, so if you add something to increase the sensation, that might help them to swallow quicker and more efficiently.

So it could be, like I said, exercises, and some places will use very high-tech systems to aid in the person completing swallowing exercises, so it could be like I worked at a facility that used SEMG, and that’s surface electromyography, and that gives a patient visual feedback, so that person would have electrodes attached and they can see on a monitor when they swallow, they can see the strength of the swallow, so that gives them feedback to guide them in improving the strength of their swallow. So like I said, it could be exercises and there are a variety of different programs that people might use, and some of that depends on the SLP’s training.

We’re seeing more often respiratory muscle strength training to help with swallowing or if someone who has a voice disorder, so that strengthens the muscles to give that person adequate force for breathing in and coughing if they need to cough out, like if something’s aspirated like I mentioned earlier.

Schenk: That’s actually a good segue. Aside from a choking hazard that comes along with the swallowing or feeding disorder, what are, if any, some major problems that can come about due to that disorder? You mentioned aspiration – can you elaborate what aspiration is?

What is aspiration? Why is this a problem with nursing home residents?

Sena: Sure. So actually everybody aspirates every now and then. Aspiration technically means if something that isn’t supposed to go into the lungs, like food or drink, reaches down below the vocal cords.

Smith: It goes down the wrong pipe.

Sena: I’m sorry?

Smith: It goes down the wrong pipe, yeah.

Sena: Correct. Exactly, yeah. So that’s technically aspiration. And then like the average person, if you’re healthy, you’re able to cough it up or your body manages to absorb it and you’re fine. And we might aspirate even, you know, our saliva. But if you have someone who either aspirates a lot of whatever isn’t supposed to be going into the lungs or they’re medically fragile, then their body may not be able to handle whatever is aspirated and that could lead to aspiration pneumonia. So that’s a big complication and there are several factors that tie into that, so it’s not just something going down the wrong pipe but there are several other things that can lead to aspiration pneumonia, like if the person doesn’t have good oral care, so like if they don’t take good care of their mouth so there’s lots of bacteria in there, that increases the risk of aspiration pneumonia. And then besides that, like in nursing facilities, there’s worry about if people lose weight, so if someone isn’t able to safely eat enough to sustain themselves, then that creates this issue of weight loss and the person become more medically fragile, and so then that becomes a downward spiral.

Smith: Yeah, one of the things I’ve noticed is – and to me, I think the fault lies with the CNAs or just them not following through on what they’re supposed to, and I say this as I used to be a CAN, I know it’s a hard job.

Sena: Oh, yeah.

Smith: But when you’ve got somebody who speech pathology has said, “Hey, this person’s on thickened liquids,” in a lot of times what I would see happen is essentially instead of liquids, they’ve got this pudding mixture and they eventually get dehydrated because the staff gets tired of trying to get them to swallow it or doesn’t show enough patience, because if you can’t intake fluids, that’s even worse than not being able to take in nutrition in many ways.

How does thickened liquid factor into nursing home resident nutrition and hydration?

Sena: Yeah. I mean that’s a really smart observation on your part about dehydration. So that is a big risk. So when I work in a skilled nursing facility and I talked about deciding for each resident what would be best for them. You have to consider dehydration. And so like thickened liquids technically, as long as a person drinks enough, they should be able to stay hydrated, but the issue is will the person drink it? Will they have access to the liquids? You were talking about almost like a pudding consistency, and some people do need that consistency, but it’s just so important for us to educate the staff and keep observing to make sure that the resident is getting enough intake if they’re not able to access it themselves so that they stay hydrated.

Smith: And that they’re follow you all’s orders, because what you would see a lot of times, and they may have gotten rid of everything but the pre-thickened liquids, but they used to have this thickener agent, and it would be up to the staff to thicken it to the right consistency and I don’t know that there was enough communication in some places. I don’t know there was enough communication with the staff to say, “This is what honey looks like. This is what nectar looks like.” And you put too much of that stuff in there and it’s like thick apple sauce.

Sena: And it’s interesting because they have even studied SLPs in how we mix thickened liquids if it’s not something pre-thickened. And even SLPs, we’re not consistent. So all of the facilities I have worked at use pre-thickened liquids so that there’s no guesswork, so it says nectar, you know it’s nectar, it says honey, you know it’s honey.

Schenk: Yeah. So Sena, we’ve kind of talked about swallowing and feeding disorders. What about the concept of communication disorders? What is communication disorder and how does an SLP deal with that in a nursing home resident?

What are common communication disorders treated by speech therapy?

Sena: Okay. So language disorder in a nursing home resident generally would be considered aphasia. So aphasia is an acquired language impairment and we would see that typically in someone with a stroke, someone who had a head injury, but if you have someone with dementia and their general cognition and their language is declining, usually you wouldn’t cause that aphasia. You might, but you would call that a cognitive linguistic impairment, and the severity depends on what is causing the language difficulty. So someone might have had a mild stroke in the left brain and maybe they just have difficulty recalling words or recalling the names of things, but you can have someone with a massive stroke and they’re not able to understand the directions that the staff tells them. They’re not able to understand if you’re asking them questions, and they may not be able to produce sentences or even words, so it depends on the injury and the extent of it, but also other factors like their pre-existing skills and other underlying general health and cognition.

With speech, if you have someone who’s had a stroke, they may have what we call dysarthria, and there are different kinds of dysarthria, so someone might have slurred speech but someone might have a strained quality, and some people, you may know that there’s something a little different with their speech but they’re still pretty easy to understand but you could just have someone with a severe dysarthria or an apraxia, which is difficulty with planning how to say what you want to say, so your brain can’t quite get the message to your mouth and your other speech muscles to be able to say what you want to say. So they could be someone whom you’re not understanding anything, and in that case, we would do intensive speech therapy, like also you might need to give them some kind of communication board if they can write. Maybe they can write what they want or need. They might be able to point to a picture of what they want or need.

So for some people with the swallowing, we would deliver skilled therapy services to improve their speech and their communication, the language, but you may also need to give them some kind of alternative way to communicate for their safety. So like if they’re in pain, you want them to be able to tell you they’re in pain and where and to what extent.

Schenk: That makes sense. So just from a broad standpoint, and this might sound like it’s intuitive, but how does the actual communication improvement affect the overall health of the nursing home resident?

How does a resident’s communication skills improve overall health?

Sena: I think that’s a really good question because sometimes I’ve noticed in my years of skilled nursing that patients are very focused on walking. They want to walk, and don’t appreciate as much the ability to communicate. But once you lose the ability to communicate, you really appreciate that you can’t say what you want, you can’t say what you need, and I think about one resident who I worked with in particular who for quite some time was not able to communicate at all and was struggling with some of the things that we were feeding this person, so this person had some global difficulties. And then after several months, the person went out to the hospital and had a shunt put in and drained fluids off the brain and this person came back and was able to tell us what she liked and what she didn’t like in terms of what she ate, so that to me is a really good example of, “Oh man, we were giving this person” – for example – “ketchup on something and now we’re finding out they hate ketchup.”

So it could be something as simple as this person likes this, this person doesn’t like that. So that’s a quality of life thing, being able to say what you prefer, what you don’t want, and it’s also a safety issue, so the person, like I said, being able to tell you they’re in pain, being able to tell you that they’re feeling a little bit dizzy and they’re not ready to get up for physical therapy.

It’s important for social connectiveness, so one issue for people who have aphasia, so that language impairment, is that they’re sometimes socially isolated. So we hear about residents who have difficulties communicating and they have lost friends and family members over time. They don’t visit as much because they don’t know how to communicate with the residents, and we know that will impact quality of life if you lose those relationships and social connections. So communication is so important for that aspect, and I mean, like you said, intuitively I would assume that your general health is better supported when you have social connections and when you have family visiting you and friends visiting you, even if communication is a struggle.

Smith: And it’s very clear for those that are in this field and hopefully it’s very clear for people who are listening now how important SLPs are. So just – we’re almost out of time, but just briefly, do you have a sense of what the market is like for SLPs? In other words, there’s always a shortage of CNAs in Georgia. Do you find the same for SLPs across the nation?

Is there a shortage of nursing home speech pathologists?

Sena: That’s a really good question because I think it’s been changing over the years and now that I’m faculty and graduating students, I should really be in tune with what the market is like. But I can tell you that I have had students over the past few years who I’ve supervised in nursing facilities who didn’t have any difficult finding work after they graduated, so the work is out there. So that tells me that there is probably still somewhat of a shortage, but it’s not as bad as it was several years ago.

Schenk: Sena, can you touch on a little bit about what type of training and what type of certification SLPs need to acquire before they can go out to the long-term care setting?

What type of training or certification is required to be a speech pathologist?

Sena: Okay. So you have to have your master’s degree to practice, and so it just depends on your training. Sometimes the master’s degree program will be a two-year program, sometimes a three-year program, but yeah, you need to have your master’s degree, and most of us, maybe all of us would have the national association certifications, so the National Speech, Language, Hearing Association, so we have our certificate of clinical competency from ASHA, and then your state licensure. And then there may be other specific skills that the person would need to be trained to do certain therapies, but that wouldn’t necessarily be required to work in a skilled nursing facility.

Schenk: There you go. Well we often recommend to family members of nursing home residents to get to know the nursing home staff, get to know the CNAs, get to know the nurses, get to know the director of nursing, and now I’m adding the speech language pathologist to that list of people that you should probably know if your loved one is being treated for that.

Sena: Yeah, exactly.

Schenk: Sena, you have been an excellent resource for this and we really appreciate you coming on the show and sharing your knowledge with everybody.

Sena: Thank you so much. I appreciate the time and the interest, so I really appreciate it.

Schenk: Thank you.

Smith: Yeah, speech language pathology is – I really think as a marketing subject, they need to maybe change the title of what that is because I think a lot of people get confused when they hear speech language, and it’s not “My Fair Lady.” It’s not like where he’s trying, he’s the bachelor, the English gentleman who’s trying to teach…

Schenk: I feel like we’ve done this before, but I think I understand what you’re saying.

Smith: He’s trying to teach Liza how to speak properly. It’s not that. It also involves…

Schenk: Oh, right, right, right. Like literally, one of those exercises where you – alliteration.

Smith: Elocution or whatever.

Schenk: Yes, yes. No, I got you.

Smith: Where you’re trying to… Alliteration is the – gosh.

Schenk: More than one consonant over and over again.

Smith: Right, right. This is just a hard morning.

Schenk: We’re meandering.

Smith: But no, it involves the ability to intake food. It involves the ability to avoid dehydration and malnutrition.

Schenk: Which are potentially lethal conditions.

Smith: They’re some of the worst and most common occurrences in nursing homes. And aspiration pneumonia – those three things right there, and aspiration pneumonia where something goes down the wrong pipe and you’re not strong enough to cough it out of your lungs, dehydration and malnutrition are major problems in nursing homes, and speech pathology is the gatekeeper to try and avoid that.

Schenk: That’s right. So we really appreciate Sena coming on and sharing that knowledge with us.

Smith: Yeah.

Schenk: I’ll point this out, that Will received two accolades from asking good questions. I only got one.

Smith: Right.

Schenk: So Sena evidently liked Will’s questions more than she liked my questions, which is – I don’t know, I feel like that’s pretty average. That’s an average week. That happens a lot.

But that is actually going to complete this episode of the Nursing Home Abuse Podcast. So Will, you’re walking down the street, all right? Somebody comes up to you, grabs you by the shoulders and yells into your face, “How in the world do I listen or watch the Nursing Home Abuse Podcast?” What do you say to him?

Smith: Well I wonder if we’re not missing anything and the answer to this is changing to how people get podcasts, but if it hasn’t changed and we’re not too old to keep up with the trends, you can go to iTunes, which is…

Schenk: No, you can’t go to iTunes anymore. As of 2019, last year, as of last year, iTunes does not exist.

Smith: Okay. We’ll not an Apple user.

Schenk: Well you know, you could go to the jukebox and type in Episode…

Smith: I’ve never had iTunes so I didn’t know. But you can still go to Stitcher. You can still go to Spotify.

Schenk: Spotify.

Smith: You can still go to YouTube.

Schenk: Wherever you get a podcast.

Smith: Yeah, YouTube is where I get most of mine.

Schenk: And the gentleman that approached you in the street says, “That’s not good enough. I want more out of this.”

Smith: Then I would say go to NursingHomeAbusePodcast.com.

Schenk: Okay.

Smith: Which is you can go straight to the source.

Schenk: Go straight there.

Smith: You can watch the videos and you can read the transcript as well.

Schenk: That’s right. That’s right. Or the YouTube channel, if YouTube still exists.

Smith: Yeah. A year from now.

Schenk: That’s right. And with that, we will see you next time.

Smith: See you next time.