Clock of the Week – September 25, 2017 Micrographia

Clock of Week Sept 25Scan
Clock of the week drawn by 79-Y/O male with bilateral embolic CVA (note size approximately 8 mm)
WESTBOROUGH, MA September 25, 2017 This clock is unique simply on the basis of it’s size.  The scale below the 3 clocks is used for measuring wounds.  It was given to me by the certified wound care specialist here at Whittier.  The top clock was the “finished” product.  One can see all the numbers were written and there was a series of hands drawn that appear as scribble moving from left to right.  The numbers fall outside of the circle – drawn by the patient.  You can appreciate what effort went into the clock as small as it was – only 8 millimeters across.  Micrographia is a term given to drawings that are tiny – a syndrome often assigned to dysfunction in the frontal lobe of the brain.  Just to be sure, I consulted with Lezak – 3rd Edition.  Micrographic written output is seen in patients with Parkinson’s Disease. In another blog published in 2016, I shared a similar clock and describe this interesting syndrome.
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Clock of the Week

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Dr. Michael Sefton at Boston Museum of Fine Arts
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

 

 

Click and see the interesting “Clock of the week

Construction and Self-monitoring

WESTBOROUGH, MA August 6, 2017 Self-monitoring refers to the capacity to observe one’s own behavior in real time. It is easy to see when someone lacks this important neurocognitive feature. Walk into any middle school and there will be hundreds of boys who act and behave without forethought.  Self-monitoring is a higher-order function that sets us apart from other species – even primates and is thought to mature in the second or third decade of life. It is possible to lose the ability to watch and adjust behavior such as with traumatic brain injury involving frontal lobe structures and in disorders of cognition such as dementia.  How is it possible to lose appreciation for the organization of the task (see drawing on left) and fail to notice one’s errors?
The bicycle task requires a rudimentary capacity to envision the bike and draw it from the image one has in his head.  It requires conceptualization, motor control and visual motor integration for success.  The task is age old – like the clocks frequently featured in these pages. Self-monitoring is a prerequisite for social pragmatics – a fancy term for acting your age. In some cases the failure in self-monitoring results in errors in behavior that can become socially debilitating – especially when the patient demonstrates an indifference to his limitations and does not respond to redirection and feedback.  The task of constructing a bicycle is a screening for higher order deficits.  Like the clock drawing it requires planning, organization, even mechanical awareness.  Muriel Lezak says that regardless of lesion the task requires judgment, organization, conceptual integration, and accurate self-appraisal.  Those with defective self-monitoring often miss important features and omit crucial parts of the bicycle’s mechanism like pedals, chain or both (Lezak, 1995)

 

 

“The capacity to self-monitor and modify one’s behavior is required in an open society or the lack of order would result in people being oblivious to each other and indifferent toward their personal effect on social and interpersonal relationships”    Michael Sefton 2017
In the first bike drawing the patient constructed the bicycle as asked but became confused very quickly.  the two objects extending out from the left and right are wheels that were drawn after I had asked “how does it work?” Interestingly one of the scoring criteria are the correct placement of spokes on the wheels. There are no spokes on the wheels of the second and third drawings. In some cases the concept of perseveration is revealing of decreased self-monitoring.  In a published blog the concept is described.  It is the process of repeating the same response over and over without awareness.

Lezak, M. Neuropsychological Assessment – Third Edition. Oxford Press, 1995.
Sefton, M. (2016) Perseveration, severation, eration, ation, blog post, taken August 8, 2017.

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

Delirium: sudden onset often lingering emotional impact

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
Parasitemia
Try as he might a patient with delirium cannot complete simple tasks according to Sefton.

Perseveration, severation, eration, ation

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

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Patient asked to copy her name – Frances

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.