The Clock Drawing Test A review of its accuracy in screening for dementia

Aprahamian, Ivan; Martinelli, José Eduardo; Neri, Anita Liberalesso; Yassuda, Mônica Sanches

doi:10.1590/S1980-57642009DN30200002

Abstract

The Clock Drawing Test (CDT) is a simple neuropsychometric instrument that can be easily applied to assess several cognitive functions. Over the past 20 years, the CDT has aroused considerable interest in its role for the early screening of cognitive impairment, especially in dementia. Although the CDT is considered an accurate test for dementia screening, recent studies including comparisons with structured batteries such as the CAMCOG have shown mixed results.

Objectives:

To investigate the importance of the CDT compared to other commonly used tests, in the diagnosis of dementia in the elderly; (2) to evaluate the reliability and correlation between available CDT scoring scales from recent studies.

Methods:

A systematic search in the literature was conducted in September 2008 for studies comparing CDT scoring systems and comparing the CDT with neuropsychiatric batteries.

Results:

Twelve studies were selected for analyses. Seven of these studies compared CDT scoring scales while five compared the CDT against the CAMCOG and the MMSE. Eight studies found good correlation and reliability between the scales and the other tests.

Conclusion:

Despite the mixed results in these studies, the CDT appears to be a good screening test for dementia.

Key words:
clock drawing test; dementia; elderly.

Resumo

O Teste do Desenho do Relógio (TDR) é um instrumento neuropsiquiátrico simples que pode ser aplicado facilmente para avaliar diversas funções cognitivas. Nos últimos 20 anos, o TDR tem despertado interesse considerável sobre seu papel no rastreio precoce de declínio cognitivo, especialmente na demência. Apesar do TDR ser considerado um bom teste para o rastreio da demência, estudos recentes com comparações com baterias neuropsiquiátricas como o CAMCOG mostram resultados variados.

Objetivos:

Investigar a importância do TDR quando comparado com outros testes comumente utilizados no diagnóstico de demência; avaliar a confiabilidade e a correlação entre escalas de pontuação do TDR em estudos recentes.

Métodos:

Uma busca sistemática na literatura foi concluída em setembro de 2008, incluindo estudos que compararam sistemas de pontuação de TDR e que compararam o TDR com baterias neuropsicométricas.

Resultados:

Doze estudos foram selecionados para análise. Sete compararam escalas de pontuação de TDR e cinco compararam o TDR com o CAMCOG e o MEEM. Oito estudos encontraram boa correlação e confiabilidade entre as escalas e outros testes.

Conclusão:

Apesar dos resultados variados nesses estudos, o TDR parece ser um bom teste de rastreio cognitivo para demência.

Palavras-chave:
teste do desenho do relógio; demência; idosos.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

References

¹
Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000;15:548-561.
²
Critchley M. The parietal lobes. New York, NY: Hafner Publishing Company; 1953.
³
Freedman M, Leach L, Kaplan E, et al. Clock-drawing: a neuropsychological analysis. New York, NY: Oxford University Press, 1994.
⁴
Goodglass H, Kaplan E. The assessment of aphasia and related disorders. Philadelphia, PA: Lea and Febiger; 1983.
⁵
Moore V, Wyke MA. Drawing disability in patients with senile dementia. Psychol Med 1984;14:97-105.
⁶
Villa G, Gainotti G, De Bonis C. Constructional disabilities in focal brain damaged patients: Influence of hemispheric side, locus of lesion and coexistent mental deterioration. Neuropsychologia. 1986;24:497-510.
⁷
Henderson VW, Mack W, Williams BW. Spatial orientation in Alzheimer's disease. Arch Neurol 1989;46:391-394.
⁸
Libon DJ, Swenson R, Barnoski E, Sands LT. Clock drawing as an assessment tool in dementia. Arch Clin Neuropsychol 1993;8:405-416.
⁹
Rouleau I, Salmon DP, Butters N, et al. Quantitative and qualitative analyses of clock drawings in Alzheimer's and Huntington's Disease. Brain Cogn 1992;18:70-87.
¹⁰
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;37:725-729.
¹¹
Tuokko H, Hadjistavropoulos T, Miller JA, 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.
¹²
Wolf-Klein GP, Silverstone FA, Levy AP, Brod M. Screening of Alzheimer's disease by clock drawing. J Am Geriatr Soc 1989;37:730-734.
¹³
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.
¹⁴
Borson S, Brush M, Gil E, et al. The clock drawing test: utility for dementia detection in multiethnic elders. J Gerontol A Biol Sci Med Sci 1999;54:534-540.
¹⁵
Fuzikawa C, Lima-Costa MF, Uchoa E, Barreto SM, Shulman KI. A population-based study on the intra- and inter-rater reliability of the Clock-Drawing Test in Brazil: the Bambui Health and Ageing Study. Int J Geriatr Psychiatry 2003;18:450-456.
¹⁶
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.
¹⁷
Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-mental State Examination score. CMAJ. 2002;167: 859-864.
¹⁸
Royall DR, Mulroy AR, Chiodo LK, Polk MJ. Clock drawing is sensitive to executive control: a comparison of six methods. J Gerontol Psychol Sci Soc Sci 1999;54:P328-P333.
¹⁹
Scanlan JM, Brush M, Quijano C, Borson S. Comparing clock tests for dementia screening: naive judgments vs formal systems-what is optimal? Int J Geriatr Psychiatry 2002;17: 14-21.
²⁰
Shulman KI, Herrmann N, Brodaty H, et al. IPA survey of brief cognitive screening instruments. Int Psychogeriatr 2006;18:281-294.
²¹
Bourke J, Castleden CM, Stephen R, Dennis M. A comparison of clock and pentagon drawing in Alzheimer's disease. Int J Geriatr Psychiatry 1995;10:703-705.
²²
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.
²³
Watson YI, Arfken CL, Birge SJ. Clock completion: an objective screening test for dementia. J Am Geriatr Soc. 1993;41: 1235-1240.
²⁴
Mendez MF, Ala T, Underwood K. Development of scoring citeria for the clock drawing task in Alzheimer's disease. J Am Geriatr Soc 1992;40:1095-1099.
²⁵
Herrmann N, Kidron D, Shulman KI, et al. Clock tests in depression, Alzheimer's disease, and elderly controls. Int J Psyquiatry Med 1998; 28:437-447.
²⁶
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.
²⁷
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.
²⁸
Schramm U, Berger G, Muller R, Kratzsch T, Peters J, Frolich 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.
²⁹
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.
³⁰
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.
³¹
Richardson HE, Glass JN. A comparison of scoring protocols on the clock drawing test in relation to ease of use, diagnostic group, and correlations with Mini-Mental State Examination. J Am Geriatr Soc 2002;50:169-173.
³²
American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatry Association; 1994.
³³
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.
³⁴
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.
³⁵
Lam LWC, Chiu HFK, Ng KO, 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;53B:353-357.
³⁶
Connor DJ, Seward JD, Bauer JA, et al. Performance of three clock scoring systems across different ranges of dementia severity. Alzheimer Dis Assoc Disord 2005;19:119-127.
³⁷
Lee H, Swanwick GRJ, Cohen RF, Lawlor BA. Use of the clock drawing test in the diagnosis of mild and very mild Alzheimer's disease. Int Psychogeriatr 1996;8:469-476.
³⁸
Powlishta KK, Von Dras DD, Stanford A, et al. The clock drawing test is a poor screen for very mild dementia. Neurology 2002;59:898-903.
³⁹
Lessig M, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clock-drawing errors for dementia screening. Int Psychogeriatr 2008;20:459-470.
⁴⁰
Tombaugh TN, McIntyre NT. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922-935.
⁴¹
Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry. 1998;64:588-594.
⁴²
Ferrucci L, Cecchi F, Guralnik JM, et al. for the FINE Study Group. Does the clock drawing predict cognitive decline in older persons independent of the Mini-Mental State Examination. J Am Geriatr Soc. 1996;44:1326-1331.
⁴³
Juby A. Correlation between the Folstein Mini-Mental State Examination and Three Methods of Clock Drawing Scoring. J Geriatr Psychiatry Neurol 1999;12:87-91.
⁴⁴
Nishiwaki Y, Breeze E, Smeeth L, Bulpitt CJ, Peters R, Fletcher AE. Validity of the Clock-Drawing Test as a screening tool for cognitive impairment in the elderly. Am J Epidemiology 2004;160:797-807.
⁴⁵
Solomon PR, Hirschoff A, Kelly B, et al. A 7 minute neurocognitive screening battery highly sensitive to Alzheimer's disease. Arch Neurol 1998;55:349-355.
⁴⁶
Scanlan J, Borson S. The Mini-Cog: receiver operating characteristics with expert and naive raters. Int J Geriatr Psychiatry 2001;16:216-222.
⁴⁷
Heinik J, Solomesh I, Shein V, Becker D. Clock drawing test in mild and moderate dementia of the Alzheimer's type: a comparative and correlation study. Int J Geriatr Psychiatry. 2002; 17:480-485.
⁴⁸
Heinik J, Solomesh I, Bleich A, Berkman P. Are the Clock-Drawing Test and the MMSE Combined Interchangeable with CAMCOG as a Dementia Evaluation Instrument in a Specialized Outpatient Setting? J Geriatr Psychiatry Neurol 2003;16:74-79.
⁴⁹
Van der Burg M, Bouwen A, Stessens J, et al. Scoring clock tests for dementia screening: a comparison of two scoring methods. Int J Geriatr Psychiatry 2004;19:685-689.

Publication Dates

Publication in this collection
Apr-Jun 2009

History

Received
16 Feb 2009
Accepted
18 May 2009

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry 2000;15:548-561.

[2] ²
Critchley M. The parietal lobes. New York, NY: Hafner Publishing Company; 1953.

[3] ³
Freedman M, Leach L, Kaplan E, et al. Clock-drawing: a neuropsychological analysis. New York, NY: Oxford University Press, 1994.

[4] ⁴
Goodglass H, Kaplan E. The assessment of aphasia and related disorders. Philadelphia, PA: Lea and Febiger; 1983.

[5] ⁵
Moore V, Wyke MA. Drawing disability in patients with senile dementia. Psychol Med 1984;14:97-105.

[6] ⁶
Villa G, Gainotti G, De Bonis C. Constructional disabilities in focal brain damaged patients: Influence of hemispheric side, locus of lesion and coexistent mental deterioration. Neuropsychologia. 1986;24:497-510.

[7] ⁷
Henderson VW, Mack W, Williams BW. Spatial orientation in Alzheimer's disease. Arch Neurol 1989;46:391-394.

[8] ⁸
Libon DJ, Swenson R, Barnoski E, Sands LT. Clock drawing as an assessment tool in dementia. Arch Clin Neuropsychol 1993;8:405-416.

[9] ⁹
Rouleau I, Salmon DP, Butters N, et al. Quantitative and qualitative analyses of clock drawings in Alzheimer's and Huntington's Disease. Brain Cogn 1992;18:70-87.

[10] ¹⁰
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;37:725-729.

[11] ¹¹
Tuokko H, Hadjistavropoulos T, Miller JA, 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.

[12] ¹²
Wolf-Klein GP, Silverstone FA, Levy AP, Brod M. Screening of Alzheimer's disease by clock drawing. J Am Geriatr Soc 1989;37:730-734.

[13] ¹³
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.

[14] ¹⁴
Borson S, Brush M, Gil E, et al. The clock drawing test: utility for dementia detection in multiethnic elders. J Gerontol A Biol Sci Med Sci 1999;54:534-540.

[15] ¹⁵
Fuzikawa C, Lima-Costa MF, Uchoa E, Barreto SM, Shulman KI. A population-based study on the intra- and inter-rater reliability of the Clock-Drawing Test in Brazil: the Bambui Health and Ageing Study. Int J Geriatr Psychiatry 2003;18:450-456.

[16] ¹⁶
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.

[17] ¹⁷
Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-mental State Examination score. CMAJ. 2002;167: 859-864.

[18] ¹⁸
Royall DR, Mulroy AR, Chiodo LK, Polk MJ. Clock drawing is sensitive to executive control: a comparison of six methods. J Gerontol Psychol Sci Soc Sci 1999;54:P328-P333.

[19] ¹⁹
Scanlan JM, Brush M, Quijano C, Borson S. Comparing clock tests for dementia screening: naive judgments vs formal systems-what is optimal? Int J Geriatr Psychiatry 2002;17: 14-21.

[20] ²⁰
Shulman KI, Herrmann N, Brodaty H, et al. IPA survey of brief cognitive screening instruments. Int Psychogeriatr 2006;18:281-294.

[21] ²¹
Bourke J, Castleden CM, Stephen R, Dennis M. A comparison of clock and pentagon drawing in Alzheimer's disease. Int J Geriatr Psychiatry 1995;10:703-705.

[22] ²²
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.

[23] ²³
Watson YI, Arfken CL, Birge SJ. Clock completion: an objective screening test for dementia. J Am Geriatr Soc. 1993;41: 1235-1240.

[24] ²⁴
Mendez MF, Ala T, Underwood K. Development of scoring citeria for the clock drawing task in Alzheimer's disease. J Am Geriatr Soc 1992;40:1095-1099.

[25] ²⁵
Herrmann N, Kidron D, Shulman KI, et al. Clock tests in depression, Alzheimer's disease, and elderly controls. Int J Psyquiatry Med 1998; 28:437-447.

[26] ²⁶
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.

[27] ²⁷
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.

[28] ²⁸
Schramm U, Berger G, Muller R, Kratzsch T, Peters J, Frolich 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.

[29] ²⁹
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.

[30] ³⁰
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.

[31] ³¹
Richardson HE, Glass JN. A comparison of scoring protocols on the clock drawing test in relation to ease of use, diagnostic group, and correlations with Mini-Mental State Examination. J Am Geriatr Soc 2002;50:169-173.

[32] ³²
American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatry Association; 1994.

[33] ³³
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.

[34] ³⁴
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.

[35] ³⁵
Lam LWC, Chiu HFK, Ng KO, 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;53B:353-357.

[36] ³⁶
Connor DJ, Seward JD, Bauer JA, et al. Performance of three clock scoring systems across different ranges of dementia severity. Alzheimer Dis Assoc Disord 2005;19:119-127.

[37] ³⁷
Lee H, Swanwick GRJ, Cohen RF, Lawlor BA. Use of the clock drawing test in the diagnosis of mild and very mild Alzheimer's disease. Int Psychogeriatr 1996;8:469-476.

[38] ³⁸
Powlishta KK, Von Dras DD, Stanford A, et al. The clock drawing test is a poor screen for very mild dementia. Neurology 2002;59:898-903.

[39] ³⁹
Lessig M, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clock-drawing errors for dementia screening. Int Psychogeriatr 2008;20:459-470.

[40] ⁴⁰
Tombaugh TN, McIntyre NT. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922-935.

[41] ⁴¹
Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry. 1998;64:588-594.

[42] ⁴²
Ferrucci L, Cecchi F, Guralnik JM, et al. for the FINE Study Group. Does the clock drawing predict cognitive decline in older persons independent of the Mini-Mental State Examination. J Am Geriatr Soc. 1996;44:1326-1331.

[43] ⁴³
Juby A. Correlation between the Folstein Mini-Mental State Examination and Three Methods of Clock Drawing Scoring. J Geriatr Psychiatry Neurol 1999;12:87-91.

[44] ⁴⁴
Nishiwaki Y, Breeze E, Smeeth L, Bulpitt CJ, Peters R, Fletcher AE. Validity of the Clock-Drawing Test as a screening tool for cognitive impairment in the elderly. Am J Epidemiology 2004;160:797-807.

[45] ⁴⁵
Solomon PR, Hirschoff A, Kelly B, et al. A 7 minute neurocognitive screening battery highly sensitive to Alzheimer's disease. Arch Neurol 1998;55:349-355.

[46] ⁴⁶
Scanlan J, Borson S. The Mini-Cog: receiver operating characteristics with expert and naive raters. Int J Geriatr Psychiatry 2001;16:216-222.

[47] ⁴⁷
Heinik J, Solomesh I, Shein V, Becker D. Clock drawing test in mild and moderate dementia of the Alzheimer's type: a comparative and correlation study. Int J Geriatr Psychiatry. 2002; 17:480-485.

[48] ⁴⁸
Heinik J, Solomesh I, Bleich A, Berkman P. Are the Clock-Drawing Test and the MMSE Combined Interchangeable with CAMCOG as a Dementia Evaluation Instrument in a Specialized Outpatient Setting? J Geriatr Psychiatry Neurol 2003;16:74-79.

[49] ⁴⁹
Van der Burg M, Bouwen A, Stessens J, et al. Scoring clock tests for dementia screening: a comparison of two scoring methods. Int J Geriatr Psychiatry 2004;19:685-689.

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