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
 

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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

All this from a clock…? A cognitive test for the ages.

Resurrecting the work of Dr. Edith Kaplan 

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This clock was drawn by a 92-year old right handed woman undergoing physical rehabilitation who has suspected dementia.
The clock drawing is an almost ubiquitous task on neurocognitive functioning that most clinicians are now using to determine whether or not there is evidence of cognitive slippage in the person being evaluated.  When I first make a request for the clock drawing patients inevitably say “I am not an artist“. But in truth the clock is a drawing that children learn sometime in the second or third grade.
I have had a fascination with the clock drawing for over 20 years that grew out of the training I received while a postdoctoral student at the Boston City Hospital in Boston.  I was thrilled to see what kinds of drawings people would come up with and surprised with the kind of interpretations I could make using the data that could be obtained at bedside.  I have many clocks published on this site.  The video library I am developing may be of interest to some.  It shows the directions and actual construction of the drawing.
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. In fact, Dr. Kaplan gave out a prize for the clock of the year of all the clocks submitted for supervision among her many students in neurology, neuropsychology and psychiatry at the Boston University School of Medicine, B.U. and Clark University doctoral psychology programs, Boston V.A. Medical Center, and Boston City Hospital – at which I did my internship and fellowship. Dr. Kaplan looked at hundreds of clocks during the short time I was at BCH.
There were some very interesting clocks that were constructed by patients of all walks of life – afflictions from dementia to traumatic brain injury to cerebral vascular accident and more.  I have added a “clock of the week” feature on this website in a (failed?) attempt to generate the same excitement that Dr. Kaplan generated for so many students a long time ago.  I have tried to keep it up to date and provide background information on each one.  So far, I have only received a single clock from a speech pathologist here at Whittier Rehabilitation Hospital.  She seems interested in the clock drawing as a cognitive assessment tool and I sometimes have patients tell me that they had just completed a clock drawing prior to my visit. I am planning to add video of the clocks being drawn by cases on which I am consulted.  These are sometimes interesting in themselves.  I hope to have a few linked within the next couple weeks.  Simply click on the clock of the day and be directed to the video of the clock being constructed.
Everyone is giving their patients the clock drawing test these days it seems. Unfortunately for me I am usually the last person to use the test and patients are wise to it. Not a problem though because it is not a trick.  You can do it or not.  Send your ideas and feedback and perhaps I will award a “Clock of the Year Award” as Dr. Kaplan did so long ago.  See my video at the You Tube link below.  See the history of my interest and some early clocks at a prior publication. I am particularly interested in those clocks that are indicative of micrographia and its possible link to frontal-temporal dementia.  Perhaps I am a bit overzealous on using this bedside assessment tool.  The bicycle is also a good test but you must ask your patient “tell me how it works…” once they finish it.
https://concussionassessment.wordpress.com/topics-in-neuropsychology/clock-drawing-what-can-it-tell-you-besides-the-time/