Mr. R presented to our general medicine floor a few months ago after a fall, and had been unable to stay home unattended during the day without problems. He had experienced a stroke 1 month prior to admission, outside the US, and as far as we learned had received nothing but the most basic treatment to stabilize him, no rehabilitation whatsoever. While this gentleman had virtually no motor involvement, he had MAJOR deficits in short term memory, to the point where he had what I would call "5 questions a day," which varied slightly day-to-day, but would be repeated for the duration of that day no matter how they were answered. He retained very little of the answers that were provided, though this ability waxed and waned. This would have been a great enough barrier to home discharge, however, he also had severe visual involvement. I appealed for a neuro-ophthalmology consult but they declined to participate since this was not an acute event. So I did what I could to evaluate this issue.
Clock Drawing: I found this interesting since the numbers are running counterclockwise, and he did draw them in descending order. I couldn't find any information on other cases with the numbers running backwards.
These pictures are his attempts to reproduce the above drawings. He was able to describe the shapes in the drawings somewhat, but unable to figure out what the whole picture was.
We had a similar issue when he was trying to '"cross out the m's" or reproduce written letters. He could write letters accurately but couldn't read them effectively unless directly cued to trace the example and trace the letter in question.Mr R's decreased vision was really a secondary problem to the decreased short term memory. He would occasionally report new, altered visual symptoms which made evaluation difficult, and functionally, his vision was less limiting than other deficits. For instance, he needed help to find his way to the bathroom, but needed only verbal cues for perseveration to shave his face. I believe the family had to pursue nursing placement since they couldn't provide 24 hour supervision, which is sad, but between his memory and visual deficits he did need that level of care.
1 comment:
I find that sometimes doctors are hesitant to get involved because there really is nothing they would do to intervene anyway. That is particularly true when you have a (currently) static CNS lesion.
The complicating problem is that therapy may be able to help - specifically focusing on compensatory techniques, adaptations, and even perhaps remediation... but that our allowed intervention period is often restricted. This kind of severe visuoconstructive and cognitive problem may improve over a long period of time and this leads to a mismatch between what the insurance will typically 'cover' and what the patient actually needs.
In my experience it is not uncommon to see a lot of progress with these problems well after the point that the patient has disengaged from the medical model - which is truly unfortunate.
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