By: Megan M. Hamilton, MS, CCC-SLP
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Ms. Hamilton
This article will address how a forensic speech language pathologist (SLP) can assist in determining if dehydration leading to hypernatremia or hyponatremia in the elderly can be considered a result of unmanaged dysphagia, substandard care, negligence on the part of medical staff or an unavoidable consequence of a medical condition.
Dysphagia is an umbrella term for difficulty swallowing in which the safe transit of a bolus of food or liquid is impeded at some stage of the swallow process. Dysphagia occurs secondary to multiple medical conditions, events and comorbidities and complications of dysphagia include malnutrition, dehydration, pneumonia and aspiration. The diagnosis of dysphagia is determined via clinical and/or instrumental evaluation of swallow function by an SLP.
There are many definitions of dehydration which can serve to hamper the diagnostic process, but for the purposes of this article dehydration is defined as “the rapid decrease of >3% of body weight.” When the body loses more water than it takes in, cellular homeostasis and physiological functions are negatively impacted, and severe repercussions can include impaired kidney function, renal failure and respiratory infection.
Dehydration is one of the ten most frequent diagnoses for hospital admission in older adults. Ironically, that diagnosis is more complicated that it may seem. There is currently no definitive test for dehydration. Basic metabolic panels include hematological and urinary biomarkers for dehydration, but they do not always reflect a patient’s actual state until severe dehydration develops. It has been postulated that renal parameters do not truthfully indicate dehydration because kidney function is decreased with age. There may be clinical signs and symptoms of dehydration in the absence of lab indicators, but patients who present to the hospital with hypernatremia from severe dehydration may have had unremarkable lab results previous to hospitalization. When water loss exceeds sodium loss, the sodium level in the blood becomes abnormally high, a condition referred to as hypernatremia. Hypernatremia can lead to hypernatremia shock, sepsis and death.
Patients at risk for dehydration should be regularly evaluated for dysphagia and provided treatment when appropriate. The forensic SLP can review strategies and interdisciplinary care planning for the prevention or management of dehydration to determine if they meet standards of care. Forensic analysis of the SLP evaluation, treatment and discontinuation processes can help determine if they meet standards of care and strengthen your case. Contact Lios Manhe LLC Expert Witnesses at hamilton@liosmanhe.com.
SLPs do not determine cause of death, but treat multiple medical conditions and events requiring an integrative understanding of how these conditions and any comorbidities affect the dysphagic population. Educating the community on how conditions and comorbidities contribute to severity of deficits and Pt morbidity is incumbent upon the SLP. Avoiding and managing dehydration is a standard of care for many conditions, yet dehydration can be a complication of specific medical conditions that render it difficult to determine whether dehydration affected the patient’s medical status or the patient’s medical status resulted in dehydration.
At Lios Manhe LLC Expert Witnesses our mission is to be a trusted partner to plaintiff or defense by providing thorough analysis and independent opinions supported by science and based upon evidence collected. Contact hamilton@liosmanhe.com for expert opinion in your medical malpractice case.
Megan M. Hamilton, MS, CCC-SLP, earned her Master of Science degree from Marquette University and holds a lean six sigma green belt from Purdue University as well as a Certificate of Clinical Competence from the American Speech Language and Hearing Association (ASHA). Megan currently provides consultation to hospital speech language pathology and serves as a forensic medical SLP throughout the United States. Megan has held positions as direct care provider, site manager, regional vice president, and division manager of clinical education for national rehabilitation providers in long term care, sub acute, and pediatric care. She brings over 30 years of experience to her clients.
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By: Megan M. Hamilton, MS, CCC-SLP
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