Living with Dementia

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Clock drawing of 78-year old male with advanced dementia
WESTBOROUGH, MA February 23, 2018 Dementia is an affliction that slowly robs patients of their capacity to remember new information. Meanwhile their personal history remains readily available to them. That is why so many are able to share stories sometimes over and over. The cost of living with dementia for those so diagnosed is not a singular phenomena.  It effects the entire family and the wider community in which the patient lives. For many living with dementia is a lonely experience with sometimes  overwhelming sadness seeing a loved one slowly transform into child-like dependency.  Caregivers are at high risk for burn out when they care for a loved one day-after-day.  For many living with a person who has dementia can be an unforgettable challenge that often evokes guilt, resentment and despair.
There are many myths associated dementia that are worth pointing out.  First, old age and dementia are not synonymous.  Patients always say to me “what do you expect I am 82 years old” when I first begin the assessment process.  Research according to the APA, has shown in the right environment memory should not fail solely on the basis of age.
Part of this post was first publish nearly 3 years ago in 2015 and remains a timely addition to the literature on dementia, its assessment and impact on quality of life for those involved.  I have made some changes to the post from 2-1-2016 to update it and introduce another post that will be published shortly about dementia.  Pleased stay tuned to this blog and learn all about the affliction of dementia and more on the use of clocks for the assessment of cognitive changes.  I have added a person story that is compelling and has to do with this topic.  Thanks – I hope you like the upcoming posts.

“For many living with a person who has dementia can be an unforgettable challenge that evokes guilt, resentment and despair.” Michael Sefton 2018

The assessment of dementia is often stressful and the diagnosis is difficult to make.  The stress comes from the rare times that psychologist must give “bad news” to families of patients suffering with changes in their mental faculties. Unlike our physician brethren, psychologists rarely  have to give family members bad news or news that reflects a change in life expectancy.  One might expect this as normal from a physician who specializes in cancer or tumor treatment.  But in general, our discipline is not called upon to provide such subjective prognostic diagnoses very often. Dementia is one of those conditions primarily diagnosed by neuropsychological testing that has obvious impact on the life expectancy and the overall quality of life of those afflicted with it.
This clock above was drawn by a 78-year old man who was referred for outpatient neuropsychological assessment to determine the extent of change in dementia from his initial testing 24 months earlier.  You can learn quite a bit from the drawings of people thought to be suffering from dementia.  In this case, the patient was friendly and compliant.  He put forth a good effort and worked with diligence and earnest.  The task is the same for all cases – “draw a clock, put all the numbers on it and set the hands for 11:10.”
This clock effectively demonstrated the decline in the gentleman’s neurocognition.  It was poorly organized.  There was some neglect of the left hemi-space.  He had no self-monitoring or internal executive capacity to guide his construction.  He seemed surprised when I pointed out his work.  The numbers were not correctly placed. The slash marks were meant as minute marks and not number 11.  However, there were repeated numerals and reversals.  No hands were placed.
I learned about cognitive testing while an intern at Boston City Hospital – now B.U. Medical Center in the South End.  I loved my time there.  I wrote a blog about clocks and the utility of the clock drawing about a year ago called “All this from a Clock”.  If interested in the clock drawing take a look at the link I posted.  There is growing from clinicians around the world about dementia and using the clock as a screening tool.  The ABC in Australia recently chose one of the clocks recently published to feature on an upcoming program on dementia it is not clear when the program will be broadcast in Australia but I will post a link to the show once it is ready for broadcast. Stay tuned to http://www.concussionassessment.wordpress.com and Michael Sefton for further details.
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Clock of the week: February 16, 2018

WESTBOROUGH, MA February 16, 2018 Here is the clock of the week for mid February, 2018.  It is quite unusual as you can see. The clock of the week is sent to me by a speech language pathologist here at Whittier
Name in clock
Rehabilitation Hospital in Westborough, MA.  It was drawn by a 76-year old H.S. graduate with one year of college.  As you can see this patient was provided with standardized directions that I have described in many other posts.  “Draw the face of a clock with all the numbers – set the hands for 11:10.”  It is amazing how the brain operates – or in some cases fails to appreciate the task demands and process the 3 steps of the task as it is given. What is also missing in this creation is an awareness of the errors made relative the task demands.
In this case the speech language pathologist drew the circle because she was using the SLUMS Examination – a V.A. Healthcare screening tool. The SLUMS gives the patient a circle but in general the directions prefer the patient to draw the circle him/herself.
Whatever clock
  The name has been altered for privacy.  What do you make of this clock? Whatever, it’s about
12 before 10? No?

Clock of the Week: 1-25-18

Whatever clock
Unusual clock seen store window in Rockland, ME  January, 2018
Westborough, MA February 1, 2018 The video below is the clock of the week for this week in January, 2018. It is an interesting construction by a 81-year old male who is undergoing treatment for respiratory failure and myelodysplastic disease – a blood disorder in errant white blood cell production. He has had difficulty with all of his activities of daily living including dressing, bathing, personal hygiene and toileting.  He is recovering slowly and receiving daily therapy for these physical and occupational deficits.
“Renowned neuropsychologist Dr. Edith Kaplan too had a love affair with clocks (and owls as I recall) and taught us the unique importance of this seemingly simple neuropsychological instrument.” Sefton, 2015
 Clock video
The “clock drawing” task is described throughout the pages of this blog and is widely used by psychologists as a screening for cognitive dysfunction.  I like it because it is not threatening and is not a great challenge to the patient.  That said, I have had many people say ” I am not an artist” when asked to draw the face of a clock.  Interestingly, I suspect those who deny being artistically gifted (drawing a clock) may have some degree of preserved insight into their declining cognitive ability.
Clock of the Week: 1-25-18
https://www.youtube.com/watch?v=5FetKtiEzJE
The video is produced by the Neuropsychology Service at Whittier Rehabilitation Hospital. HIPPA protected.

 


Sefton, M. (2015) All this from a clock? Blog post: https://concussionassessment.wordpress.com/2015/04/29/all-this-from-a-clock-a-cognitive-test-for-the-ages/ . Taken January 26, 2018

Clock of the Year – Vote for your favorite of 2017

WESTBOROUGH, MA It is time once again to select the “Clock of the Year”.  Voting will go on for the next week.   There are 10 clocks featured this year each one drawn by a patient undergoing rehabilitation at Whittier Rehabilitation Hospital in Westborough, MA.  The diagnoses of each patient may or may not be presented with the clock as it scrolls through.  Any clock with a measuring tape would be presented in millimeters-centimeters not inches.  The clocks shown in millimeters are tiny – micrographic in quality.  The first clock in the slideshow is drawn by a 93-year old – each one would then become a successive number through # 10.

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I have published many blogs about the use of the clock drawing in clinical practice.  Clock drawing was first introduced to me in my practice as a pre-doctoral student in psychology at the V.A. Medical Center in Boston by Dr. Edith Kaplan.  She taught us that
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Michael Sefton at MFA Boston

 

something as simple as a clock drawing can become a daunting task when faced with cognitive changes from brain injury, stroke, or dementia.  I carry on this tradition in honor of Dr. Kaplan and the role she played in my formative work as a neuropsychologist.  Today, every discipline it seems uses a clock to assess problem solving, organization, and following directions in patients with suspected decline in their thinking skill. Dr Kaplan died in September, 2009 and is missed even now. The clock of the week has started to generate some clinical interest in Australia. The producer of the syndicated television show “Ask the Doctor” has asked to publish one of the featured clocks on their program.  The show will feature the clock from September 17 and the topic will be living with dementia.  I will post a link to the show once it is broadcast.

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.

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
 

SLP_93 YOScan
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
Dementia_Clock female 89 Scan
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.