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 October 7, 2016 The clock of the week brings up an interesting question. What is encephalopathy? I hear that all the time from patients and more likely, family members who are confused as to the definition of encephalopathy. I will make an effort in this blog to provide some explanation for this. Look at the clock and see that is quite confused. Remember prior published clocks and the fact that the directions are exactly the same for every person. “Draw the face of a clock, put all the numbers on it and set the hands for 11:10”. Essentially it is a three step command that requires both attention and problem solving. In prior published blogs and You Tube videos I have made an effort to illustrate the range of clocks given by patients of various diagnostic classifications.
Encephalopathy is a common manifestation in patients with sepsis (infectious illness) such as pneumonia and urinary track infection, delayed hemodialysis, and many others. In refers to brain dysfunction often due to multifactorial issues including metabolic and infectious causes. According to the Health Line encephalopathy may be temporary or permanent. The patient who created the illustrated drawing was very cooperative but subject to altered mental status when getting sick, fatigued or on dialysis days. The treatment for encephalopathy depends on the underlying reason for the AMS but largely is treating the symptom picture to manage the patient comfortably.
Symptoms of encephalopathy often begin rapidly and may be seen as confused behavior, decreased attention, and poor problem solving. Neuropsychology services across the country are referred these patients in earnest in hope of tracking changes in their cognitive status and behavior. The assessment process is lengthy. At some point, patients are asked to make up a sentence containing a noun and a verb as part of the basic cognitive screening. As you can see from the illustration below, this patient had difficulty with this task. Almost any sentence will suffice but in this case the woman added the heart to represent the word ‘love’ and placed a smiley face at the bottom of her page to indicate her completion of the task. Persons with encephalopathy often exhibit unusual limitations in their awareness of their condition and exhibit varying levels of confusion throughout the day. Slowly these symptoms resolve – sometimes quite rapidly. Just as rapidly, some patients are vulnerable to altered mental status at the first sign of infection.
WESTBOROUGH, MA October 8, 2016 Second impact syndrome is a rare but generally catastrophic injury that results from a second blow to the head that immediately follows a concussive injury – often undiagnosed or an injury that was previously diagnosed but not fully healed. The second injury to an already damaged brain results in catastrophic swelling within the brain often incompatible with survival. Scottish boxer Mike Trowell died of a severe brain injury occurring in a sanctioned boxing match in Glasgow, Scotland on September 29.
Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma. This leaves an athlete gravely injured unless immediate neurosurgical intervention can be provided (Bey & Ostick, 2009). Sadly, even with the best care many patients with SIS succumb to their injuries within a few minutes. Most believe that concussions create a metabolic crisis in the brain that results in a gross change in cerebral efficiency – an inability to match the external cerebral energy demand – especially sporting activity at the elite level.
In general, if the brain fully heals an athlete is at no greater risk of concussion than someone who has never sustained a concussion. However, when an athlete returns to play before he or she is fully healed they are at high risk for a second or third concussion and at risk for SIS. It is well know that there is a cumulative effect of injury to the brain with repeated trauma. In fact, repeated trauma results in a significant reduction in brain volume that can seriously reduce information processing speed and other neurocognitive functions according to a study in the British Journal of Sports Medicine in 2015. The greater number of fights resulting in more blows to the head has a significant impact on speed of processing. Certainly a well established link between repeated head trauma and dementia, depression, and other signs of neurocognitive decline has been found in U.S. football players.
Boxer fatally injured with second impact that was sustained in a fight in Scotland recently. Scottish Boxer Mike Towell was critically injured on September 30, 2016 during a fight with Dale Evans in Glasgow, Scotland. 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. He was transported to the trauma center in Glasgow ultimately being placed on life support. He lived 12 hours once the decision had been made to terminate life support. His partner Chloe Ross reported that Towell had been experiencing headaches in the weeks prior to the fight that were attributed to stress. Medical authorities may not have allowed Towell to fight had the recent history been known. Towell may have been highly vulnerable to concussion as a result of his boxing history and unique neurocognitive underpinning. So when he stayed in the fight he unknowingly put himself at risk for lethal injury.
Bey,T and Ostick, B. Second Impact Syndrome West J Emerg Med. 2009 Feb; 10(1): 6–10 Taken October 1, 2016
Loosemore, M., et al. Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. British Journal of Sports Medicine doi:10.1136/bjsports-2015-094755.
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.