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.
WESTBOROUGH, MA February 16, 2018 Here is the clock of the week for mid February, 2018. It is quite unusual as you can see. The clock of the week is sent to me by a speech language pathologist here at Whittier
Rehabilitation Hospital in Westborough, MA. It was drawn by a 76-year old H.S. graduate with one year of college. As you can see this patient was provided with standardized directions that I have described in many other posts. “Draw the face of a clock with all the numbers – set the hands for 11:10.” It is amazing how the brain operates – or in some cases fails to appreciate the task demands and process the 3 steps of the task as it is given. What is also missing in this creation is an awareness of the errors made relative the task demands.
In this case the speech language pathologist drew the circle because she was using the SLUMS Examination – a V.A. Healthcare screening tool. The SLUMS gives the patient a circle but in general the directions prefer the patient to draw the circle him/herself.
The name has been altered for privacy. What do you make of this clock? Whatever, it’s about
12 before 10? No?
Westborough, MA February 1, 2018 The video below is the clock of the week for this week in January, 2018. It is an interesting construction by a 81-year old male who is undergoing treatment for respiratory failure and myelodysplastic disease – a blood disorder in errant white blood cell production. He has had difficulty with all of his activities of daily living including dressing, bathing, personal hygiene and toileting. He is recovering slowly and receiving daily therapy for these physical and occupational deficits.
“Renowned neuropsychologist Dr. Edith Kaplan too had a love affair with clocks (and owls as I recall) and taught us the unique importance of this seemingly simple neuropsychological instrument.” Sefton, 2015
The “clock drawing” task is described throughout the pages of this blog and is widely used by psychologists as a screening for cognitive dysfunction. I like it because it is not threatening and is not a great challenge to the patient. That said, I have had many people say ” I am not an artist” when asked to draw the face of a clock. Interestingly, I suspect those who deny being artistically gifted (drawing a clock) may have some degree of preserved insight into their declining cognitive ability.
The video is produced by the Neuropsychology Service at Whittier Rehabilitation Hospital. HIPPA protected.
Sefton, M. (2015) All this from a clock? Blog post: https://concussionassessment.wordpress.com/2015/04/29/all-this-from-a-clock-a-cognitive-test-for-the-ages/ . Taken January 26, 2018
WESTBOROUGH, MA It is time once again to select the “Clock of the Year”. Voting will go on for the next week. There are 10 clocks featured this year each one drawn by a patient undergoing rehabilitation at Whittier Rehabilitation Hospital in Westborough, MA. The diagnoses of each patient may or may not be presented with the clock as it scrolls through. Any clock with a measuring tape would be presented in millimeters-centimeters not inches. The clocks shown in millimeters are tiny – micrographic in quality. The first clock in the slideshow is drawn by a 93-year old – each one would then become a successive number through # 10.
I have published many blogs about the use of the clock drawing in clinical practice. Clock drawing was first introduced to me in my practice as a pre-doctoral student in psychology at the V.A. Medical Center in Boston by Dr. Edith Kaplan. She taught us that
something as simple as a clock drawing can become a daunting task when faced with cognitive changes from brain injury, stroke, or dementia. I carry on this tradition in honor of Dr. Kaplan and the role she played in my formative work as a neuropsychologist. Today, every discipline it seems uses a clock to assess problem solving, organization, and following directions in patients with suspected decline in their thinking skill. Dr Kaplan died in September, 2009 and is missed even now. The clock of the week has started to generate some clinical interest in Australia. The producer of the syndicated television show “Ask the Doctor” has asked to publish one of the featured clocks on their program. The show will feature the clock from September 17 and the topic will be living with dementia. I will post a link to the show once it is broadcast.
Westborough, MA June 6, 2017 The clock of the week is depicted below. It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital. I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine. I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient. It was drawn by a 93-year old male with congestive heart
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s. This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient. The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well. I once had a patient draw and elaborate grandfather clock fit for a castle. The clock face became secondary and insignificant – for him. The clock is a regular feature here at Concussion Assessment and Management.
Anyone can submit a clock for consideration of the clock of the week. Upload to my email address: firstname.lastname@example.org – No identifying HIPPA protected information please but a brief overview is always helpful.
Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/pagets-disease-of-bone/home/ovc-20183843 Taken June 6, 2017
WESTBOROUGH, MA March 28, 2016 Whenever surgery is recommended there are inherent risks that should be understood. The fast answer is “yes, there are risks when you replace someone’s aortic valve.” But not so fast.
Cardiac surgery has become almost commonplace in the current medical society. Here in the Boston area there are several heart centers providing surgical treatments and risks have been greatly reduced in the past 25 years. Procedures are now minimally invasive and require much less recovery time than the former procedures. Many centers are also using robotic assistance in valve replacement. There are at least 3 major centers in Boston with excellent surgical teams. Your physician will discuss these with you but the patient must understand the risk versus reward conundrum. You can read the list below for a bullet point visual. This is the case whenever one embarks on treatment – “what are the risks of taking one drug over another?” or “is there a risk when I undergo surgery to replace a stenotic heart valve?
One’s heart valves are meant to last a lifetime. The heart valves are paper thin and amazingly flexible and strong. The majority of people are born with the valves they will have at the end of life – 5-6 billion beats later. Arguably the greater risk associated with valve replacement surgery may be linked to the pre-surgical health of the recipient of the valve. It is common that patients have multiple comorbid medical conditions such a diabetes, poor cardiac health, hypertension, and obesity. The outcomes become only slightly murky with the host of illnesses I just cite.
My role in the cardiac rehabilitation is to assess cognitive functions when necessary. This includes concentration, attention, S-T memory, problem solving, and higher order thinking skill. It is not uncommon for patients to have altered mental status following surgery. Sometimes this is simply the result of pain cocktail and anesthesia but other conditions can contribute to changes in one’s cognition as well. Sometimes I am asked to provide support and counseling for those few patients who exhibit affective changes or frank signs of depression. On occasion behavior therapy is needed to redirect idiosyncratic motor restlessness or agitation. In general the goal of cardiac rehabilitation is to enhance functional capacity in the areas of endurance, physical fitness and activities of daily living to regain their independence. Full recovery requires a change in habits and lifestyle. This takes time.
The rehabilitation process is a continuum of care provided to those recovering from surgery who may be ready for the changes that will take them forward. This includes physical exercise and the nutritional support needed to enhance patient outcome.
The vast majority of patients who undergo valve replacement surgery sail right through it and never come to hospital acute rehabilitation. Most are referred to outpatient rehabilitation where they stay at home and attend rehabilitation during the day. For those who are sent for inpatient rehabilitation they wrestle with fatigue as much as anything. Many were in poor physical shape prior to surgery because of the insidious impact of declining cardiac health in the months or years prior to the procedure. Post surgical depression is common in as many at 25-40 % of cases. Psychotherapy and coaching can assist in the management of feelings that are sometimes present during recovery. I have heard “why am I doing this…” just as much as: “I can do this and have a second chance for health…”.
Risks of valve replacement
- Blood clots
- Cardiac arrhythmia – atrial fibrillation
- Excess bleeding
- Transient ischemia or stroke
- Kidney failure
- Death – 1-2 %
NHS – UK website – taken 3-10-2016
The Cleveland Clinic has a wonderful video that is attached.