Oh My GERD

Music:
[0:00] Music

Speaker1:
[0:15] Hi, everyone. I'm Emily.

Speaker0:
[0:18] And this is Eva.

Speaker1:
[0:20] And you're listening to Speech Talk.

Speaker0:
[0:22] We're your research book club so you can do evidence-based practice in practice.

Speaker1:
[0:27] So let's get walking. So today we're focusing on a common condition that can impact more than just digestion. Gastroesophageal reflux disease, a.k.a.

Speaker0:
[0:40] GERD. Say it 10 times fast.

Speaker1:
[0:43] While heartburn is the most well-known symptom, GERD can have many more effects on your overall health. And today we're going to be exploring how that can impact our clients specifically in the skilled nursing facilities.

Speaker0:
[0:56] Exactly. So understanding how GERD is affecting swallowing and overall PO intake is important for providing our best possible care. Chronic GERD can damage the esophagus mildly to severely. And today we're going to be talking about how GERD symptoms can manifest and affect our clients.

Speaker1:
[1:13] Yeah, so research has shown a strong link between GERD conditions like esophagitis, where the esophagus becomes inflamed due to constant acid exposure. The inflammation can disrupt the normal swallowing process, making it difficult for food to travel down smoothly.

Speaker0:
[1:30] Yeah, part of the reason that happens is because of esophageal dysmotility. So there's been enough damage within the esophagus because of the acid leaking that the muscles are becoming weak and they're struggling to propel food downwards. In severe cases, chronic esophagitis can lead to barrettes or berets. I never know how it's said. Esophagus. I probably should have looked that up. Or, you know, basically which is the thickening and reddening of the esophagus,

Speaker0:
[1:57] which unfortunately in turn has a small but associated increased risk for esophageal cancer. And I'm not saying that anytime our patient is reporting heartburn, we should be like, cancer. But it's good to note that that's a possible outcome for long-term, bad girl.

Speaker1:
[2:16] And when we're talking to our clients, we want to make sure we're looking for more of those symptoms that aren't just the heartburn, right? We're looking for chest pain. We're looking at, of course, we're looking at heartburn. We're looking for chest pain. Is there a difficulty swallowing? Are they saying there's a lump in their throat? Are they burping? Like, not just I chugged a Coke and now I have the burps, but like they're burping after water. that's

Speaker0:
[2:42] Always why i am burping just constantly checking coca-cola we should get advertising money for saying coca-cola.

Speaker1:
[2:48] Yeah let's call them they have good money so regard to church and so like not just burping but like burping with that acid taste in your mouth sore throat coughing all of those are symptoms of something going wrong lower than just your regular old swallow Yeah.

Speaker0:
[3:10] And one of the ones I hear a lot from patients is, you know, during a bedside smile, I always ask, do you have pain, difficulty or discomfort, pain? Are you feeling it anywhere? And if they're able to say yes, you know, trying to help them localize it. But for our patients who have difficulty with language or cognitively or having trouble describing their symptoms, I'm like, is it in your mouth? Is it in your throat? Is it in your chest? Does it feel lower? And just trying to give them the opportunity to describe where the pain is happening because that self-description of like, oh, my chest is experiencing a lot of pain when I swallow is a great indicator for GERD and some other saugageal symptoms too.

Speaker1:
[3:53] With keeping that caveat that you do have difficulty with localization of pain through like your whole esophagus. So even if someone says like, yeah, I have pain in my chest, it could be anywhere through your esophagus that that person is actually feeling like a food is sticking or anything. The localization sensors for your esophagus are not they're not fabulous they're they're right they kind of do what they're supposed to do but they're like that

Speaker0:
[4:23] Is a great point i love that it's funny my first like run-in with bad gird was beret barrettes i don't know i'm gonna stick with berets for the rest of the session.

Speaker1:
[4:38] It sounds fancy.

Speaker0:
[4:39] It sounds fancy. And this guy was like in so much pain swallowing. He was avoiding eating because of how hurtful it was. And so we were saying like downward trending weights, refusal of meals, like all these just classic issues but he had horrible communication skills not like he had like couldn't describe things it's just that getting like a straight conversation with him was so hard I'd be like all right so tell me where the pain is or like when during a meal are you having discomfort and he'd be like do you think my head is attractive and I was like can we focus on the whole you're not eating thing yeah, He's like, I'm concerned I haven't dated a woman in the five years I've been here. He looks like, okay. Again, you've lost 10 pounds.

Speaker1:
[5:36] I bet your face would be very attractive if you had a cheeseburger.

Speaker0:
[5:42] You know what would look really great on you is eating again. I would love that for you.

Speaker1:
[5:47] Let's try that. Right?

Speaker0:
[5:51] But we eventually got him sent out. And it turns out the esophagitis turned to, where's esophagus? They got so bad that there was esophageal erosion. So basically what was happening was that he was getting, oh, and he was having periodic coffee ground emesis, really. That kind of coffee ground look when you throw up, which is indicative of a GI breed. And it turns out the erosion was so bad that when he was eating solids, it was eroding the tissue lining of his esophagus, which was causing these small, fresh bleeds, which was resulting in the coffee grounds when he was vomiting. And I was like, that is a crazy amount of damage. Like, that's really bad.

Speaker1:
[6:34] Yeah, I've never heard of that. That's a good one.

Speaker0:
[6:37] That was the first time I had a patient on thin liquids consistently. Emily and I also talked a lot about knowing when a referral or a request is not for you, that you need to refer back. The facility kept being like, oh, well, he's been on thin liquids for a long time. He doesn't like it. Can you advance him? And I was like, no, this isn't like a speech therapist decides when his esophagus stops bleeding. Like you need to send him in for periodic checkups. Like I don't have the healing touch. So yeah, know when it's not for you.

Speaker1:
[7:16] So when is it for us? So first we have to screen our patients and know these GERD symptoms, right? Like do they have herocarditis meals if we're suspecting GERD? Let's advocate to that referral to a GI. For me, in my facility, that means making actual paper, writing down patient to see GI. Follow up. Please come back to me.

Speaker0:
[7:43] Do you do that also in the EMR so that there's electronic medical records for that? Or are you guys free paper?

Speaker1:
[7:50] So I'm not allowed to write my own orders here. But I write it for the nurse to know that it's in my eval, but I also write it out so that they are going through and scheduling that and if they have questions on like why are you suggesting this like they're doing xyz

Speaker0:
[8:08] That's really good okay next we want to be doing patient education as usual and we do it for posturing during and after meals to help prevent stomach acid from refluxing back into the esophagus, As always, we want to consider who our patient is. Emily and I will talk till the sun comes up on the effects of cognition on treatment approaches. And if your patient can hear you when you say you need to stay upright in bed for 30 minutes after a meal, more power to that. But if they are the type of patient who every 15 seconds goes, when can I lay down? Then we need to get our CNAs involved and try to create strategies. Should we have a loop in their wheelchair for meals? Do we need to put on the TV to help them stay calm during the meal and have something to focus their attention on? I think a good timing indicator for CNAs for when a patient can get back in bed or lay down after a meal is usually when trays are cleared.

Speaker0:
[9:10] I don't know how big your facilities are, but to get all the trays cleared from a unit is like 20-ish to 30 minutes. Um so it's like hey don't worry about it until after everything is cleared for meals like do your stuff and then come and do um like repositioning or putting them back to bed but don't let them go to sleep before then yeah.

Speaker1:
[9:35] Yeah yeah that's the same pretty much the same for me too like their their passing trays or collecting trays it it naturally gives the patient a good amount of time to be up after meals. So it's a good strategy all around because then it lets them have less work. Patients are ready to go to bed by then. Normally they've had their therapies already. So it worked out all around. But other precautions. So you want to be avoiding trigger foods. What do I mean by trigger foods? The best foods. We're talking fatty foods. We're talking spicy foods. We're talking acid foods. We're talking pleasure foods. Can't have it. It's gone. No soup for you.

Speaker0:
[10:23] This is my one thing I know about Seinfeld.

Speaker1:
[10:27] I love that show. But it really is all the best food. Unless you work in a skilled nursing facility and they say pepper is spicy. They have not seen as spice. since the golden ages. But for, I mean, younger people or education to the CNA is about like, maybe doctoring their food. Some people do. They'll prescribe their own likes and dislikes on to the residents. You're like, of course they don't like this. It has no flavor. But like, We know sweet is the last one to go, so they don't need a spicy meal in the first place. But I also don't need four things of cranberry juice, right? They don't need four containers of milk. Milk is a surprising one for GERD, but it's a trigger. That's the one I think that surprises most people. And they're like, what? I can't have milk. It's so creamy. I'm like, nope. As lactose as it is. That's why. It's going to make everything more difficult. And coffee. Everybody wants to drink coffee all day long. And that's acidic and it has caffeine. It's a double whammy.

Speaker0:
[11:38] Cigarettes and coffee, I swear to God, are like the engine that drives 25% of my patients.

Speaker1:
[11:46] I know. There's a schedule around. Is it time yet? They're like scratching it.

Speaker0:
[11:50] Scratching up their arm. It's like that 10 a.m. coffee hour. Let me at it. I know I just had it with my breakfast, but can't be down to activities.

Speaker1:
[11:58] And then you get the added bonus of Tic-Tac-Toe Day.

Speaker0:
[12:04] Bingo and coffee is like the savior of the SNF experience.

Speaker1:
[12:08] It really is. Oh, and then, so another way to help limit some of these girder triggers is to have more smaller meals. This one is kind of hard to do in a stiff environment. I saw one paper in the actual leader that somebody said, was able to implement small meals at their sniff and like, God bless you, woman. I don't know how the heck you did that.

Speaker0:
[12:34] Okay. But I will say that for folks who I have who fatigue during meals and are feeders, it's like a high level combination. I don't know what the lady in the article is targeting, but for folks who I have who are very like, they're either fatigued or just are fatigued, like they're lethargic and they have no eating when not alert recommendation. I'll say, you know, round with them, feed them part of the meal, put it away, come back after like you've checked in on a few other people, give them the rest of it. So even though it's not like a true smaller meal, it is breaking it up a little bit. Does that really count as two small meals? I don't know. But I will say that cognitively, it's been pretty successful for some of my patients.

Speaker1:
[13:22] Yeah, that's a good point too, Eva, because it gives your CNAs some time. Because a lot of times people are rushing. They have other things to get to. They don't want to sit there for 15 minutes and feed somebody. But if you're like, okay, the goal is to maybe do 25% to 30% now, then we would do another 25% to 30% in another 40 minutes after a couple showers or something.

Speaker0:
[13:48] Yeah, exactly. I will say that I have told Emily a lot about my pregnancy experiences, but fatty foods, when my doctor tried to tell me I couldn't have them, I almost flipped a table. I was like, no, no, no, no. I put a tablespoon of butter on every piece of toast I eat for breakfast, and that's absolutely not changing.

Speaker0:
[14:15] Yeah, so I hear you. Folks are getting recommended no spices and no fats. It's an actual travesty.

Speaker1:
[14:22] We're all having a Teresa Giudice moment.

Speaker0:
[14:26] I don't know what that means. I'll look it up. I'm so behind. Okay, anyways, some research. In a research paper conducted by Ruviki, I hope I said your name right, et al., their paper titled The Impact that GERD on Health-Related Quality of Life had some findings that indicated people with GERD report worse emotional well-being than people with diabetes or hypertension, which did improve its treatment. And I felt like this was a pretty impactful statement because recognizing that our patients with GERD are hoarding really poor measures for pain, mental health, and social functionality gives us the opportunity to empathize with them and target concrete goals. A great way to measure or better understand how GERD is affecting your patient is through the EAT-10, which relies largely on subjective patient-reported outcomes. You know them saying do they feel that their ability to eat out is being impacted are they worried about eating is their pleasure decreasing with eating all that is a great way for you to develop your plan of treatment and is really motivating because people want to know that what they're doing is going to make them better and so it gives them kind of like a focus for are looking for how their treatment is improving their lives.

Speaker1:
[15:50] So what do we do to manage? Um, got a good old Tums. We also have management with proton pump inhibitors. So if we're, or PPIs. So if we're talking about Eva's patient with the coffee ground emesis, we're thinking more PPI lane, right? Like he's having a lot of, a lot of trouble, but that's not our lane to diagnose. We have to refer out to GI. So what is a PPI? The PPI Okay, proton pump inhibitor is just limiting the amount of acid your stomach is producing. So it's limiting the effects of acid erosion on your stomach and the stomach. But like all medications, there's contradictions, right? The Cleveland Clinic said prolonged use of PPI can lead to kidney damage, increased risk of C. Diff, which is nobody wants. So bad.

Speaker0:
[16:45] My friends, when I was working at this really large facility and I had not encountered C. Diff before, I'm like, oh, I see they've seen it on someone's diagnosis. Like, what is that? I have my cochlear implant. So you're like, you'll smell it before you get there.

Speaker1:
[17:02] And you'll never forget it. But yeah, it's increasing the risk of C. Diff because these proton-informed emitters are limiting the amount of bacteria in your system. So less bacteria, less your body's able to fight off the bad bacteria. You also have increased risk of fractures because you're not able to absorb as much nutrients. So people who are walkie-talking around, they're more likely to have fractures. So how mobile are our patients actually? Are they going to benefit from this proton pump anameter that could possibly make them break a hip again?

Speaker0:
[17:43] And as Emily and I have discussed, like, old people are already so good at breaking things. Hips, forearms, shoulders, ribs, they're just cracking from top to toe. What?

Speaker1:
[17:58] But I want to make sure that the people who are cracking are not crack-a-lacking too much. So always think about the patient first, right? So if there's all these contradictions, make sure you're providing that information to your nurses and the doctors to have a whole person experience to help prescribe proper medications.

Speaker0:
[18:28] Yeah, obviously, we're not the ones writing the prescription for a PPI. But, you know, if we're concerned, as we always say, like, we're that fine line between the facility and, like, the GI console. And a lot of times, we're the person who refers out to GI. So, like, recognizing a potential opportunity to discuss a console is definitely a value added that we can provide.

Speaker1:
[18:52] Yeah, yeah, because the GI is going to be able to tell us everything we need to do. Because this, I mean, GERD is not our lane, right? We're talking about this because all of these things end up being connected, but it's a highway of a system, and we are one step before that GI exit. So maybe PPIs aren't necessarily appropriate. Maybe we just need a Tums if our patient can't avoid that spicy meatball.

Speaker0:
[19:21] I love it every time. Also, my husband is kind of Italian, so I feel like that is fully us.

Speaker1:
[19:33] Italian adjacent.

Speaker0:
[19:35] He's like Italian adjacent.

Speaker1:
[19:37] I get the Jews' approval for the Italian adjacent.

Speaker0:
[19:42] Yes. So good. So good. But lastly, on the PPI situation, is we did look at an article in the Neurology Journal called Cumulative Use of PPI's and Risk of Dementia, which indicated higher rates of dementia when PPI's have been used for greater than 4.4 years. So, again, in terms of knowing your patient holistically, are we looking at short-term use? Are we looking at long-term use? How old are they? And they started showing presence of cognitive impairments and kind of getting their physician involved if there's some concerns for cognitive impairments and they've been on PPS. Again, we're not usually the people combing through pharmacy orders, but every once in a while, it's been relevant. I had a guy with GERD who got prescribed Ferris something. Again, I don't know the names of meds.

Speaker1:
[20:50] They make them so hard.

Speaker0:
[20:51] They do. It's like they don't want you to know what you're taking. But it was basically an iron supplement and it just made everything taste horrible to him and then on top of that he had his GERD so it was like kind of a gag reflex combined with his GERD and like he could not get anything down it was horrible like he just went from being able to eat normal foods he had medication for like three days and all of a sudden was just like, nothing staying down, For those not watching, the blech was me doing a visualization of projectile vomiting. And for those not watching, which is nobody because this is a podcast, we are in our pajamas. It is late.

Speaker0:
[21:42] Do we have any more GERD stories before we wrap up?

Speaker1:
[21:45] Yes, this one. I worked in a facility where I had to fight tooth and nail for any kind of GERD medicine. Like it was really like asking for a Tums was asking for a holy grail. Like nobody, nobody could find a Tums to save their life. I have PR in order for Tums. Like we're having, we're having spaghetti. This guy needs a Tums. Um, but I kept getting the same referral for this guy. He's like, oh, he's coughing during his meals. Like, so I went to go see him, did a bedside and he wasn't coughing. It was a pretty consistent throat clear. But I stay with him outside of a meal, too, because I was trying to be thorough. And it was still there. So I was in a dementia unit. So I really didn't have any way to accurately tell me about his experiences outside of, you know, the here and right now. Are you experiencing heartburn right now? No, no, I'm totally fine.

Speaker1:
[22:45] I was able to get him a fees, though. And in his fees, we saw swelling, right? We saw swallowing and opening of the esophagus, immediately able to show that GERD had some impact on his structures. In that phase, we saw that he had no actual impact on his swallowing. He was just swole up. Still recommended. So swole. It's not the good swole. It's a bad swole.

Speaker0:
[23:17] That's a cute swole.

Speaker1:
[23:18] And I still, I was like, all right, cool. regular thin diet but homie needs tums i'm still i still don't know if he ever got the tums

Speaker0:
[23:29] This is wild.

Speaker1:
[23:30] Right in my discharge basically

Speaker0:
[23:32] Opioids like i'm you can't be popping these like candy.

Speaker1:
[23:38] You ask my kids that have you i so i get uh tums for pregnancy, they have these one kinds that actually taste like candy, and my kids go nuts for them. I have to like, that's not a problem. Tums are the hot ticket.

Speaker0:
[23:54] I love it. I had gummy bear candy as a kid, and I was always, I have no gummy bear candy. That's obviously candy. I meant gummy bear vitamins. I was like, oh, mom, I really feel like I need some vitamins. I was a little kid trying to scheme for, you know, vitamin C and calcium.

Speaker1:
[24:12] It's better than the Flintstone. You ever take the Flintstone ones?

Speaker0:
[24:15] Oh, God. Yeah, I remember those.

Speaker1:
[24:17] Those are awful. Those are chalky. Okay, we're on topic.

Speaker0:
[24:22] Wow, that chair was, that creek, me adjusting was, like, listening to my patient's joints. Anyways, I feel like this was a really great discussion of GERD and like the panoply of ways that it can manifest. I think we should call it.

Speaker0:
[24:37] Anyways, we'd love to hear from you all and tell us if you've had any crazy experiences with GERD. If you found anything that works in your facility, anything you think we've missed that we should take a look into. And as always, if you want to let us know something you've been seeing in your facility that we could do some research on, hit us up on the social media.

Speaker1:
[25:00] Thanks for listening.

Speaker0:
[25:01] Bye.

Speaker1:
[25:04] You've been listening to Speech Talk.

Speaker0:
[25:06] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker1:
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Speaker0:
[25:23] If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker1:
[25:37] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker0:
[25:50] We're your hosts, Eva Johnson and Emily Brady.

Speaker1:
[25:53] Our editor and engineer is Andrew Sims.

Speaker0:
[25:55] Our music is by Omar Benzvi.

Speaker1:
[25:57] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

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[26:14] Speech Talk is a proud member of the Human Content Podcast Network.

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