WESTBOROUGH, MA March 20, 2018 I am frequently asked about helmets and those that claim to be protective against concussion. As of this publication there are no helmets that unequivocally protect against the forces that impact the brain in the course of an athletic contest. The stunning Ted Talk video below reveals details about the protection offered by helmets today. Concussion is described as occurring in lower brain centers not the surface of the brain as the CDC graphic describes.
“Players are rarely hit by a direct linear force. They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.” Sefton, 2018
In fact, there is a newly designed mouth piece that has a built in gyroscope that is capable of measuring g-forces and rotation of the head resulting from head strikes. Researchers now believe it is the rotational force that sends energy into the skull and brain that causes the greatest cognitive and behavioral changes in the event of a concussion. Players are rarely hit by a direct linear force. They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.
“Players are rarely hit by a direct linear force. They are struck from the side or oblique angle and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.” Sefton, 2018
My mother Ann in 2018, she is 89-years old and loves to read but has been less active in past 12 months. She is holding a book given to her by best-selling author Bruce Coffin. She is quite emotionally resilient and enjoys reading and spending time with her children and grandchildren. She does not have dementia.
WESTBOROUGH, MA March 2, 2018 Dementia is the diagnosis given to individuals who have experienced an insidious decline in their neurocognitive functions. Practitioners around the world are using the clock instrument to assess cognitive status among a patient population who presents with cognitive or thinking changes who have insidious decline in their thinking capacity for whatever reason. I have published a great deal about the clock and was surprised this week to be contacted by Nicholas Searles a producer for the Australian television show “Ask the Doctors“. Mr. Searles works for the Austrailian Broadcast Corporation (ABC) wanted to display a clock on the upcoming show that was published on my website as the Clock of the Week in September 2017. These clocks are quite telling as to the cognitive functioning – including problem solving of the patient asked to construct them. See the prior publications of the clock of the week and dementia .
“Take care of yourselves, rest as much as you can, read good books, sing loud songs (when you’re alone…would be best) and read a poem now and then” Ann Sefton, 2015
What is the prominent feature of dementia? By definition dementia is an insidious decline in cognitive functioning over time this includes attention and memory functioning. Insidious change often translates into ‘not every member of the family sees the problem at the same time’. Very often, the patient is the last one to notice that anything is wrong with him or her. This raises considerable fear and sometimes conflict among family members. Everyone handles this particular stress differently. Insidious means that there are subtle but cumulative changes in cognitive functioning among these patients. This included a mixed bag of problems that include both physical and cognitive changes that are slow to present themselves and are sometimes missed by family and even the primary care physician. Sometimes activities of daily living such as bathing and dressing become the first things noticed by members of a caring family and often the source of great conflict. Mom or dad just does not want to “clean up” like they used to – bathing and dressing. Generally they will say “I took a shower this morning” but they may be wearing the same clothes or even undergarments suggesting this may not be the case. Just as frequently, the previously fastidious parent has shown changes in his or her awareness and concern over things that once were carefully controlled. I had one daughter of a dementia patient say that her mom never offers cookies or coffee when people visit and this was something she had done her entire life for visitors which she noticed a big change in her mom’s social behavior.
As a practitioner, when I begin a new patient exam, I make an effort to hear from members of immediate family as to what they have noticed about their loved one? This can be benign or it can be gut wrenching. I try to establish rapport and trust. I do this with empathy and professional concern that may enlist both family and patient in the lengthy process of the examination . Without trust a nervous patient will not be able to participate fully in the examination because of intrusive anxiety over the conflict they may feel about being brought to this office to spend signficant time with someone they do not know.
No easy task, I recently had to bring my mother to the hospital with changes in her cognition that we did not anticipate. Her photograph is posted above. My mother is a resilient and positive woman who is curious and smart. She is kind and gentle. See her comments in the blog I posted a couple years ago called Words to Live by. They are quite kind and endearing. She lost her husband – our father in 1984 and has not remarried. My father was only 56 when he died. My sister alerted me one morning that something was different about our mother. It was upsetting and I admit not wanting to take a close look at the true problem – maybe dementia. I had to bring her to her primary doctor for a quick exam whom then said she needed to be seen at the local emergency department right away. Ugh. I knew what that meant. Many hours of tests, C-T scans, and labs to rule out a cardiac event or an infection, or a cerebral vascular attack – stroke or something else. The entire event was humbling and I grew to appreciate the emergency physicians who deal with these cases daily. The physician who took care of my mother was sensitive and thorough. She listened to my mothers fear and apprehension about being in the hospital. Ultimately, mom was discharged home but still has a struggle with initiation and verbal expression that is unclear to us in terms of where it comes from.
None of us expects to grow old – nor do we expect our parents to ever age or become infirm. But they certainly do and of late, I am faced with the anguish of loosing touch with my mother as a result of her change in cognitive status and I am not sure just why. I am heart-broken when I think about this and she is not diagnosed with dementia. Her change in thinking and problem solving resulted from an infection she developed that came on gradually. The fact remains though that once vulnerable to altered mental status (AMS) one will need to think about possible treatable causes of changes in cognition before anything else. In our case, Mom is at risk for confusion and disorientation whenever she is sick with another condition like urinary track infection, bronchitis, even severe seasonal allergy. And this all means that she is at risk of falls and a host of other age-related problems both accidental and medical. These must be avoided to keep her quality of life and independence.
Dementia a growing problem as baby boomers grow old
I was approached by the Australian Broadcasting Company (ABC) in February 2018 who were interested in the clocks I have published over the years. The ABC somehow found my website and wanted my input on the clocks drawn by dementia patients. The ABC in Australia has a program called “Ask the Doctor” that airs weekly. The clock will be presented as part of the overall change in cognitive functioning when patients slowly become demented. The upcoming program is focused on “Living with Dementia” and will feature a clock that I published offering web site viewers an example of the changes in cognitive functioning when dementia takes hold. I hope to post a link to the program once it is broadcast.
The incidence of dementia is growing dramatically as those individuals born in 1950’s through the mid 1960’s become older. Because of this the medical establishment will soon be asked to modify the standard of care for this growing number of people in need. The assessment of these patients will be tenuous due to volume and lack of clinicians trained in working with geriatric cases. Like never before older American’s and those around the world will begin to show the age-related changes in gait pattern, balance, strength, memory, and problem solving that place them in direct harm for age-related changes in functional capacity. Some will require the services of a neuropsychologist who are on stand-by to provide assessments of patient memory, attention, and other cognitive functions like problem solving, judgment and reasoning that most of us take for granted. I have published clock drawings of some of these patients when of interest. Often they may seem sensational or impossible to believe. When you examine clock-after-clock one can see changes in problem solving and motor skill associated with the demands of the task and can make significant assumptions once the clock is scored. I learned about the clock drawing from Dr. Edith Kaplan in 1984-1986 while a student at Boston City Hospital and V.A. Healthcare in Boston. More importantly, these same problem solving tasks are likely to interfere with individual functional tasks needed by the patient to safely live his or her life. IADL’s are those functional skills such as cooking, cleaning, and making meals that are both automatic and often overlooked.
There are specialists everywhere who are charged with evaluating older patients and determining what is the best course of action for keeping them safe. Falls are a huge problem for older patients everywhere. Of 80 patients in our hospital, I would guess 30-40 percent are admitted secondary to mechanical falls. I will admit my mother has fallen 4 times in 3 years but so far has not bumped her head. That said, falls are a significant risk factor for dementia because an older brain will not tolerate repeated bumps and does not fully recover from falls. There are many people brought to hospital after a fall because of hip fracture or shoulder fracture who are not fully assessed for concussion or worse traumatic brain injury. The first question is always “did you lose consciousness?” and more often than not the patient was not rendered unconscious by the fall but may still have bona-fide neurocognitive changes in functioning.
Using the clock as a cognitive assessment tool – Growing interest around the world
The clocks below are those chosen by the producers at the Australian Broadcasting Company for a show called “Ask the Doctor”. I am told the show may be downloaded in the iTunes library for free or very low-cost. I will post a link when the show is broadcast so check back here if interested. You see the clocks below and may ask yourself “what happened here or why is this so hard for some people?” I had one email last year who asked whether the clock had been drawn by a person suffering form blindness as a reason for its idiosyncratic presentation.
No. In fact, those who are blind are often better at these tasks relying on internal conceptualization and approximate visual spatial configuration. I often say if I blindfolded you I would still expect a successful clock drawing.
When patient slowly loses cognitive function as in those afflicted with dementia their appreciation of performance is often lost and the appreciation for the complexity of the task may become minimized e.g. “I am not an artist”. While drawing the clock many do not self-monitor and do not notice the error pattern until it is all done. Some say “that does not look right..?” while others explain the results because “they are not artists” or the task is too simple for them. The clocks drawn to the left are those that will be discussed in the upcoming Australian Broadcast Company program “Ask the Doctor”
Clock of the week September 1, 2017
Sefton, M. (2015) Words to live by. Blog Post: https://msefton.wordpress.com/2014/12/28/words-to-live-by-trimble/ taken March 2, 2018
Westborough, MA February 10, 2018 The link between breathing and the fear response has recently been highlighted in the Neuroscience News who reviewed a study from Northwestern University. This study coincided nicely with the ideas I have posted for several years about delayed recovery from post-concussion syndrome (PCS) about the impact of paced breathing on the body’s changing response pattern. The study looked at the link between nasal breathing and the activation of fear and memory centers deep within the brain. Behavioral data in healthy subjects suggest that changing from mouth breathing to nose breathing may have an influence on systems deep within the brain. The discussion presented in the Neuroscience paper findings “imply that, rather than being a passive target of heightened arousal or vigilance, the phase of natural breathing is actively used to promote oscillatory synchrony and to optimize information processing in brain areas mediating goal-directed behaviors” I have seen the results of this firsthand in the biofeedback work I do. Respiratory sinus arrhythmia (RSA) is a term used to describe the changes in heart rate that are normal with oscillating rates of breathing. In some cases a patient can breath so erratically that his heart rate falls out of synchrony with sympathetic-parasympathetic regulation.
“The breathing systematically influences cognitive tasks related to amygdala and hippocampal functions.” Zelano, C. et. al. 2016
Christina Zelano, Heidi Jiang, Guangyu Zhou, Nikita Arora, Stephan Schuele, Joshua Rosenow and Jay A. Gottfried Journal of Neuroscience 7 December 2016, 36 (49) 12448-12467; DOI: https://doi.org/10.1523/JNEUROSCI.2586-16. 2016
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.