Editor’s note: This text-based course is a transcript of the webinar, Assessment of Cognitive-Linguistic Skills: The SLP's Role in Acute Care, presented by Lisa Mechler, CCC-SLP.
After this course, participants will be able to:
- List at least 2 rationales for assessing cognitive-linguistic skills of patients in the acute care setting.
- Identify at least 3 cognitive skills that are targeted during cognitive assessment and treatment.
- Describe 2-3 ways to formally and/or informally assess cognitive skills in the acute care setting.
Introduction and Overview
Welcome everyone. It's a pleasure to be here with you today to discuss the assessment of cognitive-linguistic skills and the SLP's role in acute care. This is a topic that is near and dear to my heart, so I appreciate you all being here.
Today, we'll discuss a brief overview of cognitive-linguistic skills and their assessment in acute care. We'll talk about why assessment of cognitive skills is important in acute care. We'll also review a couple of formal cognitive assessments and then we'll jump into our informal cognitive assessments. Towards the end, we'll discuss interdisciplinary care and discharge planning, and then review a brief case study before we conclude.
As SLPs, we work with patients on a variety of different disorders in acute care. Of course, our role may differ, depending on the patients and their needs at the time. However, I do think it's important for us to keep cognitive-linguistic impairments on our radar when we're considering patients' needs.
What is a Cognitive-Linguistic Impairment?
First of all, it's important to know that no two cognitive impairments are alike, and that the same injury or site of lesion can result in drastically different symptoms across patients. Generally speaking, a cognitive impairment can include difficulty with attention, initiation, insight, memory, judgment, reasoning or problem-solving. We may also see patients who have reduced safety awareness, as well as individuals with emotional lability or a pragmatic deficits.
As we know, a cognitive impairment is not just a list of symptoms. It can affect many facets of a patient's life. As such, it's important for us as speech pathologists to remember what these deficits can mean for a patient in his or her daily life. We need to look at a patient's ability to complete activities of daily living (ADLs), such as bathing, feeding and toileting. We also look at a person's ability to complete instrumental activities of daily living (IADLs), such as grocery shopping or managing finances. These are the tasks that go beyond basic personal care and that allow us to function independently in the world.
The following is a list of the possible functional repercussions of a cognitive impairment, including (but not limited to):
- Inability to complete basic human needs (e.g.: bathing, eating, etc.)
- Difficulty managing household (e.g.: cleaning, cooking, etc)
- Mismanagement of finances
- Missed appointments (Social, medical, work, etc.)
- Loss of employment
- Loss of relationships
- Loss of independence
I want to draw your attention to the last bullet point on that list: loss of independence. Patients who have cognitive impairment may begin to rely on others to complete some basic tasks for them. Well-intentioned family members may jump in and assume these responsibilities for our patients. One of our main goals as SLPs is to help facilitate independence for our patients. Therefore, it's important to look at the functional impact of their newly acquired deficits, and also support the patients as they cope with this loss of independence.
Of course, we know that cognitive impairments can accompany TBIs and strokes, but there other diagnoses that result in possible cognitive impairments as well. These other diagnoses include:
- Parkinson’s disease
- Brain tumor
- Aneurysm rupture
- Heart failure
- Acute hepatic encephalopathy
- Metabolic processes
I'd like to mention that the term encephalopathy is an umbrella term that encompasses any change in cognitive function. There are many different reasons for a general encephalopathy, such as medication-induced cognitive changes. It's important to determine the etiology, or the cause, of a cognitive impairment in our patients. We need to be sure that the diagnosis and the etiology weren't skilled therapy intervention, because with some of these encephalopathies, medical management is the only way to address the impairment.
Cognitive Impairment vs. Delirium
Along those lines, I want to take a moment to differentiate between a true cognitive impairment and delirium. As clinicians in acute care and even SNFs, we're probably used to seeing delirium all the time. But it's important for us to be able to determine what's delirium versus a true cognitive impairment, because we could give a patient with delirium all the therapy in the world, but it likely will not make a functional impact.
- Cognitive impairment usually presents consistently. In other words, every time we go to see the patient, their deficits are pretty consistent or constant. With delirium, patients fluctuate a great deal, even sometimes minute to minute.
- With cognitive impairments, usually medical management is not helpful in reversing the condition, whereas medical management of delirium can be helpful.
- Both cognitive impairments and delirium have acute onset, especially if we're talking about acute care.
- The patient with a cognitive impairment doesn't have any clouding of consciousness, meaning they're alert and typically able to participate in therapy. On the other hand, the consciousness of a patient with delirium can be impacted.
- With both, typically more than one cognitive domain is impacted, but the differentiation here is that with delirium, patients usually have high levels of disorganized thought. Every minute they're talking about something different, and they're highly nonsensical.
- With a cognitive impairment, attention may or may not be affected, whereas with delirium, usually those patients have very high levels of inattention.
Importance of Cognitive-Linguistic Assessment
According to ASHA, our role is to identify patients' strengths and deficits related to cognition and their related language components, as well as diagnose a cognitive disorder. We can also make recommendations for ongoing speech therapy treatment and recommendations for referrals to other providers.
So far, we've talked about the who and the what of cognitive impairments. Now, I'd like to look at why it's important to assess cognition in acute care. I've heard many reasons why some clinicians don't address cognitive disorders in this setting: the patients are changing too quickly, they may have too many medical issues to benefit from therapy, or there are too many distractions. Some of these reasons may very well be true, but let's take a look at some of the research that supports our early involvement.
First, we'll look at the research about strokes. Studies show us that patients often demonstrate an acute global cognitive decline after a stroke (Levine et al., 2015) and that many patients who have no or few visible deficits may actually have an underlying cognitive impairment (Jokinen et al, 2015; Tatemichi et al., 1994). They can be identified with further testing.
Other research shows us that some patients have an increased rate in cognitive decline after a stroke (Levine et al., 2015) and that strokes can result in both early onset dementia and delayed onset dementia (Mok et al., 2016). Over time when considering patients who come in and out of the hospital, the acute care setting may be our opportunity to identify cognitive impairments in some of these patients. Last but certainly not least, cognitive impairments are a risk for dependent living after a stroke (Tatemichi et al., 1994). As we discussed earlier, as SLPs, our role is to facilitate independence and we can't do that if we're not assessing cognitive skills early and then referring patients to the appropriate ongoing therapy after their hospitalization.
Parkinson's disease is another condition that is highly correlated with cognitive impairment and decline (Walton et al., 2017). Even at the time of initial diagnosis, patients may have a mild cognitive impairment. Because participation in social and cognitive activities reduces the risk of further decline, it only makes sense that we get involved early. Patients with heart failure also often demonstrate a mild cognitive impairment (Agarwal et al., 2016; Huynh et al., 2016). For whatever reason, this impairment often goes unnoticed with this population. However, these cognitive impairments are significant enough that they increase of patients risk for readmission to the hospital or even death. Research shows us that completing caregiver education reduces the risk for readmission to the hospital, which at the very least we can complete in the acute care setting