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Clock Drawing Test

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Book cover Cognitive Screening Instruments

Abstract

The clock drawing test (CDT) has long been recognized as a useful component for the screening of cognitive disorders. It provides a user-friendly visual representation of cognitive functioning that is simple and rapidly administered, making it appealing to clinicians and patients alike. The ease of use and wide range of cognitive abilities required to complete the CDT successfully have made this test an increasingly popular cognitive screening measure in both research and clinical settings. This chapter summarizes and compares the numerous CDT scoring methods that have been described in the literature. Also, psychometric properties are presented for the CDT when used for cognitive screening in a variety of neurologic conditions, including Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, vascular disease, schizophrenia, stroke, and traumatic brain injury. Cultural, ethnic, and educational considerations for the CDT are also discussed.

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References

  1. Kim H, Chey J. Effects of education, literacy, and dementia on the Clock Drawing Test performance. J Int Neuropsychol Soc. 2010;16:1138–46.

    Article  PubMed  Google Scholar 

  2. Shulman K. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry. 2000;15:548–61.

    Article  PubMed  CAS  Google Scholar 

  3. Sugawara N, Yasui-Furukori N, Umeda T, Sato Y, Kaneda A, Tsuchimine S, et al. Clock drawing performance in a community-dwelling population: normative data for Japanese subjects. Aging Ment Health. 2010;14:587–92.

    Article  PubMed  Google Scholar 

  4. Critchley M. The parietal lobes. New York: Hafner; 1966.

    Google Scholar 

  5. Cacho J, García-García R, Fernández-Calvo B, Gamazo S, Rodríguez-Pérez R, Almeida A, et al. Improvement pattern in the Clock Drawing Test in early Alzheimer’s disease. Eur Neurol. 2005;53:140–5.

    Article  PubMed  Google Scholar 

  6. Piovezan MR, Teive HAG, Piovesan EJ, Mader MJ, Werneck LC. Cognitive function assessment in idiopathic Parkinson’s disease. Arq Neuropsiquiatr. 2007;65:942–6.

    Article  PubMed  Google Scholar 

  7. Riedel O, Klotsche J, Spottke A, Deuschl G, Förstl H, Henn F, et al. Cognitive impairment in 873 patients with idiopathic Parkinson’s disease. J Neurol. 2008;255:255–64.

    Article  PubMed  Google Scholar 

  8. Rouleau I, Salmon DP, Butters N, Kennedy C, Maguire K. Quantitative and qualitative analyses of clock drawings in Alzheimer’s and Huntington’s disease. Brain Cogn. 1992;18:70–87.

    Article  PubMed  CAS  Google Scholar 

  9. Lee AY, Kim JS, Choi BH, Sohn EH. Characteristics of clock drawing test (CDT) errors by the dementia type: quantitative and qualitative analyses. Arch Gerontol Geriatr. 2009;48:58–60.

    Article  PubMed  Google Scholar 

  10. Zhou A, Jia J. The value of the clock drawing test and the mini-mental state examination for identifying vascular cognitive impairment no dementia. Int J Geriatr Psychiatry. 2008;23:422–6.

    Article  PubMed  Google Scholar 

  11. Bozikas VP, Kosmidis MH, Gamvrula K, Hatzigeorgiadou M, Kourtis A, Karavatos A. Clock Drawing Test in patients with schizophrenia. Psychiatry Res. 2004;121:229–38.

    Article  PubMed  Google Scholar 

  12. Heinik J, Lahav D, Drummer D, Vainer-Benaiah Z, Lin R. Comparison of a clock drawing test in elderly schizophrenia and Alzheimer’s disease patients: a preliminary study. Int J Geriatr Psychiatry. 2000;15:638–43.

    Article  PubMed  CAS  Google Scholar 

  13. Krivoy A, Weizman A, Laor L, Hellinger N, Zemishlany Z, Fischel T. Addition of memantine to antipsychotic treatment in schizophrenia inpatients with residual symptoms: a preliminary study. Eur Neuropsychopharmacol. 2008;18:117–21.

    Article  PubMed  CAS  Google Scholar 

  14. Adunsky A, Fleissig Y, Levenkrohn S, Arad M, Noy S. Clock drawing task, mini-mental state examination and cognitive-functional independence measure: relation to functional outcome of stroke patients. Arch Gerontol Geriatr. 2002;35:153–60.

    Article  PubMed  CAS  Google Scholar 

  15. De Guise E, LeBlanc J, Gosselin N, Marcoux J, Champoux MC, Couturier C, et al. Neuroanatomical correlates of the clock drawing test in patients with traumatic brain injury. Brain Inj. 2010;24:1568–74.

    Article  PubMed  Google Scholar 

  16. Mendez MF, Ala T, Underwood KL. Development of scoring criteria for the clock drawing task in Alzheimer’s disease. J Am Geriatr Soc. 1992;40:1095–9.

    PubMed  CAS  Google Scholar 

  17. Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry. 1998;64:588–94.

    Article  PubMed  CAS  Google Scholar 

  18. Frey KL, Arciniegas DB. Revisiting the neuroanatomical correlates of the clock drawing test among persons with traumatic brain injury. Brain Inj. 2011;25:539–42.

    Article  PubMed  Google Scholar 

  19. Iracleous P, Nie JX, Tracy CS, Moineddin R, Ismail Z, Shulman KI, et al. Primary care physicians’ attitudes towards cognitive screening: findings from a national postal survey. Int J Geriatr Psychiatry. 2010;25:23–9.

    PubMed  Google Scholar 

  20. Milne A, Culverwell A, Guss R, Tuppen J, Whelton R. Screening for dementia in primary care: a review of the use, efficacy and quality of measures. Int Psychogeriatr. 2008;20:911–26.

    Article  PubMed  CAS  Google Scholar 

  21. Reilly S, Challis D, Burns A, Hughes J. The use of assessment scales in Old Age Psychiatry Services in England and Northern Ireland. Aging Ment Health. 2004;8:249–55.

    Article  PubMed  CAS  Google Scholar 

  22. Shulman KI, Herrmann N, Brodaty H, Chiu H, Lawlor B, Ritchie K, et al. IPA survey of brief cognitive screening instruments. Int Psychogeriatr. 2006;18:281–94.

    Article  PubMed  Google Scholar 

  23. Ismail Z, Rajji TK, Shulman KI. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry. 2010;25:111–20.

    Article  PubMed  Google Scholar 

  24. Kaplan E. The process approach to neuropsychological assessment of psychiatric patients. J Neuropsychiatry Clin Neurosci. 1990;2:72–87.

    PubMed  CAS  Google Scholar 

  25. Shulman KI, Feinstein A. Quick cognitive screening for clinicians. Mini mental, clock drawing and other brief tests. London: Martin Dunitz; 2003.

    Google Scholar 

  26. Freedman M, Leach L, Kaplan E, Winocur G, Shulman K, Delis DC. Clock drawing: a neuropsychological analysis. New York: Oxford University Press; 1994.

    Google Scholar 

  27. Pinto E, Peters R. Literature review of the Clock Drawing Test as a tool for cognitive screening. Dement Geriatr Cogn Disord. 2009;27:201–13.

    Article  PubMed  Google Scholar 

  28. Lam LCW, Chiu HFK, Ng KO, Chan C, Chan WF, Li SW, et al. Clock-face drawing, reading and setting tests in the screening of dementia in Chinese elderly adults. J Gerontol B Psychol Sci Soc Sci. 1998;53:353–7.

    Article  Google Scholar 

  29. Goodglass H, Kaplan E, Barresi B. Boston diagnostic aphasia examination (BDAE). Philadelphia: Lea and Febiger; 1983.

    Google Scholar 

  30. Shulman KI, Shedletsky R, Silver IL. The challenge of time: clock-drawing and cognitive function in the elderly. Int J Geriatr Psychiatry. 1986;1:135–40.

    Article  Google Scholar 

  31. 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;12:189–98.

    Article  PubMed  CAS  Google Scholar 

  32. Robertson D, Rockwood K, Stolee P. A short mental status questionnaire. Can J Aging. 1982;1:16–20.

    Article  Google Scholar 

  33. Shulman KI, Pushkar Gold D, Cohen CA, Zucchero CA. Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry. 1993;8:487–96.

    Article  Google Scholar 

  34. Sunderland T, Hill JL, Mellow AM, et al. Clock drawing in Alzheimer’s disease: a novel measure of dementia severity. J Am Geriatr Soc. 1989;37:725–9.

    PubMed  CAS  Google Scholar 

  35. 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;16:935–40.

    Article  PubMed  CAS  Google Scholar 

  36. Wolf-Klein GP, Silverstone FA, Levy AP, et al. Screening for Alzheimer’s disease by clock drawing. J Am Geriatr Soc. 1989;37:730–4.

    PubMed  CAS  Google Scholar 

  37. Hachinski VC, Lassen NA, Marshall J. Multi-infarct dementia: a cause of mental deterioration in the elderly. Lancet. 1974;304:207–9.

    Article  Google Scholar 

  38. 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.

    Article  PubMed  CAS  Google Scholar 

  39. Morris J, Heyman A, Mohs R, et al. The consortium to establish a registry for Alzheimer’s disease (CERAD): I. Clinical and neuropsychological assessment of Alzheimer’s disease. Neurology. 1989;39:1159–65.

    Article  PubMed  CAS  Google Scholar 

  40. Borson S, Brush M, Gil E, Scanlan J, Vitaliano P, Chen J, et al. The Clock Drawing Test: utility for dementia detection in multiethnic elders. J Gerontol A Biol Sci Med Sci. 1999;54:M534–40.

    Article  PubMed  CAS  Google Scholar 

  41. Teng EL, Hasegawa K, Homma A, Imai Y, Larson E, Graves A, et al. The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr. 1994;6:45–58.

    Article  PubMed  CAS  Google Scholar 

  42. Tuokko H, Hadjistavropoulos T, Miller J, Beattie B. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease. J Am Geriatr Soc. 1992;40:579–84.

    PubMed  CAS  Google Scholar 

  43. Death J, Douglas A, Kenny RA. Comparison of clock drawing with Mini Mental State Examination as a screening test in elderly acute hospital admissions. Postgrad Med J. 1993;69:696–700.

    Article  PubMed  CAS  Google Scholar 

  44. Watson YI, Arfken CL, Birge SJ. Clock completion: an objective screening test for dementia. J Am Geriatr Soc. 1993;41:1235–40.

    PubMed  CAS  Google Scholar 

  45. Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983;140:734–9.

    PubMed  CAS  Google Scholar 

  46. 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;24:229–44.

    Article  PubMed  CAS  Google Scholar 

  47. Manos PJ. Ten-point clock test sensitivity for Alzheimer’s disease in patients with MMSE scores greater than 23. Int J Geriatr Psychiatry. 1999;14:454–8.

    Article  PubMed  CAS  Google Scholar 

  48. Shua-Haim J, Koppuzha G, Shua-Haim V, Gross J. A simple score system for clock drawing in patients with Alzheimer’s disease. Am J Alzheimers Dis Other Demen. 1997;12:212–5.

    Article  Google Scholar 

  49. Lin KN, Wang PN, Chen C, Chiu YH, Kuo CC, Chuang YY, et al. The three-item clock-drawing test: a simplified screening test for Alzheimer’s disease. Eur Neurol. 2003;49:53–8.

    Article  PubMed  Google Scholar 

  50. Lessig MC, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clock-drawing errors for dementia screening. Int Psychogeriatr. 2008;20:459–70.

    Article  PubMed  Google Scholar 

  51. 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;30:173–86.

    Article  PubMed  Google Scholar 

  52. Royall DR, Mulroy AR, Chiodo LK, Polk MJ. Clock drawing is sensitive to executive control: a comparison of six methods. J Gerontol B Psychol Sci Soc Sci. 1999;54:P328–33.

    Article  PubMed  CAS  Google Scholar 

  53. 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;17:14–21.

    Article  PubMed  Google Scholar 

  54. Van Der Burg M, Bouwen A, Stessens J, Ylieff M, Fontaine O, De Lepeleire J, et al. Scoring clock tests for dementia screening: a comparison of two scoring methods. Int J Geriatr Psychiatry. 2004;19:685–9.

    Article  PubMed  Google Scholar 

  55. Matsuoka T, Narumoto J, Shibata K, Okamura A, Nakamura K, Nakamae T, et al. Neural correlates of performance on the different scoring systems of the clock drawing test. Neurosci Lett. 2011;487:421–5.

    Article  PubMed  CAS  Google Scholar 

  56. Bozikas V, Giazkoulidou A, Hatzigeorgiadou M, Karavatos A, Kosmidis M. Do age and education contribute to performance on the clock drawing test? Normative data for the Greek population. J Clin Exp Neuropsychol. 2008;30:199–203.

    Article  PubMed  CAS  Google Scholar 

  57. Hershkovitz A, Jacubovski O, Alima Bot M, Oshry V, Brill S. Clock drawing and rehabilitation outcome in hip fracture patients. Disabil Rehabil. 2010;32:2113–7.

    Article  PubMed  CAS  Google Scholar 

  58. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6–18.

    PubMed  CAS  Google Scholar 

  59. Ehreke L, Luppa M, König HH, Riedel-Heller SG. Is the Clock Drawing Test a screening tool for the diagnosis of mild cognitive impairment? A systematic review. Int Psychogeriatr. 2010;22:56–63.

    Article  PubMed  Google Scholar 

  60. Yamamoto S, Mogi N, Umegaki H, Suzuki Y, Ando F, Shimokata H, et al. The Clock Drawing Test as a valid screening method for Mild Cognitive Impairment. Dement Geriatr Cogn Disord. 2004;18:172–9.

    Article  PubMed  Google Scholar 

  61. Lee KS, Kim EA, Hong CH, Lee DW, Oh BH, Cheong HK. Clock drawing test in mild cognitive impairment: quantitative analysis of four scoring methods and qualitative analysis. Dement Geriatr Cogn Disord. 2008;26:483–9.

    Article  PubMed  Google Scholar 

  62. Ehreke L, Luck T, Luppa M, König HH, Villringer A, Riedel-Heller SG. Clock Drawing Test – screening utility for mild cognitive impairment according to different scoring systems: results of the Leipzig Longitudinal Study of the Aged (LEILA 75+). Int Psychogeriatr. 2011;23:1592–601.

    Article  PubMed  Google Scholar 

  63. Winblad B, Palmer K, Kivipelto M, Jelic V, Fratiglioni L, Wahlund LO, et al. Mild cognitive impairment – beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment. J Intern Med. 2004;256:240–6.

    Article  PubMed  CAS  Google Scholar 

  64. Blake H, McKinney M, Treece K, Lee E, Lincoln NB. An evaluation of screening measures for cognitive impairment after stroke. Age Ageing. 2002;31:451–6.

    Article  PubMed  Google Scholar 

  65. Beinhoff U, Hilbert V, Bittner D, Gron G, Riepe MW. Screening for cognitive impairment: a triage for outpatient care. Dement Geriatr Cogn Disord. 2005;20:278–85.

    Article  PubMed  Google Scholar 

  66. Forti P, Olivelli V, Rietti E, Maltoni B, Ravaglia G. 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;30:20–7.

    Article  PubMed  Google Scholar 

  67. Ravaglia G, Forti P, Maioli F, Servadei L, Martelli M, Brunetti N, et al. Screening for mild cognitive impairment in elderly ambulatory patients with cognitive complaints. Aging Clin Exp Res. 2005;17:374–9.

    PubMed  Google Scholar 

  68. Parsey CM, Schmitter-Edgecombe M. Quantitative and qualitative analyses of the Clock Drawing Test in Mild Cognitive Impairment and Alzheimer disease: evaluation of a modified scoring system. J Geriatr Psychiatry Neurol. 2011;24:108–18.

    Article  PubMed  Google Scholar 

  69. Meier D. The segmented clock: a typical pattern in vascular dementia. J Am Geriatr Soc. 1995;43:1071–3.

    PubMed  CAS  Google Scholar 

  70. Kitabayashi Y, Ueda H, Narumoto J, Nakamura K, Kita H, Fukui K. Qualitative analyses of clock drawings in Alzheimer’s disease and vascular dementia. Psychiatry Clin Neurosci. 2001;55:485–91.

    Article  PubMed  CAS  Google Scholar 

  71. Wiechmann AR, Hall JR, O’Bryant S. The four-point scoring system for the clock drawing test does not differentiate between Alzheimer’s disease and vascular dementia. Psychol Rep. 2010;106:941–8.

    Article  PubMed  Google Scholar 

  72. Fisher BW, Flowerdew G. A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995;43:175–8.

    PubMed  CAS  Google Scholar 

  73. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. Ann Intern Med. 1990;113:941–8.

    PubMed  CAS  Google Scholar 

  74. Manos PJ. Letter to the editor: monitoring cognitive disturbance in delirium with the ten-point clock test. Int J Geriatr Psychiatry. 1998;13:646–8.

    Article  PubMed  CAS  Google Scholar 

  75. Bryson GL, Wyand A, Wozny D, Rees L, Taljaard M, Nathan H. The clock drawing test is a poor screening tool for postoperative delirium and cognitive dysfunction after aortic repair. Can J Anaesth. 2010;58:267–74.

    PubMed  Google Scholar 

  76. Rasmussen L, Larsen K, Houx P, Skovgaard LT, Hanning C, Moller J. The assessment of postoperative cognitive function. Acta Anaesthesiol Scand. 2001;45:275–89.

    Article  PubMed  CAS  Google Scholar 

  77. Saka E, Elibol B. Enhanced cued recall and clock drawing test performances differ in Parkinson’s and Alzheimer’s disease-related cognitive dysfunction. Parkinsonism Relat Disord. 2009;15:688–91.

    Article  PubMed  Google Scholar 

  78. Suhr J, Grace J, Allen J, Nadler J, McKenna M. Quantitative and qualitative performance of stroke versus normal elderly on six clock drawing systems. Arch Clin Neuropsychol. 1998;13:495–502.

    PubMed  CAS  Google Scholar 

  79. Cooke DM, Gustafsson L, Tardiani DL. Clock drawing from the occupational therapy adult perceptual screening test: its correlation with demographic and clinical factors in the stroke population. Aust Occup Ther J. 2010;57:183–9.

    Article  PubMed  Google Scholar 

  80. Benton A, Tranel D. Visuoperceptual, visuospatial, and visuoconstructive disorders. In: Heilman KM, Valenstein E, editors. Clinical neuropsychology. 3rd ed. New York: Oxford University Press; 1993. p. 165–213.

    Google Scholar 

  81. Writer BW, Schillerstrom JE, Regwan HK, Harlan BS. Executive clock drawing correlates with performance-based functional status in people with combat-related mild traumatic brain injury and comorbid posttraumatic stress disorder. J Rehabil Res Dev. 2010;47:841–50.

    Article  PubMed  Google Scholar 

  82. Mahurin RK, DeBettignies BH, Pirozzolo FJ. Structured assessment of independent living skills: preliminary report of a performance measure of functional abilities in dementia. J Gerontol. 1991;46:58–66.

    Article  Google Scholar 

  83. Herrmann N, Kidron D, Shulman KI, Kaplan E, Binns M, Soni J, et al. The use of clock tests in schizophrenia. Gen Hosp Psychiatry. 1999;21:70–3.

    Article  PubMed  CAS  Google Scholar 

  84. American Psychiatric Association. DSM-IV: diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association; 1994.

    Google Scholar 

  85. Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep. 1962;10:799–812.

    Article  Google Scholar 

  86. Goodglass H, Kaplan E. The assessment of aphasia and related disorders. Philadelphia: Lea and Febiger; 1972.

    Google Scholar 

  87. Miles T, Briscoe B, Kim S. Age, gender, and impaired clock drawing in the generalist primary care setting. J Ky Med Assoc. 2007;105:59–65.

    PubMed  Google Scholar 

  88. Stewart R, Richards M, Brayne C, Mann A. Cognitive function in UK community-dwelling African Caribbean elders: normative data for a test battery. Int J Geriatr Psychiatry. 2001;16:518–27.

    Article  PubMed  CAS  Google Scholar 

  89. Fuzikawa C, Lima-Costa MF, Uchôa E, Shulman K. Correlation and agreement between the Mini-mental State Examination and the Clock Drawing Test in older adults with low levels of schooling: the Bambuí Health Aging Study (BHAS). Int Psychogeriatr. 2007;19:657–67.

    Article  PubMed  Google Scholar 

  90. Borson S, Scanlan J, Brush M, et al. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15:1021–7.

    Article  PubMed  CAS  Google Scholar 

  91. Silverstone FA, Duke WM, Wolf-Klein GP. Clock drawing helps when communication fails. J Am Geriatr Soc. 1993;41:1155.

    PubMed  CAS  Google Scholar 

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Mainland, B.J., Shulman, K.I. (2013). Clock Drawing Test. In: Larner, A. (eds) Cognitive Screening Instruments. Springer, London. https://doi.org/10.1007/978-1-4471-2452-8_5

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