Westborough, MA May 10, 2018 Clock of the week for May 10, 2018. Here is an interesting clock drawn by a 79-year old right handed male. He is a nursing home resident who is suffering with the effects of dementia. This clock is interesting because the subject was working quickly and until he reached the number placement. This is a good clock overall but fails appreciably in the self-monitoring needed for success.
He had been both efficient and spatially accurate. Ultimately his performance was negatively effected by the problem solving element of the three-step command required for success.
My mother Ann in 2018, she is 89-years old and loves to read but has been less active in past 12 months. She is holding a book given to her by best-selling author Bruce Coffin. She is quite emotionally resilient and enjoys reading and spending time with her children and grandchildren. She does not have dementia.
WESTBOROUGH, MA March 2, 2018 Dementia is the diagnosis given to individuals who have experienced an insidious decline in their neurocognitive functions. Practitioners around the world are using the clock instrument to assess cognitive status among a patient population who presents with cognitive or thinking changes who have insidious decline in their thinking capacity for whatever reason. I have published a great deal about the clock and was surprised this week to be contacted by Nicholas Searles a producer for the Australian television show “Ask the Doctors“. Mr. Searles works for the Austrailian Broadcast Corporation (ABC) wanted to display a clock on the upcoming show that was published on my website as the Clock of the Week in September 2017. These clocks are quite telling as to the cognitive functioning – including problem solving of the patient asked to construct them. See the prior publications of the clock of the week and dementia .
“Take care of yourselves, rest as much as you can, read good books, sing loud songs (when you’re alone…would be best) and read a poem now and then” Ann Sefton, 2015
What is the prominent feature of dementia? By definition dementia is an insidious decline in cognitive functioning over time this includes attention and memory functioning. Insidious change often translates into ‘not every member of the family sees the problem at the same time’. Very often, the patient is the last one to notice that anything is wrong with him or her. This raises considerable fear and sometimes conflict among family members. Everyone handles this particular stress differently. Insidious means that there are subtle but cumulative changes in cognitive functioning among these patients. This included a mixed bag of problems that include both physical and cognitive changes that are slow to present themselves and are sometimes missed by family and even the primary care physician. Sometimes activities of daily living such as bathing and dressing become the first things noticed by members of a caring family and often the source of great conflict. Mom or dad just does not want to “clean up” like they used to – bathing and dressing. Generally they will say “I took a shower this morning” but they may be wearing the same clothes or even undergarments suggesting this may not be the case. Just as frequently, the previously fastidious parent has shown changes in his or her awareness and concern over things that once were carefully controlled. I had one daughter of a dementia patient say that her mom never offers cookies or coffee when people visit and this was something she had done her entire life for visitors which she noticed a big change in her mom’s social behavior.
As a practitioner, when I begin a new patient exam, I make an effort to hear from members of immediate family as to what they have noticed about their loved one? This can be benign or it can be gut wrenching. I try to establish rapport and trust. I do this with empathy and professional concern that may enlist both family and patient in the lengthy process of the examination . Without trust a nervous patient will not be able to participate fully in the examination because of intrusive anxiety over the conflict they may feel about being brought to this office to spend signficant time with someone they do not know.
No easy task, I recently had to bring my mother to the hospital with changes in her cognition that we did not anticipate. Her photograph is posted above. My mother is a resilient and positive woman who is curious and smart. She is kind and gentle. See her comments in the blog I posted a couple years ago called Words to Live by. They are quite kind and endearing. She lost her husband – our father in 1984 and has not remarried. My father was only 56 when he died. My sister alerted me one morning that something was different about our mother. It was upsetting and I admit not wanting to take a close look at the true problem – maybe dementia. I had to bring her to her primary doctor for a quick exam whom then said she needed to be seen at the local emergency department right away. Ugh. I knew what that meant. Many hours of tests, C-T scans, and labs to rule out a cardiac event or an infection, or a cerebral vascular attack – stroke or something else. The entire event was humbling and I grew to appreciate the emergency physicians who deal with these cases daily. The physician who took care of my mother was sensitive and thorough. She listened to my mothers fear and apprehension about being in the hospital. Ultimately, mom was discharged home but still has a struggle with initiation and verbal expression that is unclear to us in terms of where it comes from.
None of us expects to grow old – nor do we expect our parents to ever age or become infirm. But they certainly do and of late, I am faced with the anguish of loosing touch with my mother as a result of her change in cognitive status and I am not sure just why. I am heart-broken when I think about this and she is not diagnosed with dementia. Her change in thinking and problem solving resulted from an infection she developed that came on gradually. The fact remains though that once vulnerable to altered mental status (AMS) one will need to think about possible treatable causes of changes in cognition before anything else. In our case, Mom is at risk for confusion and disorientation whenever she is sick with another condition like urinary track infection, bronchitis, even severe seasonal allergy. And this all means that she is at risk of falls and a host of other age-related problems both accidental and medical. These must be avoided to keep her quality of life and independence.
Dementia a growing problem as baby boomers grow old
I was approached by the Australian Broadcasting Company (ABC) in February 2018 who were interested in the clocks I have published over the years. The ABC somehow found my website and wanted my input on the clocks drawn by dementia patients. The ABC in Australia has a program called “Ask the Doctor” that airs weekly. The clock will be presented as part of the overall change in cognitive functioning when patients slowly become demented. The upcoming program is focused on “Living with Dementia” and will feature a clock that I published offering web site viewers an example of the changes in cognitive functioning when dementia takes hold. I hope to post a link to the program once it is broadcast.
The incidence of dementia is growing dramatically as those individuals born in 1950’s through the mid 1960’s become older. Because of this the medical establishment will soon be asked to modify the standard of care for this growing number of people in need. The assessment of these patients will be tenuous due to volume and lack of clinicians trained in working with geriatric cases. Like never before older American’s and those around the world will begin to show the age-related changes in gait pattern, balance, strength, memory, and problem solving that place them in direct harm for age-related changes in functional capacity. Some will require the services of a neuropsychologist who are on stand-by to provide assessments of patient memory, attention, and other cognitive functions like problem solving, judgment and reasoning that most of us take for granted. I have published clock drawings of some of these patients when of interest. Often they may seem sensational or impossible to believe. When you examine clock-after-clock one can see changes in problem solving and motor skill associated with the demands of the task and can make significant assumptions once the clock is scored. I learned about the clock drawing from Dr. Edith Kaplan in 1984-1986 while a student at Boston City Hospital and V.A. Healthcare in Boston. More importantly, these same problem solving tasks are likely to interfere with individual functional tasks needed by the patient to safely live his or her life. IADL’s are those functional skills such as cooking, cleaning, and making meals that are both automatic and often overlooked.
There are specialists everywhere who are charged with evaluating older patients and determining what is the best course of action for keeping them safe. Falls are a huge problem for older patients everywhere. Of 80 patients in our hospital, I would guess 30-40 percent are admitted secondary to mechanical falls. I will admit my mother has fallen 4 times in 3 years but so far has not bumped her head. That said, falls are a significant risk factor for dementia because an older brain will not tolerate repeated bumps and does not fully recover from falls. There are many people brought to hospital after a fall because of hip fracture or shoulder fracture who are not fully assessed for concussion or worse traumatic brain injury. The first question is always “did you lose consciousness?” and more often than not the patient was not rendered unconscious by the fall but may still have bona-fide neurocognitive changes in functioning.
Using the clock as a cognitive assessment tool – Growing interest around the world
The clocks below are those chosen by the producers at the Australian Broadcasting Company for a show called “Ask the Doctor”. I am told the show may be downloaded in the iTunes library for free or very low-cost. I will post a link when the show is broadcast so check back here if interested. You see the clocks below and may ask yourself “what happened here or why is this so hard for some people?” I had one email last year who asked whether the clock had been drawn by a person suffering form blindness as a reason for its idiosyncratic presentation.
No. In fact, those who are blind are often better at these tasks relying on internal conceptualization and approximate visual spatial configuration. I often say if I blindfolded you I would still expect a successful clock drawing.
When patient slowly loses cognitive function as in those afflicted with dementia their appreciation of performance is often lost and the appreciation for the complexity of the task may become minimized e.g. “I am not an artist”. While drawing the clock many do not self-monitor and do not notice the error pattern until it is all done. Some say “that does not look right..?” while others explain the results because “they are not artists” or the task is too simple for them. The clocks drawn to the left are those that will be discussed in the upcoming Australian Broadcast Company program “Ask the Doctor”
Clock of the week September 1, 2017
Sefton, M. (2015) Words to live by. Blog Post: https://msefton.wordpress.com/2014/12/28/words-to-live-by-trimble/ taken March 2, 2018
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.
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
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.
The name has been altered for privacy. What do you make of this clock? Whatever, it’s about
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
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.
WESTBOROUGH, MA January 20, 2018 More is becoming known about Chronic Traumatic Encephalopathy or CTE. It is now able to be diagnosed prior to the death of the patient by identifying unique protein markers in the blood of those who have sustained multiple brain injuries. Former professional wrestler Chris Benoit was found to have CTE after killing his wife and son before killing himself in 2007. But murder or other violence against others has not typically been associated with CTE until recently. As recently as summer, 2017, the brain of former N.E. Patriots star Aaron Hernandez was also found to have signs of severe CTE raising the specter of its possible impact on his violent life and eventual death by suicide. I have posted post-mortem photos of his brain first published on the Boston University site in a prior blog on my Concussion site (Sefton, 2017). See that post by clicking here. It is now understood that an athlete need not have sustained numerous concussions in his career to be found to have CTE at time of death. More so, the accumulation of repeated blows to the head – subconcussive force – is being implicated in the etiology of this complex disease process. So contact sports like football, rugby and ice hockey are being closely scrutinized by experts in concussion, athletic training and sports medicine. Researchers at BU School of Medicine have reported that a protein known as CLL11 may be elevated in the brain and spinal fluid of athletes with a history of brain injury. It holds some promise of being able to diagnose athletes before death. This protein leads to elevate Tau protein a known cause of progressive brain damage associated with dementia.
“CTE has been found to cause erratic and sometimes tragic behavior by some NFL players, perhaps most notably Hall of Fame linebacker Junior Seau, who killed himself last year. The disease, only recently diagnosable before death, has often been found in former and longtime football players.” Mellinger, 2014 K.C. Star
Riding a bicycle is a leading cause of brain injury in childhood. Recently, CTE has not been diagnosable before death. It has been found over and over in former and longtime football players. Domestic violence behaviors cut across all socioeconomic strata. They germinate in an environment of secrecy often early in courtship. During this time abusive spouse slowly isolates his intimate partner from her support – family, friends, finances. “In doing so there is a subtle but undeniable manipulation of control – usually coupled with threats and intimidation. There is growing awareness that red flag behaviors precede DV and domestic violence homicide. Things like pathological jealousy, forced sexual contact, manipulating friendships, detachment from members of immediate family and others are the early signs of domestic violence.” (Sefton, 2012) Some believe that the most significant pre-incident red flag is whether or not the victim truly believes she is going to be killed by her intimate partner one day and that these victims are at most risk of death.
Sefton, M (2012) Athletes and Celebrities Not Immuned: Kansas City Chief’s player kills wife and self in act of DVH, Blog post December 1, 2014, taken December 28, 2017.
Sefton, M. (2017). Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE. Blog post, Nov 19, 2017 Taken December 28, 2017
WESTBROUGH, MA January 18, 2018 The scientists studying the damaged brains of older athletes have had the opportunity to study brain damage in athletes who died from other causes. In 4 such cases, there was evidence of chronic traumatic encephalopathy (CTE) that was not commensurate with the degree of brain trauma that was observed during their athletic careers according to Felice Freyer of the Boston Globe. This recent study was published in the journal Brain illustrates that the onset of CTE may be closer to onset of brain injury than first thought not much later in life.
“The report, published Thursday in the journal Brain, also provides what Goldstein called “the best evidence to date” supporting the theory that CTE is caused not just by concussions, but rather by any blow to the head, including mild impacts. Instead of diagnosing and responding to concussions, he said, coaches would do better to protect children from all hits to the head.” Felice Freyer – Boston Globe 1-8-18
The possibility of younger athletes developing CTE and the symptoms associated with this progressive disease is quite worrisome especially to parents. It was always thought that CTE would develop later in life if at all. With the prospects of the disease having a much earlier onset the cost of CTE over a lifetime is incalculable in terms of medical costs and neuropsychological sequelae that may evolve in time. The true impact of this and the consequence for repeated, subclinical blows to the head is only now becoming clear.
Like dementia of the Alzheimer’s type the build up of tau protein underlies the changes associated with CTE. “Chronic traumatic encephalopathy is a condition bringing forth progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. We analysed post-mortem brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury and found evidence of chronic traumatic encephalopathy in 68 subjects: all males, ranging in age from 17 to 98 years (mean 59.5 years), including 64 athletes, 21 military veterans (86% of whom were also athletes) and one individual who engaged in self-injurious head banging behavior” according to the journal Brain. McKee, A. et. al. 2017