Clock of the Week June 6

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
 

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Right handed 93-y/o male with probable dementia
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: msefton@whittierhealth.com – 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
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Is there risk associated with valve replacement surgery?

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Clock drawing of 66-year old patient who was recent recipient of prosthetic aortic valve. Premorbid health was otherwise excellent.

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

  • Infection
  • 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.

Cleveland Clinic Cardiac – Valve Replacement video

Encephalopathy with lingering concern of illness

Encephalopathy_clockWhat is encephalopathy?  People who have it generally do not see anything wrong with themselves. Patients are admitted to the rehabilitation hospital for the purpose of regaining as much independence as possible – even those with encephalopathy.  But it takes time.  Most stay 4-6 weeks although this depends upon the diagnosis and recommendation of the physician. However long a patient is given rehabilitation there is always a lingering concern of illness going forward.
Everyone in the rehabilitation team worries about a patient when the discharge is imminent and the patient seems unready to be sent home.  Anything can happen including unexpected fall, change in sleep hygiene, confusion, even new infection.  In some rare cases any of these calamities may befall an unprepared, uninsightful patient.  Even when there is a spouse on board with the discharge plan there are inevitable factors that may compromise a successful discharge resulting in potential problems once home. Encephalopathy results from infection, toxins, anoxia, and other metabolic conditions.  Most adults have experienced encephalopathy at one time or another perhaps after drinking too much.  The primary sign of encephalopathy is altered mental status, cognitive slowing and confusion.  Another feature is diminished self-monitoring and awareness that directly impacts insight, judgment and problem solving.
The clock drawing attached to this blog was drawn by a 65 year old woman with obvious confusion, disorientation, and limited insight.  She is frustrated to be in the hospital and both she and her supportive husband are pushing for her discharge home. “Why am I here?” see remarked with incredulity.  The clock drawing task is a simple one.  I have posted several blogs in hope of showing what a fascinating tool it is to assess cognitive functioning.  I have been using the clock drawing for 30 years since learning of its value in neuropsychological screening from Dr. Edith Kaplan at the V.A. Medical Center in Boston in the mid-1980’s. What happened with this clock?
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Image by Sefton
The woman who constructed this drawing has encephalopathy as a result of a respiratory illness that resulted in her needing a breathing tube to sustain her respiratory drive. At some point when her breathing stopped she sustained an anoxic injury.  This stems from the lack of oxygen in the brain and may lead to ischemic, inflammatory changes in the structures of the brain that are thought to subserve memory and learning.  The lady first drew the clock with all the numbers crunched together which may be seen in the upper right aspect of the drawing above.  Because of her confusion she was unable to plan and organize her drawing.  This is typical of some conditions like dementia.  However, the patient is a 65-year old woman and we now all know that “65 is the new 55” – when it comes to modern aging.
All kidding aside, the patient in this blog was entirely independent in the months before the current illness.  She was then asked to try again with the clock drawing – the directions are standardized.  At this point everything else was drawn – circle after circle providing vivid evidence of the perseveration, lack of self-monitoring and confusion associated with her ongoing condition. She thought nothing of it.  Now, she has convinced her spouse to bring her home where she most certainly will be more comfortable and may recover more quickly.  Not so fast.  Look again at the clock and the design copy below that was crafted a few days after the featured clock of the week above.
The rehabilitation team has lingering concerns about her safety and cognitive functioning and are looking to the patient’s family to impart those concerns in their own feedback to this impaired woman. By agreeing to take her home they are setting up an outcome that is unlikely to be favorable.  The hospital is manned with nurses, aides and physician support 24 hours a day.  There is no way that a singular spouse is able provide for this level of support and remain healthy himself. Caregiver burnout is a significant source of stress for all family members. This nice lady needs maximum assistance for all of her activities of daily living including dressing and bathing.  She has been in the hospital for 2 weeks and will need 2-4 weeks of additional rehabilitation to help in her recovery.  Her family seems concerned that the hospital may result in a depressive episode and they are correct.  But going home before she is safe to do so may result in greater harm and further hospital time. Caregivers are also at great risk of illness due to the effects of stress on the immune system.  I always encourage family members to “get to know the rehab team” who are taking care of their loved one and establish a trust with them.  That way when the discharged date is announced there will be no questioning the judgment and recommendations of those who know best. The design to the left is an example of clinical perseverationPerseveration.
The clock above was drawn by a 65-year old woman who is encephalopathic as a result of acute respiratory failure and hypoxic brain injury who wrongly believes she is ready to be discharged from the hospital.

Michael Sefton, Ph.D. is the director of Psychology and Neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA

Clock of the Week – Dementia

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Clock drawing of 78-year old male with advanced dementia
WESTBOROUGH, MA February 1, 2016 This clock 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.

Adding Content and Genre to these pages

WESTBOROUGH, MA June 7, 2015 In response to questions I have received from visitors to the web site I have decided to add a wider genre of content to include neuropsychology in general.  I have had a tab labeled neuropsychology since the beginning and it has been linked to topics of importance such as traumatic brain injury, cardiac arrhythmia, and dementia.  These topics effect everyone at some point especially those people working in the medical field – brain injury, stroke, pain management, and more.

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Michael Sefton, Ph.D.

Neuropsychology is the study of the relationship between brain and behavior.  When you think about it that includes just about everything from acquired injury, substance abuse to autism.  The topics I will post are those in which I am involved here at Whittier and in my practice.  I am adding to the content published here and will continue to work with those afflicted with concussion and post-concussion syndrome and their families. I am very excited to add biofeedback and EEG biofeedback to my practice. While I have limited assessment openings – biofeedback has been a demonstrated modality to enhance functioning.

On my other site I have included posts about domestic violence, the “active shooter”, juvenile fire setting and more that also effect many of us who work with people. That site may be reached at http://www.msefton.wordpress.com

All this from a clock…? A cognitive test for the ages.

Resurrecting the work of Dr. Edith Kaplan 

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This clock was drawn by a 92-year old right handed woman undergoing physical rehabilitation who has suspected dementia.
The clock drawing is an almost ubiquitous task on neurocognitive functioning that most clinicians are now using to determine whether or not there is evidence of cognitive slippage in the person being evaluated.  When I first make a request for the clock drawing patients inevitably say “I am not an artist“. But in truth the clock is a drawing that children learn sometime in the second or third grade.
I have had a fascination with the clock drawing for over 20 years that grew out of the training I received while a postdoctoral student at the Boston City Hospital in Boston.  I was thrilled to see what kinds of drawings people would come up with and surprised with the kind of interpretations I could make using the data that could be obtained at bedside.  I have many clocks published on this site.  The video library I am developing may be of interest to some.  It shows the directions and actual construction of the drawing.
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. In fact, Dr. Kaplan gave out a prize for the clock of the year of all the clocks submitted for supervision among her many students in neurology, neuropsychology and psychiatry at the Boston University School of Medicine, B.U. and Clark University doctoral psychology programs, Boston V.A. Medical Center, and Boston City Hospital – at which I did my internship and fellowship. Dr. Kaplan looked at hundreds of clocks during the short time I was at BCH.
There were some very interesting clocks that were constructed by patients of all walks of life – afflictions from dementia to traumatic brain injury to cerebral vascular accident and more.  I have added a “clock of the week” feature on this website in a (failed?) attempt to generate the same excitement that Dr. Kaplan generated for so many students a long time ago.  I have tried to keep it up to date and provide background information on each one.  So far, I have only received a single clock from a speech pathologist here at Whittier Rehabilitation Hospital.  She seems interested in the clock drawing as a cognitive assessment tool and I sometimes have patients tell me that they had just completed a clock drawing prior to my visit. I am planning to add video of the clocks being drawn by cases on which I am consulted.  These are sometimes interesting in themselves.  I hope to have a few linked within the next couple weeks.  Simply click on the clock of the day and be directed to the video of the clock being constructed.
Everyone is giving their patients the clock drawing test these days it seems. Unfortunately for me I am usually the last person to use the test and patients are wise to it. Not a problem though because it is not a trick.  You can do it or not.  Send your ideas and feedback and perhaps I will award a “Clock of the Year Award” as Dr. Kaplan did so long ago.  See my video at the You Tube link below.  See the history of my interest and some early clocks at a prior publication. I am particularly interested in those clocks that are indicative of micrographia and its possible link to frontal-temporal dementia.  Perhaps I am a bit overzealous on using this bedside assessment tool.  The bicycle is also a good test but you must ask your patient “tell me how it works…” once they finish it.
https://concussionassessment.wordpress.com/topics-in-neuropsychology/clock-drawing-what-can-it-tell-you-besides-the-time/