- Clock Drawing Test
- Cognitive screening
- Mild cognitive impairment
Background/Aims: The Clock Drawing Test (CDT) is used in clinical practice for the screening of cognitive disorders. This systematic review aims to present and discuss the CDT scoring methods available in the literature, in order to find differences in administration and utility of the CDT. Methods: A literature search was carried out in Medline (1966 to June 2008), Psychinfo (1967 to June 2008) and EMBASE (1980 to June 2008). Results: All studies showed good interrater and test-retest reliabilities. The correlation with other standard screening tests was statistically significant in most studies, but the results were influenced by age, education and language. In studies that included patients with mild or questionable dementia, the CDT had a low sensitivity and variable specificity. Conclusion: The CDT has the characteristics of a good screening method for moderate and severe dementia. However, the scoring method used and potential confounders need to be taken into consideration.
Copyright © 2009 S. Karger AG, Basel
- Mashta O: Number of people in UK with dementia will more than double by 2050. BMJ 2007;334:447.
- Flicker C, Ferris SH, Reisberg B: Mild cognitive impairment in the elderly: predictors of dementia. Neurology 1991;41:1006–1009.
- Peterson RC, Smith GE, Waring SC: Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999;56:303–308.
- Peterson RC, O’Brien J: Mild cognitive impairment should be considered for DSM-V. J Geriatr Psychiatry Neurol 2006;19:147–154.
- Petersen RC, Doody R, Kurtz A: Current concepts in mild cognitive impairment. Arch Neurol 2001;58:1985–1992.
- Binetti G, Magni E, Padovani A, Cappa SF, Bianchetti A, Trabucchi M: Executive dysfunction in early Alzheimer’s disease. J Neurol Neurosurg Psychiatry 1996;60:91–93.
- Royall DR, Cabello M, Polk MJ: Executive dyscontrol: an important factor affecting the level of care received by elderly retirees. J Am Geriatr Soc 1998;46:1519–1524.
- Woodard JL, Dorsett ESW, Cooper JG, Hermann P, Sager MA: Development of a brief cognitive screen for mild cognitive impairment and neurocognitive disorder. Aging Neuropsychol Cogn 2005;12:299–315.
- Callahan CM, Henrie HC, Tierney WM: Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med 1995;122:422–429.
- Blessed G, Tomlinson BE, Roth M: The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry 1968;114:797–811.
- 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.
- Schramm U, Berger G, Müller R, Kratzsch T, Peters J, Frölich L: 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.
- Royall DR, Mahurin RK: EXIT25, QED, and DSM-IV: very early Alzheimer’s disease. J Neuropsychiatry Clin Neurosci 1994;6:62–64.
- Teng EL, Hasegawa K, Homma A, Imai Y, Larson E, Graves A, Sugimoto K, Yamaguchi T, Sasaki H, Chiu D: The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr 1994;6:45–58.
- Tombaugh TN, McIntyre NJ: The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc 1992;40:922–935.
- Narain P, Rubenstein LZ, Wieland GD, Rosbrook B, Strome LS, Pietruszka F, Morley JE: Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status. J Am Geriatr Soc 1988;36:775–783.
- Bush C, Kozak J, Elmslie T: Screening for cognitive impairment in the elderly. Can Fam Physician 1997;43:1763–1768.
- Esteban-Santillan C, Praditsuwan R, Ueda H, Geldmacher DS: Clock Drawing Test in very mild Alzheimer’s disease. J Am Geriatr Soc 1998;46:1266–1269.
- Storey JE, Rowland JTJ, Basic D, Conforti DA: Accuracy of the Clock Drawing Test for detecting dementia in a multicultural sample of elderly Australian patients. Int Psychogeriatr 2002;14:259–271.
- Agrell B, Dehlin O: The clock-drawing test. Age Ageing 1998;27:399–403.
- Tuokko H, Hadjistavropoulos T, Miller A, Beattie BL: The clock test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease. J Am Geriatr Soc 1992;40:579–584.
- Shulman KI: Clock-drawing: is this the ideal cognitive screening test? Int J Geriatr Psychiatry 2000;15:548–561.
- Shulman KI, Shedletsky R, Silver IL: The challenge of time: clock-drawing and cognitive function in the elderly. Int J Geriatr Psychiatry 1986;1:135–140.
- Shulman KI, Gold DP, Cohen CA, Zucchero CA: Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry 1993;8:487–496.
- Wolf-Klein GP, Silverstone FA, Levy AP, Brod MS: Screening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc 1989;37:730–734.
- Sunderland T, Hill JL, Mellow AM, Lawlor BA, Gundersheimer J, Newhouse PA, Grafman JH: Clock drawing in Alzheimer’s disease, a novel measure of dementia severity. J Am Geriatr Soc 1989;37:725–729.
- 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.
- 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;18:70–87.
- Tuokko H, Hadjistavropoulos T, Rae S, O’Rourke N: A comparison of alternative approaches to the scoring of clock drawing. Arch Clin Neuropsychol 2000;15:137–148.
- Watson YI, Arfken CL, Birge SJ: Clock completion: an objective screening test for dementia. J Am Geriatr Soc 1993;41:1235–1240.
- 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 Psychiatry Med 1994;24:229–244.
- Cahn DA, Salmon DP, Monsch AU, Butters N, Wiederholt WC, Corey-Bloom J: Screening for dementia of the Alzheimer type in the community: the utility of the Clock Drawing Test. Arch Clin Neuropsychol 1996;11:529–539.
- Lam LC, Chiu HF, Chan C, Chan WF, Li SW, Wong M: Clock-face drawing, reading and setting tests in the screening of dementia in Chinese elderly adults. J Gerontol B Psychol Sci Soc Sci 1998;53:353–357.
- Borson S, Brush M, Gil E, Scanlan J, Vitalino P, Chen J, Cashman J, Sta Maria MM, Barnhart R, Roques J: The Clock Drawing Test: utility for dementia detection in multiethnic elders. J Gerontol Med Sci 1999;54A:M534–M540.
- Royall DR, Mulroy AR, Chiodo LK, Polk MJ: Clock drawing is sensitive to executive control: a comparison of six methods. J Gerontol Psychol Sci 1999;54B:328–333.
- Cacho J, Garcia-Garcia R, Arcaya J, Vicente JL, Lantada N: A proposal for the application of the Clock Drawing Test in Alzheimer’s disease. Rev Neurol 1999;28:648–655.
- Jitapunkul S, Worakul P, Kiatprakoth J: Validity of clinical use of the clock-drawing test in Thai elderly patients with memory problems. J Med Assoc Thai 2000;83:342–347.
- Lin KN, Wang PN, Chen C, Chiu YH, Kuo CC, Chuang YY, Liu HC: The three-item clock-drawing test: a simplified screening test for Alzheimer’s disease. Eur Neurol 2003;49:53–58.
- Heinik J, Solomesh I, Berkman P: Correlation between the CAMCOG, the MMSE, and three Clock Drawing Tests in a specialized outpatient psychogeriatric service. Arch Gerontol Geriatr 2004;38:77–84.
- Beinhoff U, Hilbert V, Bittner D, Grön G, Riepe MW: Screening for cognitive impairment: a triage for outpatient care. Dement Geriatr Cogn Disord 2005;20:278–285.
- Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA: 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.
- O’Rourke N, Tuokko H, Hayden S, Beattie BL: Early identification of dementia: predictive validity of the clock test. Arch Clin Neuropsychol 1997;12:257–267.
- Lee H, Swanwick GRJ, 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.
- Casartelli M, Caputo L, Pesavento N, Lucchi T, Annoni G, Vergani C: The Clock Drawing Test as a screening instrument of cognitive function in the elderly. Ric Psicol 1995;19:87–108.
- Manos PJ: Ten-point clock test sensitivity for Alzheimer’s disease in patients with MMSE scores greater than 23. Int J Geriatr Psychiatry 1999;14:454–458.
- Chan CC, Yung CY, Pan PC: Screening of dementia in Chinese elderly adults by the Clock Drawing Test and the time and change test. Hong Kong Med J 2005;11:13–19.
- Cacho J, Garcia-Garcia R, Fernandez-Calvo B, Gamazo S, Rodriguez-Peres R, Almeida A, Contador I: Improvement pattern in the Clock Drawing Test in early Alzheimer’s disease. Eur Neurol 2005;53:140–145.
- Scanlan J, Borson S: The Mini-Cog: receiver operating characteristics with expert and naïve raters. Int J Geriatr Psychiatry 2001;16:216–222.
- Heinik J, Solomesh I, Lin R, Raikher B, Goldray D, Merdler C, Kemelman P: 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. J Geriatr Psychiatry Neurol 2004;17:73–80.
- 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.
- Storey JE, Rowland JTJ, Basic D, Conforti DA: A comparison of five clock scoring methods using ROC (receiver operating characteristic) curve analysis. Int J Geriatr Psychiatry 2001;16:394–399.
- Scanlan JM, Brush M, Quijano C, Borson S: Comparing clock tests for dementia screening: naïve judgements vs. formal systems – what is optimal? Int J Geriatr Psychiatry 2002;17:14–21.
- Van der Burg M, Bouwen A, Stessens J, Ylieff M, Fontaine O, de Lepeleire J, Buntinx F: Scoring clock tests for dementia screening: a comparison of two scoring methods. Int J Geriatr Psychiatry 2004;19:685–689.
- Yamamoto S, Mogi N, Umegaki H, Suzuki Y, Ando F, Shimokata, Iguchi A: The Clock Drawing Test as a valid screening method for cognitive impairment. Dement Geriatr Cogn Disord 2004;18:172–179.
- Leung JCW, Lui VWC, Lam LCW: Screening for early Alzheimer’s disease in elderly Chinese patients using the Chinese Clock Drawing Test. Hong Kong J Psychiatry 2005;15:14–17.
- Powlishta KK, Von Dras DD, Stanford A, Carr DB, Tsering C, Miller JP, Morris JC: The Clock Drawing Test is a poor screen for very mild dementia. Neurology 2002;59:898–903.
- Seigerschmidt E, Mosch E, Siemen M, Förstl H, Bickel H: The Clock Drawing Test and questionable dementia: reliability and validity. Int J Geriatr Psychiatry 2002;17:1048–1054.
- Connor DJ, Seward JD, Bauer JA, Golden KS, Salmon DP: Performance of three clock scoring systems across different ranges of dementia severity. Alzheimer Dis Assoc Disord 2005;19:119–127.
- Chiu YC, Li CL, Lin KN, Chiu YF, Liu HC: 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;45:75–84.
- Moore MF, Wyke MA: Drawing disability in patients with senile dementia. Psychol Med 1992;14:97–105.
Dr. Elisabete Pinto
Care of the Elderly, Imperial College London, Faculty of Medicine
Hammersmith Campus, Du Cane Road
London W12 0NN (UK)
Tel. +44 20 8383 4282, Fax +44 20 8383 3378, E-Mail email@example.com
Accepted: October 16, 2008
Published online: February 19, 2009
Number of Print Pages : 13
Number of Figures : 0, Number of Tables : 6, Number of References : 60
Dementia and Geriatric Cognitive Disorders
Vol. 27, No. 3, Year 2009 (Cover Date: March 2009)
Journal Editor: Chan-Palay V. (New York, N.Y.)
ISSN: 1420-8008 (Print), eISSN: 1421-9824 (Online)
For additional information: http://www.karger.com/DEM
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.