Can you draw the clock?
If not, Toni Miles may want to study you.
If someone asked you to draw a clock, could you? Could you make a circle and put all the numbers from 1 to 12 in the right place, not add extra numbers and draw hands to indicate a specific time? Most people can do the task with no effort—yet some can‘t.
Drawing a clock is a simple and proven screening tool for dementia or other cognitive problems associated with the frontal cortex of the brain. If Toni Miles had her way, the task would be part of any routine visit to a primary care physician’s office.
That‘s how it works when Miles, the Ole A., Mabel Wise and Wilma Wise Nelson Chair in Clinical Geriatrics Research, conducts “real-time research” at primary care practices in Louisville.
Miles came to the University of Louisville in 2003 from the University of Texas Health Science Center at San Antonio, bringing with her 20 years of research experience in geriatrics. She has published more than 100 papers and abstracts and 14 book chapters, holds posts at the University of Pittsburgh and at the University of Illinois in epidemiology and is regarded as one of the nation’s leading gerontologists.
The chair was created with a $2 million endowment made possible by a gift from the estate of Wilma Wise Nelson and matching funds from Kentucky‘s Research Challenge Trust fund, or “Bucks for Brains.”
All of Miles’ research experience, plus personal experience with elderly relatives, has brought her to one conclusion: “We‘ve reached the point in medicine where we’ve got to focus on where the doctor and patient come together, and that’s inside a practice.”
“I’ve been studying the development of frailty in old age for about 15 years,” Miles says. “I’ve been working with a group of scientists on a big study of 3,000 older adults. We can tell you all kinds of interesting things about what‘s happened to these people as they‘ve gone through their seventh decade of life. If the usual course of research plays itself out, what we know won’t make its way into practice for another 15 years. That‘s ridiculous.”
Miles has developed a way to study the prevalence of dementia and cancer in the nation‘s aging population and at the same time give doctors the benefit of her findings now. She and an interdisciplinary team of research associates conduct practice-based research—with a twist. It happens in “real time.”
Practice-based research, often difficult because of regulations and logistics, is not new, she says, but real-time research is. “In real-time research, the people who need the information most get it first.”
Miles and three or four members of the research team spend a day at a primary care practice in the Louisville community where they ask each patient over age 18 to draw a clock with all the numbers and indicate the time 1:45. The highest score is four. Participants receive a point each for drawing a circle, using the numbers one through 12 and putting the numbers and hands in the right places.
That night, Miles analyzes clock data collected daily and compiles a report on the prevalence of cognitive impairment at that practice. She presents it to the practice at the next day‘s staff meeting.
“I call it my UPS version of research,” she says. “You want it overnight, you’ve got it.”
Individual results may be even more immediate.
In one case, Miles received a poorly drawn clock from a woman not diagnosed with a cognitive disorder at one medical practice. She took her findings straight to the woman‘s doctor.
“Because of her behavior, her doctor thought she was just anxious,” Miles says. “But it‘s clear from (the clock) that her anxiety stems from the fact that she‘s frightened by her inability to focus.”
In this case, the doctor re-evaluated the patient’s diagnosis and altered treatment. Of the 34 people Miles and her team screened that day, two showed signs of cognitive disorder that were so subtle they were undetectable in a 15-minute medical encounter.
“People with cognitive impairment dementia—who are mildly cognitively impaired—are probably the most complex patients a primary care provider can manage,” Miles explains. “It’s only recently that we’ve had treatments that slow the progress of the disease, but there still is no systematic way of identifying patients.”
How a person draws a clock can indicate problems with cognitive function, help detect dementia before the symptoms are extreme and point to other possible problems with a person’s ability to plan and carry out a task.
“Under the age of 50,” Miles says, “there are no mistakes unless there is something wrong with a person.”
Dementia, or cognitive impairment, is not just a geriatric condition, she explains. Cognitive impairment also can be caused by drug abuse, large doses of chemotherapy and poorly controlled diabetes.
“Sleep deprivation is one cause of bad clock drawing that is reversible ,” she says.
“There are all kinds of reasons people draw bad clocks. It’s a detective game, but in primary care you need a timesaving way to kick-start the process,” Miles says. “Clock drawing lets practitioners be proactive about picking up cases of dementia.”
So far, 22 practices, including U of L’s department of family and geriatric medicine clinics in Louisville, Bowling Green and Madisonville in Kentucky, are participating in real-time research. Miles estimates the practices serve up to 200,000 people, and says that she hopes to recruit more practices.
Miles also is working on a grant proposal for the National Cancer Institute to study the prevalence of cancer survivors in Louisville primary care practices. Like the dementia study, it could have implications for how medicine is practiced in those sites, she explains—from indicating a need to screen male prostate cancer survivors for osteoporosis to giving physicians data they need to justify when to screen for cancer of the prostate, colon and breast.
“Primary care practitioners face the challenge of patients whose medical needs span issues as diverse as cancer screening and dementia,” Miles says. “Real-time research is a translation strategy that promises to smooth the implementation of important new basic research into standard clinical care.“