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 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.
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
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.
WESTBOROUGH, MA September 15, 2017 Much has been published about the utility of the clock drawing in making preliminary assumptions about the cognitive health of an individual who may be referred for neuropsychological assessment. I use it all the time and those of you who have submitted clocks for publication here agree with my assumptions. The photograph at the left was taken at the Boston Museum of Fine Arts by a colleague Dr. David Kent, a neuropsychologist from Worcester, MA. There are several posts that identify some of the literature behind the assumptions I make about clock drawing and cognition. Here is another link: Clocks and cognition
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: email@example.com – No identifying HIPPA protected information please but a brief overview is always helpful.
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.