Clock of the Year – Vote on your favorite

Dec15_18 Clock of weekScan
Clock drawing by intelligent 71-year old
Every year I publish a series of clock drawings. Some people really like seeing the range of clocks that people draw including the clock above – drawn by a 71-year old right handed woman with confusion. One could argue that she had much of the task drawn correctly until she tried to correctly set the hands as instructed. I like this clock because it illustrates the break down in problem solving of the three steps required for success. Ostensibly, this patients followed the directions as instructed. The numerals were correctly placed and finally she placed hands on the clock. Arguably, by drawing too many hands she may have been exhibiting a perseverative response, decreased self-monitoring and error detection, and a failure in understanding the problem in terms of the correct time – 11:10. In this case she asked “AM or PM” but did realize her error relative her specific drawing. She drew no circle into which the numerals were to have been placed.  The yearly ritual of finding the clock of the year has begun. What fun!
“For many living with a person who has dementia can be an unforgettable challenge that evokes guilt, resentment and despair.” Michael Sefton 2018
The clock above was drawn by a 71-year old female who is in the hospital because of an infection.  When this was drawn her infection had been cleared up.  She is a verbally gifted woman with a full education.  Her family has seen a change in her thinking skills in the past 12 months and now wonders what can be done? Her verbal intelligence is in the 90th percentile with an estimated VIQ of 120.  Verbal abilities often interfere with the assessment process and there comes a time in every assessment when the examiner must put a stop to the fun and frivolity of making acquaintance. 
This year I received a few more drawings from clinicians in the community including the clock of the week from December 10, 2018.  One of the clocks that was published this year was featured on the Australian Broadcasting Company television series “Ask the Doctor“. The clock is featured about 16 minutes into the broadcast. I have been given permission by the ABC to display the link to the broadcast. I will publish several clocks and I ask that readers vote on the most interesting clock.  We will vote for 2 weeks in January.  Happy New Year and have a safe holiday.



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

Clock of the week_Nov8
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.

Grapheme_He shouted

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.

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: Alzheimer’s

84-Year old female with Alzheimer’s Dementia

WESTBOROUGH, MA August 2, 2018  Here is the clock of the week. It is drawn by Helen, an 84-year old right handed woman suffering from the affects of Dementia of the Alzheimer’s Type – DAT.  I have published weekly or monthly clocks on these pages for the past 3 years.  Recently I have added links to the video taken in our Neuropsychology service at Whittier Rehabilitation Hospital.
All HIPPA compliance rules are followed in terms of patient confidentiality.  I encourage readers to send in clocks for me to publish.  Helen had significant difficulty constructing this clock.  Unlike some of the recent clocks I have published this clock was normal size.  Helen had a resting tremor that closely resembled the movement pattern seen in patient’s with Parkinson’s Disease.

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.

90 DATBicycleScan

Bicycle drawn by same 90 year old patient


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.