Clock of the Week – September 25, 2017 Micrographia

Clock of Week Sept 25Scan
Clock of the week drawn by 79-Y/O male with bilateral embolic CVA (note size approximately 8 mm)
WESTBOROUGH, MA September 25, 2017 This clock is unique simply on the basis of it’s size.  The scale below the 3 clocks is used for measuring wounds.  It was given to me by the certified wound care specialist here at Whittier.  The top clock was the “finished” product.  One can see all the numbers were written and there was a series of hands drawn that appear as scribble moving from left to right.  The numbers fall outside of the circle – drawn by the patient.  You can appreciate what effort went into the clock as small as it was – only 8 millimeters across.  Micrographia is a term given to drawings that are tiny – a syndrome often assigned to dysfunction in the frontal lobe of the brain.  Just to be sure, I consulted with Lezak – 3rd Edition.  Micrographic written output is seen in patients with Parkinson’s Disease. In another blog published in 2016, I shared a similar clock and describe this interesting syndrome.
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Clock of the Week

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Dr. Michael Sefton at Boston Museum of Fine Arts
WESTBOROUGH, MA September 15, 2017  Much has been published about the utility of the clock drawing in making preliminary assumptions about the cognitive health of an individual who may be referred for neuropsychological assessment.  I use it all the time and those of you who have submitted clocks for publication here agree with my assumptions.  The photograph at the left was taken at the Boston Museum of Fine Arts by a colleague Dr. David Kent, a neuropsychologist from Worcester, MA. There are several posts that identify some of the literature behind the assumptions I make about clock drawing and cognition.  Here is another link: Clocks and cognition

 

 

Click and see the interesting “Clock of the week

The state of knowledge and policy on concussion in Rugby Football Union

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Westborough, MA  August 15, 2017 Just as American’s have begun to understand the true impact of concussion and the risk associated with repeat concussion and other blows to the head, the Rugby Football Union has started to take a serious look at the problem with respect to the long-term consequence of brain injury.  According to the New York Times in April 2014 “a tidal wave of earnings” may confound the rightful medical response to concussion injuries and dominate the return to play decisions on behalf of athletes who are found to have concussion. The remove-from-competition protocol has not taken hold in European rugby where players are routinely returned to play after a 5 minute time out during which they are examined by team medical personnel. Most are back on the pitch within 5 minutes. I have seen college Rugby games where this precise “recovery” was the norm.  The NCAA has protocols for managing concussion but in some club sports these protocols are not followed.
In 2011, Ben Robinson, a 14-year old boy in Northern Ireland, died from second impact syndrome resulting from playing through a concussion. He returned to the game three times after first being injured in a high school rugby match.  Ultimately he died after collapsing on the rugby pitch. Second impact syndrome results from a repeat brain injury resulting in a metabolic “energy crisis” that interferes with brain function including maintaining homeostasis on a cellular level. I  have documented it in several published Word Press Human Behavior posts.
More recently Irish Boxer Mike Towell died from second impact syndrome hours after his fight much the same way as 14-year old Ben Robinson.  He was seriously injured early in the bout and knocked down.  His toughness and tenacity along with unacceptable referee decision making allowed him to return to the fight. “The assumption that rugby had a better handle on concussions than football, however, might have been flawed from the get-go. The most recent injury audit performed by England’s Rugby Football Union (RFU) established that concussions in elite-level professional games were occurring at a rate of 13.4 per 1,000 player hours.” Bandidi, 2016
The NCAA protocol is cited here.  “Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be “available” at all NCAA varsity practices in the following contact/collision sports: basketball; equestrian; field hockey; football; ice hockey; lacrosse; pole vault; rugby; skiing; soccer; wrestling.” Female athletes are particularly vulnerable to concussion and tend to have longer recover times. Concussion is sometimes considered an invisible injury largely due to the absence of frank signs of injury on the outside of the head.
According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  Michael Sefton blog 2016

Burns, J. NY Times, In Europe, Echoes of America as Concussions Spur Debate, April 5, 2014. https://www.nytimes.com/2014/04/06/sports/in-europe-echoes-of-america-as-concussions-spur-debate.html?_r=0  Taken June 13, 2017
Sefton, M. (2016) Second Impact Syndrome. https://concussionassessment.wordpress.com/2016/10/03/second-impact-syndrome-rare-but-often-fatal/ Taken August 7, 2017
Bandidi, P. (2016) Rugby, like NFL, doesnt have the conussion-issue figured out.  http://www.espn.com/espn/story/_/id/16029747/rugby-nfl-concussion-issue-figured-out Taken August 7, 2017
NCAA Concussion Concussion Safety Protocol. Guidelines https://www.ncaa.org/sites/default/files/2017SSI_ConcussionSafetyProtocolChecklist_20170322.pdf Taken August 8, 2017

Construction and Self-monitoring

WESTBOROUGH, MA August 6, 2017 Self-monitoring refers to the capacity to observe one’s own behavior in real time. It is easy to see when someone lacks this important neurocognitive feature. Walk into any middle school and there will be hundreds of boys who act and behave without forethought.  Self-monitoring is a higher-order function that sets us apart from other species – even primates and is thought to mature in the second or third decade of life. It is possible to lose the ability to watch and adjust behavior such as with traumatic brain injury involving frontal lobe structures and in disorders of cognition such as dementia.  How is it possible to lose appreciation for the organization of the task (see drawing on left) and fail to notice one’s errors?
The bicycle task requires a rudimentary capacity to envision the bike and draw it from the image one has in his head.  It requires conceptualization, motor control and visual motor integration for success.  The task is age old – like the clocks frequently featured in these pages. Self-monitoring is a prerequisite for social pragmatics – a fancy term for acting your age. In some cases the failure in self-monitoring results in errors in behavior that can become socially debilitating – especially when the patient demonstrates an indifference to his limitations and does not respond to redirection and feedback.  The task of constructing a bicycle is a screening for higher order deficits.  Like the clock drawing it requires planning, organization, even mechanical awareness.  Muriel Lezak says that regardless of lesion the task requires judgment, organization, conceptual integration, and accurate self-appraisal.  Those with defective self-monitoring often miss important features and omit crucial parts of the bicycle’s mechanism like pedals, chain or both (Lezak, 1995)

 

 

“The capacity to self-monitor and modify one’s behavior is required in an open society or the lack of order would result in people being oblivious to each other and indifferent toward their personal effect on social and interpersonal relationships”    Michael Sefton 2017
In the first bike drawing the patient constructed the bicycle as asked but became confused very quickly.  the two objects extending out from the left and right are wheels that were drawn after I had asked “how does it work?” Interestingly one of the scoring criteria are the correct placement of spokes on the wheels. There are no spokes on the wheels of the second and third drawings. In some cases the concept of perseveration is revealing of decreased self-monitoring.  In a published blog the concept is described.  It is the process of repeating the same response over and over without awareness.

Lezak, M. Neuropsychological Assessment – Third Edition. Oxford Press, 1995.
Sefton, M. (2016) Perseveration, severation, eration, ation, blog post, taken August 8, 2017.

The results of postmortem examination of over 100 brains of NFL athletes are in

WESTBOROUGH,MA July 25, 2017 The laboratory at the Boston University School of Medicine has recently completed its initial examination of over 100 brains donated by the family members of those athletes who have died because of marked behavior and personality changes attributed to playing football.  The results confirm the presence of destructive proteins that have come to be known as chronic traumatic encephalopathy.  This was first reported over 10 years ago and was featured in the movie Concussion released in 2015 starring Will Smith as Bennet Omalu, M.D. who first reported on the syndrome.

Clock of the Week June 6

Westborough, MA June 6, 2017 The clock of the week is depicted below.  It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital.  I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine.  I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient.  It was drawn by a 93-year old male with congestive heart
 

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Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s.  This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient.  The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well.  I once had a patient draw and elaborate grandfather clock fit for a castle.  The clock face became secondary and insignificant – for him.  The clock is a regular feature here at Concussion Assessment and Management.  
Anyone can submit a clock for consideration of the clock of the week.  Upload to my email address: msefton@whittierhealth.com – No identifying HIPPA protected information please but a brief overview is always helpful. 

Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/pagets-disease-of-bone/home/ovc-20183843 Taken June 6, 2017

The Trial and Error Associated with Cognitive Decline

Westborough, MA May 25, 2017 Cognitive changes are common in patients with dementia. They become increasingly problematic with the disease progression. Some people suffering with dementia have difficulty with even the most basic activity of daily living like dressing themself.  Things taken for granted like following directions become a chore as the progression of dementia effects individuals who suffer with the disease.  This places a great burden on caregivers who must take over those important functions of daily life.
The clock drawing has been a feature on my blog for several years.  It is fun to see people work through the task.  Most people complete the task effortlessly.  Some are a bit defensive because it seems like such a benign request – “draw a clock…” and I often get “I am not an artist…” in anticipation of failure.  I have published over a dozen posts about the clock drawing as a measure of cognitive functioning.  Patient with dementia often experience a slow cognitive decline whereby even tasks like constructing a clock become a challenge.

The clocks drawn in this post reflect the effort of a person of 89-years of age who tried very hard to get it right.  She had enough preservation of her self- monitoring
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3 Clocks drawn in succession by 89-year old female with hypoxia and underlying dementia of Alzheimer’s type – note size in centimeters 

that she could tell something was wrong.  As you can see the left most circle was the first attempt.  It was too small according to the patient and she wanted to try again.  The middle clock was her next attempt and shows her disorganization and minimal change in the size of the drawing – approximately 3 centimeters in size. In the center of the drawing there are 2 hands that roughly represent the time 11:10.  She told me she needed more space to place the hands so that they could be clearly read and offered to try a third time.  On the right is her final attempt.  There are two hands (to the right of the number 9 and a second pointing to the number 2). As you can see the circle is only 2 cm in size and was a modest improvement over the first two attempts.
She had fun drawing the clock and did not feel as though she had failed the task. I was encouraging and praised her for staying with the task. At some point she had lost her capacity to plan and execute her visual motor function of crafting the circle.  Each attempt was made with the goal of drawing a larger circle. This fine woman was still capable of doing many of her activities of daily living and enjoying her friends and family.  She was not at all upset that I had been asked to help with her care.
Dementia requires family support and can be costly to those in need of care.  The risk of caregiver fatigue exists in all families.  As much as possible, I enourage people to allow the patient to work toward completing their own self-care unless there are risks such as falling due to poor balance. This requires herculean patience and sensitivity because there is often a degree of “awareness” of the cognitive changes experienced by the patient himself. Preserved dignity and sense of independence go a long way toward quality of life in the latter stages of dementia.  Most spouses will do whatever it takes to support a loved one with whom they have shared 50 or more years of marriage and experience the decline in functioning as both a personal failure and a heart breaking loss.