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.

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.

Clock of the week – a man of Trump’s age

femaledementia_clockscan
Drawn by 70-year old male
WESTBOROUGH, MA November 10, 2016 You may be interested in the Clock of the week on this day after the presidential election of Donald J. Trump.  It was drawn by a male with obvious cognitive dysfunction.  The task is simple – draw a clock and set the hands for 11:10. In this case the patient became stuck. He asked me “how do I do it” and I replied start with the circle.  As you may notice the man drew the large circle quite well.  I thought to myself “hmm, not bad”.  Next he drew one small circle after another.  Finally he was able to approximate the minute hand only – as you can plainly see it is set juxtapose where the 2 might be.
Dementia is an insidious neurological disease that robs patients of their mental functioning – including memory, problem solving and the capacity to think with critical acumen.  The late president Ronald Reagan succumbed to dementia of the Alzheimer’s type in 2004 after a decade of declining cognitive prowess.  He was 69 when he entered the White House. It has grown more prevalent in the past decade. Neuropsychologists are uniquely qualified to manage the cognitive and behavioral changes associated with dementia. There is no cure for dementia at the present time. Exercise and mental activity are two components of maintaining a healthy mind and body into one’s old age.  My practice is filled with older patients many of whom do not believe in the adage about old age being “the golden years”.  In fact, many older patients are lonely and demoralized.  Many are afraid of what the next president may do to their healthcare, housing and social security pensions.
Let us hope that our next president will maintain his mental faculties well into old age. His somewhat unbridled behavior is not unlike that of patients suffering with some forms of dementia that negatively impacts judgment, planning and decision-making. Mr. Trump will be 70 years old when he enters the White House in January 2017.  The oldest man to ever be elected to the office of the president.

What is encephalopathy?

encephalopathy_clock_80female
80-year old right handed woman with sepsis and hypoxemia

WESTBOROUGH, MA October 7, 2016 The clock of the week brings up an interesting question.  What is encephalopathy? I hear that all the time from patients and more likely, family members who are confused as to the definition of encephalopathy.  I will make an effort in this blog to provide some explanation for this.  Look at the clock and see that is quite confused.  Remember prior published clocks and the fact that the directions are exactly the same for every person.  “Draw the face of a clock, put all the numbers on it and set the hands for 11:10”.  Essentially it is a three step command that requires both attention and problem solving.  In prior published blogs and You Tube videos I have made an effort to illustrate the range of clocks given by patients of various diagnostic classifications.

Encephalopathy is a common manifestation in patients with sepsis (infectious illness) such as pneumonia and urinary track infection, delayed hemodialysis, and many others. In refers to brain dysfunction often due to multifactorial issues including metabolic and infectious causes.  According to the Health Line encephalopathy may be temporary or permanent.  The patient who created the illustrated drawing was very cooperative but subject to altered mental status when getting sick, fatigued or on dialysis days.  The treatment for encephalopathy depends on the underlying reason for the AMS but largely is treating the symptom picture to manage the patient comfortably.

make-up-a-sentencescan
“I want you to make up a sentence…”

Symptoms of encephalopathy often begin rapidly and may be seen as confused behavior, decreased attention, and poor problem solving.  Neuropsychology services across the country are referred these patients in earnest in hope of tracking changes in their cognitive status and behavior.  The assessment process is lengthy.  At some point, patients are asked to make up a sentence containing a noun and a verb as part of the basic cognitive screening.  As you can see from the illustration below, this patient had difficulty with this task.  Almost any sentence will suffice but in this case the woman added the heart to represent the word ‘love’ and placed a smiley face at the bottom of her page to indicate her completion of the task.  Persons with encephalopathy often exhibit unusual limitations in their awareness of their condition and exhibit varying levels of confusion throughout the day.  Slowly these symptoms resolve – sometimes quite rapidly.  Just as rapidly, some patients are vulnerable to altered mental status at the first sign of infection.

Second Impact Syndrome: rare but often fatal

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25-year old Boxer Mike Towell  (BBC photo)
WESTBOROUGH, MA October 8, 2016 Second impact syndrome is a rare but generally catastrophic injury that results from a second blow to the head that immediately follows a concussive injury – often undiagnosed or an injury that was previously diagnosed but not fully healed. The second injury to an already damaged brain results in catastrophic swelling within the brain often incompatible with survival.  Scottish boxer Mike Trowell died of a severe brain injury occurring in a sanctioned boxing match in Glasgow, Scotland on September 29.
Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma. This leaves an athlete gravely injured unless immediate neurosurgical intervention can be provided (Bey & Ostick, 2009).  Sadly, even with the best care many patients with SIS succumb to their injuries within a few minutes. Most believe that concussions create a metabolic crisis in the brain that results in a gross change in cerebral efficiency – an inability to match the external cerebral energy demand – especially sporting activity at the elite level.
In general, if the brain fully heals an athlete is at no greater risk of concussion than someone who has never sustained a concussion.  However, when an athlete returns to play before he or she is fully healed they are at high risk for a second or third concussion and at risk for SIS. It is well know that there is a cumulative effect of injury to the brain with repeated trauma. In fact, repeated trauma results in a significant reduction in brain volume that can seriously reduce information processing speed and other neurocognitive functions according to a study in the British Journal of Sports Medicine in 2015. The greater number of fights resulting in more blows to the head has a significant impact on speed of processing. Certainly a well established link between repeated head trauma and dementia, depression, and other signs of neurocognitive decline has been found in U.S. football players.
Boxer fatally injured with second impact that was sustained in a fight in Scotland recently.  Scottish Boxer Mike Towell was critically injured on September 30, 2016 during a fight with Dale Evans in Glasgow, Scotland.  According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  He was transported to the trauma center in Glasgow ultimately being placed on life support.  He lived 12 hours once the decision had been made to terminate life support.  His partner Chloe Ross reported that Towell had been experiencing headaches in the weeks prior to the fight that were attributed to stress.  Medical authorities may not have allowed Towell to fight had the recent history been known. Towell may have been highly vulnerable to concussion as a result of his boxing history and unique neurocognitive underpinning.  So when he stayed in the fight he unknowingly put himself at risk for lethal injury.
REFERENCES
Bey,T and Ostick, B. Second Impact Syndrome West J Emerg Med. 2009 Feb; 10(1): 6–10 Taken October 1, 2016
Loosemore, M., et al. Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. British Journal of Sports Medicine doi:10.1136/bjsports-2015-094755.

Concussion Update at Whittier

 

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Michael Sefton, Ph.D.

WESTBOROUGH, MA September 28, 2016 There will be a free seminar offered at Whittier Rehabilitation Hospital in Westborough on Wednesday September 28, 2016 on Sports-related Concussion along with updated information about post concussion syndrome and its treatment.  The program is presented by Michael Sefton, Ph.D., director of neuropsychology and psychological services at Whittier Rehabilitation Hospital and certified brain injury specialist.  The program begins at 5:30 with a dinner being served.  Call WRH at 508-870-2222 to reserve your spot.

 

 

 

Bike of the week – acquired brain injury

Bicycle_SDH
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.