Specific algorithm method of scoring the Clock Drawing Test applied in
               cognitively normal elderly

Mendes-Santos, Liana Chaves; Mograbi, Daniel; Spenciere, Bárbara; Charchat-Fichman, Helenice

doi:10.1590/1980-57642015DN92000007

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Dementia & Neuropsychologia

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Original Articles • Dement. neuropsychol. 9 (2) • Apr-Jun 2015 • https://doi.org/10.1590/1980-57642015DN92000007 copy

Specific algorithm method of scoring the Clock Drawing Test applied in cognitively normal elderly

Método com algoritmo específico para pontuação do teste do desenho do relógio em idosos cognitivamente normais

Authorship SCIMAGO INSTITUTIONS RANKINGS

The Clock Drawing Test (CDT) is an inexpensive, fast and easily administered measure of cognitive function, especially in the elderly. This instrument is a popular clinical tool widely used in screening for cognitive disorders and dementia. The CDT can be applied in different ways and scoring procedures also vary.

OBJECTIVE:

The aims of this study were to analyze the performance of elderly on the CDT and evaluate inter-rater reliability of the CDT scored by using a specific algorithm method adapted from Sunderland et al. (1989).

METHODS:

We analyzed the CDT of 100 cognitively normal elderly aged 60 years or older. The CDT ("free-drawn") and Mini-Mental State Examination (MMSE) were administered to all participants. Six independent examiners scored the CDT of 30 participants to evaluate inter-rater reliability.

RESULTS AND CONCLUSION:

A score of 5 on the proposed algorithm ("Numbers in reverse order or concentrated"), equivalent to 5 points on the original Sunderland scale, was the most frequent (53.5%). The CDT specific algorithm method used had high inter-rater reliability (p<0.01), and mean score ranged from 5.06 to 5.96. The high frequency of an overall score of 5 points may suggest the need to create more nuanced evaluation criteria, which are sensitive to differences in levels of impairment in visuoconstructive and executive abilities during aging.

Clock Drawing Test; inter-rater reliability; elderly; neuropsychology

You should mark with an “X” all the items present in the clock drawn
(a)	Presence of circle.	(j)	Presence of hour hand.
(b)	Presence of 12 numbers.	(k)	Presence of minute hand.
(c)	Numbers entered in the internal limit of the clock.	(l)	Minute hand proportionally larger than the hour hand.
(d)	Number in the correct ascending order.	(m)	One of the hands between 2 and 3.
(e)	Numbers in correct spatial position.	(n)	One of the hands on exactly 9.
(f)	Can you draw a straight vertical line between 12 and 6.	(o)	Wrong use of hands (digital or circling the numbers).
(g)	Can you draw a straight horizontal line between 3 and 9.	(p)	Some evidence of having understood that it is a clock.
(h)	Numbers not concentrated in one part of the clock.	(q)	Did not try or did not represent a clock.
(i)	Presence of two pointers.
Follow the algorithm for the score, but consider these three points initially
1. If the item “o” is checked, the score is 6 points.
2. If the item “p” is checked, the score is 2 points.
3. If the item “q” is checked, the score is 1 point.
The score will be 10-6 if the clock and the numbers are drawn correctly
10	Correct time (no “X” in the items: “o”, “p”, “q”).
9	Very mild disorder of hands (absence of “X” in at least one item: “l”, “m” or “n”).
8	Mild disorder of hands (absence of “X” in at least 2 items: “l”, “m”, “n”).
7	Severe disorder of hands (absence of “X” in the items: “l”, “m”, “n”).
6	Wrong use of hands (presence of “X” in item “o”).
The score will be 5-1 if the drawing of the clock and the numbers are incorrect
5	Numbers in reverse order or concentrated (no “X” in the items: “d” or “h”).
4	Numbers missing and located outside the boundary of the clock (no “X” in items: “b” and “c”).
3	Absence of hands (no “X” in the items: “i”, “j”, “k”).
2	Only some evidence of having understood that it is a clock (presence of “X” in item p).
1	Not tried or did not represent a clock (presence of “X” item in q).

Sociodemographic characteristics		Mean	SD*	Minimum value	Maximum value
Age		72.6	5.9	60	84
Years of education		9.8	4.2	3	24
Instruments and scales	MMSE (Memory Figures Test)	25.2	3.3	18	30
	Incidental Memory	25.4	1.1	2	8
	Immediate Memory 1	7.9	1.3	4	10
	Immediate Memory 2	8.6	1.1	5	10
	5 Minutes - Delayed Memory	7.7	1.5	4	10
	Recognition	9.9	0.3	8	10
Verbal Fluency		15	4.8	5	27
Lawton’s Scale		20.1	1.4	18	21
GDS		1.9	2.1	0	8

N	Mean	Median	Standard deviation	Minimum score	Maximum score
100	5.22	5	2.02	2	10

Examiners	Mean	SD
1	5.06	2.24
2	5.66	2.57
3	5.96	2.74
4	5.73	2.55
5	5.23	1.95
6	5.6	2.71

Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br

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[1] Helenice Charchat-Fichmann. Rua Marquês de São Vicente 255 / 2º andar - Departamento de Psicologia - 22543-900 Rio de Janeiro RJ - Brasil. E-mail: hcfichman@puc-rio.br; hcharchat@uol.com.br

10-6	Drawing of clock face with circle and numbers is generally intact.
10	Hands are in correct position.
9	Slight errors in placement of hands.
8	More noticeable errors in placement of hour and minute hands.
7	Placement of hands is significantly off course.
6	Inappropriate use of clock hands (i.e., use of digital display or circling of numbers despite repeated instructions).
5-1	Drawing of a clock face with circle and numbers is not intact.
5	Crowding of numbers at one end of the clock or reversal of numbers. Hands may still be present in some fashion.
4	Further distortion of number sequence. Integrity of clock face is now gone (i.e., numbers missing or placed at outside of the boundaries of the clock face).
3	Numbers and clock face no longer obviously connected in drawing. Hands are not present.
2	Drawing reveals some evidence of instructions being received but only a vague representation of a clock.
1	Either no attempt or an uninterpretable effort is made.