The Trial and Error Associated with Cognitive Decline

Westborough, MA May 25, 2017 Cognitive changes are common in patients with dementia. They become increasingly problematic with the disease progression. Some people suffering with dementia have difficulty with even the most basic activity of daily living like dressing themself.  Things taken for granted like following directions become a chore as the progression of dementia effects individuals who suffer with the disease.  This places a great burden on caregivers who must take over those important functions of daily life.
The clock drawing has been a feature on my blog for several years.  It is fun to see people work through the task.  Most people complete the task effortlessly.  Some are a bit defensive because it seems like such a benign request – “draw a clock…” and I often get “I am not an artist…” in anticipation of failure.  I have published over a dozen posts about the clock drawing as a measure of cognitive functioning.  Patient with dementia often experience a slow cognitive decline whereby even tasks like constructing a clock become a challenge.

The clocks drawn in this post reflect the effort of a person of 89-years of age who tried very hard to get it right.  She had enough preservation of her self- monitoring
Dementia_Clock female 89 Scan
3 Clocks drawn in succession by 89-year old female with hypoxia and underlying dementia of Alzheimer’s type – note size in centimeters 

that she could tell something was wrong.  As you can see the left most circle was the first attempt.  It was too small according to the patient and she wanted to try again.  The middle clock was her next attempt and shows her disorganization and minimal change in the size of the drawing – approximately 3 centimeters in size. In the center of the drawing there are 2 hands that roughly represent the time 11:10.  She told me she needed more space to place the hands so that they could be clearly read and offered to try a third time.  On the right is her final attempt.  There are two hands (to the right of the number 9 and a second pointing to the number 2). As you can see the circle is only 2 cm in size and was a modest improvement over the first two attempts.
She had fun drawing the clock and did not feel as though she had failed the task. I was encouraging and praised her for staying with the task. At some point she had lost her capacity to plan and execute her visual motor function of crafting the circle.  Each attempt was made with the goal of drawing a larger circle. This fine woman was still capable of doing many of her activities of daily living and enjoying her friends and family.  She was not at all upset that I had been asked to help with her care.
Dementia requires family support and can be costly to those in need of care.  The risk of caregiver fatigue exists in all families.  As much as possible, I enourage people to allow the patient to work toward completing their own self-care unless there are risks such as falling due to poor balance. This requires herculean patience and sensitivity because there is often a degree of “awareness” of the cognitive changes experienced by the patient himself. Preserved dignity and sense of independence go a long way toward quality of life in the latter stages of dementia.  Most spouses will do whatever it takes to support a loved one with whom they have shared 50 or more years of marriage and experience the decline in functioning as both a personal failure and a heart breaking loss.

Bike of the week – acquired brain injury

Draw a bike – How does it work?

WESTBOROUGH, MA June 6, 2016 The Bike of the week is drawn by a 86-year old man who is undergoing inpatient rehabilitation for an acquired brain injury and stroke. Actually I rarely publish the drawings made by patients I see unless I am going through a dry spell of interesting clocks.  The man who drew this bicycle was independent prior to a fall and driving.  In this case, there was a a fall 2 months ago – in April 2016 from which he largely recovered.  He underwent lab studies and a C-T scan of his brain being diagnosed with subdural hematoma (SDH).  The C-T scan revealed a collection of blood in the frontal part of his brain known as a subdural hematoma (SDH) often associated with brain trauma from a fall or motor vehicle crash.  The patient in this case had fallen in his bathroom. He had been prescribed a blood thinner and his atrial fibrillation which was stopped.  These levels were supratherapeutic – too high making him at high risk for bleeding – in this case in his brain. He was taken off the blood thinner in the weeks following the traumatic injury to allow the bleeding in his brain to be controlled. In late May, 2016, he was found at home to be slurring his words and demonstrating right hand weakness. He was rushed to Cape Cod Hospital and diagnosed with a left MCA ischemic stroke and he was treated conservatively.

Bleeding on the brain is a life threatening condition that will eventually result in herniation of brain tissue and death unless it is controlled.  Trauma can lead to edema or swelling of brain tissue.  In many cases, neurosurgery is required to remove subdural blood allowing space in the skull for the brain to swell as much as needed to recover.  In some rare cases, the part of the skull is actually removed to allow for brain swelling.  By removing a portion of the skull the brain tissue does not efface ipsilateral tissue or cause herniation by crowding out other viable brain tissue.



Clock of the week – 4-8-2016

WESTBOROUGH, MA 4-8-2016 “What is up with the clock of the week?”  For those of you who have been following these pages you may already know.  As you can sMicrographicMetabolic_Encephee it is quite small – 23 mm in size – about 1 inch.  It is almost a clean circle but you can see that the 77-year old male had trouble placing the hands.  He is in the hospital for rehabilitation following an episode of altered mental status.  He is a 1996 heart transplant recipient previously in good health. Send your clocks to me at

Clock of the week 3-23-16

Clock drawing 23 mm or 0.9 inch


WESTBOROUGH, MA  March 23, 2016  Here is a new clock drawn by a 85-year old male who is undergoing acute rehabilitation here is Westborough.  As you can see from the measuring tape it is about 23 mm in size.  It is just a bit over 1 inch in size.  Although somewhat subjective, I would call this an example of micrographia. In general micrographic drawing refers to constructions and writing that are well below the expected size – especially when the patient is copying a design and produces a tiny drawing – micrographic in size.  It is associated with lesions of the basal ganglia or neurodegeneration in the midbrain and is often seen in patients with Parkinson’s Disease.  Some might argue that micrographia results from diminished frontal-executive functioning.  This explanation is plausible to me but must include the system of attention as well. The patient who drew this clock needed two hands to craft some of his work by using his non-dominant left hand to steady the right as he wrote or drew.  He had sustained a cardiac arrest and was successfully resuscitated.  This man is not diagnosed with Parkinson’s. 

I have added a second clock of the week  also an example of micrographia. This clock was drawn by a 54-year old woman undergoing rehabilitation for a liver transplant.  She

Micrographia 2Scan
Micrographic clock only 19 mm in size drawn by 54 year old female

had had a long history of alcohol dependence resulting in damage to her liver.  A transplant was undertaken in February 2016.  Her drawing of 19 mm is only 3/4 inch in size.  I use a mechanical pencil to be sure and get as much detail in the drawings as possible.  Patients undergoing liver transplantation require weeks of rehabilitation due to the stress on the body this procedure instills. Below I have added another example drawn by the woman who is receiving treatment following a liver transplant.

Luria patterns

The Luria patterns is a test of set switching – thought to be a frontal lobe function.  This requires both attention to detail and the capacity to change the shape and angle of each character.  Some people fail to appreciate that the pattern is only 2 shapes – flat & pointed – repeated over and over.  I hope these drawings are of interest to those in training and or those with years of training in neuropsychology.  I enjoy receiving the occasional clock drawing or some other construction of interest.  Please do not hesitate to send your interesting clocks along with patient information and your interpretation.