Animal Assisted Therapy Takes You To The Heart Of The Matter

  

Happy Birthday, franki

Today is franki's birthday. In case you haven't learned from previous posts, he is my registered therapy dog. Eight years ago, Dr Linda Buettner started Florida Gulf Coast Pet Partners, and franki and I were among the first teams to be registered. Dr Buettner, now living in North Carolina, was not only an animal lover, but also a researcher in the area of Alzheimers and Dementia.

She knew from her own clinical research and that of others, that Animal Assisted Therapy could enrich the lives of older adults at home and in nursing homes.

Over the last 8 years, franki has brought me straight to the heart of many of my patients and others we have visited. As we make our way down the halls of the nursing home the grumpiest nurses smile, the quietest patients make eye contact, and for others, franki serves as the cue for them to share stories about their own lives and pets they loved. As for franki,  any pet partner will tell you, their animals take the work seriously. He has tolerated being hugged a bit too tightly by psychiatric patients, drooled on by a few others, and as he gets older, I notice him looking longingly at the resident's bed, hoping for an invitation to hop in and nap.

The unconditional love that all pet owners experience, seems to be the ingredient  that is infused into pet visits with a patient. Last year I was working with a woman, Nancy, who had language problems from several previous strokes. She loved to talk, but as a listener, it was difficult to follow the content of her speech as she flitted from topic to topic, never quite finishing a thought. One day, during a visit in which I was accompanied by franki, she began telling me a story of how she started an animal assisted therapy program in Miami, where she had lived much of her life. Knowing Nancy's  proclivity for confabulation and story telling, I listened with a skeptical ear. Perhaps sensing my doubting, or to re-live the experience again, she demanded that I pull a large photo album off a bookshelf. As we began to turn the pages together, there ,in photos and article after article was the documentation of her work of introducing animal assisted therapy to her community over 30 years ago. 

We talked about her work, and  how now, many years later that she was on  the receiving end of a pet visit. Her words are poignant, and reminded me that we health care providers often know very little about the lives and history of our patients. Giving them the time and the opportunity to share those narratives, whether talking to us or our pets, may serve to calm and reassure them of their value still in life.

Watch Nancy's video below:

For more information about becoming a Pet Partner, please visit:

http://www.deltasociety.org/



Tips For Communicating After Stroke When Yes is No and Right is Left

Last month while visiting my family, my aunt suffered a stroke. The stroke occurred on the left side of her brain, resulting in right sided paralysis and language problems (aphasia). During the first week of her hospitalization, while she was still in ICU, my mom and I went to visit her. My aunt was awake, but obviously dazed, and unsure of what had happened or where, exactly, she was.

Contributing to my aunt's apparent confusion, was the usual ICU clamor of nurse's conversations, phones ringing, other patients and their families talking, and televisions set to the local news station.

Adding to all of the activity, the physician on call came for a visit. He was pleasant enough, but after a brief introduction, and with no prior knowledge of my aunt, he set about with his bedside exam of sensory testing. "close your eyes," he instructed. "Now, tell me, am I touching your right or left?" My aunt opened her eyes, as if  trying to understand what he was asking. "no, no, close your eyes, he instructed." And once again, he delivered his series of questions: " am I touching the right the left? " "Can you feel it, yes? no?" I could tell that my aunt was unable to follow the line of questioning, and as is typical of individuals soon after a stroke, her answers were unreliable. The physician, now appearing frustrated by his attempt to glean a clear response, left her bedside. My aunt turned to me with a bewildered look, and said: "I am so confused."  The most relevant statement the physician needed to hear as it clearly reflected her current state.

Patients recovering from stroke are bombarded with daily questions from hospital staff and visitors, which often adds to their overall confusion and frustration.  If you have a family member or friend who has recently suffered a stroke and is now experiencing difficulty understanding or using language below are some tips for easing the communication frustration:

•  If the individual uses hearing aids or glasses be sure they are available and being used by staff members. Frequently families will leave hearing aids at home not wanting them to get lost. While I understand the concern, not being able to hear AND not being able to understand or use language is only going to compound the patient's confusion and delay language recovery.
• Limit your use of "yes/no" questioning to simple, closed-end questions. For example, rather than asking: "do you want to get up in the chair or stay in bed?"  Ask: "do you want to sit in the chair?" Adding head nods and other gestures, pointing to the words: yes/no, may also help to obtain a more reliable response.
• Orient the individual daily and frequently. Hospital staff members should all be wearing name tags. It might also be helpful for family members to  wear a name tag when visiting so as to eliminate quizzing about names that the individual cannot easily retrieve.
• A note pad or wipe off board can be used to chronicle visitors and daily events. So, now, instead of asking about the day, you can initiate and orient by saying: "oh, I see___ came for a visit today", or" PT had you up in the chair today."
• Meals may be the best use of your visiting time as nursing is often short handed. If you visit following a meal and notice a green bean still in the individuals mouth or  they are having frequent choking and coughing, alert the physician or nurse to a possible swallowing problem.
• Turn the TV off when visiting and, and select programming carefully. Do you really want CNN or Fox news to be the stimulation a recovering brain is receiving?

Recovery from stroke can be a long journey of months, and for an individual with aphasia the early weeks can be frustrating, confusing, and scary.  Your reassurance and simple communication can help support recovery.

For additional information abut aphasia visit: http://www.aphasia.org/

Communication Impairments Contribute To A Nursing Home Patient's Confusion

According to MedPage Today, Two high-ranking senators asked the Centers for Medicare and Medicaid Services (CMS) to take a closer look at potential over prescribing of antipsychotics to nursing home residents. The drugs in question are being used in nursing homes to control behavioral problems related to dementia. Reportedly the senators are urging CMS to consider requiring that physicians, who off-label prescribe drugs with black box warnings to seniors, certify that a Part D provider will cover the drug.

If CMS followed the senators' advice, Medicare payments for antipsychotics that "lack a medically-accepted indication" should be drastically reduced, the senators said.

Although cost savings to Medicare seems to be the intent behind the senators request, and overuse and misuse of any sort of medication for nursing home residents desirable, one can't help but wonder what resources the Senators will be willing to suggest CMS provide to nursing homes so that they are better able to manage resident's maladaptive behavior in a non-pharmaceutical way.

For example, hearing aids are not a covered benefit to Medicare recipients, despite the fact that hearing loss is the third most prevalent chronic condition in older Americans, and it is the number one communicative disorder of the aged; between 25% and 40% of the population aged 65 years or older is hearing impaired  and age related hearing loss ( presbycusis) as high as  80% in seniors 85 years or more.

(source: http://www.asha.org/research/reports/hearing.htm)

If one adds to hearing loss a speech and language impairment resulting from stroke or other neurological diagnosis, or related to dementia, one might see that there could potentially be  an escalation in behavioral problems among persons not able to communicate basic wants and needs, including pain.

Although an assessment of a resident's speech and hearing is required by nursing homes desirous of Medicare reimbursement, a speech-language pathologist, the best qualified to make judgements about an individuals communication abilities, is not always the one making that judgement.

I cannot tell you the countless times I have walked into an elderly patient's room in a hospital or nursing home and the patient is extremely hard of hearing, and without hearing aids. As I shout my way through the interview, I wonder how many more staff members have come in and out of the patient's room making comments, asking questions, and providing information that was never heard or understood by the patient. It is not hard to imagine how that sort of confusion along with an unfamiliar environment could easily lead to inappropriate patient behavior.

Management of Medicare spending is a reality, but decisions by CMS that are more politically driven than clinically motivated will not be good for anyone.

The International Classification of Functioning, Disability and Health (ICF) was established by WHO, 2001. It is a model that promotes evaluation of the interaction between a person's health condition (disease/disorder) and the environmental and personal factors (among them sensory functions) that serve as facilitators or barriers to functioning. Patient with dementia as well as other neurodegenerative diseases would benefit from periodic evaluations, which includes  an assessment of their communication . Nursing homes would benefit from the resources to meet those needs, and in doing so, the role of medications, including the need for psychotropic drugs might be better elucidated..

Parkinson's Speech and DBS: Where Is The Speech Pathologist When It's TIme To Program?

Last weekend , while participating in a Parkinson's retreat, I had the opportunity to meet a number of people who are now post DBS ( Deep Brain Stimulation) surgery. The numbers of individuals receiving DBS are definitely growing, and I am seeing more post DBS patients within my own private practice and also at many of the conferences or other Parkinson's events I participate in. I have heard many stories and testimonials about the remarkable motor improvement that has been achieved following this surgery, including, for some the difference between being in a wheelchair to being able to walk easily. Unfortunately, I am also beginning to know if someone is post DBS in the first few moment of our conversation, because so many now following surgery also have some speech impairment, or what is referred to as (dysarthria).

Dysarthria is a motor speech impairment, usually characterized by speech which may be slurred, faster than normal, and/or sometimes with stuttering-like problems. These changes to speech are a bit different than the speech and voice problems we usually associate with idiopathic Parkinson's disease, such as the soft or breathy voice, and consequently may not be as easily changed or improved by just being cued to be "loud". In fact,  speech improvement post DBS seems most responsive to subtle tweaking and changes in the actual programming itself. So, now my BIG GRIPE.

Over the last two years when presenting at any Parkinson's conference, I always ask for a show of hands indicating how many people were referred to a speech-language pathologist following their diagnosis of PD. Without exception, the dismal show of hands is usually around 5% of the people present. When talking face to face with individuals exhibiting dysarthria following DBS surgery, the percentage of individuals who have been evaluated or treated by a speech-language pathologist is even less. Some patients seem embarrassed to even be admitting to me that their speech is less than desirable, and others admit that when they have brought it up to their neurologist, it has been met with a questioning gaze, the covert message: "aren't you satisfied yet?" At a recent support group meeting, a woman told me that when she raised concerns about her speech/voice to her physician, he responded: "your speech is the least of your worries." I was outraged to hear this, and her voice conveyed a sense of shame and resolve that perhaps she should just be satisfied and not seek further improvement.

This blog  post is not meant to be an indictment against DBS, and as noted earlier, I have been witness to many a wonderful story about improved quality of life following DBS surgery. But this is meant to be a call to action for patients to discuss this issue with their neurosurgeon and neurologist before the procedure, and to DEMAND a consult with a speech-language pathologist as a routine part of the evaluation prior to undergoing DBS and following the surgery. If changes in speech or breathing or swallowing are something you have observed following DBS surgery, than your speech pathologist should be invited to participate in the programming sessions. Only a licensed speech-language pathologist familiar with neurogenic diseases is going to be able to distinguish  if speech difficulty is a problem of motor strength, coordination or some emergence of a dystonia. A pre-DBS evaluation of speech and swallowing will help to distinguish a new problem that is related to the surgery.

A  baseline speech and swallowing evaluation at the time of your initial diagnosis of Parkinson's Disease, which includes a video recording, may be the best way to judge progress from treatment, decline from disease progression, or changes that come about in response to any other  medical or surgical intervention.

For more information regarding DBS, please visit:

http://www.dbs-stn.org/

Parkinson's and Your Voice: A Prescription For Well Being

It is less than four hours since I left the Western Pennsylvania 6th annual Parkinson's Wellness retreat. I am  now sitting in the airport  dealing with flight delays  which include the possibility that I may not get home until well after midnight tonight. While it's tempting to get cranky, the mood of the weekend is simply too strong within me to allow anything to shift my mood to the negative. So, after a brief recitation of the serenity prayer...I am ready to share with you my experience from the weekend...and what an experience it was.

Of the many conferences or other events organized for people with Parkinson's disease that I have participated in or attended over the last 4 or 5 years, this was magical. Many of the conference organizers have been attending the retreat since it's inception six years ago, and it is evident that they brought clear intention to the design of the program. Each preceding retreat , it seems, has  deposited energy into the ground and like sacred compost , has resulted in an incredible meld of beautiful surroundings, warmth and friendship and a relevant educational program.

For the first time at a PD event, there were none of the depressing lectures that  typically detail the myriad of symptoms that can occur through the course of the disease, and their corresponding  pharmaceutical fix.The physical symptoms of speech and swallowing were discussed by me and my colleague, Dr Roxanne Diez Gross,  but the information, techniques and strategies  for managing symptoms were placed into the broader context of  the "Treatment Triangle". The "retreat-ment triangle, to be exact, which emphasized that participants  be: informed, present and centered.

 Meditations led by Deborah Grice Conway,PhD, a clinical psychotherapist  set the tone for each day, and Paul Short,PhD, a neuropsychologist  helped to place speech and voice issues into the  bigger realm of communication. Communication that takes place with partners and other family members, professionals, and most importantly, with self , as he reminded participants that you are more than your Parkinson's.

It is hard for me to identify a favorite moment from the weekend, but, being a dancer at heart, I would have to say that the Saturday night contra dance caused the magic dust to start sprinkling down. Some enjoyed the music from the sidelines and others braved the dance floor. A young woman who had informed me earlier  that she didn't think she could manage to dance given the fact that she typically uses a rolling walker, suddenly appeared across from me on the floor, walker no where in sight. As my hand reached for hers across a moving star I knew  that she too was a dancer at heart.  A couple,Vera and John, were dragged by me reluctantly to the dance floor. "we'll fall, exclaimed Vera, we're both unsteady on our feet," but as I handed her off to one of the gents and swept up John as my partner, he could not wipe the smile off his face, and of course, neither fell.

Other organizations planning conferences could learn alot from the folks in PA. They really" get it."  They clearly not only understand, but truly believe that individuals with Parkinson's and their families need to know how to stay whole. To learn how to manage  physical symptoms while honoring the spirit.

I didn't want to leave....and I can only hope that they will invite me back.
Namaste

Living Well With Parkinson's Disease

In one more day I will be leaving for Western Pennsylvania, where I will be participating in the sixth annual Living Well With Parkinson's Retreat.

Last weekend I created a power point presentation incorporating the theme of the weekend: Self-Management of Parkinson's Disease. Specifically,  conference organizers hope to emphasize that participants be informed, be centered, and be present. Towards that goal, I decided to share a few of my preliminary thoughts on this matter:

Be Informed: Know the disease and it's symptoms.

As many as 90% of people with Parkinson's Disease (PD) may develop a speech and voice disorder.

As many as 95% of people with PD may develop a swallowing disorder.

To protect dopamine cells, exercise should start as early as possible, yet, patients receive referrals to physical and speech therapy only 12 - 16% of the time. Voice Aerobics was begun in 1999 as an after therapy program designed to provide ongoing practice and strengthening of voice after formal therapy was completed.

Be Centered: "Know Yourself"

Patients are NOT all alike. The art and science of speech and voice therapy must integrate evidenced based research with a patient's individual abilities and goals. Speech therapy is NOT a "one size fits all."

Appropriate treatment for for voice and speech disorders should address the underlying  physiology that causes the impairment.

Successful treatment will include whatever approaches help YOU to reach your goals.

Be Present: "Know Others"

The nature and the quality of the relationship between the patient and the health care provider is critical to the treatment outcome.

The art and science of speech and voice therapy asks:

Why did the patient come to therapy?

What is the patient's perception of the problem?

It is essential to build up a patient's sense of personal responsibility. Unrealistic expectations and over stringent criteria can set a patient up for failure.

What Are Your Goals?

A community based program or a home program which provides visual and verbal cues can prevent individuals from returning to baseline immediately after completing speech or physical therapy. A guided program which requires no memorization and offers ongoing cueing can allow patients with mild dementia to practice independently and lessen caregiver and care partner responsibility.

Be Present: "Know Others"

"Voice is the essence of who we are". Use all of the methods available to preserve and improve  your voice.

My Mission:

To enlist individuals in their treatment, and to help them express their personality and spirit through voice. To educate and empower.

 Mary Spremulli,MA,CCC-SLP