Clock Drawing Test-Modified and Integrated Approach(CDT-MIA): Description and Preliminary Examination of its Validity and Reliability in Dementia Patients Referred to a Specialized Psychogeriatric Setting

Abstract

The authors developed a scoring system for clock drawing, based on modification and integration of 3 established scoring methods. The Clock Drawing Test-Modified and Integrated Approach (CDT-MIA) is a 4-step, 20-item instrument, with a maximum score of 33, which emphasizes differential scoring of contour, numbers, hands, and center. It was administered to 139 patients (93 with and 46 without dementia). Dementia patients revealed significantly more impairment on the CDT-MIA total score and hours and hands subscores. Correlations between CDT-MIA and 2 CDTs were high. With receiver operating characteristics (ROC) curves, the area constructed under CDT-MIA curve was large. The best trade-off between sensitivity and specificity for CDT-MIA was the cut-point 23 (91% and 80%, respectively). The internal consistency of CDT-MIA was high, and there was a high degree of interrater reliability. Thus, CDT-MIA was found to be a valid and reliable evaluation instrument for dementia patients in a specialized setting.

Keywords

clock drawing MMSE dementia psychogeriatric outpatients

Get full access to this article

View all access options for this article.

References

1. Shulman KI . Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000; 15:548-561.

2. Scanlan JM , Brush M , Quijano C , et al.

Comparing clock tests for dementia screening: naive judgments vs formal systems—what is optimal?

Int J Geriatr Psychiatry 2002; 17:14-21.

3. Tuokko H , Hadjistavropoulos T , Rae S , et al. A comparison of alternative approaches to the scoring of clock drawing. Arch Clin Neuropsychol 2000; 15:137-148.

4. Storey JE , Rowland JT , Basic D , et al. A comparison of five clock scoring methods using ROC (receiver operating characteristic) curve analysis. Int J Geriatr Psychiatry 2001; 16:394-399.

5. Schramm U , Berger G , Muller R , et al. Psychometric properties of Clock Drawing Test and MMSE or Short Performance Test (SKT) in dementia screening in a memory clinic population. Int J Geriatr Psychiatry 2002; 17:254-260.

6. Cosentino SA , Jefferson AL , Chute DL , et al. Clock drawing in dementia: validation of a novel scoring system sensitive to subcortical pathology. Arch Clin Neuropsychol 2002; 17:720-721.

7. Williams K , Cahn-Weiner DA , Grace J , et al. Comparison of clock-drawing performance in Alzheimer’s disease, Parkinson’s disease and dementia with Lewy bodies. Arch Clin Neuropsychol 2002; 17:737-737.

8. Heinik J , Solomesh I , Raikher B , et al. Can clock drawing test help to differentiate between dementia of the Alzheimer’s type and vascular dementia? A preliminary study. Int J Geriatr Psychiatry 2002; 17:699-703.

9. Moretti R , Torre P , Antonello RM , et al. Ten-Point Clock Test: a correlation analysis with other neuropsychological tests in dementia. Int J Geriatr Psychiatry 2002; 17:347-353.

10.

10. Kitabayashi Y , Ueda H , Narumoto J , et al. Qualitative analyses of clock drawings in Alzheimer’s disease and vascular dementia. Psychiatr Clin Neurosci 2001; 55:485-491.

11.

11. Rascovsky K , Salmon DP , Ho GJ , et al. Cognitive profiles differ in autopsy-confirmed frontotemporal dementia and AD. Neurology 2002; 58:1801-1808.

12.

12. Juby A , Tench S , Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. Can Med Assoc J 2002; 167:859-864.

13.

13. Royall DR , Mulroy AR , Chiodo LK , et al. Clock drawing is sensitive to executive control: a comparison of six methods. J Gerontol B Psychol Sci Soc Sci 1999; 54:328-333.

14.

14. Royall DR , Cordes JA , Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry 1998; 64:588-594.

15.

15. Heinik J , Solomesh I , Shein V , et al. Correlation between clock-drawing test and paranoid and delusional ideation in dementia of the Alzheimer’s type. Int J Geriatr Psychiatry 2001; 16:735-736.

16.

16. Heinik J , Solomesh I , Shein V , et al. Clock drawing test in mild and moderate dementia of the Alzheimer’s type: a comparative and correlation study. Int J Geriatr Psychiatry 2002; 17:480-485.

17.

17. Esteban-Santillan C , Praditsuwan R , Ueda H , et al. Clock drawing test in very mild Alzheimer’s disease. J Am Geriatr Soc 1998; 46:1266-1269.

18.

18. De Jager CA , Hogervorst E , Combrinck M , Budge M. Sensitivity and specificity of neuropsychological tests for mild cognitive impairment, vascular cognitive impairment and Alzheimer’s disease. Psychol Med 2003; 33:1039-1050.

19.

19. Seigerschmidt E , Mosch E , Siemen M , et al. The clock drawing test and questionable dementia: reliability and validity. Int J Geriatr Psychiatry 2002; 17:1048-1054.

20.

20. Powlishta KK , Von Dras DD , Stanford A. The clock drawing test is a poor screen for very mild dementia. Neurology 2002; 59:898-903.

21.

21. Lee H , Swanwick GR , Coen RF , Lawlor BA . Use of the clock drawing task in the diagnosis of mild and very mild Alzheimer’s disease. Int Psychogeriatr 1996; 8:469-476.

22.

22. Wolf-klein GP , Silverstone FA , Levy AP , et al. Screening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc 1989; 37:730-734.

23.

23. Herrmann N , Kidron D , Shulman KI , et al. Clock tests in depression, Alzheimer’s disease and elderly controls. Int J Psychiatry Med 1998; 28:437-447.

24.

24. Kirby M , Denihan A , Bruce I , et al. The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry 2001; 16:935-940.

25.

25. Lee H , Lawlor BA . State-dependent nature of the clock drawing task in geriatric depression. J Am Geriatr Soc 1995; 43:796-798.

26.

26. Gruber NP , Varner RV , Chen YW , Lesser JM . A comparison of the clock drawing test and the Pfeiffer Short Portable Mental Status Questionnaire in a geropsychiatry clinic. Int J Geriatr Psychiatry 1997; 12:526-532.

27.

27. Berger AK , Fahlander K , Wahlin A , et al. Negligible effects of depression on verbal and spatial performance in Alzheimer’s disease. Dement Geriatr Cogn Disord 2002; 13:1-7.

28.

28. Bozikas VP , Kosmidis MH , Kourtis A , et al. Clock drawing test in institutionalized patients with schizophrenia compared with Alzheimer’s disease patients. Schizophr Res 2003; 59:173-179.

29.

29. Heinik J , Lahav D , Drummer D , et al. Comparison of a clock drawing test in elderly schizophrenia and Alzheimer disease patients: a preliminary study. Int J Geriatr Psychiatry 2000; 15:638-643.

30.

30. Heinik J , Solomesh I , Bleich A , Berkman P.

Are the clock drawing test and the MMSE combined interchangeable with CAM-COG as a dementia evaluation instrument in a specialized outpatient setting?

J Geriatr Psychiatr Neurol 2003; 16:74-79.

31.

31. Brodaty H , Moore CM . The clock drawing test for dementia of the Alzheimer’s type: a comparison of three scoring methods in a memory disorders clinic. Int J Geriatr Psychiatry 1997; 12:619-627.

32.

32. Solomon PR , Hirschoff A , Kelly B , et al. A 7 minute neurocognitive screening battery highly sensitive to Alzheimer’s disease. Arch Neurol 1998; 55:349-355.

33.

33. Scanlan J , Borson S. The Mini-Cog: receiver operating characteristics with expert and naive raters. Int J Geriatr Psychiatry 2001; 16:216-222.

34.

34. Freedman M , Leach L , Kaplan E , et al. Clock-drawing: a neuropsychological analysis. New York: Oxford University Press, 1994.

35.

35. Paganini-Hill A , Clark LJ , Henderson VW , et al. Clock drawing: analysis in a retirement community. J Am Geriatr Soc 2001; 49:941-947.

36.

36. Manos PJ , Wu R. The ten point clock test: a quick screen and grading method for cognitive impairment in medical and surgical patients. Int J Psych Med 1994; 24:229-244.

37.

37. Heinik J , Solomish A , Berkman P. Types of ambulatory services for the elderly with cognitive and mental disturbances: current status. Harefuah 1998; 135:124-126.

38.

38. Folstein MF , Folstein SE , McHugh PR . ‘Mini-Mental State’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189-198.

39.

39. Werner P , Heinik J , Mendel A , et al. Examining the reliability and validity of the Hebrew version of the Mini-Mental State Examination. Aging (Milano) 1999; 11:329-334.

40.

40. American Psychiatric Association . Diagnostic and statistical manual of mental disorders, Fourth edition. Washington, DC: American Psychiatric Association, 1994.

41.

41. Hughes CP , Berg L , Danziger WL , et al. A new clinical scale for the staging of dementia. Br J Psychiatry 1982; 140:566-572.

42.

42. Shulman KI , Gold DP , Cohen CA , et al. Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry 1993; 8:487-496.

43.

43. Lockwood KA , Alexopolous GS , van Gorp WG . Executive dys-function in geriatric depression. Am J Psychiatry 2002; 159:1119-1126.

44.

44. Shulman K , Feinstein A. Quick cognitive screening for clinicians. Mini Mental, Clock Drawing and other brief tests. London: Martin Dunitz, 2003.

45.

45. Mendez MF , Ala T , Underwood KL . Development of scoring criteria for the clock drawing task in Alzheimer’s disease. J Am Geriatr Soc 1992; 40:1095-1099.