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.

Sports specific recovery from Concussion

blurry hockey
Body checking starts at age 11 in most sanctioned ice hockey programs  PHOTO: Mike Sefton
October 9, 2018 Cognitive and emotional symptoms often occur when an athlete sustains a concussion. Individual sports have somewhat different trajectories when it comes to recovery – sometimes because of the nature of the sport and sometimes unique to the athlete and his or her emotional predisposition. Ice hockey is a high speed collision sport. Many athletes play the game on a year round basis chasing a dream of collegiate or professional status. Ice hockey has a high degree of collision-related concussions according to the National Council on Youth Sports.
Contrary to current beliefs, even currently healthy youth hockey players reported higher persisting psychological symptoms among those with a history of concussion. Psychological sequelae appeared unique to a history of concussion as athletes with a history of musculoskeletal injuries did not present with the same persisting psychological symptoms. A study in Pittsburgh looked at the incidence of concussion among younger and older adolescent players from elite hockey programs.  They found a higher rate of concussion among younger players.  In a post last month I presented the notion that size matters when it comes to elite (younger) athletes playing against older and more physically developed athletes.  Concussions tend to be both more frequent and more long lasting.
As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up against older and more developed players. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the shear difference in size and strength.  Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are athletic failures and weak unless they play through their injuries – including concussion according to Sefton, 2018.
In 2016 the majority college ice hockey player spend one to two years in junior hockey (ages 17-21) allowing them to continue their physical development prior to entering college hockey.  This includes not only Division I scholarship programs but Division II and Division III programs as well.  Very few natural freshmen play college hockey at 18 years of age unless they are highly gifted athletes. Even these players are coached and managed by trainers with ongoing development programs, weight training, and nutritional support to enhance upper body size and strength.    Michael Sefton, 2016
Even though sport concussion is considered a unique subset of MTBI, results suggest that a smaller percentage of youth may be more prone to psychological sequelae following concussion. This means that not all concussions are created equal. Along with colleagues across the country I have been saying this for over 20 years. There is a literature on elite ice hockey players and a co-occurring mood disorder that needs to be addressed as they heal.
When I first started taking an interest in MTBI, also called concussion, physicians did not believe that someone sustained a brain injury unless there was a bonafide loss of consciousness. This remains one of the greatest myths in brain injury rehabilitation and I still hear from people that a son or daughter has a concussion “but he did not get knocked out” as if that minimizes the significance of the injury they sustained. Finally, I am still getting significant push back from the parents of children who are diagnosed with multiple concussions. The recovery from concussion two or three is not the same trajectory as the first. Many wonder why their child hasn’t bounced back like they did the first time around. And common to second concussion irritability and other mood-related changes are common.
I suggest to parents expect the unexpected and try not to attribute changes in school functioning to laziness alone. Plan on working with the school-based support team and athletic trainer as you return to learn and return to play.  Most elite programs offer emotional support for athletes suffering with the effects of concussion. Many feel isolated or marginalized because they may appear normal and walk and talk just like other members of the team. Athletes recovering from concussion are at higher risk of second concussion if they return to play before their injuries heal.  This takes 7-21 days on average.
The Pittsburgh study, published in Pediatrics in 2016, revealed that the population of ice hockey players they studied had a higher preponderance of players who had sustained one or more concussions.  This is what I experienced in looking at junior level ice hockey (typically aged 16-20 years) teams a few years ago.  I was surprised when I asked how many had sustained a prior concussion and most all the players raised their hands. Fighting is first allowed in this level of play and sometimes becomes a handicap for players with sites set on collegiate play.  In many cities across the country junior hockey is the only show in town.  Some cities in the mid-west actually televise games and report scores on local sports programs.
Remember no two concussions are the same. Sports all have their return to play protocol that begins with recognizing the importance of controlled exertion in the setting of concussion and recovery.

Sefton, M. (2016). Body Checking in Hockey: When size matters. Blog post: Taken October 9, 2018

National Council on Youth Sports
. Report on trends and participation in organized youth sports. Available at: Published 2008. Accessed March 17, 2015


Kontos, A. (2016) Incidence of Concussionin Youth Hockey Players PEDIATRICS Volume 137, number 2 , February 2016 :e 20151633 Taken October 9, 2018

Clock of the Week: September 10, 2018

Sept_Parkinson'sScan WESTBOROUGH, MA  September 7, 2018 Here is the Clock of the Week for the week of September 10, 2018. It is an interesting clock that illustrates both confusion and intrusion errors.  The task is simple. It involves a 3- step process of drawing the circle, placing the numbers, and correctly placing the hands to read 11:10.  I have espoused this task for several years now and publish interesting clocks.  Last week, I was sent a clock that a speech pathologist here at the hospital was able to obtain from one of her patients.  This clock was drawn by a 85-year old male diagnosed with Parkinson’s Disease (PD).  He is right handed and has had PD for 15 years.  He has also had a prior stroke which complicates the interpretation of this drawing.

What is interesting about this clock was the written language that appears in the middle of the clock face. This is an intrusion error from the prior task I had given him.  He was asked to write a sentence. He completed the sentence and later, components of the same sentence showed up as a perseveration that intruded on the task at hand (the clock drawing).  This is a sign of a lost cognitive “set”. He was drawing a clock and trying to place the numbers when just as quickly he began writing the prior sentence. Interestingly, the clock has no features in the lower quadrants of the drawing.  He was able to roughly construct a circle but was stuck with the upper components of the clock.  It looked to me that he understood that setting the clock for 11:10 meant that he needed to focus on the upper left and upper right sides of the drawing. As he drew the clock he seemed to get stuck drawing the hash marks of the numerals.

He has significant problems with both immediate and remote memory.  PD has a life expectancy of 10-15 years.  His case is complicated by a prior CVA and will likely result in a loss in his independence for going home.

When younger athletes “play up” : concussion and the fantasy of greatness

August 20, 2018  Athletes across the country are getting set for fall sports season.  Both high school and university athletes have started their respective training camps and “try-outs” for football, soccer, field hockey, fall lacrosse, cross country, and even interscholastic ice hockey.  I have already had calls to see young boys who are playing with varsity teams and may be outsized by 50 pounds or more.  The allure of playing for the varsity team can be intoxicating to both student athletes and parents alike. The fantasy of popularity, physical dominance, and record setting success all add to the stress of playing high school or collegiate sports. Younger athletes are at higher risk of injury and for prolonged recovery from injury.
As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the eventual outcome.  Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are failures and weak unless they play through their injuries – including concussion.
With all the fan fare surrounding the NFL training camps varsity high school barely registers on the sports radar screen.  It is a thrilling time for players who are invited to varsity practices when they may still be an underclassman or even still in middle school.  Behind the scenes, there are coaches and parents colluding to allow younger players to suit up as varsity athletes all with the unspoken belief that starting earlier on the varsity team will better prepare the growing athlete for a Division 1 college experience – even a scholarship.
I provided on-field EMS coverage for a number of years in Massachusetts at youth and varsity high school level sports. I have also provided concussion management for university and AHL teams for several years. I have seen significant harm done to individual players when they are invited to play on varsity teams prior to having all the physical and emotional tools needed to understand a balance between school, competition, and injury – when these occur.  Smaller, younger athletes pay a large price for playing up on varsity teams.  The same goes for “walk on” freshman who try out for college football or other collegiate teams. They are asked to compete against athletes who are significantly stronger and heavier putting them in danger.  Most are emotionally ill-equipped and physically unprepared for the difference in skill development and may be prone to serious injury.  Sadly, when some walk on players become injured they are not afforded the first class rehabilitation afforded the varsity players. There is a great difference between a walk-on freshman at 18-years of age and a player who has been in the collegiate system for 2 or more years. The average high school athlete does not receive the expert weight training needed to be prepared to compete at the collegiate level and puts himself (or herself) at risk when positioned against their upperclass collegiate counterpart. Similarly, when a boy or girl in grade 7-8 is invited to “try out” for a varsity team a similar mismatch in size and skill set should be expected. Many school districts allow younger students to play varsity interscholastic sports if they qualify and have the skill sets.
Arguably some coaches encourage this competition as a rite of passage leaving the younger athlete vulnerable to serious injury including concussion.  When this happens the player becomes marginalized and feels forgotten and unimportant which has a profound impact on his self-esteem and can derail his high school or collegiate playing career.  I spend a fair amount of time teaching the re-exertion steps necessary for safe return-to-play and more importantly, for getting back to class.  A specific return to play protocol outlining gradual increase in physical activity including management of concussion, headaches, decreased balance, dizziness, and emotional well-being.  One particular protocol has been established by the Concussion in Sport Group (Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell, McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med.).
“I have taken care of players who have been injured playing hockey but the recovery time is significantly longer for the young, smaller athlete.” Michael Sefton This is consistent with the findings published recently from the Hasbro Children’s Hospital study.
There is a risk to athletes who compete against players out of their weight class.  Youth football organizations like Pop Warner and the American Youth Football Association require weekly weigh ins to avoid the physical mismatch and thereby reduce the risk to younger, less physically and emotionally developed athletes. Similarly,the sport of wrestling has had athletes compete in weight class for decades. Once injured with concussion, the return to play is now standardized with respect to the individual athlete’s symptom profile and history. This has changed across New England since 2009 when school sand colleges began requiring both pre-season screening and a systematic return-to-play protocol.  Returning to play after concussion requires a stepwise process. Each step is monitored by a trainer, coach or volunteer with training in concussion.  Athletes must remain asymptomatic at each phase of their return before they are released to 100 percent full contact at game speed.  This is not always easy to arrange as many school districts have no athletic trainer or share the services of an athletic trainer among several sports.
Concussion occurs with and without a lapse in consciousness.  Any force hitting the skull can induce the cascade of physiological effects of concussion.  These symptoms generally last 3-21 days with the subtle cognitive consequences being most lingering.  The Concussion Assessment and Management Program (CAMP) keeps track of patient’s who require support after concussion.  CAMP is now located at Whittier Rehabilitation Hospital in Westborough, MA and offers a complete range of concussion assessment and management protocols.  Many people wrongly believe that they may return to practice and then games without first being cleared by a physician or neuropsychologist specializing in concussion.  Most states require this clearance before an athlete may return to play. Rhode Island was the first state in New England to require concussion education for all parents, athletes, coaches, and referees.  Most states have followed suit.  The state of Connecticut has an outstanding concussion training program for coaches.

P McCrory, K Johnston, W Meeuwisse, M Aubry, R Cantu, J Dvorak, T Graf-Baumann, J Kelly, M Lovell, P Schamasch. Br J Sports Med. 2005 Apr; 39(4): 196–204. doi: 10.1136/bjsm.2005.018614 PMCID: PMC1725173
Sefton, M. (2014)  Post-concussion Syndrome. Blog post: Taken 8-15-2018