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.
WESTBOROUGH, MA 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
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.
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.
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
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.
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.