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.
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
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.
“The syndrome consists of musculoskeletal pain, headaches, sensitivity to sound and light, sleep disturbance, changes in memory and balance, anxiety and depression. The emotional impact of this leaves patients feeling alone and frustrated” Sefton, 2016
The likelihood of getting a concussion while playing sports is between 10-30 percent of high school and college athletes. As many as 29 percent of these injured players may go on to experience post-concussion syndrome. It is important for team physicians, trainers, and primary care doctors to understand and treat people with lingering symptoms of concussion.
In a blog post published in September it is noted that concussion is an invisible injury and recovery takes time – generally 2-3 weeks. The consequence to individual athletes or others recovering from car crash, falls, and any brain trauma can be debilitating and effect a few bodily systems. The emotional stress of lingering symptoms should not be underestimated. Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.
A multidisciplinary approach is best that allows for restoration of physical activity and acknowledgement of both physical and emotional symptoms. Pain management is a useful intervention including aquatics. My approach to treatment includes biofeedback, education and psychotherapy. This helps reduce the autonomic effects of acute stress and the inflammatory impact on the fight/flight response – including blood pressure, sleep, and rate of breathing.
Sefton, M. What is PCS: and why do I care? Blog post: https://concussionassessment.wordpress.com/2016/09/30/what-is-pcs-and-why-do-i-care/. Taken October 1, 2016.
WESTBOROUGH, MA September 28, 2016 Postconcussion Syndrome is a complex disorder that can stymie many physicians because of the abundance of both physical and emotional symptoms. There are about 3-25 percent of patients who are diagnosed with concussion that go on to have a longer duration of symptoms – sometimes a year or more . That is quite a discrepancy in the prevalence of cases.
The PCS cases with whom I have worked having prolonged symptoms from concussion often experience both physical and emotional symptoms that can be debilitating. “Post-concussion syndrome is a complex disorder in which various symptoms — such as headaches, light and sound sensitivity and dizziness — last for weeks and sometimes months after the injury that caused the concussion.” (Mayo Clinic) If someone you know suffers from PCS the effects to a family system can be dramatic especially when the head of household can no longer go to work. Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.
Sometimes vague physical symptoms create an overwhelming emotional response that comes from the lingering resentment patients feel when seeing doctors who seem unable to understand their needs. Sometimes the outward appearance of lingering concussion may appear to be solely a psychiatric condition rather than someone who is recovering from a brain injury. Some physicians unfairly believe prolonged symptoms may be linked to ongoing litigation.
In a blog published in December 2015, Concussion and PCS was discussed in some detail. “Like concussion, it is an invisible injury that renders many people unable to work. Headaches, neck pain, fatigue, visual changes, irritability, sensitivity to sound and light, depression, and poor sleep hygiene were common” (Sefton, 2015). The long-term impact negatively impacts both physical and emotional functioning by slowly increasing autonomic activation and impact sleep, appetite, and emotional well-being.
When I am working with someone who has been symptomatic for months or more it is quite apparent how frustrated they can become. It is important for the patient to feel they are believed in the story they are telling. Their symptoms are real and in many cases life changing. I realize that they have never received the proper education from experts to understand their concussion and its potential recovery course. Someone with prolonged PCS can be difficult to work with because symptoms can be refractory to traditional therapy. The last thing they may want is to sit with a neuropsychologist and retrace their steps all the way back to the beginning of their symptoms or personal injury. A multidisciplinary approach is best for all involved and should include physical exertion that does not exacerbate existing symptoms (Makdissi, et al, 2016).
Meanwhile, there is a growing body of literature that links prolonged symptoms of concussion to major life stress that can imprint psychologically – like PTSD when the timing is right.
Mayo Clinic Website, http://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/basics/definition/con-20032705. Taken September 28, 2016
Sefton, M. Concussion: physician’s once espoused a link to unresolved litigation. Blog post: https://wordpress.com/stats/insights/concussionassessment.wordpress.com Taken October 1, 2016.
Makdissi, et al. The difficult concussion patient. Br J Sports Med. 2013 Apr;47(5):308-13. doi: 10.1136/bjsports-2013-092255 Taken October 1, 2016
“The last thing a person who has been suffering with the effects of a concussion wants is to be told they should go and see a neuropsychologist who will take them all the way back to the beginning – where no one seems willing to go.” Michael Sefton
WESTBOROUGH, MA September 30, 2016 The clock of the week is drawn by a 77-year-old male with Parkinson’s Disease. It is representative of his execution of the internal
ized concept of “clock” with the given task of setting the hands to read 10 past 11. Many people discredit the utility of the clock drawing because on the outside it appears to lack psychometric rigor. I disagree and have used the clock drawing for many years as a tool to screen motor control, visual spatial capacity, problem solving, self-monitoring, and other frontal controls. The particular clock above is not a complete disaster. As you can see there is a circle. The next feature illustrated is the presence (or absence) of all the numbers, In this case it is clear that all 12 numerals are represented on the face of the clock. Admittedly the numbers fail to appreciate the contour of the circle but they are grossly appropriate. Finally, the task requires the patient to set the clock so that the time is set for 11:10 (intentionally vague). The errors produced often provide grist for the diagnostic mill in terms of the types of mistakes, e.g. missing numbers, broken gestalt of circle, numbers crowded to one side of the clock, time set in error. In the past several months I have published clocks drawn by patients here at Whittier. Many people have expressed an interest in the clock drawing and I find that everyone is using the clock as a cognitive screening measure. Here at Whittier our speech pathologists use it with every admission. I have found it funny when someone says “what another clock?”. These patients usually check out just fine on the tests we use as a measure of perfunctory neurocognition.
Written Language in PD
Here is a sample of the same patient’s written language . He is asked to write 2 sentences that are quite easy. Poor written expression is common in most people who suffer with Parkinson’s because PD is a disease that attacks motor pathways resulting in sometimes wild tremors and poor motor control making them at risk for falls. These sentences do not replect the tremulous motor output often found in the work of patients with PD. In this case his symptoms are well controlled on his current medication. He is seen by a neurologist and intenal medicine physician almost daily. The sentences are: He shouted the warning; and Baseball players are tough.