Clock of the Week: Loss of Conceptual Accuracy and Integrity

This is a clock recently submitted by by a Whittier Speech Language Pathologist who was working with a 90-year old male who was recently admitted to our hospital.  He is very sick with a complex medical history.  He was admitted to a hospice service – essentially receiving comfort measures only.  The conceptual errors in this drawing made me ask about his hearing.  Did he understand the task? The clock was dawn using his dominant hand.  Clearly there are other elements in the drawing. Some staffers though it looked like a shoe.  It seemed to me as I looked at this unscoreable clock that the patient has lost a conceptual awareness of what clock means. Next, I would be interested in knowing whether he could be prompted into copying a clock such as the one on the wall in each patient room. Finally, as a patient entering hospice one is reminded that life expectancy can be quite short and the changes in cognition are common.

 

Successful clock? By now you all know.

What do you think about this clock drawing. It looks pretty good from the execution of the circle but you see the number placement is slightly off. Hmm? What do you expect perfection? Well truthfully yes the clock drawing is a task that should be quite routine – even when you are 70, 80, or even 90 years of age. Now the time it takes to complete the task varies from person to person and co-occurring illnesses, etc. As you watch this video what do you think about the hand placement? Does the clock read 10 minutes past 11? Or is it off?

Michael Sefton

This clock is unusual in that it was correctly drawn but with a square face

Clock of the week

Drawn by 65-year old right handed male

One of the clocks previously published here at the Concussion Assessment and Management blog was chosen by the Australian Broadcast Company as an illustration of how dementia effects cognition in older Australians. I was contacted 6 months ago by the show’s producers. I think they struck by the simplicity of the task and the variety of responses we see clinically. The program called “Ask the Doctor” is a weekly broadcast in Australia about varying health concerns faced by the aging population down under.  Like here in the United States, health concerns including Alzheimer’s dementia are covered by the producers of the show.  I was sent a link to the show and have asked permission to post the broadcast that contains the clock drawing.  It shows how important it is to understand cognition and dementia. I will post a link to the You Tube video of the original clock drawing below.

The Clock of the Week is drawn by a 65-year old male who is struggling from the effects of respiratory failure and its impact on debility.  He has a tracheostomy tube in place and cannot speak.  He communicates using gesture such as when he is thirsty. He is irritable and was eager to write to me when given the chance.

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Here is a sample of his written language output.  He was asked to write the sentence “Baseball players are tough”.  You can see from the writing above that he put forth his best effort but still has a way to go to use written output as a bona fide communication modality. In cases such as this the clinical team is asked to use Yes/No inquiry to assess his language and for gaining deeper understanding of the physical and emotional adjustment through which this man is going.  He is participating in treatment in spite of his frustration, anxiety, and thirst. Once he is able to swallow he will be given a hospital diet by mouth.  Until then he receives full nutrition via a gastronomy tube in his stomach.

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Here is a copy of the You Tube video that depicts the clock that was used on the Australian Broadcast Company “Ask the Doctor” program that was broadcast in October, 2018.  In Australia there are thousands of new cases of dementia diagnosed weekly. Watch the video and share it.

Clock of the Week: September 10, 2018

 WESTBOROUGH, MA  September 7, 2018 Here is the Clock of the Week for the week of September 10, 2018. It is an interesting clock that illustrates both confusion and intrusion errors.  The task is simple. It involves a 3- step process of drawing the circle, placing the numbers, and correctly placing the hands to read 11:10.  I have espoused this task for several years now and publish interesting clocks.  Last week, I was sent a clock that a speech pathologist here at the hospital was able to obtain from one of her patients.  This clock was drawn by a 85-year old male diagnosed with Parkinson’s Disease (PD).  He is right handed and has had PD for 15 years.  He has also had a prior stroke which complicates the interpretation of this drawing.

What is interesting about this clock was the written language that appears in the middle of the clock face. This is an intrusion error from the prior task I had given him.  He was asked to write a sentence. He completed the sentence and later, components of the same sentence showed up as a perseveration that intruded on the task at hand (the clock drawing).  This is a sign of a lost cognitive “set”. He was drawing a clock and trying to place the numbers when just as quickly he began writing the prior sentence. Interestingly, the clock has no features in the lower quadrants of the drawing.  He was able to roughly construct a circle but was stuck with the upper components of the clock.  It looked to me that he understood that setting the clock for 11:10 meant that he needed to focus on the upper left and upper right sides of the drawing. As he drew the clock he seemed to get stuck drawing the hash marks of the numerals.

He has significant problems with both immediate and remote memory.  PD has a life expectancy of 10-15 years.  His case is complicated by a prior CVA and will likely result in a loss in his independence for going home.

When younger athletes “play up” : concussion and the fantasy of greatness

August 20, 2018  Athletes across the country are getting set for fall sports season.  Both high school and university athletes have started their respective training camps and “try-outs” for football, soccer, field hockey, fall lacrosse, cross country, and even interscholastic ice hockey.  I have already had calls to see young boys who are playing with varsity teams and may be outsized by 50 pounds or more.  The allure of playing for the varsity team can be intoxicating to both student athletes and parents alike. The fantasy of popularity, physical dominance, and record setting success all add to the stress of playing high school or collegiate sports. Younger athletes are at higher risk of injury and for prolonged recovery from injury.

As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the eventual outcome.  Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are failures and weak unless they play through their injuries – including concussion.

With all the fan fare surrounding the NFL training camps varsity high school barely registers on the sports radar screen.  It is a thrilling time for players who are invited to varsity practices when they may still be an underclassman or even still in middle school.  Behind the scenes, there are coaches and parents colluding to allow younger players to suit up as varsity athletes all with the unspoken belief that starting earlier on the varsity team will better prepare the growing athlete for a Division 1 college experience – even a scholarship.

I provided on-field EMS coverage for a number of years in Massachusetts at youth and varsity high school level sports. I have also provided concussion management for university and AHL teams for several years. I have seen significant harm done to individual players when they are invited to play on varsity teams prior to having all the physical and emotional tools needed to understand a balance between school, competition, and injury – when these occur.  Smaller, younger athletes pay a large price for playing up on varsity teams.  The same goes for “walk on” freshman who try out for college football or other collegiate teams. They are asked to compete against athletes who are significantly stronger and heavier putting them in danger.  Most are emotionally ill-equipped and physically unprepared for the difference in skill development and may be prone to serious injury.  Sadly, when some walk on players become injured they are not afforded the first class rehabilitation afforded the varsity players. There is a great difference between a walk-on freshman at 18-years of age and a player who has been in the collegiate system for 2 or more years. The average high school athlete does not receive the expert weight training needed to be prepared to compete at the collegiate level and puts himself (or herself) at risk when positioned against their upperclass collegiate counterpart. Similarly, when a boy or girl in grade 7-8 is invited to “try out” for a varsity team a similar mismatch in size and skill set should be expected. Many school districts allow younger students to play varsity interscholastic sports if they qualify and have the skill sets.

Arguably some coaches encourage this competition as a rite of passage leaving the younger athlete vulnerable to serious injury including concussion.  When this happens the player becomes marginalized and feels forgotten and unimportant which has a profound impact on his self-esteem and can derail his high school or collegiate playing career.  I spend a fair amount of time teaching the re-exertion steps necessary for safe return-to-play and more importantly, for getting back to class.  A specific return to play protocol outlining gradual increase in physical activity including management of concussion, headaches, decreased balance, dizziness, and emotional well-being.  One particular protocol has been established by the Concussion in Sport Group (Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell, McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med.).

“I have taken care of players who have been injured playing hockey but the recovery time is significantly longer for the young, smaller athlete.” Michael Sefton This is consistent with the findings published recently from the Hasbro Children’s Hospital study.

There is a risk to athletes who compete against players out of their weight class.  Youth football organizations like Pop Warner and the American Youth Football Association require weekly weigh ins to avoid the physical mismatch and thereby reduce the risk to younger, less physically and emotionally developed athletes. Similarly,the sport of wrestling has had athletes compete in weight class for decades. Once injured with concussion, the return to play is now standardized with respect to the individual athlete’s symptom profile and history. This has changed across New England since 2009 when school sand colleges began requiring both pre-season screening and a systematic return-to-play protocol.  Returning to play after concussion requires a stepwise process. Each step is monitored by a trainer, coach or volunteer with training in concussion.  Athletes must remain asymptomatic at each phase of their return before they are released to 100 percent full contact at game speed.  This is not always easy to arrange as many school districts have no athletic trainer or share the services of an athletic trainer among several sports.

Concussion occurs with and without a lapse in consciousness.  Any force hitting the skull can induce the cascade of physiological effects of concussion.  These symptoms generally last 3-21 days with the subtle cognitive consequences being most lingering.  The Concussion Assessment and Management Program (CAMP) keeps track of patient’s who require support after concussion.  CAMP is now located at Whittier Rehabilitation Hospital in Westborough, MA and offers a complete range of concussion assessment and management protocols.  Many people wrongly believe that they may return to practice and then games without first being cleared by a physician or neuropsychologist specializing in concussion.  Most states require this clearance before an athlete may return to play. Rhode Island was the first state in New England to require concussion education for all parents, athletes, coaches, and referees.  Most states have followed suit.  The state of Connecticut has an outstanding concussion training program for coaches.

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P McCrory, K Johnston, W Meeuwisse, M Aubry, R Cantu, J Dvorak, T Graf-Baumann, J Kelly, M Lovell, P Schamasch. Br J Sports Med. 2005 Apr; 39(4): 196–204. doi: 10.1136/bjsm.2005.018614 PMCID: PMC1725173

Sefton, M. (2014)  Post-concussion Syndrome. Blog post:  https://concussionassessment.wordpress.com/consultation/post-concussion-syndrome-pcs/ Taken 8-15-2018

Clock of the Week: 8-15-18

Westborough, MA August 15, 2018 The clock of the week is submitted by a Speech Language Pathologist working with patients here at Whittier Rehabilitation Hospital.  The patient who constructed this weeks prize winner is a 64-year old male with bronchiolitis obliterans, a lung disease characterized by fixed airway obstruction. Inflammation and scarring occur in the airways of the lung, resulting in severe shortness of breath and dry cough according to Wikipedia (2018). Just looking at the clock it may be safe to say that there is significant cognitive decline and/or altered mental status depicted in the lack of appreciation for the task demand.  It is not clear to what extent his lung disease may have left him vulnerable to the effects of hypoxia – the lack of oxygen in the blood.  Depending upon how long the brain goes with depleted levels of oxygen and how low the oxygen saturation drops can have a great deal of impact on anoxic brain injury.

Anoxia has a profound impact on cognition and functional independence.  I want to thank the astute speech language pathologist for obtaining this clock drawing in the course of her patient assessment. I am curious as to what treatment options and methods she may be using with this interesting patient. I would welcome other clock submissions.

Clock of the Week: July 23, 2018

WESTBOROUGH, MA July 24, 2018 Some people believe that the simple task of drawing a clock is like a window into the brain (Eknoyan,et al. (2012). I have posted reviews of clock drawing over several years.  Edith Kaplan, Ph.D. is credited with teaching me the importance of these neurocognitive protocols in 1985 while I was training at Boston City Hospital. Dr Kaplan saw the clock drawing as a parietal lobe test (Kaplan, 1988) but many debate that focal attribution of the clock drawing may under represent the clinical utility of this perfunctory task.  Tranel and collegues (2008) found that the clock drawing has several potential neuropsychological correlates represent the neuroanatomic underpinnings of the individual clocks scored and rated in their research.

“Documenting the type of clock-drawing errors can contribute to the clinical evaluation of patients with suspected neuropsychiatric disorders and syndromes”  Eknoyan, et al.

Watch the video below and enjoy a complete assessment of a single patient undergoing neuropsychological assessment.  Post your thoughts and let me know what your observations say to the underpinnings of cognition we are seeing.  This patient was cooperative and friendly.  He is only 82 years of age and was undergoing treatment for a recent mechanical fall.

Michael Sefton

References

Eknoyan, D. et al. (2012) Journal of Neuropsychiatry Clin Neuroscience, 24:3 Summer.

Kaplan, E. (1988) The Process Approach. In Boll T, Bryant, BK, editors. Clinical Neuropsychology and Brain Function. Washington DC, APA.

Tranel, D, et al. (2008) Does the Clock Drawing Test have Focal Neuroanatomical Correlates? Neuropsychology, 22(5) 553-562.

Hearing Loss and quality of life

WESTBOROUGH, MA July 16, 2018  I have recently been taking care of a couple of men who have experienced significant hearing loss as they aged. The loss of any sensory system contributes to a significant change in independence and satisfaction in life.  In this systematic review and meta-analysis of 36 epidemiologic studies and 20 264 unique participants, age-related hearing loss was significantly associated with decline in all main cognitive domains and with increased risk for cognitive impairment and incident dementia. Increased risks for Alzheimer disease and vascular dementia were not statistically significant.

“Hearing loss may have a profoundly detrimental effect on older people’s physical and mental well-being, and even health care resources,” says senior study investigator and Johns Hopkins otologist and epidemiologist Frank Lin, M.D., Ph.D.

“Our results underscore why hearing loss should not be considered an inconsequential part of aging, but an important issue for public health,” says Lin, an assistant professor at the Johns Hopkins University School of Medicine and the university’s Bloomberg School of Public Health. According to Lin, as many as 27 million Americans over age 50, including two-thirds of men and women aged 70 years and older, suffer from some form of hearing loss.

“Dr Frank Lin says social isolation resulting from hearing loss may explain the physical and mental declines – as well as the cognitive deficits – that afflict older adults. This, in turn, may lead to more illness and hospitalization, he says. His team already has further research under way to see if treating hearing loss with counseling and hearing aids can reduce people’s risk of cognitive decline and dementia”.

Tinnitus is sometimes associated with hearing loss. Tinnitus is also known as ringing in the ears and is described by many as a constant high pitched sound or whistling noise.  It is sometimes attributed to “trauma” from years of employment or working in an industry that required no hearing protection.

I have begun using a new protocol in my biofeedback session for those most bothered by tinnitus.  Neurofeedback is a non- invasive neuromodulation technique which records a subject’s neuronal activity, extracts relevant aspects of brain processes by means of real time signal processing and returns feedback to the subject as visual or auditory stimuli. The aim of neurofeedback is to change behavioral traits or medical conditions associated with altered neural activity as demonstrated for chronic tinnitus.”

“Subjective tinnitus has been described as the constant perception of an auditory sensation that does not correlate to any external acoustic stimulus (Stouffer and Tyler, 1990). It can be perceived as either pitch or noise-like sound and its perception may be unilateral, bilateral or spread out in the whole head (De Ridder et al., 2014b).”

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Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA. Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;144(2):115–126. doi:10.1001/jamaoto.2017.2513

Güntensperger D, Thüring C, Meyer M, Neff P and Kleinjung T (2017) Neurofeedback for Tinnitus Treatment – Review and Current Concepts. Front. Aging Neurosci. 9:386. doi: 10.3389/fnagi.2017.00386

De Ridder, D., Fransen, H., Francois, O., Sunaert, S., Kovacs, S., and van de Heyning, P. (2006). Amygdalohippocampal involvement in tinnitus and auditory memory. Acta Otolaryngol. 126, 50–53. doi: 10.1080/03655230600895580

Stouffer, J. L., and Tyler, R. S. (1990). Characterization of tinnitus by tinnitus patients. J. Speech Hear. Disord. 55, 439–453. doi: 10.1044/jshd.55 03.439

Visual Motor Skill and Dementia

July 2, 2018 Simple tasks become more difficult and often are impossible.  Tasks like copying a simple design or making simple line drawings become cognitively onerous

Size in millimeters

You can see from the drawing above that the 90 year old woman had difficulty initiating and executing the task.  “Draw-a-clock” seems simple enough.  I have been using this technique for over 20 years with very interesting findings.  The

The task relies on existing internal template of clock along with enduring problem solving and self-monitoring. The second drawing was initiated at her own choosing.  When given the choice she asked to draw the bicycle. That drawing is shown below.  Both posts are tiny in size – only 2-3 cm and reveal just how lost the self-monitoring component of cognition has become for this interesting patient.

The most interesting piece of this illustration is the diamond shape.  We had just stopped working on drawing shapes from the Mattis Dementia Rating Scale.  The final shape is a diamond.  Shortly afterward I gave her the standard instructions to draw a clock.  I have published many clocks in these pages to illustrate the complexity of the task.  She initiated the task by constructing another diamond and began putting the numbers in the contour of the diamond – rather than the typical circular drawing.  This is the first time I ever had the clock drawn in a diamond and this is an example of a contaminated response whereas one task intrudes into the next task as I just described.  These types of errors are common in patients with dementia.  I have attached the link to the actual video taken of the task as she created the clock.  Here is the link to the video taken of this clock drawing.

Bicycle drawn by same 90 year old patient

 

Update: Michael Schumacher now living with severe TBI – 4 years on

June 28, 2018 Michael Schumacher is a former Formula 1 race car driver and champion.  He was severely injuryed in a skiing accident in French Alps near Switzerland 4 years ago in late 2013.  He was treated at a trauma center in Grenoble, France.  His wife and family were on a holiday.  They are devastated by the loss of Michael who is now is a minimally responsive condition that was once called near coma state.  He continues to receive daily therapies including physical and occupational therapy.  Information about Michael is released infrequently because the family is very private.  His care has cost over 20 million Euros since the accident.

Michael Schumacher and wife Corinna in 2013            AFP photo

F1 fans are also still keeping Schumacher close in their thoughts – with the official Ferrari supporters club unfurling a massive 30-metre long banner at pre-season testing in Spain ahead of the 2018 season.

Little is known about the day-to-day condition of this once great Formula 1 athlete except he is no longer able to function at the same level as he once did as a result of the tragic accident in late 2013.  His family stands with him and continues to look for treatment options.  There is some thought to move Michael to Texas in the US where he owns a ranch.  There are recovery services that may be offered to him that may afford Schumacher some improvement in his functioning and provide more hope for his loving and supportive family. Both his son and daughter have gone on to their adult lives and are successful adult athletes.

 

Gina-Marie Schumacher Photo Splash News

 

On Father’s Day 2017, his son Mick Schumacher reported “My role model is my dad. Simply because he is the best – my idol.” Meanwhile, his 20-year old daughter Gina-Marie has gone on to a career in the equestrian sport. At the Audi Generation Awards she said “I would like to thank the jury, but especially my parents for the love they give me every day,” she said, after revealing she used to go karting with her legendary father but chose a different career path because “horses are better”.