Qualitative analysis of the Clock Drawing Test by
                    educational level and cognitive profile

Fabricio, Aline Teixeira; Aprahamian, Ivan; Yassuda, Mônica Sanches

doi:10.1590/0004-282X20140004

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Articles • Arq. Neuro-Psiquiatr. 72 (4) • Apr 2014 • https://doi.org/10.1590/0004-282X20140004 copy

Qualitative analysis of the Clock Drawing Test by educational level and cognitive profile

Análise qualitativa do Teste do Desenho do Relógio por faixas de escolaridade e perfil cognitivo

Authorship SCIMAGO INSTITUTIONS RANKINGS

The use of a qualitative scale for the Clock Drawing Test (CDT) may add information about the pattern of errors committed.

Objective:

To translate and adapt the Modified Qualitative Error Analysis of Rouleau into Brazilian Portuguese and to examine the pattern of errors according to educational level and cognitive profile.

Method:

180 adults (47-82 years) completed the CDT. Participants were stratified into age and educational levels and separated between those with and without changes in cognitive screening tests (Mini-Mental State Examination, Verbal Fluency).

Results:

No significant differences were found in CDT scores among age groups. Among participants without cognitive impairment, those with lower education often presented graphic difficulties, conceptual deficits and spatial deficits. Participants with cognitive deficits, demonstrated more frequently conceptual and spatial errors.

Conclusion:

The qualitative analysis of the CDT may contribute to the identification of cognitive changes. Education level has to be taken into consideration during the analysis.

Clock Drawing Test; cognitive screening; dementia; elderly; education

	Min.	Max.	Total (n=180)	NC (n=141)	CD (n=39)	p
Female/Male	-	-	144/36	109/32	35/04	0.086^*
Age	47	82	64.98 (6.79)	65.18 (6.69)	64.69 (7.80)	0.700^***
Education	01	25	9.04 (4.47)	9.38 (4.50)	7.56 (3.79)	0.028^**
Income	01	10 ou +	3.46 (2.20)	3.65 (2.29)	2.62 (1.76)	0.005^**
MMSE	18	30	26.87 (2.51)	27.53 (1.97)	24.62 (2.81)	<0.001^**
VF	03	28	15.28 (4.07)	16.50 (3.27)	10.90 (3.66)	<0.001^***
CDT Shulman	1	5	3.77 (1.21)	3.92 (1.15)	3.21 (1.24)	0.001^**
CDT Sunderland	2	10	8.61 (1.72)	8.77 (1.71)	8.05 (1.67)	0.001^**
CDT Rouleau	8	16	14.04 (1.53)	14.28 (1.48)	13.21 (1.44)	<0.001^**

	1-4 years (n=32)	5-8 years (n=27)	>8 years (n=82)	p-value^*
MMSE	26.28 (2.57)	26.89 (1.89)	28.23 (1.34)	<0.001^**
VF	15.41 (3.04)	16.07 (3.59)	17.06 (3.16)	0.022^**
CDT Shulman	3.25 (1.46)	4.11 (0.97)	4.12 (0.99)	0.008
CDT Sunderland	7.66 (2.43)	8.93 (1.14)	9.15 (1.32)	0.002
CDT Rouleau	13.40 (1.84)	14.40 (1.33)	14.57 (1.22)	0.004

	1-4 years (n=32)	5-8 years (n=27)	>8 years (n=82)	p
Size of the Clock	18.7	18.5	24.4
Small	15.6	14.8	14.6	0.991
Large	3.1	3.7	9.8	0.347
Graphic Difficulties	56.3	51.8	28.1
Mild	50.0	40.7	23.2	0.014
Moderate	6.3	11.1	4.9	0.516
Severe	0	0	0
Stimulus-Bound Responses	9.4	7.4	3.7
Pointers tied to stimulus	3.1	3.7	0	0.240
Time in print or digital	6.3	3.7	3.7	0.817
Conceptual Deficits	53.2	22.2	21.9
Misrepresentation of the clock itself	6.3	0	0	0.032
Misrepresentation of the time	37.5	18.5	19.5	0.100
Numbers out of order or missing	9.4	3.7	2.4	0.254
Spatial/Planning Deficits	78.2	29.6	43.8
Neglect of the left hemi-space	0	0	0
Deficit in planning	46.9	29.6	34.1	0.327
Deficit in spatial planning of numbers	21.9	0	1.2	<0.001
Numbers written outside of the clock face	3.1	0	8.5	0.195
Numbers written counterclockwise	6.3	0	0	0.032
Perseveration	37.6	18.5	15.8
Perseveration of hands	18.8	14.8	7.3	0.184
Perseveration of numbers	18.8	3.7	8.5	0.127

	NC % (n=141)	CD % (n=39)	p
Size of the Clock	22	33.3
Small	14.9	28.2	0.054
Large	7.1	5.1	0.663
Graphic Difficulties	39	56.4
Mild	32.6	41.0	0.328
Moderate	6.4	15.4	0.72
Severe	0	0	0
Stimulus-Bound Responses	5.7	10.3
Pointers tied to stimulus	1.4	2.6	0.62
Time in print or digital	4.3	7.7	0.38
Conceptual Deficits	29.1	71.7
Misrepresentation of the clock itself	1.4	5.1	0.164
Misrepresentation of the time	23.4	48.7	0.002
Numbers out of order or missing	4.3	17.9	0.003
Spatial/Planning Deficits	49	64.1
Neglect of the left hemi-space	0	0	0
Deficit in planning	36.2	53.8	0.046
Deficit in spatial planning of number	5.7	5.1	0.895
Numbers written outside of the clock face	5.7	2.6	0.430
Numbers written counterclockwise	1.4	2.6	0.621
Perseveration	21.2	28.2
Perseveration of hands	9.9	10.3	0.848
Perseveration of numbers	11.3	17.9	0.167

		CDT Shulman	CDT Sunderland	CDT Rouleau
Age	Rho	-0.52	0.054	0.109
Age	p	0.46	0.443	0.124
Education	Rho	0.269	0.280	0.276
Education	p	<0.001	<0.001	<0.001
Income	Rho	0.297	0.303	0.266
Income	p	<0.001	<0.001	<0.001
MMSE	Rho	0.353	0.349	0.375
MMSE	p	<0.001	<0.001	<0.001
VF	Rho	0.194	0.194	0.242
VF	p	0.009	0.009	0.001

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[1] Correspondence: Mônica Sanches Yassuda; Avenida. Arlindo Bettio 1000/322-J Ermelino Matarazzo; 03828-000 São Paulo SP – Brasil; E-mail: yassuda@usp.br