My
Mother's Response to StrokeMy
Mother's Response to Stroke
On November 18, 2004 my mother had a massive right hemisphere hemorrhagic stroke.
What that means is that over the course of a few hours, 2/3rds of the right side of her brain was destroyed because of a burst blood vessel. Hemorrhagic strokes are less common than thrombotic, in which a blood vessel is blocked and a section of the brain is cut off from oxygen. Hemorrhagic strokes are more often fatal.
We were lucky. My mother survived and she has, throughout the recovery, retained her orientation to who she is and who we are. She has known that she was in a hospital and she's always retained the date and time of day. These are the basics required for orientation and social and intellectual functioning.
My mother, 79 at the time of her stroke, had in her life-time earned a master's degree in education and managed real estate for many years. She had a pre-existing lower right visual field deficit from a serious illness. You may notice some effect of that in drawings below.
This is a 1980 CT scan of her brain:
We viewed MRI scans after her stroke and the right hemisphere is mostly gone-- in places your could see some tissue, but at most 1/3rd.
Here is the MRI report.
Here is the report of CT scans done on 11/21/04
Here are CT Scans from 11/29/04. Note that on the scan the "right side" of the brain is on the left side of the scan.
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What she lost from the stroke was use of her left arm and leg and her left side visual field. Why left? Because the right side of the brain controls the left half of the body. She also lost for a time her larger geographic sense. She knew she was in a hospital but couldn't figure out where that hospital was relative to home. She didn't understand where we went when we left the hospital at the end of the day. On December 2, 2004, approximately two weeks after her stroke, I asked her to draw a clock face. Why a clock face? |
Drawing a clock face has been used as a measure of visual-spatial ability. It requires a high degree of planning and organization. You should try it. On a scrap of paper, draw a clock face and think about what it requires from you.
You have to draw items in relation to one another. You have to know numbers in sequence and switch between the verbal task of writing numbers and the spatial task of recording them. This is an integration task. You have to grasp the left and right sides of the clock and you have to add in hands pointing to a particular time. You have to plan ahead to think where parts must be placed relative to one another.
Since the right hemisphere involves visual spatial abilities in the typical person, this seemed an appropriate task to get some idea of her progress. It is a structured observation.
So my mother drew this clock face that first time: Notice that other items she drew or wrote on the page (which I've cut off) begin to infringe on the clock's location. That's a loss of gestalt or overall organization. You can see that she wrote the 12 and the 6 several times, trying to figure out where they belonged. She would sign her name when she got frustrated. Her speech was flat and without variation or emotion. The right hemisphere provides emotional tone and context. She also took things literally. If you say you'll be back in a minute-- she's looking for you in a minute. She spoke mostly in short sentences. My favorite from this time period "I feel like a third world nation." "Are you..." questions (Are you feeling okay?) were hard for her because they required thinking of herself as a whole. She did better with "Is..." (Is your arm hurting?). |
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She could not understand directions like 'up, back, front, left, right' and integrate them with movement, which made therapy challenging, especially as the therapists ignored this deficit and persisted in giving directions verbally. If you asked her something, you would get an answer...in about 10 minutes. It took that long for the message to work its way through the brain. We learned that if we wrote out directions for her, she would get it very quickly. The same message orally would have to be repeated many many times. On the same day she drew this clock, she wiggled her left toes.
We continued to ask her to draw clock faces, about every 2 weeks so we could have some standard for tracking her cognitive improvement.
December 14, 2004.
This one shows what is called 'left side neglect'. A right hemisphere stroke patient will often behave as if the left side of his/her body doesn't exist, failing to comb the left side of one's hair, not washing the left side of the face.
Actually, what is happening is right side over-control. The right side of the body (that is, the left hemisphere of the brain) is hyperactive because the other side no longer moderates its influence. The visual and physical sensations hitting the right side get all the attention.
Mother displayed relatively little left side neglect. She always washed all of her face and combed all of her hair, or needed only a little prompt.
Her greatest problem was not seeing a person on the left side and not seeing food on the left side of her plate or feeling it in the left side of her mouth. The later, actually, is quite dangerous as she could choke or aspirate leftover food when she would lay down to sleep. For many weeks we would have to watch her and check her mouth after she ate.
This was a bad week for her. She was emotionally labile and confrontive. Depression appeared as well which also interfered with her cooperation with therapy. 4:00 was a particularly difficult time of day for her when she'd be almost inconsolable.
For the above clock she did the inside 12 and 6, then the circle, then 1-6 inside and then the outside 12 to 11 and pointed to the 12. Watching the process shows the struggle to figure out how to organize the information.
I should mention throughout her entire stroke she was always able to tell time off a regular clock face on the wall. It is not a matter of being unable to perceive the clock. It is a question of producing organized responses. And don't make too much of lop-sided circles. We didn't always have her sitting up at a desk to draw these as it was difficult to get her up.
During this period her voice became less mechanistic, with more tonal variation. She began to roll herself over and could raise her left leg. She could now sit up for over an hour and was eating solid food. She also had her 80th birthday and got McDonald's and ice cream and cake.
December 26, 2004
She manages all of the numbers and a decent circle. Just the 9 and 10 reversed, there at the far left point where she will be at her weakest.
She wrote the sentence at the top spontaneously, "Here it is!"
She has also gained some movement in her left leg by this time and some shoulder movement.
She was able to phone my home.
It now takes her 5 minutes to process a question or comment from someone. She was able to do her basic self-care (wash her face, brush her teeth) and she stood and took a step while supported.
We noted that she would say she didn't want to do therapy or eat but she would move her body in the direction of the therapist or keep lifting the fork. We speculate that this was the right side expressing its desire.
January 16, 2005
Hands first appear on the clock and it takes a couple of tries. The numbers are all in sequence. This time she's lost the spatial configuration on the bottom of the clock.
The 1, 2, and 3 required a prompt.
The therapists have her walking with support.
She fails to shift her conversation with whomever is speaking to her. This has been true since the beginning but it is more noticeable as she is talking more.
Her pronouns have been confused since the beginning. A person may be he, she, you, including herself. She may repeat a sentence someone else says and uses it as a comment.
She had to learn a new phone system in a new facility. It took 2 nights. She is moving her shoulder and her reading and voice tones continue to improve.
February 4, 2005
This was on lined-paper that didn't scan well.
She volunteered the 12:00 at the top but drew a 6:00 (or maybe a 12:30). She has only one set of hands and has the arrows effectively attached to the arms.
She had to learn a new phone system that was more complex. It took several nights.
She is walking longer distances with help and a hemi-walker.
She tried to stand on her own, fell, and cut her head badly--7 stitches.
March 4, 2005
This one she drew while laying down and the paper was resting on the blanket. She needed a prompt to get 7 to 10 but did the others on her own. All numbers in sequence and two hands.
She seems now to have regained her larger geographic sense. She can tell me that St. Louis is further than Louisville and that Louisville is relatively close to where she is. She understands that I don't drive home to Bowling Green (a 2 hour drive) every night when I am visiting her. She still has pronoun difficulty.
She can walk with a quad cane with help. We took her out to church. Her first 'for fun' trip out of a hospital since November 18. It improved her responsiveness to therapy tremendously.
She was able to sing hymns from memory but had difficulty following the lines in the hymnal.
She still has no arm or elbow movement. As she says, she still has the stroke in her arm.
March 13, 2005
Mother drew this clock with confidence and no hesitation while sitting at a table. Notice the nice spacing of numbers.
She is still having difficulty with pronouns and we are having trouble with her ankles swelling terribly and therefore she can't do walking. She also had difficulty with tone-- what happens is the brain sends messages to move and ordinarily, there are countering messages to do some inhibition. With the brain damage, there is no inhibition so the leg (or arm, etc). shoots out stiffly and can't be bent easily.
We are also concerned because her anxiety from the fall is keeping her from effectively moving her body when she is in therapy. She gets so anxious, she forgets the proper sequence of steps. In the midst of some other activity (e.g., a shower) she will pull herself up standing before anyone can help...but ask her to perform on command and she panics.
She has learned left from right and has been able to follow the lines of a hymn. Her shoulder movement has improved as has her strength. We had to write out 'getting in the car' directions to get her past her fear and confusion about the action. It's a complex spatial thing to get in a car-- stand, swivel, sit, swivel and bend legs.
The most exciting news is that during this week she is getting some sensation in her upper shoulder. We have learned that arms 'return' later than legs because the legs get much more deep pressure (e.g., standing on them, pushing on them) than do arms. My mother is really reluctant to lean on her left arm so my sister is regularly having my mother push against her with her arm as much as possible. She has also complained of specific pain in her fingers, not a general ache.
Mother made a trip to the dentist and we learned that because of the blood thinners she has to take she is more at risk for gum disease. He checked and she has sensation in 2/3rds of her left cheek and he recommended an electric toothbrush. She laid in the dentist chair at about 18 degrees without complaining...back in November we couldn't lay her down past 45 degrees.
She still has the feeding tube in her stomach although it hasn't been used in awhile...Back in November she thought it was the best invention ever...but she's become aware of it in a different way now and thinks it's gross.
March 27, 2005.
This clock doesn't look as good. What's the difference?
For the first time I asked her to draw a specific time, 10 until 10. She paused a long time, clearly confused. She wrote in the 12 and the 10, then tried to draw in the hands. Then added the numbers-- notice the additional 10. She seemed a little distressed at her difficulty, telling me to draw it and wanting to look at my answer. So we had her just draw a clock face next....
March 27, 2005.
She drew this one as smoothly as the March 13 clock.
This difference illustrates the complexity of what appears to be a simple task. She isn't just duplicating an image, hard enough, but she must apply some knowledge to it.
This particular week I observed that her conversational skills were noticeably improved with myself and my sister and with others. She could make a statement, we could comment on it, **she would comment on our comment and add a comment of her own, all on topic**. The part between brackets is new. To comment on someone's comment requires listening and processing it in a timely manner-- seconds. Prior to this time her processing would be hours (right after the stroke) to minutes.
Also on the cognitive plus side is real evidence of taking interest in an activity outside of her care/health. A friend at church has been knitting her adorable hats. The staff at the home are very attracted to the hats and mother has said she wants to arrange it so they can buy hats of their own-- she wants to take orders and is asking our advice on how to manage the money.
We did notice that she does not refer to herself as our 'mother' although she calls us her daughters. If we ask who she is to us, she says her name.
She has walked 70 feet and is happy doing so-- she wanted to walk further. We are ordering her a new wheelchair so she can pull herself along and get more exercise in her ankles, hopefully reducing the swelling. (Her feet dangle above the ground in her current one unless she has the leg rests, which prevent her from pulling herself along). I've noticed that she is moving her torso more and is using her feet to push herself into a better posture more.
Since March 27...
I've noticed her self-correcting on which pronoun she is using for a person, changing from she to he. She also said, "changing the subject" and brought up a new topic. That 'signal' to the other person in the conversation requires thinking about what is going on, not just about what she is saying. They have started working on her with money and she currently believes all money is paper and couldn't identify coins.
She has walked 90 feet and tells me later she is unhappy when they stop. Her new wheelchair has arrived but she doesn't seem too happy with it. We can't yet tell why. My sister tells me that mother pulled her left arm into her middle using the elbow. She may get her gastric tube out next week.
They called me from Walmart. Mother is excited to be out (they ate at Cheddars) and thinks Walmart is huge. Mother has graduated-- she has no restrictions on eating. The only reason she is still in food group is she won't use the rocker knife. (Or maybe it's that the food is better there.)
April 9, 2005. Draw 10 until 10:00.
She drew the 12, then 6 then 3, 4, 5, 6, 7, 8, 9, 10, 11. Hesitated on the arrows. Notice she left out 1, 2 (thinking 12 was it), had spacing difficulty on the 6,7 and had the arrow on one hand pointing to the center of the clock.
April 9, 2005. Draw a clock.
She drew 12, then 6. then reversing from 6 to 12 then 1, 2, 3, 4, 5. Pause, then 7 to 11.
What's wrong? These are worse.
We had been noticing her language and balance was deteriorating. Sure enough, she had a Urinary Tract Infection, or UTI. These are a common problem for older adults, particularly those who have difficulty getting to the restroom. They can produce confusion and the appearance of dementia. If you see a confused older adult, check for UTI. It was apparent in her poorer performance in physical therapy and general functioning.
Another contributing factor this week is that she was moved to a different room in a different part of the nursing home. This was a bad period-- she also lost the capacity to side step, necessary for getting into cars and she is having a worse time getting going when she starts to walk. Mother has also, for the first time, realized how much difficulty she has in speaking. I've tried to reassure her that is normal for awhile and she'll improve. Everyone is discouraged.
We tested her the next morning because another possible hypothesis was that we'd had her out too long on the 9th. She had done 10 transfers (1 transfer = in or out of the car). So we tried in the morning when she is at her best. Week of April 11, 2005. Treating the UTI has made a tremendous change. Her balance is back. She pretty much got herself into the car and, most spectacular, she was willing to lay almost flat for 45 minutes. This will enable the therapists to do the next level of muscle work. We are seeing definite signs of elbow movement. She is optimistic her hand will come back.
The speech therapist has reduced her time with mother and is having us ask her "why" questions...a graduation of sorts. April 17 she told me she felt good about working to be more independent. Soon she gets a botox injection to help reduce the spasticity in her arm. Everyone is teasing her about the botox. She actually called me on the 19th and, with a prompt, was able to say "I am your mother." That noun, mother, is one she lost in reference to herself. She would call us her daughters and could say other people were mothers to their children. And she could talk about her mother. But this is the first she's completed that phrase since the stroke. Brain damage does funny things like that.
In the meantime, she's been started on a muscle relaxant. What is spasticity? As they explained it to us, it's the force that draws your arm toward your chest. If she wasn't on the muscle relaxant she'd be in a lot of pain and her arm would be drawn in. We've been dealing with tone up til now (which is the force that draws your arm away). Tone can be managed with exercises.
April 23, 2005. Draw 10 until 10:00
She drew the 12, 6, then 1-2-3-4-5. The hands then 11, 10, 9, 8, 7, 6, 5, 4 and more hands. The extra hands and the extra 6,5,4 are called perseveration-- inability to stop oneself. It's common with any type of damage.
My sister and I believe the problems are due to the muscle relaxant. We have observed considerably more cognitive difficulty since she was started on it. I try to call her and I hear her pick up the phone, but she can't seem to figure out the next step. (At least that is what I'm inferring is happening). Her conversation is harder to follow.
She clearly has more strength in her shoulder which means she is moving it more which means the swelling in her hand has gone down and she doesn't have to wear that glove.
She asked us to buy her a whistle. Why? The toilet in the new place has a pull cord to call for help, like all do in a nursing facility....however it is on the side that is paralyzed. She can't balance herself and get to it.
We got her one and she tried to blow it-- but because of paralysis didn't get a good seal around the whistle at first. With a bit of practice she improved.
She's been frustrated because her watch would end up covered by sweaters, etc. and she loves to check the time. With one hand, she can't pull her sweater back. (No wearing on the paralyzed side--potential for swelling). I wore a ring watch there and she wanted to try it on...then said thank you for the watch. She's quite a force of nature. But it is a perfect solution and she thought of it. I went out and got a few more for her (and one for me that she won't see!).
Having brain damage doesn't 'make you stupid'. It's more like it gives you holes where you can't process.
Week of April 28, 2005-- she tells me that she is noticing how she repeats what other people say. For example, if I said, "I went to the grocery." she might say as well, "I went to the grocery." She said she is having trouble recalling nouns and is pausing more. I tried to encourage her, explaining that was just a phase of stroke recovery. She said her arm hurts (still the spasticity). She also said "I don't have the same pep as last year."
On the positive side the therapists tell us she is continuing to improve and that is a very rare thing for a person of this age and with this severe a stroke. Mother tells us that she is getting tingling sensations in her lower arm, maybe in her hand. She is optimistic the hand will come back.
My sister and I are frustrated that we apparently have to choose between muscle rehabilitation (the muscle relaxant) and cognitive progress. However, mother is happy in the facility, especially because she isn't alone. She loves that she just presses a button and they come.
Spontaneously wrote "Be kind and be gentle, for those who is gentler is dearer than gold."
[Means to say "Be kind and be gentle to those who are old because kindness and gentleness are dearer than gold."]
05/03/05
05/07/05
05/07/05 try 2
Week of May 8, 2005-- She had a full week previously. On Monday she had botox shots (7 or 8) in her arm and leg to try to combat the spasticity. Then on Friday she had her gastrict tube removed (finally!). It was just a little pop and out it came but it did bleed a lot because no one thought about the blood thinners she was on. She was fine by the next day. However, we could tell that her worry about these events had been high. She was irritable in therapy on Saturday and talked some about not doing it any more. Her clocks were poor and when I tried to have her read about turning when walking she wasn't interested. Last week she had walked willingly, but refused to turn around and walk back. Whenever there's a new physical thing, writing out the instructions usually helps. She isn't learning her new remote for the tv. And she thinks a tape I brought her of family videos is some special channel on tv.
On the plus side, her language was better (she's been off the muscle relaxant about 5 days) and she was doing less repeating and missing fewer words. She's also spending more time with other residents in the lounge-- she's fascinated by a 102 year old lady and she wants to be just like her current roommate in drss and style. She enjoyed Mother's Day very much. Nevertheless, I returned home feeling somewhat sad.
May 10, 2005-- I've talked to mother twice since I left and she is doing much better-- Today she called me and said "This is your mother." This is the first time she's labelled herself as 'mother' since November. She also walked today without being followed by someone pushing a wheelchair. That's a first. And more importantly, yesterday she turned and turned and turned-- 7 times she pivoted in walking. You try to write out the instructions..it's a complex set of shifting. I complemented her and asked if reading the directions helped and she said yes because then she can think about it more easily.
She's also thinking about other people again-- trying to think how a lady with almost no voice can make her wants known, perhaps by using mother's pen. Being able to think outside of your own needs is a very good sign. More than that, it is difficult for a right hemisphere stroke patient to a) initiate conversation with strangers and then b) keep the conversation going and mother was doing both.
Tonight she's wondering if her arm will come back-- she said it is 'drawing' (that means it has spasms). They are happening less often. I told her it could take a year before we'd know.
On the funny side, they'd been feeding her on a plastic plate and she wanted a china one. (Who knows why-- she happily eats burgers out of a paper box?!). When they wouldn't bring china she said she'd write the pope. She's convinced that threat delivered a china plate for dinner tonight.
She's spelling words in preparation for a spelling bee-- s-i-g-n-i-f-i-c-a-n-t was the longest. She only paused once.
May 12, 2005--She has a kidney and urinary tract infection and some virus causing vomiting. Life is up and down this week. She managed to call me but sounded miserable.
It turns out the May 12 event was actually a heart attack (congestive heart failure) with none of the usual symptoms. All the nurses thought it was pneumonia but the emergency room picked up the heart attack using a blood test. She recovered from the heart attack but it cost her progress in therapy, both physical and otherwise.
Try 1
5/22/05 Try 2
5/29/05
6/16/05
6/26/05
7/16/05
9/18/05
9/20/05
12/25/05
March 8, 2007
We asked her to imitate a clock, rather than draw spontaneously, which the prior clocks were. Notice no circle and no left side numbers.
Over the ensuing 6 months
Early February, 2006
We have come to realize that mother has special difficulty with words denoting familial relationships. She has not/cannot say "I am your mother". We don't think it is just the pronoun difficulty (although that is a hard sentence). We think it is the word "mother" (and "daughter" and "husband", although she knows "spouse") when applied to herself. She can name other people as mother and daughter, but so far hasn't been able to state relationships to her, such as her mother. We asked and she either couldn't or didn't want to say where babies come from-- suggesting the stork. I don't think that's reticence.
February 22, 2006
This past week my sister noticed behavior similar to when we'd get a cognitive improvement in the first year-- a certain restless and quality of irritability different than just grumpiness or tiredness. We both commented on her increased smoothness of speaking and increased complexity of language-- using several sentences on a single topic. There is also greater spontaneity of speech rather than re-use of stock phrases she's used many times. Last night she said an amazing thing. I have been sick with a bad cold and she asked after my health then said. "You are my baby." (I am the youngest). The correct use of pronouns with a possessive and proto-relationship term were firsts.
March 13, 2007
It's hard to balance caregiving at a distance and keeping this page up-to-date. We'd settled into a routine of taking her out every few weeks, giving her rides to get snacks and enjoying various nursing home activities. Around Christmas, 2006, she caught the stomach flu that was epidemic in retirement homes. It was very bad. My sister and I got it and I haven't been that sick in a long time. I don't know how she survived it. In mid January 2007 we took her to the hospital with a very rapid heart beat and feeling ill. She also had a massive urinary tract infection and her kidneys weren't functioning well. We believe she may have had another stroke at that time and possibly again two weeks later. We had difficulty getting her meds balanced. We're realizing that the down times are coming closer together and it takes longer to recuperate. We find enjoyment in the simple daily activities and she does as well.
March 13, 2009
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My sister had her draw another clock. Mother thought she had done a good job and wanted to draw another. I haven't asked for a long time. It is clear she has been going downhill in terms of vocabulary and comprehension. So what is left? She enjoys her pleasures--Animal Planet, good food, the weekly tea party, getting her hair fixed, knowing what is going on in the lives of her CNAs. She laughs and tells simple jokes. She is acutely interested in everything around her. So far she isn't in pain and for that we are thankful. It's a good life for her. We know we don't have a long time with her and just enjoy her as she is. |
September 10, 2009
Mother went into the hospital with pneumonia on May 8. The ups and downs came faster and faster--kidney failure, diabetes diagnosed, etc. On Thursday the 14th we walked into her room and she said "I think I'm dying." We consulted with the minister, the MDs, and her wishes and chose to take her back to her home (the nursing home) that day. She had some time to say goodbye to friends then gradually faded into sleeping all the time (the drugs).
Monday morning we were talking at her bedside with our minister and I saw a shining circular light on the ceiling above her head, dancing. We looked at one another in surprise. It looked like a halo. Eventually we realized it was a reflection from her glass of water sitting in the window catching the morning sun. A short while later she died. And the "halo" was gone as well. She lived well and fully regardless of her circumstances. I hope I can do as well.
All Clocks in Sequence
Here you can compare all the clocks in sequence. The fastest improvement after a stroke comes in the first 3 months, up through the 5th clock below (the green areas). Then the next fastest set of improvement comes in the next 3 months. The slowest improvement comes in the next 6 months...and finally by the end of one year you have most of what is going to come back. Improvement can and does happen later, but it is less predictable.
12/02/04
12/14/04
12/26/04
1/16/05
2/4/05
3/4/05
3/13/05
Requested she draw 10 until 10
3/27/05
Draw 10 until 10. UTI 4/9/05
Draw 10 until 10. muscle relaxant
4/23/05
5/3/05
Try 1
5/7/05, Try 2
May 18, 2005 is the end of 6 months.
Try 1
5/22/05 Try 2
5/29/05
6/16/05
6/26/05
7/16/05
9/18/05
9/20/05
12/25/05
March 8, 2007
We asked her to imitate a clock, rather than draw spontaneously, which the prior clocks were. Notice no circle and no left side numbers.
March 9, 2009
She thought she had done a good job and wanted to draw another. It's been clear she has been losing ground and just wearing out.
Speech Clips
Here are a few sound bites of mother speaking on my answering machine. Turn your sound way up. If you have a phone modem connection, it may take awhile to download these.
Several months before her stroke
About 2 months after her stroke She just says "ok...Norma"
Summer of 2005 She says "Hello Sally hope everything is going well bye bye....I walked 78 feet this morning..this afternoon" then my sister closes.
For more information
Likitcharoen, Y. & Phanthumchinda. (2004). Environmental reduplication in a patient with right middle cerebral artery occlusion. Journal of the Medical Association of Thailand, 87(12). Available online: http://www.medassocthai.org/journal/files/Vol87_No12_1526.pdf Has a picture of a clock face drawn by someone with less pervasive damage than mother.
Sachdev P, Lloyd J, McIvor B. (2001). Neuropsychaitric disorders. In Bloch S, Singh B (eds) Textbook of Psychiatry. Melbourne Univ Press, Melbourne, 332-358. Available online: http://www.inaweb.org/education/disorders/notes.doc
Copersino, M., Serper, M. & Allen, M. (March 2003) Emergency Psychiatry: Rapid Screening for Cognitive Impairment in the Psychiatric Emergency Service: II. A Flexible Test Strategy. Psychiatric Services. 54:314-316. Available online: http://ps.psychiatryonline.org/cgi/content/full/54/3/314
South, M., Greve, K., Bianchini, K., & Adams, D. (2001). Interrater Reliability of Three Clock Drawing Test Scoring Systems. Applied Neuropsychology. 8(3), pp. 174-179. Available online: http://www.leaonline.com/doi/abs/10.1207/S15324826AN0803_7;jsessionid=nxvn5RynrXwf
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