Early Cognitive Impairment: Role of Clock Drawing Test

doi:10.1016/S0377-1237(10)80087-5

Medical Journal Armed Forces India

Volume 66, Issue 1, January 2010, Pages 25-28

https://doi.org/10.1016/S0377-1237(10)80087-5 Get rights and content

Abstract

Background

Folstein's Mini Mental Status Examination (MMSE) often fails to identify executive dysfunction even if quite severe. Detailed neuropsychological tests and extensive bedside tests are available to evaluate executive function, but most of them are time consuming. This study was done to determine the value of a Clock Drawing Test (CDT) as a simple tool to identify cognitive dysfunction in various neurological disorders and to assess its utility as an adjunct to MMSE in identifying executive dysfunction in a a busy out patient department (OPD).

Methods

A total of 81 patients suffering from neurological disorders and 81 controls were studied. All subjects received the MMSE and the CDT. The CDT is divided into an unprompted task that is sensitive to executive control (CDT 1) and a copying task which is not (CDT 2).

Result

All the three tests (CDT 1, CDT 2 and MMSE) could recognize cognitive and executive function deficits, when compared with age and sex matched controls (p < 0. 001). CDT scores correlated strongly with the level of executive function deficits. CDT+MMSE detected 95% cases as abnormal as compared to 47% detected by MMSE alone.

Conclusion

CDT along with MMSE can detect executive control deficits and cognitive deficits. The CDT 1 tests executive control performance, while CDT 2 tests posterior cortical deficits.

Introduction

The potential of clock drawing test (CDT) as a screening tool for cognitive impairment has long been a matter of great interest. A completely normal clock suggests that a number of functions are intact [1]. Clock drawing involves comprehension, perception, memory, gross motor function, visual spatial organization, concentration, numerical knowledge, concept of time and inhibition of distracting stimuli. Though it appears simple, drawing of a clock correlates to a complex goal directed behaviour in an abstract environment [1, 2].

Routine tests of cognition such as the Folstein's test or Mini Mental Status Examination (MMSE) often fail to identify executive dysfunction even if severe. There are neuropsychological and extensive bedside tests available to evaluate executive function, but most of them are time consuming. We undertook this study to determine the value of CDT as a simple bed side tool to identify cognitive dysfunction and to assess its utility as an adjunct to MMSE in identifying potential executive dysfunction in a clinical setting [3, 4].

Alzheimer's disease is a typical primary degenerative dementia characterised by defective declarative memory and impaired anterograde learning. However, disturbance of executive function often occurs before the memory decline and can cause problems in day-to-day activities. For example, patients retain their ability to dress but are unable to initiate the task or choose appropriate clothes. The challenge is to identify executive cognitive dysfunction in such patients. Early diagnosis of cognitive deficits in primary degenerative dementia facilitates planning (e.g. execution of will, precautions and advanced directives) while the patient is still capable of taking important decisions [5]. Besides Alzheimer's, various neurological diseases are also known to affect cognition e.g. cerebrovascular accidents (CVA), space occupying lesions (SOL) and infections.

Inability to complete a CDT in a busy outpatient department (OPD) does not establish a diagnosis of dementia but indicates further testing is needed [1, 2, 3, 4, 5, 6, 7, 8]. A normal or equivocal MMSE result doesn't exclude the diagnosis of dementia. However, addition of CDT with careful selection of instructions and time to be depicted can be a useful adjunct [11, 12]. In screening for dementia, CDT proves superior to MMSE [13]. CDT is not designed to be the only form of cognitive evaluation and should be an adjunct to the MMSE [6, 10, 14].

Section snippets

Material and Methods

A total of 81 patients and 81 control subjects were recruited for the study. The study was carried out in the internal medicine outpatient department (OPD) of AFMC, neurology OPD of Command Hospital (Southern Command) and old age homes located in Pune. Informed consent was taken and confidentiality assured. Age, sex and education matched controls were also studied to minimize the confounding effect. Both cases and controls were exposed to CDT (1 and 2) and MMSE tests.

The survivors of stroke,

Results

In this study, age group of patients varied from 20-79 years and male to female ratio was 58:23. The subjects were divided into groups according to the aetiology (Table 1).

Examples of clocks drawn are shown in Table 2. Since the data is in terms of scores given to individuals (cases and controls), non parametric Mann-Whitney U test was applied. The hypothesis was to test whether there is any significant difference between the cases and controls with respect to their mean scores (Table 3).

All

Discussion

In this study we have found that a CDT can be administered which is strongly associated with an executive function measure. We found that CDT when combined with MMSE is a sensitive tool for detection of cognitive and executive function deficits in various neurological conditions (p value= 0.00), which is in agreement with other studies by Royall et al [3].

When the MMSE score is abnormal and suspicion of cognitive impairment high, abnormal CDT reinforces the diagnosis of cognitive impairment.

Conflicts of Interest

None identified

Intellectual Contribution of Authors

Study Concept : Col SP Gorthi

Drafting & Manuscript Revision : C Mittal

Statistical Analysis : C Mittal, Col S P Gorthi

Study Supervision : Maj Gen S Rohatgi, vsm

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There are more references available in the full text version of this article.

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Original ArticleEarly Cognitive Impairment: Role of Clock Drawing Test

Abstract

Background

Methods

Result

Conclusion

Introduction

Section snippets

Material and Methods

Results

Discussion

Conflicts of Interest

Intellectual Contribution of Authors

Psychiatry Res

The ten point clock test: a quick screen and grading method for cognitive impairment in medical and surgical patients

Int J Psychiatry Med

Comments on the executive control of clock drawing

J Am Geriatr Soc

CLOX: an executive clock drawing test

J Neurol Neurosurg Psychiatry

The clock drawing Test

Age and Ageing

A 7 minute neuron cognitive screening battery highly sensitive to Alzheimer's disease

Arch neural

Dementias that present with and without posterior cortical features: an important clinical distinction

J Am Geriatr Soc

The challenge of Time: clock drawing and cognitive functioning in the elderly

Int J Geriatr Psychiatry

Original Article
Early Cognitive Impairment: Role of Clock Drawing Test