Most clinicians working in a rehabilitation setting are aware of the common complications that can arise if diabetes is not appropriately managed, but are we aware of ALL the possible complications and comorbidities that come with diabetes? One complication that does not really stand out is cognitive impairment. We often associate cognitive impairment/decline with aging, dementia, stroke, etc. Diabetes is not one of those conditions that automatically sparks “cognitive impairment”, or speech therapy, as a potential need.
As of 2020, the Centers for Disease Control (CDC) estimates that 34.2 million Americans (10.5% of the U.S. population) are currently living with diabetes. Of those 34.2 million people, 7.3 million people are undiagnosed!Clinicians know that living with and managing diabetes can be a complicated and daunting task. Diabetes management is so much more than just “checking your sugar.” Per the Mayo Clinic, persons currently living with diabetes are also at a greater risk for cardiovascular disease, neuropathy, nephropathy, retinopathy, foot damage, foot damage, hearing impairment, Alzheimer’s Disease, and depression. All of those things sound familiar, right? We must be willing to ask ourselves, ‘Are we giving our patients all of the tools to be successful at home when their inpatient stat is over? Are we looking at the whole person?’ Although both individuals and their physicians are increasingly aware of cognitive decline in relation to diabetes, this awareness still lags behind that of other diabetes complications.
In recent years, several different governing bodies have started to come out with recommendations and guidelines regarding diabetes and cognitive impairment.
Per Biessels and Whitmer in 2019, the recommendations have two main general components: (1) cognitive impairment in individuals with diabetes should be actively sought for, because unrecognized cognitive impairment is associated with adverse health outcomes, and (2) findings should lead to an individualized diabetes management regimen, compatible with the individual’s capabilities, generally with more lenient treatment targets and simplified treatment regimens to improve treatment compliance and reduce treatment-related risks.
Here is a summary of the guidelines from the Endocrine Society Clinical Practice Guidelines in 2019: Perform cognitive screening inpatients 65 years and older. Repeat every 2 to 3 years after a normal screening test result for patients without cognitive complaints or repeat 1 year after a borderline normal test result. In patients with diagnosis of cognitive impairment, simplifying medication regimes and tailoring glycemic targets (i.e., less stringent) is suggested. As with any type of guidelines, implementation and follow up can be a challenge.
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What can we do for inpatient rehabilitation patients with diabetes that we suspect have some degree of cognitive impairment?
Refer to speech-language pathology! The inpatient rehabilitation setting lends itself to interdisciplinary team communication and management which only improves patient outcome and successful home discharges. A large portion of patients with diabetes may not have a diagnosis that warrants an automatic referral to speech therapy. It is important to note that occupational therapy can address cognitive impairment in patients as well, but it can be beneficial to get a speech-language pathology referral to address cognitive impairment for more intensive treatment. Occupational therapy has a laundry list (sometimes literally!) of items to address during an inpatient rehabilitation stay and a referral to speech-language pathology can take some of those items off their clinical plate so they can focus on upper extremity strength/coordination, as well as activities of daily living (bathing, dressing, etc.), and the ever-present toileting tasks such as toilet transfer and personal hygiene.How can you secure a speech therapy referral for diabetes?
It is simple: COMMUNICATE AND DOCUMENT. When doing the thorough chart review prior to the initial evaluation, take note of not only the reason for admission (or the immediate known problem), but also take note of the patient’s comorbidities, most recent hospitalization trends, and discharge support system (if noted in the chart). These items will not only help you provide more comprehensive treatments and interventions for the patient, but it will also give you a better idea of the “big picture” for the patient.
Take note and DOCUMENT any type of increased difficulty with organization, sequencing, problem solving, or memory that is occurring during things like bathing, dressing, toileting, and ambulation. All disciplines of therapy can comment on cognition – even physical therapy! COMMUNICATE with the attending physician and speech department to secure the referral for a formal cognitive evaluation by the speech-language pathologist even if you are ‘on the fence’ about the need for more formal cognitive intervention. It is better to make the referral and have the evaluation completed with no formal interventions needed than to not have it completed it all.
Why make a referral for speech therapy for someone with diabetes?
It is becoming increasingly well known that speech-language pathologists do much more in their clinical practice than just focus on functional communication. Speech-language pathologists address impairments in attention, memory, processing, problem solving, and executive functioning. Within those areas falls medication management, which is a known issue that people with diabetes can struggle with.
Medication noncompliance can occur for a variety of reasons such as the medications making the patient feel ill, forgetfulness, decreased organization, financial constraints, and a general misunderstanding of the importance of being compliant. The Agency for Healthcare Resource and Quality has a resource page for people transitioning to the community in regards to medication management and can be found here. These are some great resources, but it is important to note that sometimes more than just compensatory strategies are needed.
Speech therapy can utilize evidence-based treatments for cognition that can improve the person with diabetes’s ability to manage medication and utilize those strategies – what good is a pill box or planner if the patient does not know how to utilize it appropriately? The American Congress of Rehabilitation Medicine (ACRM) has published an evidenced based manual of cognitive therapy interventions that range from impairments in attention and memory to impairments in insight and executive functions. These interventions can assist with laying the cognitive groundwork needed to implement a successful medication management system or program.
As outlined above, speech therapy can serve an integral role in the treatment of patients with diabetes… but including the SLP is not where the buck stops for a comprehensive treatment plan.
Including the patient’s support system day 1 is also an important part of setting up the patient for success. The caregiver needs to be just as educated and involved regarding the patient’s cognitive impairment as the patient themselves and their treatment team. This education and training can be completed throughout the course of the patient’s stay and must involve the interdisciplinary treatment team.
Involving your facility’s pharmacist in the caregiver education and training is critical to setting up a medication management system for success. The caregiver being able to demonstrate teachback of the information being taught is an important point – make sure they are not just nodding along with you! Ensure both the patient and the caregiver know how to operate the glucometer, administer insulin, and all the other moving parts that go into diabetes management. Educate and train not just once, but OFTEN!
Diabetes is a multifaceted chronic condition that requires not only management from the patient, but management of the entire interdisciplinary team. Speech therapy can play a critical role in assisting patients with managing their diabetes as it is evident that cognitive impairment is prevalent in those individuals currently diagnosed with diabetes. Speech-language pathologists can provide patients with cognitive therapy and strategies to assist with successfully managing and understanding their chronic conditions. In addition, education of the patient’s caregivers and support system can also increase compliance and successful management.