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 May 25, 2017 Cognitive changes are common in patients with dementia. They become increasingly problematic with the disease progression. Some people suffering with dementia have difficulty with even the most basic activity of daily living like dressing themself. Things taken for granted like following directions become a chore as the progression of dementia effects individuals who suffer with the disease. This places a great burden on caregivers who must take over those important functions of daily life.
The clock drawing has been a feature on my blog for several years. It is fun to see people work through the task. Most people complete the task effortlessly. Some are a bit defensive because it seems like such a benign request – “draw a clock…” and I often get “I am not an artist…” in anticipation of failure. I have published over a dozen posts about the clock drawing as a measure of cognitive functioning. Patient with dementia often experience a slow cognitive decline whereby even tasks like constructing a clock become a challenge.
The clocks drawn in this post reflect the effort of a person of 89-years of age who tried very hard to get it right. She had enough preservation of her self- monitoring
that she could tell something was wrong. As you can see the left most circle was the first attempt. It was too small according to the patient and she wanted to try again. The middle clock was her next attempt and shows her disorganization and minimal change in the size of the drawing – approximately 3 centimeters in size. In the center of the drawing there are 2 hands that roughly represent the time 11:10. She told me she needed more space to place the hands so that they could be clearly read and offered to try a third time. On the right is her final attempt. There are two hands (to the right of the number 9 and a second pointing to the number 2). As you can see the circle is only 2 cm in size and was a modest improvement over the first two attempts.
She had fun drawing the clock and did not feel as though she had failed the task. I was encouraging and praised her for staying with the task. At some point she had lost her capacity to plan and execute her visual motor function of crafting the circle. Each attempt was made with the goal of drawing a larger circle. This fine woman was still capable of doing many of her activities of daily living and enjoying her friends and family. She was not at all upset that I had been asked to help with her care.
Dementia requires family support and can be costly to those in need of care. The risk of caregiver fatigue exists in all families. As much as possible, I enourage people to allow the patient to work toward completing their own self-care unless there are risks such as falling due to poor balance. This requires herculean patience and sensitivity because there is often a degree of “awareness” of the cognitive changes experienced by the patient himself. Preserved dignity and sense of independence go a long way toward quality of life in the latter stages of dementia. Most spouses will do whatever it takes to support a loved one with whom they have shared 50 or more years of marriage and experience the decline in functioning as both a personal failure and a heart breaking loss.
WESTBOROUGH, MA September 28, 2016 There will be a free seminar offered at Whittier Rehabilitation Hospital in Westborough on Wednesday September 28, 2016 on Sports-related Concussion along with updated information about post concussion syndrome and its treatment. The program is presented by Michael Sefton, Ph.D., director of neuropsychology and psychological services at Whittier Rehabilitation Hospital and certified brain injury specialist. The program begins at 5:30 with a dinner being served. Call WRH at 508-870-2222 to reserve your spot.
WESTBOROUGH, MA April 1, 2016 The Neuropsychology Service at WRH has added both physiologic and EEG biofeedback to the service for those afflicted with concussion, TBI, and trauma. The protocol involves heart rate variability and controlled or paced breathing as a means of gaining enhanced resonance in the autonomic nervous system. Autonomic storming is a common reaction to traumatic brain injury and can be debilitating over and above the structural changes that impact condition and behavior. It is not new and has utility in treating anxiety and other stress-related conditions. The protocol is designed to activate the body’s parasympathetic function as a “quieting mechanism” – to put the brakes on for relief and a variety of physical symptoms including pain, irritability, and depression. The “protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in their body using controlled, paced, breathing and prototypic progressive relaxation” according to Michael Sefton, Ph.D., Director of Psychological and Neuropsychological services at Whittier Rehabilitation Hospital in Westborough, MA. Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions. Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist. Contact Dr. Sefton for more information of this protocol or an appointment 508-871-2077.
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.
WESTBOROUGH, MA March 10, 2016 There is a growing consensus that sooner rather than later may be a better return to play protocol among high level athletes. The notion that they undergo complete and total rest after being injured may be an unreasonable expectation. I have previously espoused “total rest” for some athletes I see in practice but I am now realizing an important shift in the current standard of care.
Given the proclivity toward years of daily training among elite athletes – and not so elite athletes I might add, allowing a modest amount of noncompetitive, non-contact exertion may facilitate the recovery process. The athletes should remain well below his or her cardiac maximum – some say 50-65 % of maximum
for 10-12 minutes while taking the initial steps toward recovery. Changes in balance is a common consequence that may result from subtle changes in the vestibular system in the middle ear and/or decreased neurocognitive efficiency. This too can be worked slowly in a controlled rehabilitation setting.
Concussion is a serious injury or force applied to the skull transferred to the brain. It is now well known that injuries to the brain have lasting impact – especially among younger athletes. The second or third concussion may be vastly different from recovery to the number one injury in terms of recovery time. This should be monitored by a concussion specialist. Returning to work and school will also require support. Return to play protocols are also key for athletes who are injured in season.