Identification of individuals who will eventually develop dementia is critical for early intervention, treatment, and care planning. The clock drawing test (CDT) is a widely used cognitive screening tool that has been well accepted among clinicians and patients for its ease of use and short administration time. This review explores the value of the CDT for predicting the later development of dementia in cognitively intact older adults and patients with mild cognitive impairment (MCI). Additionally, we reviewed studies that examined the ability of the CDT to monitor declines in cognitive functioning over time. A PubMed literature search for articles that included a longitudinal analysis of the CDT was conducted. The search included articles published up to June 2013 and manual cross-referencing of bibliographies. Relevant studies were categorized, summarized, and critiqued. The consensus from the studies reviewed suggests that the CDT is a useful measure of cognitive decline over time. Conceptual clock drawing errors (eg, misrepresentation of time) detected this decline most effectively. In addition, the CDT appears to differentiate at baseline between cognitively intact older adults who will develop dementia up to 2 years postbaseline. Finally, the CDT has been found to differentiate between patients with MCI who will progress to dementia up to 6 years postbaseline. The CDT appears useful for the longitudinal assessment of cognitive impairment and together with other validated measures may be helpful for predicting conversion to dementia. Cost-effective and practical ways of predicting risk of dementia will become increasingly critical as we develop disease-modifying treatments.
KatzmanRAronsonMFuldP. Development of dementing illnesses in an 80-year-old volunteer cohort. Ann Neurol. 1989;25(4):317–324.
2.
LinnRTWolfPABachmanDL. The ‘preclinical phase’ of probable Alzheimer’s disease: a 13-year prospective study of the Framingham cohort. Arch Neurol. 1995;52(5):485–490.
3.
TouchonJRitchieK. Prodromal cognitive disorder in Alzheimer’s disease. Int J Geriat Psychol. 1999;14(7):556–563.
4.
BondiMWMonschAUGalaskoDButtersNSalmonDPDelisDC. Preclinical cognitive markers of dementia of the Alzheimer type. Neuropsychology. 1994;8(3):374–384.
5.
HowiesonDBDameACamicioliRSextonGPayamiHKayeJA. Cognitive markers preceding Alzheimer’s dementia in the healthy oldest old. J Am Geriatr Soc. 1997;45(5):584–589.
6.
LocascioJJGrowdonJHCorkinS. Cognitive test performance in detecting, staging, and tracking Alzheimer’s disease. Arch Neurol. 1995;52(11):1087–1099.
7.
MasurDMSliwinskiMLiptonRBBlauADCrystalHA. Neuropsychological prediction of dementia and the absence of dementia in healthy elderly persons. Neurology. 1994;44(8):1427–1432.
8.
PetersenRCSmithGEIvnikRJKokmenETangalosEG. Memory function in very early Alzheimer’s disease. Neurology. 1994;44(5):867–872.
9.
WelshKAButtersNHughesJPMohsRCHeymanA. Detection and staging of dementia in Alzheimer’s disease: use of the neuropsychological measures developed for the Consortium to Establish a Registry for Alzheimer’s disease. Arch Neurol. 1992;49(5):448–452.
10.
BennettDA. Update on mild cognitive impairment. Curr Opin Neurol. 2003;3(5):379–384.
GrundmanMPetersenRCFerrisSH. Mild cognitive impairment can be distinguished from Alzheimer disease and normal aging for clinical trials. Arch Neurol. 2004;61(1):59–66.
13.
BoctiCWhiteheadVFellowsLChertkowH. Characteristics of patients with mild cognitive impairment who do not progress to dementia. Neurology. 2005;64(6):A365.
14.
RitchieK. Mild cognitive impairment: an epidemiological perspective. Clin Neurosci. 2004;6(4):401–408.
15.
RitchieKTouchonJ. Mild cognitive impairment: conceptual basis and current nosological status. Lancet. 2000;355(9199):225–228.
16.
BabinsLSlaterMEWhiteheadVChertkowH. 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.
17.
KimHCheyJ. Effects of education, literacy, and dementia on the Clock Drawing Test performance. J Int Neuropsychol Soc. 2010;16(06):1138–1146.
18.
ShulmanK. Clock–drawing: is it the ideal cognitive screening test?Int J Geriatr Psychiatry. 2000;15(6):548–561.
19.
SugawaraNYasui-FurukoriNUmedaT. Clock drawing performance in a community-dwelling population: normative data for Japanese subjects. Aging Mental Health. 2010;14(5):587–592.
20.
MendezMFAlaTUnderwoodKL. Development of scoring criteria for the clock drawing task in Alzheimer’s disease. J Am Geriatr Soc. 1992;40(11):1095–1099.
LamLCWChiuHFKNgKO. Clock-face drawing, reading and setting tests in the screening of dementia in Chinese elderly adults. J Gerontol B: Psychol Sci Soc Sci. 1998;53(6):353–357.
23.
MainlandBJShulmanKI. Clock Drawing Test. In: LarnerA, ed. Cognitive Screening Instruments: A Practical Approach. London, United Kingdom: Springer; 2012:79–109.
24.
MainlandBJAmodeoSShulmanKI. Multiple clock drawing scoring systems: simpler is better. Int J Geriatr Psychiatry. 2014;29(2):127–136.
25.
FolsteinMFFolsteinSEMcHughPR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198.
26.
IracleousPNieJXTracyCS. Primary care physicians’ attitudes towards cognitive screening: findings from a national postal survey. Int J Geriatr Psychiatry. 2010;25(1):23–29.
27.
ShulmanKIPushkar GoldDCohenCAZuccheroCA. Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry. 1993;8(6):487–496.
28.
GavrilovaSIFedorovaYBRoshchinaIFKorovaitsevaGI. Prognosis of mild cognitive impairment syndrome: data from a two-year clinical follow-up study. Neurosci Behav Physiol. 2008;38(2):129–134.
29.
Paganini-HillAClarkLJ. Longitudinal assessment of cognitive function by clock drawing in older adults. Dement Geriatr Cogn Dis Extra. 2011;1(1):75–83.
30.
RouleauISalmonDPButtersN. Longitudinal analysis of clock drawing in Alzheimer’s disease patients. Brain Cogn. 1996;31(1):17–34.
31.
LeeJHOhESJeongSHSohnEHLeeTYLeeAY. Longitudinal changes in clock drawing test (CDT) performance according to dementia subtypes and severity. Arch Gerontol Geriatr. 2011;53(2):e179–e182.
32.
ChenPRatcliffGBelleSHCauleyJADeKoskySTGanguliM. Cognitive tests that best discriminate between presymptomatic AD and those who remain nondemented. Neurology. 2000;55(12):1847–1853.
33.
EhrekeLLuppaMKönigHHVillringerARiedel-HellerSG. Does the Clock Drawing Test predict dementia? Results of the Leipzig longitudinal study of the aged (LEILA 75+). Dement Geriatr Cogn Disord. 2011;31(2):89–97.
34.
O’RourkeNTuokkoHHaydenSLynn BeattieB. Early identification of dementia: predictive validity of the clock test. Arch Clin Neuropsychol. 1997;12(3):257–267.
35.
ZanettiMBallabioCAbbateCCutaiaCVerganiCBergamaschiniL. Mild cognitive impairment subtypes and vascular dementia in community-dwelling elderly people: a 3-year follow-up study. J Am Geriatr Soc. 2006;54(4):580–586.
36.
BuchhavePStomrudEWarkentinSBlennowKMinthonLHanssonO. Cube Copying Test in combination with rCBF or CSF Aβ42 predicts development of Alzheimer’s disease. Dement Geriatr Cogn. 2008;25(6):544–552.
37.
GriffithHRNetsonKLHarrellLEZamriniEYBrockingtonJCMarsonDC. Amnestic mild cognitive impairment: diagnostic outcomes and clinical prediction over a two-year time period. J Int Neuropsychol Soc. 2006;12(2):166–175.
38.
PalmqvistSHertzeJMinthonL. Comparison of brief cognitive tests and CSF biomarkers in predicting Alzheimer’s disease in mild cognitive impairment: six-year follow-up study. PLoS One. 2012;7(6):e38639.
39.
ChenPRatcliffGBelleSHCauleyJADeKoskySTGanguliM. Patterns of cognitive decline in presymptomatic Alzheimer disease: a prospective community study. Arch Gen Psychiatry. 2001;58(9):853–858.
40.
ManosPJWuR. The ten point clock test: a quick screen and grading method for cognitive impairment in medical and surgical patients. Int J Psychol Med. 1994;24(3):229–244.
41.
FreedmanMLeachLKaplanEWinocurGShulmanKDelisDC. Clock Drawing: A Neuropsychological Analysis. 1st ed. New York: Oxford University Press; 1994.
42.
GoodglassHKaplanE. The Assessment of Aphasia and Related Disorders. Philadelphia, PA: Lea & Febiger; 1972.
43.
ShulmanKIShedletskyRSilverIL. The challenge of time: clock-drawing and cognitive function in the elderly. Int J Geriatr Psychiatry. 1986;1(2):135–140.
44.
PetersenRSTouchonJ. Consensus on mild cognitive impairment. In: RetersenRSTouchonJ, eds. Research and Practice in AD. EADS-ADCS Joint Meeting. Vol 10; 2005:24–32.
45.
WinbladBPalmerKKivipeltoM. Mild cognitive impairment-beyond controversies, towards a consensus: report of the international working group on mild cognitive impairment. J Intern Med. 2004;256(3):240–246.
46.
TuokkoHHadjistavropoulosTMillerJBeattieB. The clock test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease. J Am Geriatr Soc. 1992;40(6):579–584.
RouleauISalmonDPButtersNKennedyCMcGuireK. Quantitative and qualitative analyses of clock drawings in Alzheimer’s and Huntington’s disease. Brain Cogn. 1992;18(1):70–87.
49.
SunderlandTHillJLMellowAM. Clock drawing in Alzheimer’s disease: a novel measure of dementia severity. J Am Geriatr Soc. 1989;37(8):725–729.
50.
BusseABischkopfJRiedel-HellerSGAngermeyerMC. Subclassifications for mild cognitive impairment: prevalence and predictive validity. Psychol Med. 2003;33(6):1029–1038.
51.
Wolf-KleinGPSilverstoneFALevyAPBrodMS. Screening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc. 1989;37(8):730–734.
52.
PowlishtaKKDrasDDVStanfordA. The clock drawing test is a poor screen for very mild dementia. Neurology. 2002;59(6):898–903.
FerrucciLCecchiFGuralnikJM. Does the Clock Drawing Test predict cognitive decline in older persons independent of the Mini-Mental State Examination? The FINE Study Group. Finland, Italy, The Netherlands Elderly. J Am Geriatr Soc. 1996;44(11):1326–1331.
55.
BorsonSScanlanJBrushMVitalianoPDokmakA. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021–1027.
56.
NasreddineZSPhillipsNABédirianV. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–699.
