What is encephalopathy? People who have it generally do not see anything wrong with themselves. Patients are admitted to the rehabilitation hospital for the purpose of regaining as much independence as possible – even those with encephalopathy. But it takes time. Most stay 4-6 weeks although this depends upon the diagnosis and recommendation of the physician. However long a patient is given rehabilitation there is always a lingering concern of illness going forward.
Everyone in the rehabilitation team worries about a patient when the discharge is imminent and the patient seems unready to be sent home. Anything can happen including unexpected fall, change in sleep hygiene, confusion, even new infection. In some rare cases any of these calamities may befall an unprepared, uninsightful patient. Even when there is a spouse on board with the discharge plan there are inevitable factors that may compromise a successful discharge resulting in potential problems once home. Encephalopathy results from infection, toxins, anoxia, and other metabolic conditions. Most adults have experienced encephalopathy at one time or another perhaps after drinking too much. The primary sign of encephalopathy is altered mental status, cognitive slowing and confusion. Another feature is diminished self-monitoring and awareness that directly impacts insight, judgment and problem solving.
The clock drawing attached to this blog was drawn by a 65 year old woman with obvious confusion, disorientation, and limited insight. She is frustrated to be in the hospital and both she and her supportive husband are pushing for her discharge home. “Why am I here?” see remarked with incredulity. The clock drawing task is a simple one. I have posted several blogs in hope of showing what a fascinating tool it is to assess cognitive functioning. I have been using the clock drawing for 30 years since learning of its value in neuropsychological screening from Dr. Edith Kaplan at the V.A. Medical Center in Boston in the mid-1980’s. What happened with this clock?
The woman who constructed this drawing has encephalopathy as a result of a respiratory illness that resulted in her needing a breathing tube to sustain her respiratory drive. At some point when her breathing stopped she sustained an anoxic injury. This stems from the lack of oxygen in the brain and may lead to ischemic, inflammatory changes in the structures of the brain that are thought to subserve memory and learning. The lady first drew the clock with all the numbers crunched together which may be seen in the upper right aspect of the drawing above. Because of her confusion she was unable to plan and organize her drawing. This is typical of some conditions like dementia. However, the patient is a 65-year old woman and we now all know that “65 is the new 55” – when it comes to modern aging.
All kidding aside, the patient in this blog was entirely independent in the months before the current illness. She was then asked to try again with the clock drawing – the directions are standardized. At this point everything else was drawn – circle after circle providing vivid evidence of the perseveration, lack of self-monitoring and confusion associated with her ongoing condition. She thought nothing of it. Now, she has convinced her spouse to bring her home where she most certainly will be more comfortable and may recover more quickly. Not so fast. Look again at the clock and the design copy below that was crafted a few days after the featured clock of the week above.
The rehabilitation team has lingering concerns about her safety and cognitive functioning and are looking to the patient’s family to impart those concerns in their own feedback to this impaired woman. By agreeing to take her home they are setting up an outcome that is unlikely to be favorable. The hospital is manned with nurses, aides and physician support 24 hours a day. There is no way that a singular spouse is able provide for this level of support and remain healthy himself. Caregiver burnout is a significant source of stress for all family members. This nice lady needs maximum assistance for all of her activities of daily living including dressing and bathing. She has been in the hospital for 2 weeks and will need 2-4 weeks of additional rehabilitation to help in her recovery. Her family seems concerned that the hospital may result in a depressive episode and they are correct. But going home before she is safe to do so may result in greater harm and further hospital time. Caregivers are also at great risk of illness due to the effects of stress on the immune system. I always encourage family members to “get to know the rehab team” who are taking care of their loved one and establish a trust with them. That way when the discharged date is announced there will be no questioning the judgment and recommendations of those who know best. The design to the left is an example of clinical perseveration.
The clock above was drawn by a 65-year old woman who is encephalopathic as a result of acute respiratory failure and hypoxic brain injury who wrongly believes she is ready to be discharged from the hospital.
Michael Sefton, Ph.D. is the director of Psychology and Neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA