WESTBOROUGH, MA July 24, 2018 Some people believe that the simple task of drawing a clock is like a window into the brain (Eknoyan,et al. (2012). I have posted reviews of clock drawing over several years. Edith Kaplan, Ph.D. is credited with teaching me the importance of these neurocognitive protocols in 1985 while I was training at Boston City Hospital. Dr Kaplan saw the clock drawing as a parietal lobe test (Kaplan, 1988) but many debate that focal attribution of the clock drawing may under represent the clinical utility of this perfunctory task. Tranel and collegues (2008) found that the clock drawing has several potential neuropsychological correlates represent the neuroanatomic underpinnings of the individual clocks scored and rated in their research.
“Documenting the type of clock-drawing errors can contribute to the clinical evaluation of patients with suspected neuropsychiatric disorders and syndromes” Eknoyan, et al.
Watch the video below and enjoy a complete assessment of a single patient undergoing neuropsychological assessment. Post your thoughts and let me know what your observations say to the underpinnings of cognition we are seeing. This patient was cooperative and friendly. He is only 82 years of age and was undergoing treatment for a recent mechanical fall.
Eknoyan, D. et al. (2012) Journal of Neuropsychiatry Clin Neuroscience, 24:3 Summer.
Kaplan, E. (1988) The Process Approach. In Boll T, Bryant, BK, editors. Clinical Neuropsychology and Brain Function. Washington DC, APA.
Tranel, D, et al. (2008) Does the Clock Drawing Test have Focal Neuroanatomical Correlates? Neuropsychology, 22(5) 553-562.
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 June 21, 2018 The clock of the week was drawn by a 74-year old female patient suffering from a right hemisphere cerebral vascular accident (CVA) with a significant number of cognitive behavioral changes from her pre-illness baseline. As you can see from the scanned drawing, it took two attempts for her to be satisfied with the effort. Both drawings are quite small (micrographia) – 1.8 cm in size (0.7 inches). Why?
There are several reasons for micrographia that have to do with visual processing and self-monitoring. When a task is given such as the clock drawing the subject must be able to process the directions using existing linguistic functions. Once done there is an element of planning, e.g. “how do I start this process”?, and finally the initiation and execution of the task from first step through the final drawing. This clock was barely over 1/2 inch in size. The female used the space provided very sparingly and talked her way through the task suggesting a verbal strategy was helpful. However, as you see form the top drawing she was unsuccessful. Immediately afterward, seeing that she failed in the task, she drew the bottom left clock and felt she had done a better job.
It is always interesting to see for yourself how these tasks are completed and to what extent brain injuries interfere with the drawing of common objects like the clock. My interpretation of this clock suggests to me that her frontal feedback loop was decreased in its efficiency. It would have provided her with immediate, on-going feedback and real-time monitoring and adjustment of her work. In the second draft, she may have planned a larger circle and placed the numerals in their correct juxtaposition of one another. Finally, she may have thought for a moment and set the hands correctly for ten past eleven.
I have had discussions with speech pathologists with whom I regularly consult about the next generation of patients that are given this task as they get older and may not have learned how to construct the face of a clock when first learning to tell the time. Perhaps at some point we will ask them to draw the face of their cell phone as a screening test of current cognitive functioning.
WESTBOROUGH, MA Here is the “clock of the week” drawn by a well educated 77-year old woman undergoing rehabilitation at the hospital after she sustained a fall and broke some ribs. The clock represents her best effort at completing the 3 step problem I have described so often in these pages. Clocks are interesting and fun. They can be used to put the patient at ease when first getting started. Some patients become quite defensive when they are referred for neuropsychological assessment. It is important to establish rapport prior to initiating the battery of tests so that you may obtain the best possible result.
These data are turned into the report that physicians will use to access services and needed intervention to assist with return to functional independence whenever possible. In this case, the woman had had two prior CVA’s one on the
Right middle cerebral artery – effecting her visual motor integration and spatial awareness and the second stroke effecting her language area – including verbal fluency and word choice during free speech. I have also added a sample of her written language. Patients are all asked to “write a sentence” that I dictate to them. I have used the same 2 sentences for over 20 years and find them useful.
“Baseball players are tough”
The sentence reads Baseball players are tough. It illustrates the impact of CVA on written language. This interesting lady could no longer write checks or sign her name. Graphic formulation of words requires both the left and right sides of the brain for success. The frontal lobe is also brought in automatically to initiate, plan, and execute the verbiage and organize the thoughts into a coherent message.
During the hours of assessment I learned that this patient had sustained a fall just 5 months earlier resulting in a head strike and 3-5 days of concussion-like symptoms that slowly evaporated returning her to her baseline. This leaves her more vulnerable to cognitive change with any illness including infection or pain syndrome from fractured ribs.