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
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: firstname.lastname@example.org – No identifying HIPPA protected information please but a brief overview is always helpful.
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
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.
WESTBOROUGH, MA May 15, 2017 Multiple Sclerosis is a demyelinating disorder that affects the brain and spinal cord of those so afflicted. MS is a disease that causes the immune system to attack the protective covering around the nerve fibers (Reference.com). Many of the nerves in the brain and spinal cord are covered with a myelin sheath – something like insulation on wire. This permits the instantaneous transmission of nerve impulses from one part of the body or brain to another. In patients suffering with MS their myelin is deficient sometimes having reduced efficiency or not working at all. It is a condition that for many gets better and gets worse. As you can see from this image taken from Google images the myelin sheath is the outer layer or membrane of fatty Schwann cells and other neuroglial support cells. MS may be linked to a virus and/or immunological compromise but its true etiology is not known.
We see a fair number of persons afflicted with M.S. in the rehabilitation hospital here in Massachusetts. MS is known to be relapsing and remitting in its quality which adds to treatment complexity and frustration for patients. They are a fiercely independent group of people and I can certainly understand why that might be. On some days they are able to get themselves out and into their cars for the drive to work something we might take for granted. While on other days, they may have difficulty putting on their their shoes and making lunch. Many are frustrated and angry that they cannot take care of themselves and sometimes wind up in our hospital getting physical therapy and other restorative therapies. Aquatic therapy is a great resource we offer at Whittier in Westborough, MA. I encourage people to become familiar with aquatic programs
in their area. They can provide support, pain management and effective physical therapy for those who may have limited energy resources. Fatigue becomes a problem in nearly all patients who suffer with multiple sclerosis. Cognitive changes are common in patients who experience long-term MS that sometimes make subtle changes in personality and all higher order problem solving, reasoning, and other executive functions. Some believe there are distinct personality features in those with MS
In addition to frustration and anger, some patients are resistant to restorative solutions suggested by rehabilitation team members who want to help. Some say “they want to do things their way” and resist rehabilitative suggestions that might offer energy conservation strategies or innovative methods for greater independence. Medication is used to reduce inflammation associated with MS and prevent relapse.
Reference.com. (2017) https://www.reference.com/health/treatments-multiple-sclerosis-2ed87c70dcd71896. Taken May 6, 2017
WESTBOROUGH, MA May 1, 2017 The return to school following a brain injury should be carefully planned. School nurses tend to be the point person for parents’ whose children are coming back to school after concussion. But let’s not forget the school psychologist. My wife, Mindy Sefton, Psy.D., is trained in concussion management and has crafted some of the best return-to-learn plans I have ever seen. She works closely with the nurse and classroom teachers to be sure no student be placed at risk for failure. At her middle school there is a protocol for re-entry that is specific and tailored for individual students.
Students with acute concussion and those suffering with post concussion syndrome require assistance at school or risk falling behind their peers. Some parents are not aware but it is true that when concussion sidelines and athlete he or she is highly vulnerable for school-related changes as well. Schools or educational teams who are interested in offering a comprehensive concussion education program are encouraged to contact CAMP or Dr. Sefton directly for consultation. Student athletes often require support in school while recovering from concussion. Support protocols like reduced work, extra time for tests, and deferred projects are just three commonly prescribed accommodations.
I am happy to help public schools with their protocols. They are critically important for student success. Individual programs can be integrated slowly on a team by team basis depending upon learning style, specific sport and unique student needs. Dr. Sefton has specialized training in pediatric brain injury, concussion and neuropsychological assessment and is a member of the Academy of Brain Injury Specialists. Training for coaches and trainers is available and recommended to identify updated return-to-play protocols and current standards of care. Both web-based and individualized ImPACT testing is available for preseason and after injury assessment. Return-to-play consultation is available with trainers and team physicians 24/7 at 508-579-0417 and email email@example.com
School districts interested in using CAMP for supporting athletes injured while playing sports can contact Dr. Sefton at 508-579-0417. Parents and physicians may call Dr. Sefton at any time to discuss individual injuries and school and sports re-entry after injury. Post injury testing and neuropsychological consultation is also available.
Return-to-Learn Care Plan
Some students who are injured playing in school sports may require a return to school care plan. Dr. Sefton will consult with student, parents, and school personnel to assist with short-term accommodations in school that can assure for continued success in academic domains. Not all children require changes in their educational programs but careful consideration of the child’s school functioning is essential.
Classroom teachers should be advised to monitor the student athlete for the following signs:
Increased problems paying attention/concentrating
Increased problems remembering/learning new information
Longer time required to complete tasks
Increase in physical symptoms (e.g., headache, fatigue) during schoolwork
Greater irritability, less tolerance for stressors
WESTBOROUGH, MA April 21, 2017 There has been a great deal of research published recently about the cumulative impact of concussion. Every athlete who experiences a concussion has a unique trajectory toward recovery. It is well-known that athlete’s who experience a second or third concussion may be at risk for long-term cognitive symptoms unless they rest until the symptoms are fully resolved. It is now expected that each recovery is different and should be tailored for the presenting symptom profile and the athlete’s medical history. A combination of rest and controlled exertion seems to work best for recovery. Balance and vestibular changes from concussion require physical therapy in the days after injury. We offer these services at Whittier Rehabilitation Hospital. In cases of second or third concussion the recovery can be very different and often prolonged.
There are dozens of You Tube videos that I have posted in these pages illustrating the brain as it becomes concussed. On my first website nearly 20 years ago I purchased a .gif program to illustrate the movement of the brain during a concussion – like the one below. It cost me nearly $100 to download and post on my website. Now they are available free of cost and easily posted to social media.
A concussion is a traumatic brain injury resulting from force causing energy to pass through the brain resulting in the brain shaking within the skull. A study published in January 2016 in the Journal of Pediatrics suggests that preadolescent boys are at higher risk of concussion when playing on varsity ice hockey teams. The study at Hasbro Children’s Hospital in Providence, RI also suggested that girls playing ice hockey who are heavier may be at greater risk for concussion. On average, the preadolescent boys in the study took 54 days to become symptom free.
Here is a link to another very useful video produced by a Canadian physician Dr. Mike Evans. I often have families watch this 10 minute video before initiating our conversation. The point is that the brain is seriously impacted by energy pulsating through the skull from whatever cause. I have seen several snow boarders this winter. Spring sports usually see an uptick of concussions in lacrosse and girl’s softball. Concussion can be expected to effect all cognitive functioning including concentration, speed of mental processing, problem solving, memory, and behavior.
WESTBOROUGH, MA January 31, 2017 There is no way to avoid a stressful life it seems. Some people are better than others at reducing the impact of stress. Excercise, healthy eating, regular sleep, and mindfulness reduce the impact of the stress and tension we all experience in our lives. These behaviors are being taught to children who experience stress just like their parents in many schools. Meanwhile, concussion and more serious brain injuries result in changes in the autonomic nervous system that are sometimes life threatening. The behavioral response of these afflictions include marked restlessness, anxiety, changes in sleep hygiene, abnormal pain response, and pervasive tension.
In cases of severe brain injury one might see autonomic storming as described in a prior blog. Autonomic storming results from trauma to regions of the brain that control primitive bodily functions like respiration, heart rate, and emotional regulation. This includes profuse sweating, elevated heart rate, rapid changes in body temperature and motor restlessness. These functions are comprised in the autonomic nervous system and are known as the fight-flight mechanism. The sympathetic nervous system elevates blood pressure, respiratory drive, and gets us ready to fight or run. Meanwhile, the parasympathetic system puts the brakes on these functions allowing the body to return to its normal resting rate.
“Eventually, chronic stress could be treated as an important risk factor for cardiovascular disease, which is routinely screened for and effectively managed like other major cardiovascular disease risk factors.” Ahmed Tawakol, Harvard Medical School
Ostensibly, stress has the capacity to change this normal resting heart rate and slowly raise our levels making it difficult to truly relax. In the long term, external stress can change our heart functioning including hypertension and cardiac arrhythmia and put us at risk for cardiovascular illness including heart attack and stroke. Lifestyle changes are necessary to avoid long-term health problems from stress. Mindfulness includes deep, regular breathing, guided imagery, and progressive relaxation. It is being introduced in some public schools so that it may become part of the coping mechanisms used by kids when stress sets them off – as it undeniably will do.
Sefton, M. (2015). Heart rate variability: Biofeedback options for post-concussion syndrome, https://concussionassessment.wordpress.com/2015/08/03/heart-rate-variability-biofeedback-options-for-post-concussion-syndrome/
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.