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
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.
WESTBOROUGH, MA November 10, 2016 You may be interested in the Clock of the week on this day after the presidential election of Donald J. Trump. It was drawn by a male with obvious cognitive dysfunction. The task is simple – draw a clock and set the hands for 11:10. In this case the patient became stuck. He asked me “how do I do it” and I replied start with the circle. As you may notice the man drew the large circle quite well. I thought to myself “hmm, not bad”. Next he drew one small circle after another. Finally he was able to approximate the minute hand only – as you can plainly see it is set juxtapose where the 2 might be.
Dementia is an insidious neurological disease that robs patients of their mental functioning – including memory, problem solving and the capacity to think with critical acumen. The late president Ronald Reagan succumbed to dementia of the Alzheimer’s type in 2004 after a decade of declining cognitive prowess. He was 69 when he entered the White House. It has grown more prevalent in the past decade. Neuropsychologists are uniquely qualified to manage the cognitive and behavioral changes associated with dementia. There is no cure for dementia at the present time. Exercise and mental activity are two components of maintaining a healthy mind and body into one’s old age. My practice is filled with older patients many of whom do not believe in the adage about old age being “the golden years”. In fact, many older patients are lonely and demoralized. Many are afraid of what the next president may do to their healthcare, housing and social security pensions.
Let us hope that our next president will maintain his mental faculties well into old age. His somewhat unbridled behavior is not unlike that of patients suffering with some forms of dementia that negatively impacts judgment, planning and decision-making. Mr. Trump will be 70 years old when he enters the White House in January 2017. The oldest man to ever be elected to the office of the president.
Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do. STAT Boston Globe taken 10-17-2016
WESTBOROUGH, MA October 14, 2016 What does the term ‘to perseverate’ refer to in clinical terms. The media attached below will illustrate the concept of perseveration in its clinical presentation. The patient was asked to copy her name. A model was presented for her by the examiner. Most people have control over behavior through a series of feedback loops that become active in the brain that allow for anticipatory awareness and behavioral prospective as a person reaches full cognitive maturity. Patients who are recovering from right hemisphere lesions often exhibit the pattern
of repetition without regard for how appropriate the pattern may be in respect to the task demand. You can see that the patient draws what appear to be tee pee shaped figures and two horizontal lines – perhaps a modified upper case A. Meanwhile, she repeated the figure until she ran out of paper at the bottom margin. In blogs already published I have mentioned the term perseveration and made an effort to illustrate its unusual presentation. One can see in the feature image a circular pattern of zeros as a patient attempted the clock drawing. The patient got stuck making the number 0. In the recent blog on this topic, I posted a video for the readers use that shows one case of perseveration in an older patient drawing circles over and over.
The term refers to the pattern of repeated motor movement in spite of the indication (or feedback) that the response is no longer needed or is inappropriate. As you can see by this drawing the individual continued to make the same pattern over and over without regard for the task I had assigned – copy your name.
Treatment from serious stroke require months of cognitive rehabilitation in addition to physical and occupational therapy. patients must be taught to recognize their cognitive vulnerability to errors like this. As recovery is made most patients establish improved self-monitoring to compensate for their weaknesses. But some fail to re-establish the feedback loops and awareness that allow them to live in the world with the immediate awareness that once is enough and it is okay to stop.
WESTBOROUGH, MA September 30, 2016 The clock of the week is drawn by a 77-year-old male with Parkinson’s Disease. It is representative of his execution of the internal
ized concept of “clock” with the given task of setting the hands to read 10 past 11. Many people discredit the utility of the clock drawing because on the outside it appears to lack psychometric rigor. I disagree and have used the clock drawing for many years as a tool to screen motor control, visual spatial capacity, problem solving, self-monitoring, and other frontal controls. The particular clock above is not a complete disaster. As you can see there is a circle. The next feature illustrated is the presence (or absence) of all the numbers, In this case it is clear that all 12 numerals are represented on the face of the clock. Admittedly the numbers fail to appreciate the contour of the circle but they are grossly appropriate. Finally, the task requires the patient to set the clock so that the time is set for 11:10 (intentionally vague). The errors produced often provide grist for the diagnostic mill in terms of the types of mistakes, e.g. missing numbers, broken gestalt of circle, numbers crowded to one side of the clock, time set in error. In the past several months I have published clocks drawn by patients here at Whittier. Many people have expressed an interest in the clock drawing and I find that everyone is using the clock as a cognitive screening measure. Here at Whittier our speech pathologists use it with every admission. I have found it funny when someone says “what another clock?”. These patients usually check out just fine on the tests we use as a measure of perfunctory neurocognition.
Written Language in PD
Here is a sample of the same patient’s written language . He is asked to write 2 sentences that are quite easy. Poor written expression is common in most people who suffer with Parkinson’s because PD is a disease that attacks motor pathways resulting in sometimes wild tremors and poor motor control making them at risk for falls. These sentences do not replect the tremulous motor output often found in the work of patients with PD. In this case his symptoms are well controlled on his current medication. He is seen by a neurologist and intenal medicine physician almost daily. The sentences are: He shouted the warning; and Baseball players are tough.