Clock of the Week – May 10, 2018

Westborough, MA May 10, 2018  Clock of the week for May 10, 2018.  Here is an interesting clock drawn by a 79-year old right handed male. He is a nursing home resident who is suffering with the effects of dementia.  This clock is interesting because the subject was working quickly and until he reached the number placement.  This is a good clock overall but fails appreciably in the self-monitoring needed for success.
He had been both efficient and spatially accurate.  Ultimately his performance was negatively effected by the problem solving element of the three-step command required for success.
Dio ClockScan
Clock drawing by 79-year old male with dementia.
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Dementia: Clocks gaining interest across the globe

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My mother Ann in 2018, she is 89-years old and loves to read but has been less active in past 12 months. She is holding a book given to her by best-selling author Bruce Coffin. She is quite emotionally resilient and enjoys reading and spending time with her children and grandchildren. She does not have dementia.
WESTBOROUGH, MA March 2, 2018 Dementia is the diagnosis given to individuals who have experienced an insidious decline in their neurocognitive functions.  Practitioners around the world are using the clock instrument to assess cognitive status among a patient population who presents with cognitive or thinking changes who have insidious decline in their thinking capacity for whatever reason. I have published a great deal about the clock and was surprised this week to be contacted by Nicholas Searles a producer for the Australian television show “Ask the Doctors“.  Mr. Searles works for the Austrailian Broadcast Corporation (ABC) wanted to display a clock on the upcoming show that was published on my website as the Clock of the Week in September 2017.  These clocks are quite telling as to the cognitive functioning – including problem solving of the patient asked to construct them.  See the prior publications of the clock of the week and dementia .
“Take care of yourselves, rest as much as you can, read good books, sing loud songs (when you’re alone…would be best) and read a poem now and then”  Ann Sefton, 2015
What is the prominent feature of dementia?  By definition dementia is an insidious decline in cognitive functioning over time this includes attention and memory functioning.  Insidious change often translates into ‘not every member of the family sees the problem at the same time’. Very often, the patient is the last one to notice that anything is wrong with him or her. This raises considerable fear and sometimes conflict among family members. Everyone handles this particular stress differently.  Insidious means that there are subtle but cumulative changes in cognitive functioning among these patients.  This included a mixed bag of problems that include both physical and cognitive changes that are slow to present themselves and are sometimes missed by family and even the primary care physician. Sometimes activities of daily living such as bathing and dressing become the first things noticed by members of a caring family and often the source of great conflict.  Mom or dad just does not want to “clean up” like they used to – bathing and dressing.  Generally they will say “I took a shower this morning” but they may be wearing the same clothes or even undergarments suggesting this may not be the case. Just as frequently, the previously fastidious parent has shown changes in his or her awareness and concern over things that once were carefully controlled.  I had one daughter of a dementia patient say that her mom never offers cookies or coffee when people visit and this was something she had done her entire life for visitors which she noticed a big change in her mom’s social behavior.

As a practitioner, when I begin a new patient exam, I make an effort to hear from members of immediate family as to what they have noticed about their loved one? This can be benign or it can be gut wrenching.  I try to establish rapport and trust.  I do this with empathy and professional concern that may enlist both family and patient in the lengthy process of the examination . Without trust a nervous patient will not be able to participate fully in the examination because of intrusive anxiety over the conflict they may feel about being brought to this office to spend signficant time with someone they do not know.
No easy task, I recently had to bring my mother to the hospital with changes in her cognition that we did not anticipate.  Her photograph is posted above.  My mother is a resilient and positive woman who is curious and smart. She is kind and gentle.  See her comments in the blog I posted a couple years ago called Words to Live by. They are quite kind and endearing.  She lost her husband – our father in 1984 and has not remarried.  My father was only 56 when he died.  My sister alerted me one morning that something was different about our mother.  It was upsetting and I admit not wanting to take a close look at the true problem – maybe dementia. I had to bring her to her primary doctor for a quick exam whom then said she needed to be seen at the local emergency department right away.  Ugh.  I knew what that meant.  Many hours of tests, C-T scans, and labs to rule out a cardiac event or an infection, or a cerebral vascular attack – stroke or something else. The entire event was humbling and I grew to appreciate the emergency physicians who deal with these cases daily.  The physician who took care of my mother was sensitive and thorough. She listened to my mothers fear and apprehension about being in the hospital. Ultimately, mom was discharged home but still has a struggle with initiation and verbal expression that is unclear to us in terms of where it comes from.
None of us expects to grow old – nor do we expect our parents to ever age or become infirm. But they certainly do and of late, I am faced with the anguish of loosing touch with my mother as a result of her change in cognitive status and I am not sure just why.  I am heart-broken when I think about this and she is not diagnosed with dementia.  Her change in thinking and problem solving resulted from an infection she developed that came on gradually. The fact remains though that once vulnerable to altered mental status (AMS) one will need to think about possible treatable causes of changes in cognition before anything else.  In our case, Mom is at risk for confusion and disorientation whenever she is sick with another condition like urinary track infection, bronchitis, even severe seasonal allergy. And this all means that she is at risk of falls and a host of other age-related problems both accidental and medical. These must be avoided to keep her quality of life and independence.

Dementia a growing problem as baby boomers grow old

I was approached by the Australian Broadcasting Company (ABC) in February 2018 who were interested in the clocks I have published over the years. The ABC somehow found my website and wanted my input on the clocks drawn by dementia patients. The ABC in Australia has a program called “Ask the Doctor” that airs weekly. The clock will be presented as part of the overall change in cognitive functioning when patients slowly become demented.  The upcoming program is focused on “Living with Dementia” and will feature a clock that I published offering web site viewers an example of the changes in cognitive functioning when dementia takes hold. I hope to post a link to the program once it is broadcast.
The incidence of dementia is growing dramatically as those individuals born in 1950’s through the mid 1960’s become older.  Because of this the medical establishment will soon be asked to modify the standard of care for this growing number of people in need. The assessment of these patients will  be tenuous due to volume and lack of clinicians trained in working with geriatric cases.  Like never before older American’s and those around the world will begin to show the age-related changes in gait pattern, balance, strength, memory, and problem solving that place them in direct harm for age-related changes in functional capacity.  Some will require the services of a neuropsychologist who are on stand-by to provide assessments of patient memory, attention, and other cognitive functions like problem solving, judgment and reasoning that most of us take for granted. I have published clock drawings of some of these patients when of interest.  Often they may seem sensational or impossible to believe. When you examine clock-after-clock one can see changes in problem solving and motor skill associated with the demands of the task and can make significant assumptions once the clock is scored.  I learned about the clock drawing from Dr. Edith Kaplan in 1984-1986 while a student at Boston City Hospital and V.A. Healthcare in Boston.  More importantly, these same problem solving tasks are likely to interfere with individual functional tasks needed by the patient to safely live his or her life. IADL’s are those functional skills such as cooking, cleaning, and making meals that are both automatic and often overlooked.
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Sample clock drawn by dementia patient – primitive demonstrating no planning or problem solving

 

There are specialists everywhere who are charged with evaluating older patients and determining what is the best course of action for keeping them safe.  Falls are a huge problem for older patients everywhere.  Of 80 patients in our hospital, I would guess 30-40 percent are admitted secondary to mechanical falls.  I will admit my mother has fallen 4 times in 3 years but so far has not bumped her head.  That said, falls are a significant risk factor for dementia because an older brain will not tolerate repeated bumps and does not fully recover from falls. There are many people brought to hospital after a fall because of hip fracture or shoulder fracture who are not fully assessed for concussion or worse traumatic brain injury.  The first question is always “did you lose consciousness?” and more often than not the patient was not rendered unconscious by the fall but may still have bona-fide neurocognitive changes in functioning.

Using the clock as a cognitive assessment tool – Growing interest around the world

The clocks below are those chosen by the producers at the Australian Broadcasting Company for a show called “Ask the Doctor”.  I am told the show may be downloaded in the iTunes library for free or very low-cost.  I will post a link when the show is broadcast so check back here if interested.  You see the clocks below and may ask yourself “what happened here or why is this so hard for some people?” I had one email last year who asked whether the clock had been drawn by a person suffering form blindness as a reason for its idiosyncratic presentation.
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Clocks chosen for discussion on Australian television program focusing on dementia in 2018
No. In fact, those who are blind are often better at these tasks relying on internal conceptualization and approximate visual spatial configuration. I often say if I blindfolded you I would still expect a successful clock drawing.
When patient slowly loses cognitive function as in those afflicted with dementia their appreciation of performance is often lost and the appreciation for the complexity of the task may become minimized e.g. “I am not an artist”. While drawing the clock many do not self-monitor and do not notice the error pattern until it is all done.  Some say “that does not look right..?” while others explain the results because “they are not artists” or the task is too simple for them. The clocks drawn to the left are those that will be discussed in the upcoming Australian Broadcast Company program “Ask the Doctor”

Clock of the week September 1, 2017


Sefton, M. (2015) Words to live by. Blog Post: https://msefton.wordpress.com/2014/12/28/words-to-live-by-trimble/ taken March 2, 2018

Living with Dementia

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Clock drawing of 78-year old male with advanced dementia
WESTBOROUGH, MA February 23, 2018 Dementia is an affliction that slowly robs patients of their capacity to remember new information. Meanwhile their personal history remains readily available to them. That is why so many are able to share stories sometimes over and over. The cost of living with dementia for those so diagnosed is not a singular phenomena.  It effects the entire family and the wider community in which the patient lives. For many living with dementia is a lonely experience with sometimes  overwhelming sadness seeing a loved one slowly transform into child-like dependency.  Caregivers are at high risk for burn out when they care for a loved one day-after-day.  For many living with a person who has dementia can be an unforgettable challenge that often evokes guilt, resentment and despair.
There are many myths associated dementia that are worth pointing out.  First, old age and dementia are not synonymous.  Patients always say to me “what do you expect I am 82 years old” when I first begin the assessment process.  Research according to the APA, has shown in the right environment memory should not fail solely on the basis of age.
Part of this post was first publish nearly 3 years ago in 2015 and remains a timely addition to the literature on dementia, its assessment and impact on quality of life for those involved.  I have made some changes to the post from 2-1-2016 to update it and introduce another post that will be published shortly about dementia.  Pleased stay tuned to this blog and learn all about the affliction of dementia and more on the use of clocks for the assessment of cognitive changes.  I have added a person story that is compelling and has to do with this topic.  Thanks – I hope you like the upcoming posts.

“For many living with a person who has dementia can be an unforgettable challenge that evokes guilt, resentment and despair.” Michael Sefton 2018

The assessment of dementia is often stressful and the diagnosis is difficult to make.  The stress comes from the rare times that psychologist must give “bad news” to families of patients suffering with changes in their mental faculties. Unlike our physician brethren, psychologists rarely  have to give family members bad news or news that reflects a change in life expectancy.  One might expect this as normal from a physician who specializes in cancer or tumor treatment.  But in general, our discipline is not called upon to provide such subjective prognostic diagnoses very often. Dementia is one of those conditions primarily diagnosed by neuropsychological testing that has obvious impact on the life expectancy and the overall quality of life of those afflicted with it.
This clock above was drawn by a 78-year old man who was referred for outpatient neuropsychological assessment to determine the extent of change in dementia from his initial testing 24 months earlier.  You can learn quite a bit from the drawings of people thought to be suffering from dementia.  In this case, the patient was friendly and compliant.  He put forth a good effort and worked with diligence and earnest.  The task is the same for all cases – “draw a clock, put all the numbers on it and set the hands for 11:10.”
This clock effectively demonstrated the decline in the gentleman’s neurocognition.  It was poorly organized.  There was some neglect of the left hemi-space.  He had no self-monitoring or internal executive capacity to guide his construction.  He seemed surprised when I pointed out his work.  The numbers were not correctly placed. The slash marks were meant as minute marks and not number 11.  However, there were repeated numerals and reversals.  No hands were placed.
I learned about cognitive testing while an intern at Boston City Hospital – now B.U. Medical Center in the South End.  I loved my time there.  I wrote a blog about clocks and the utility of the clock drawing about a year ago called “All this from a Clock”.  If interested in the clock drawing take a look at the link I posted.  There is growing from clinicians around the world about dementia and using the clock as a screening tool.  The ABC in Australia recently chose one of the clocks recently published to feature on an upcoming program on dementia it is not clear when the program will be broadcast in Australia but I will post a link to the show once it is ready for broadcast. Stay tuned to http://www.concussionassessment.wordpress.com and Michael Sefton for further details.

CTE found in teenage brains by B.U. team

WESTBROUGH, MA January 18, 2018 The scientists studying the damaged brains of older athletes have had the opportunity to study brain damage in athletes who died from other causes.  In 4 such cases, there was evidence of chronic traumatic encephalopathy (CTE) that was not commensurate with the degree of brain trauma that was observed during their athletic careers according to Felice Freyer of the Boston Globe. This recent study was published in the journal Brain illustrates that the onset of CTE may be closer to onset of brain injury than first thought not much later in life.
“The report, published Thursday in the journal Brain, also provides what Goldstein called “the best evidence to date” supporting the theory that CTE is caused not just by concussions, but rather by any blow to the head, including mild impacts. Instead of diagnosing and responding to concussions, he said, coaches would do better to protect children from all hits to the head.” Felice Freyer – Boston Globe 1-8-18
The possibility of younger athletes developing CTE and the symptoms associated with this progressive disease is quite worrisome especially to parents.  It was always thought that CTE would develop later in life if at all. With the prospects of the disease having a much earlier onset the cost of CTE over a lifetime is incalculable in terms of medical costs and neuropsychological sequelae that may evolve in time. The true impact of this and the consequence for repeated, subclinical blows to the head is only now becoming clear.
Like dementia of the Alzheimer’s type the build up of tau protein underlies the changes associated with CTE. “Chronic traumatic encephalopathy is a condition bringing forth progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. We analysed post-mortem brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury and found evidence of chronic traumatic encephalopathy in 68 subjects: all males, ranging in age from 17 to 98 years (mean 59.5 years), including 64 athletes, 21 military veterans (86% of whom were also athletes) and one individual who engaged in self-injurious head banging behavior” according to the journal Brain. McKee, A. et. al. 2017

McKee, A. et. al. (2017) The spectrum of disease in chronic traumatic encephalopathy. Brain, Volume 136, Issue 1, 1 January 2013, Pages 43–64, https://doi.org/10.1093/brain/aws307

Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE

Westborough, MA November 18, 2017 The NFL has some explaining to do. Why are former athletes killing themselves and in some cases other people? As students studying the brain it was something special when you could make a correlation between an identified brain lesion and the behavior you are seeing.  I was in China in early November 2017 at a conference on RNA targeted therapy for cancer.  As the non-scientist in the group I was referred to as the clinician who saw the phenotype rather than the genotype – referring to the innumerable genetic underpinnings of cellular biology and changing science of modified nucleotides.  I understood this to have some meaningful interest to the faculty that consisted of 3 prior Nobel laureates and leading scientists in RNA targeted therapy.  So after sitting through hours of presentations I realize the importance of not making a rush to judgment about the cause of some predicted outcome. As a neuropsychologist we are asked to make assumptions about brain integrity after CNS infarcts and make educated predictions about the functional implication of focal lesions in brain.
Recently the scientists at Boston University announced the results of the post-mortem analysis of the brain of Aaron Hernandez, former N.E. Patriots receiver and convicted murderer.  Hernandez had his conviction expunged after he died while his case was on appeal. The 27-year old brain was highly suggestive of having the tell tale signs of chronic traumatic encephalopathy or CTE thought to be the result of repeated concussions and now realized as the result of hundreds – perhaps thousands of sub-concussive blows to the head that accumulate over time.  Hernandez’s brain was the youngest of the donated brains to be identified with advanced CTE. Hernandez played football for 17 years starting when he was a young boy. The question remains did the brain damage that was identified in the post-mortem analysis cause behavior change in Hernandez and could the murder of Odin Lloyd be attributed to the build up of dangerous tau protein in his brain?
“While no one can prove a causal link between Hernandez’s brain damage and his actions, there is little dispute that he displayed CTE symptoms associated with behavioral problems, such as aggressiveness, explosiveness, impulsivity, and suicide.”
Boston Globe Bob Hohler November 9, 2017
By history Aaron Hernandez was an angry, impulsive and violent teenager that his mother reported began when his father died suddenly. Coupled with this was a biological proclivity toward degenerative brain disorders such as Alzheimer’s Disease and CTE.  Both are diagnosed only after the death of the victim. We know that brain-behavior relationships exist from research in stroke and traumatic brain injury where focal injuries result in specific and expected changes in behavior.  These often result from a disconnection between functional centers of the brain including limbic structures that link centers for emotional regulation and the frontal system that exerts inhibitory control over those emotions. The athlete’s who have donated their brain’s upon their death have almost universally exhibited changes in behavior including poor impulse control, depression, and anger.

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BU Medical School and WCVB images 2017

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.