Hostname: page-component-586b7cd67f-t7czq Total loading time: 0 Render date: 2024-11-26T09:05:22.199Z Has data issue: false hasContentIssue false
  • English
  • Français

The accuracy of the Clock Drawing Test compared to that of standard screening tests for Alzheimer's disease: results from a study of Brazilian elderly with heterogeneous educational backgrounds

Published online by Cambridge University Press:  09 October 2009

Ivan Aprahamian ,
José Eduardo Martinelli ,
Anita Liberalesso Neri  and
Mônica Sanches Yassuda
Ivan Aprahamian*
Affiliation:
Gerontology Division, University of Campinas, São Paulo, Brazil Psychogeriatric Unit, Laboratory of Neuroscience (LIM 27), Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, Brazil
José Eduardo Martinelli
Affiliation:
Gerontology Division, University of Campinas, São Paulo, Brazil Geriatrics Division, Jundiaí Medical School, Jundiaí, Brazil
Anita Liberalesso Neri
Affiliation:
Gerontology Division, University of Campinas, São Paulo, Brazil
Mônica Sanches Yassuda
Affiliation:
Gerontology Division, University of Campinas, São Paulo, Brazil School of Arts, Sciences and Humanities (EACH), University of São Paulo, Brazil
*
Correspondence should be addressed to: Ivan Aprahamian, MD, MSc, Laboratory of Neurosciences – LIM 27, Rua Dr. Ovidio Pires de Campos, 785, 3rd Floor, Cerqueira César, São Paulo, SP, CEP 05403-010, Brazil. Phone: +55 11 3063 5955; Fax: +55 11 3085 5412. Email: [email protected].
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: Although the Clock Drawing Test (CDT) is the second most used test in the world for the screening of dementia, there is still debate over its sensitivity, specificity, application and interpretation in dementia diagnosis. This study has three main aims: to evaluate the sensitivity and specificity of the CDT in a sample composed of older adults with Alzheimer's disease (AD) and normal controls; to compare CDT accuracy to the that of the Mini-mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG); and to test whether the association of the MMSE with the CDT leads to higher or comparable accuracy as that reported for the CAMCOG.

Methods: Cross-sectional assessment was carried out for 121 AD and 99 elderly controls with heterogeneous educational levels from a geriatric outpatient clinic who completed the Cambridge Examination for Mental Disorder of the Elderly (CAMDEX). The CDT was evaluated according to the Shulman, Mendez and Sunderland scales.

Results: The CDT showed high sensitivity and specificity. There were significant correlations between the CDT and the MMSE (0.700–0.730; p < 0.001) and between the CDT and the CAMCOG (0.753–0.779; p < 0.001). The combination of the CDT with the MMSE improved sensitivity and specificity (SE = 89.2–90%; SP = 71.7–79.8%). Subgroup analysis indicated that for elderly people with lower education, sensitivity and specificity were both adequate and high.

Conclusions: The CDT is a robust screening test when compared with the MMSE or the CAMCOG, independent of the scale used for its interpretation. The combination with the MMSE improves its performance significantly, becoming equivalent to the CAMCOG.

Keywords

Clock Drawing TestCAMCOGMMSEAlzheimer's diseaseelderly
Type
Research Article
Information
International Psychogeriatrics , Volume 22 , Issue 1 , February 2010 , pp. 64 - 71
Copyright
Copyright © International Psychogeriatric Association 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association.Google Scholar
Borson, S. et al. (1999). The Clock Drawing Test: utility for dementia detection in multi-ethnic elders. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 54, M534–M540.CrossRefGoogle Scholar
Bottino, C. M. C., Stoppe, A. Jr, Scalco, A. Z., Ferreira, R. C. R., Hototian, S. and Scalco, M. Z. (2001) Validade e confiabilidade da versão brasileira do CAMDEX. Arquivos de Neuropsiquiatria, 59, 20.Google Scholar
Bourke, J., Castleden, C. M., Stephen, R. and Dennis, M. (1995). A comparison of clock and pentagon drawing in Alzheimer's disease. International Journal of Geriatric Psychiatry, 10, 703–705.CrossRefGoogle Scholar
Brodaty, H. and Moore, C. M. (1997). The clock drawing test for dementia of the Alzheimer's type: a comparison of three scoring methods in a memory disorders clinic. International Journal of Geriatric Psychiatry, 12, 619–627.3.0.CO;2-H>CrossRefGoogle Scholar
Brucki, S. M. D., Nitrini, R., Caramelli, P., Bertolucci, P. H. F. and Okamoto, I. H. (2003). Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arquivos de Neuropsiquiatria, 61, 777–781.CrossRefGoogle Scholar
Connor, D. J., Seward, J. D., Bauer, J. A., Golden, K. S. and Salmon, D. P. (2005). Performance of three clock scoring systems across different ranges of dementia severity. Alzheimer Disease and Associated Disorders, 19, 119–127.CrossRefGoogle ScholarPubMed
Ferrucci, L. et al. for the FINE Study Group (1996). Does the clock drawing test predict cognitive decline in older persons independent of the Mini-mental State Examination. Journal of the American Geriatrics Society, 44, 1326–1331.CrossRefGoogle ScholarPubMed
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state”: a practical method for grading the mental state of patients for clinician. Journal of Psychiatric Research, 12, 189–198.CrossRefGoogle ScholarPubMed
Freedman, M., Leach, L., Kaplan, E., Winocur, G., Shulman, K. and Delis, D. C. (1994). Clock-drawing: A Neuropsychological Analysis. New York: Oxford University Press.Google Scholar
Fuzikawa, C., Lima-Costa, M. F., Uchoa, E., Barreto, S. M. and Shulman, K. I. (2007). 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). International Psychogeriatrics, 19, 657–667.CrossRefGoogle ScholarPubMed
Heinik, J., Solomesh, I., Shein, V. and Becker, D. (2002). Clock drawing test in mild and moderate dementia of the Alzheimer's type: a comparative and correlation study. International Journal of Geriatric Psychiatry, 17, 480–485.CrossRefGoogle ScholarPubMed
Heinik, J., Solomesh, I., Bleich, A. and Berkman, P. (2003). Are the Clock-Drawing Test and the MMSE combined interchangeable with CAMCOG as a dementia evaluation instrument in a specialized outpatient setting? Journal of Geriatric Psychiatry and Neurology, 16, 74–79.CrossRefGoogle Scholar
Heinik, J., Solomesh, I. and Berkman, P. (2004). Correlation between the CAMCOG, the MMSE, and three clock drawing tests in a specialized outpatient psychogeriatric service. Archives of Gerontology and Geriatrics, 38, 77–84.Google Scholar
Hendrie, H. C. et al. (1988). The CAMDEX: replication with a US sample. Journal of the American Geriatrics Society, 36, 402–408.Google Scholar
Hubbard, E. J. et al. (2008). Clock drawing performance in cognitively normal elderly. Archives of Clinical Neuropsychology, 23, 295–327.CrossRefGoogle ScholarPubMed
Hughes, C. P., Berg, L., Danzinger, W. L., Coben, L. A. and Martin, R.L. (1982). A new scale for the staging of dementia. British Journal of Psychiatry, 140, 566–572.CrossRefGoogle ScholarPubMed
Juby, A. (1999). Correlation between the Folstein Mini-mental State Examination and three methods of clock drawing scoring. Journal of Geriatric Psychiatry and Neurology, 12, 87–91.CrossRefGoogle ScholarPubMed
Leung, J. C. W., Lui, V. W. C. and Lam, L. C. W. (2005). Screening for early Alzheimer's disease in elderly Chinese patients using the Chinese Clock Drawing Test. Hong Kong Journal of Psychiatry, 15, 14–17.Google Scholar
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D. and Stadlan, E. M. (1984). Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspices of the Department of Health and Human Services task force on Alzheimer's disease. Neurology, 34, 939–944.CrossRefGoogle ScholarPubMed
Mendez, M. F., Ala, T. and Underwood, K. (1992). Development of scoring citeria for the clock drawing task in Alzheimer's disease. Journal of the American Geriatrics Society, 40, 1095–1099.Google Scholar
Morris, J. C. (1993). The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology, 43, 2412–2414.CrossRefGoogle ScholarPubMed
Neri, M. et al. (1994). Validation of the full and short forms of the CAMDEX interview for diagnosing dementia. Cambridge Examination for Mental Disorders in the Elderly. Dementia, 5, 257–265.Google Scholar
Nunes, P. V. et al. (2008). CAMCOG as a screening tool for diagnosis of mild cognitive impairment and dementia in a Brazilian clinical sample of moderate to high education. International Journal of Geriatric Psychiatry, 23, 1127–1133.CrossRefGoogle Scholar
Pinto, E. and Peters, R. (2009). Literature review of the Clock Drawing Test as a tool for cognitive screening. Dementia and Geriatric Cognitive Disorders, 27, 201–213.Google Scholar
Powlishta, K. K. et al. (2002). The clock drawing test is a poor screen for very mild dementia. Neurology, 59, 898–903.CrossRefGoogle ScholarPubMed
Richardson, H. E. and Glass, J. N. (2002). 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. Journal of the American Geriatrics Society, 50, 169–173.CrossRefGoogle ScholarPubMed
Roth, M. et al. (1986). CAMDEX: a standardized instrument for the diagnosis of mental disorder in the elderly with special reference to the early detection of dementia. British Journal of Psychiatry, 149, 698–709.CrossRefGoogle Scholar
Royall, D. R., Cordes, J. A. and Polk, M. (1998). CLOX: an executive clock drawing task. Journal of Neurology, Neurosurgery and Psychiatry, 64, 588–594.CrossRefGoogle ScholarPubMed
Scanlan, J. M., Brush, M., Quijano, C. and Borson, S. (2002). Comparing clock tests for dementia screening: naive judgments vs formal systems – what is optimal? International Journal of Geriatric Psychiatry 17, 14–21.CrossRefGoogle ScholarPubMed
Schramm, U., Berger, G., Muller, R., Kratzsch, T., Peters, J. and Frölich, L. (2002). Psychometric properties of Clock Drawing Test and MMSE or Short Performance Test (SKT) in dementia screening in a memory clinic population. International Journal of Geriatric Psychiatry, 17, 254–260.Google Scholar
Seigerschmidt, E., Mosch, E., Siemen, M., Förstl, H. and Bickel, H. (2002). The clock drawing test and questionable dementia: reliability and validity. International Journal of Geriatric Psychiatry, 17, 1048–1054.CrossRefGoogle ScholarPubMed
Shulman, K. I. (2000). Clock-drawing: is it the ideal cognitive screening test? International Journal of Geriatric Psychiatry, 15, 548–561.3.0.CO;2-U>CrossRefGoogle ScholarPubMed
Shulman, K. I., Gold, D. P., Cohen, C. A. and Zucchero, C. A. (1993). Clock-drawing and dementia in the community: a longitudinal study. International Journal of Geriatric Psychiatry, 8, 487–496.CrossRefGoogle Scholar
Shulman, K. I. et al. (2006). IPA survey of brief cognitive screening instruments. Inernational Psychogeriatrics, 18, 281–294.CrossRefGoogle ScholarPubMed
Storey, J. E., Rowland, J. T. J., Basic, D. and Conforti, D. A. (2001). A comparison of five clock scoring methods using ROC (receiver operating characteristic) curve analysis. International Journal of Geriatric Psychiatry, 16, 394–349.CrossRefGoogle ScholarPubMed
Sunderland, T. et al. (1989). Clock drawing in Alzheimer's disease: a novel measure of dementia severity. Journal of the American Geriatrics Society, 37, 725–729.CrossRefGoogle ScholarPubMed
van der Burg, M. et al. (2004). Scoring clock tests for dementia screening: a comparison of two scoring methods. International Journal of Geriatric Psychiatry, 19, 685–689.CrossRefGoogle ScholarPubMed