Quantitative and Qualitative Analyses of the Clock Drawing Test in Mild Cognitive Impairment and Alzheimer Disease: Evaluation of a Modified Scoring System
Restricted accessResearch articleFirst published online June, 2011
Quantitative and Qualitative Analyses of the Clock Drawing Test in Mild Cognitive Impairment and Alzheimer Disease: Evaluation of a Modified Scoring System
The clock drawing test (CDT) has been used as a screening tool for identifying cognitive decline in individuals with Alzheimer disease (AD) and other dementias but has not been extensively evaluated for categorizing individuals with mild cognitive impairment (MCI). This study used both an established quantitative scoring system and a revised scoring method based on qualitative error criteria developed by Rouleau et al to demonstrate the sensitivity of the CDT to MCI. Participants were 66 cognitively healthy older adult, 33 individuals with MCI, and 33 individuals with AD. Sensitivity analyses of the 2 clock drawing methods revealed that the Modified Rouleau scoring method was more sensitive to MCI than the original Rouleau scoring system. Conceptual, graphic, and spatial-planning difficulties were the most commonly committed errors on the CDT across all groups, and conceptual errors along with graphic difficulties were committed more often in the MCI group than the cognitively healthy control group. Participants in the AD group exhibited greater deficits in all error categories and significantly lower total CDT scores compared to both the MCI and older adult controls. Findings observed in this study suggest that qualitative observations of clock drawing errors can help increase sensitivity of the CDT to MCI and that use of a more detailed scoring system is necessary to differentiate individuals with MCI from cognitively healthy older adults.
Leifer BPEarly diagnosis of Alzheimer’s disease: clinical and economic benefits . J Am Geriatr Soc.2003;51(5suppl): S281-S288.
2.
Rouleau I., Salmon DP, Butters N., Kennedy C., McGuire K.Quantitative and qualitative analyses of clock drawings in Alzheimer’s and Huntington’s disease. Brain Cogn. 1992;18(1):70-87.
3.
Brodaty H., Moore CMThe 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(6):619-627.
4.
Royall DR, Cordes JA, Polk M.CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry. 1998;64(5): 588-594.
5.
Shulman K., Shedletsky R., Silver I.The challenge of time: Clock-drawing and cognitive function in the elderly . Int J Geriatr Psychiatry. 1986;1(5):135-140.
6.
Bourke J., Castleden CM, Stephen R., Dennis M.A comparison of clock and pentagon drawing in Alzheimer’s disease. Int J Geriatr Psychiatry. 1995;10(3):703-705.
7.
O’Rourke N., Tuokko H., Hayden S., Beattie BLEarly identification of dementia: predictive validity of the clock test. Arch Clin Neuropsychol. 1997;12(3):257-267.
8.
Forti P., Olivelli V., Rietti E., et al. Diagnostic performance of an executive clock drawing task (CLOX) as a screening test for mild cognitive impairment in elderly persons with cognitive complaints. Dement Geriatr Cogn Disord.2010;30(1):20-27.
9.
Sunderland T. , Hill J., Mellow A., et al. Clock drawing in Alzheimer’s disease: a novel measure of dementia severity. J Am Geriatr Soc. 1989;37(8):725-729.
10.
Tuokko H., Hadjistavropoulos T., Miller JA, Beattie BLThe clock test: a sensitive measure to differentiate normal elderly from those with Alzheimer’s disease. J Am Geriatr Soc. 1992;40(6):579-584.
11.
Wolf-Klein GP, Silverstone FA, Levy AP, Brod MSScreening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc. 1989;37(8):730-734.
12.
Cahn DA, Salmon DP, Monsch AU, et al. Screening for dementia of the Alzheimer type in the community: the utility of the clock drawing test. Arch Clin Neuropsychol . 1996;11(6):529-539.
13.
Scanlan JM, Brush M., Quijano C., Borson S.Comparing clock tests for dementia screening: naïve judgments vs formal systems-what is optimal? Int J Geriatr Psychiatry. 2002;17(1):14-21.
14.
Yamamoto S. , Mogi N., Umegaki H., et al. The clock drawing test as a valid screening method for mild cognitive impairment. Dement Geriatr Cogn Disord. 2004;18(2):172-179.
15.
Blair M., Kertesz A., McMonagle P., Davidson W., Bodi N.Quantitative and qualitative analyses of clock drawing in frontotemporal dementia and Alzheimer’s disease. J Int Neuropsychol Soc. 2006;12(2):159-165.
16.
Freedman M., Leach L., Kaplan E., et al. Clock Drawing: A Neuropsychological Analysis. New York, NY: Oxford University Press; 1994.
17.
Rouleau I., Salmon DP, Butters N.Longitudinal analysis of clock drawing in Alzheimer’s disease patients . Brain Cogn. 1996;31(1): 17-34.
18.
Ehreke L., Luppa M., Konig H., Riedel-Heller SGIs the Clock Drawing Test a screening tool for the diagnosis of mild cognitive impairment? A systematic review. Int Psychogeriatr.2010;22(1): 56-63.
19.
Mendez MF, Ala T., Underwood KLDevelopment of scoring criteria for the clock drawing test in Alzheimer’s disease. J Am Geriatr Soc. 1992;40(11):1095-1099.
20.
Powlishta KK , Von Dras DD, Stanford A., et al. The clock drawing test is a poor screen for very mild dementia. Neurology. 2002;59(6):898-903.
21.
Morris JCThe Clinical Dementia Rating (CDR): current version and scoring rules. Neurology. 1993;43(11):2412-2414.
22.
Lee KS, Kim EA, Hong CH, et al. Clock drawing test in mild cognitive impairment: quantitative analysis of four screening methods and qualitative analysis. Dement Geriatr Cogn Disord. 2008;26(6):483-489.
23.
Babins L., Slater ME, Whitehead V., Chertkow H.Can an 18-point clock-drawing scoring system predict dementia in elderly individuals with mild cognitive impairment? J Clin Exp Neuropsychol. 2008;30(2):173-186.
24.
Chiu Y., Li C., Lin K., Chiu Y., Liu H.Sensitivity and specificity of the clock drawing test, incorporating Rouleau scoring system, as a screening instrument for questionable and mild dementia: scale development. Int J Nurs Stud. 2008;45(1):75-84.
25.
Rueda AD, Schmitter-Edgecombe M.Time estimation abilities in mild cognitive impairment and alzheimer’s disease. Neuropsychology.2009;23(2):178-188.
26.
Schmitter-Edgecombe M., Woo E., Greeley DRCharacterizing multiple memory deficits and their relation to everyday functioning in individuals with mild cognitive impairment. Neuropsychology.2009;23(2):168-177.
27.
Brandt J., Spencer M., Folstein M.The telephone interview for cognitive status. Neuropsychiatry Neuropsychol Behav Neurol. 1988;1(2):111-117.
28.
Morris JC, McKeel DW, Storandt M., et al. Very mild Alzheimer’s disease: informant-based clinical, psychometric, and pathologic distinction from normal aging. Neurology. 1991; 41(4):469-478.
29.
Hughes CP, Berg L., Danzinger WL, Coben LA, Martin RLA new clinical scale for the staging of dementia. Br J Psychiatry . 1982;140:566-572.
30.
Petersen RC , Doody R., Kurz A., et al. Current concepts in mild cognitive impairment. Arch Neurol. 2001;58(12):1985-1992.
31.
Yesavage JA , Brink TL, Rose TL, et al. Development and validation of a geriatric depression rating scale: a preliminary report. J Psychiatr Res. 1983;17(1):37-49.
32.
American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. (4th ed.). Washington, DC: American Psychiatric Association; 2000.
33.
Lezak MDNeuropsychological Assessment. (2nd ed.). New York, NY: Oxford University Press; 1983.
34.
McKhann G., Drachman D., Folstein M., et al. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA workgroup under the auspices of the Department of Health and Human Services Task Force on Alzheimer’s disease. Neurology . 1984; 34(7):939-944.
35.
Tierney MC, Fisher RH, Lewis AJ, et al. The NINCDS-ADRDA Work Group criteria for the clinical diagnosis of probable Alzheimer’s disease: a clinicopathologic study of 57 cases . Neurology. 1988;38(3):359-364.
36.
Souder E., O’Sullivan P., Pechenik G.Comparison of scoring criteria for clock drawing test. J Clin Geropsychol. 1999;5(3):139-145.
37.
Rueda A., Parsey C., Schmitter-Edgecombe M.Clock drawing in healthy aging and mild cognitive impairment [abstract]. J Int Neuropsychol Soc.2009;15(suppl.1):214.
38.
Butters N., Granholm E., Salmon DP, et al. Episodic and semantic memory: a comparison of amnesic and demented patients. J Clin Exp Neuropsychol. 1987;9(5):479-497.
39.
Lessig MC, Scanlan JM, Nazemi H., Borson S.Time that tells: critical clock drawing errors for dementia screening. Int Psychogeriatr. 2008;20(3):459-470.
40.
Shulman KIClock-drawing. Is it the ideal cognitive screening test?Int J Geriatr Psychiatry. 2000;15(6):548-561.
41.
Ainslie N., Murden N.Effect of education on the Clock-drawing dementia screen in non-demented elderly persons. J Am Geriatr Soc. 1993;41(3):249-252.
42.
Cahn DA, Wiederholt WC, Salmon DP, Butters N.Detection of cognitive impairment in Spanish-speaking elderly with the clock drawing test [Abstract]. Arch Clin Neuropsychol. 1994;9(5): 113-114.
43.
Mortimer JA , Snowdon DA, Markesbery WRHead circumference, Education and Risk of Dementia: Findings from the Nun Study. J Clin Exp Neuropsychol . 2003;25(5): 671-679.
