Following directions in real time

In order to be functional you must be able to follow directions using cognitive skills. Put simply, our brain must be able to process information – especially verbal information such as: “Are you in pain?” or “Please stand up”. The problem lies in cases where patients have sustained an injury to their brain and must now take extra time to decode the commands and turn them around into action as described above. There are many conditions that interfere with psycholinguistic comprehension including aphasia, delirium, encephalopathy, and even poor hearing. The reader should never presuppose one of the former three conditions without first ruling out the effects of hearing loss.

What is meant by following directions in real time? If you have ever tried to tell a joke to someone with very poor hearing you must often repeat your words – sometimes over and over. The effects of this have negative impact on real time communications making it almost impossible to impart comedic spontaneity into any conversation for example. This results from the real time failure of verbal understanding or inattention to pragmatic communication, inefficient processing of the sequence of language, inability to concentrate on what is being said and its linguistic salience, or an inability to hear the acoustic sounds as they are being expressed. Real time comprehension refers to the processing of information without delay, as it happens.

A number of variables interfere with this such as the need for repetition, misunderstanding of direction, delay in processing the sequence of words and understanding, and limited capacity to hear and reprocess the commands using working memory. Problems in understanding directions occur from the breakdown on any of these features of speech, memory, and attention. A neuropsychological assessment will help tease out at what point the meaning of the communication is lost. Sometimes it comes down to hearing aides and actively engaging the patient in the task itself. If they are disinterested there will be limited compliance and resistance. I always suggest a bedside examination that allows for beginning rapport and establishing trust before attempting the formal examination.


Vote for clock of the year!


Dec15_18 Clock of weekScan
# 1  This was drawn by a female with decreased self-monitoring

Dio ClockScan
# 3  Clock drawing by 79-year old male with dementia.  # 2 clock is above.  Size is about 8 millimeters measurement is shown in centimeters millimeters

Clock of the Week 8-15-18Scan
# 5  64-year old right handed male with severe lung disease

Clock of Week Sept 25Scan

# 6 Clock – A better rendition aside from square face

Lauren patientScan
# 7 Clock – Drawn without evidence of conceptual awareness


Clock of the week_Nov8
# 8 Clock shows signs of perseveration and deminished self-monitoring – the numbers go on and on

If you are interested in the clock drawing and casting a vote for clock of the year you may contact me at or by leaving a comment in the space provided at the bottom of the ballot.  I look forward to hearing from you.

Clock of the Year – Vote on your favorite

Dec15_18 Clock of weekScan
Clock drawing by intelligent 71-year old
Every year I publish a series of clock drawings. Some people really like seeing the range of clocks that people draw including the clock above – drawn by a 71-year old right handed woman with confusion. One could argue that she had much of the task drawn correctly until she tried to correctly set the hands as instructed. I like this clock because it illustrates the break down in problem solving of the three steps required for success. Ostensibly, this patients followed the directions as instructed. The numerals were correctly placed and finally she placed hands on the clock. Arguably, by drawing too many hands she may have been exhibiting a perseverative response, decreased self-monitoring and error detection, and a failure in understanding the problem in terms of the correct time – 11:10. In this case she asked “AM or PM” but did realize her error relative her specific drawing. She drew no circle into which the numerals were to have been placed.  The yearly ritual of finding the clock of the year has begun. What fun!
“For many living with a person who has dementia can be an unforgettable challenge that evokes guilt, resentment and despair.” Michael Sefton 2018
The clock above was drawn by a 71-year old female who is in the hospital because of an infection.  When this was drawn her infection had been cleared up.  She is a verbally gifted woman with a full education.  Her family has seen a change in her thinking skills in the past 12 months and now wonders what can be done? Her verbal intelligence is in the 90th percentile with an estimated VIQ of 120.  Verbal abilities often interfere with the assessment process and there comes a time in every assessment when the examiner must put a stop to the fun and frivolity of making acquaintance. 
This year I received a few more drawings from clinicians in the community including the clock of the week from December 10, 2018.  One of the clocks that was published this year was featured on the Australian Broadcasting Company television series “Ask the Doctor“. The clock is featured about 16 minutes into the broadcast. I have been given permission by the ABC to display the link to the broadcast. I will publish several clocks and I ask that readers vote on the most interesting clock.  We will vote for 2 weeks in January.  Happy New Year and have a safe holiday.


Clock of the Week: Loss of Conceptual Accuracy and Integrity

This is a clock recently submitted by by a Whittier Speech Language Pathologist who was working with a 90-year old male who was recently admitted to our hospital.  He is very sick with a complex medical history.  He was admitted to a hospice service – essentially receiving comfort measures only.  The conceptual errors in this drawing made me ask about his hearing.  Did he understand the task? The clock was dawn using his dominant hand.  Clearly there are other elements in the drawing. Some staffers though it looked like a shoe.  It seemed to me as I looked at this unscoreable clock that the patient has lost a conceptual awareness of what clock means. Next, I would be interested in knowing whether he could be prompted into copying a clock such as the one on the wall in each patient room. Finally, as a patient entering hospice one is reminded that life expectancy can be quite short and the changes in cognition are common.


Successful clock? By now you all know.

What do you think about this clock drawing. It looks pretty good from the execution of the circle but you see the number placement is slightly off. Hmm? What do you expect perfection? Well truthfully yes the clock drawing is a task that should be quite routine – even when you are 70, 80, or even 90 years of age. Now the time it takes to complete the task varies from person to person and co-occurring illnesses, etc. As you watch this video what do you think about the hand placement? Does the clock read 10 minutes past 11? Or is it off?

Michael Sefton

This clock is unusual in that it was correctly drawn but with a square face

Delirium: confusion and behavior change after Traumatic Brain Injury

Delirium is a medical condition that often has a sudden onset and waxes and wanes in response to the environment and is poorly understood. It is common among cases in the intensive care unit.  Over half of cases of traumatic brain injury (TBI) develop delirium during recover according to Maneewong, 2017.  Delirium is a sometimes unrecognized condition that manifests itself as confusion and inattention. It occurs frequently after traumatic brain injury and is classified as hyperactive or agitated delirium that manifests itself as confusion, yelling, irritability, sometimes hallucinations and paranoia.  There is also a variant of delirium that is equally worrisome known as hypoactive delirium that often flies under the radar.  These patients are quiet and sleep much of the time. Both are agonizing for family members to observe and can be a harbinger of medical complexity that may interfere with and prolong recovery.  According to the New England Journal of Medicine patients with a high incidence of coexisting illness are at greater risk for delirium (Marcantonio, 2017).  The longer delirium goes on results in a reduced likelihood that a full recovery may be made.
Recovery from traumatic brain injury generally depends on the nature of the primary trauma, location, presence of coup and contra coup injury, diffuse axonal injury, and secondary injuries such as edema, intracranial pressure change,  autonomic storming, and more.  Long-term recovery depends on admitting score on Glasgow Coma Scale, duration of coma, and post-traumatic amnesia.  Delirium during recovery from TBI may last from a day or days to weeks.  Men are at greater risk of delirium that is sometimes linked to somatosensory loss such as poor sight and hearing (Marcantonio, 2017). Delirium has significant a consequence on cognitive functioning and will impact working memory, concentration, and all higher order functions including problem solving.  Another term is encephalopathy. It is a common manifestation in patients with non-traumatic underpinning including sepsis (infectious illness) such as pneumonia and urinary track infection, delayed hemodialysis, and many others. In refers to brain dysfunction often due to multifactorial issues including metabolic and infectious causes. These are treatable causes and generally do not exhibit the combative agitated behavior seen in those with traumatic brain injury (Sefton, 2016).




Recovery and Return to Function
Rehabilitation units across the country are faced with recovering patients with symptoms of delirium and must manage the confusion and associated behaviors with the demand for acute rehabilitation that often requires 3 hours of therapy daily.  According to the NEJM review there are 4 distinctive features of delirium including: an acute change in mental status with fluctuating course (waxing/waning), poorly deployed attention, disorganized thinking (confusion) and/or altered level of consciousness – as seen in hypoactive delirium.  It can be a true emergency and often results in a trip to the emergency department. It is especially dangerous in the elderly.
A recent patient was admitted to the trauma center after a fall down the stairs. She was 75 years old. She had bleeding in her brain called a subdural hematoma that required surgery.  She underwent a craniectomy which meant that part of her skull was removed to accommodate massive swelling. According to family members she was independent and loving prior to her accident. I will call her H.S.
H.S. had post-traumatic seizure activity – including status epilepticus that is often associated with high levels of mortality. She was quite badly injured and her older age put her at high risk of a poor outcome. The intractable seizure was eventually controlled with 750 m.g. of levetiracetam on which she remains in ongoing treatment.  She was required to wear a helmet whenever she was out of bed in case of fall.  Having no skull in place over part of her brain meant that any jostling to the head could result in further injury to the dura mater within the skull. Obviously, if you are wondering, the skin flap closes the cranial vault resulting in a significant deformity to the head.  Upon admission to acute brain injury rehabilitation the 75-year old H.S. had hypoactive delirium sleeping most of the time. Gradually there became a window of time during which she was alert but passively non-compliant.  At this point she was sent back to the trauma center for cranioplasty – the surgical reinsertion of the skull.  From this point onward she has had significant, unremitting hyperactive delirium.  The unremitting nature of her condition was sad because much of her confusion stemmed from a number of fears she experienced.  I hated to think that she was acting out physically in a primal defense against some perceived threat to her existence.
The form this took was completely out of character with the pre-injury personality. This is an important distinction whereas some patients are nasty prior to injury and become nastier once brain injured.  Medication and management of symptoms are prototypical during this stage of recovery. I judged her to be at Rancho Los Amigos cognitive scale IV – confused and agitated. Her behavior was agitated and any effort to engage her in conversation was met with profanity laden criticism and accusations that would have made a sailor blush. She strongly denied having any pain.
“Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do.” STAT Boston Globe (2016)
The patient I am describing was initially given low-dose Xanex when needed.  Xanex is a benzodiazepine class of pharmacotherapy and is usually avoided in brain injury recovery.  It has little to no effect on her symptoms.  She was next given quetiapine in low doses and after a short while it was increased to 25 m.g. twice a day.  She was on a beta blocker for blood pressure control and excess adrenergic activity that can lead to autonomic storming.  I think she may have tolerated quetiapine at higher doses but we never titrated beyond the last dose.  At the same time H.S. was placed on adjuvant gabapentin as a mood stabilizer. She was on Sertraline for presumed depression given to her by a primary care physician. This combination was little to no help in the short run and the delirium worsened.  Her behavior was agitated.  She took out her tracheostomy tube and was able to verbalize immediately. Fortunately she no longer required ventilator support for breathing.
H.S. was seen by our geriatric psychiatrist over three visits.  His recommendation was to discontinue the Sertraline, quetiapine, and gabapentin and start Risperidone at 0.25 m.g. twice daily and add Depakote. Meanwhile she was kept on levetiracetam for prior seizure activity. A levetiracetam level was ordered and as of this post is pending.  The clock drawing below illustrates the global nature of the cognitive sequelae from delirium and TBI.
The outward behavior was driven by both internal confusion and external distraction.  She believed she under threat by unknown people entering her home. Efforts to point out environmental cues that she is not in her home were unsuccessful.  Her behavior was redirected and she was supported for her fear with staff efforts to gain her trust.  She was both wanting her children and angry at them at the same time.  Team therapists mentioned that she seemed to be having a conversation – with herself.  Indeed, she was heard arguing with herself from within the veil bed in which she was placed for her safety. H.S.’s daughter was distraught at her mother’s change in cognition and behavior.  She could not reach her on an emotional level.

Maneewang, J., Maneeton, B., Maneeton, N., Vaniyapong, T., Traisathit, P., Sricharoen, N., and Srisurapanont, M. (2017) Delirium after a traumatic brain injury: predictors and symptom patterns. Neuropsychiatric Disease and Treatment, 13:459-465.

Marcantonio, E. Delirium in Hospitalized Older Adults. (2018) NEJM 337; 15.

Sefton, M. (2016) What is encephalopathy? Blog post: Taken 11-10-2018

Clock of the week

Clock of the week_Nov8
Drawn by 65-year old right handed male

One of the clocks previously published here at the Concussion Assessment and Management blog was chosen by the Australian Broadcast Company as an illustration of how dementia effects cognition in older Australians. I was contacted 6 months ago by the show’s producers. I think they struck by the simplicity of the task and the variety of responses we see clinically. The program called “Ask the Doctor” is a weekly broadcast in Australia about varying health concerns faced by the aging population down under.  Like here in the United States, health concerns including Alzheimer’s dementia are covered by the producers of the show.  I was sent a link to the show and have asked permission to post the broadcast that contains the clock drawing.  It shows how important it is to understand cognition and dementia. I will post a link to the You Tube video of the original clock drawing below.
The Clock of the Week is drawn by a 65-year old male who is struggling from the effects of respiratory failure and its impact on debility.  He has a tracheostomy tube in place and cannot speak.  He communicates using gesture such as when he is thirsty. He is irritable and was eager to write to me when given the chance.

Grapheme_He shouted

Here is a sample of his written language output.  He was asked to write the sentence “Baseball players are tough”.  You can see from the writing above that he put forth his best effort but still has a way to go to use written output as a bona fide communication modality. In cases such as this the clinical team is asked to use Yes/No inquiry to assess his language and for gaining deeper understanding of the physical and emotional adjustment through which this man is going.  He is participating in treatment in spite of his frustration, anxiety, and thirst. Once he is able to swallow he will be given a hospital diet by mouth.  Until then he receives full nutrition via a gastronomy tube in his stomach.

Here is a copy of the You Tube video that depicts the clock that was used on the Australian Broadcast Company “Ask the Doctor” program that was broadcast in October, 2018.  In Australia there are thousands of new cases of dementia diagnosed weekly. Watch the video and share it.