How To Score Clock Drawing Test

Bewilder Neuropsychol. 2022 Apr-Jun; ix(two): 128–135.

Language: English language | Portuguese

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

MÉTODO COM ALGORITMO ESPECÍFICO PARA PONTUAÇÃO DO TESTE DO DESENHO Practise RELÓGIO EM IDOSOS COGNITIVAMENTE NORMAIS

Liana Chaves Mendes-Santos

¹PhD, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ, Brazil.

Daniel Mograbi

ⁱPhD, Section of Psychology, Pontifical Catholic University of Rio de Janeiro RJ, Brazil.

²Department of Psychology, Institute of Psychiatry, Rex's College London, UK.

Bárbara Spenciere

³BsC, Department of Psychology, Pontifical Cosmic Academy of Rio de Janeiro RJ, Brazil.

Helenice Charchat-Fichman

¹PhD, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ, Brazil.

Received 2022 Feb 12; Accepted 2022 Apr 25.

Abstract

The Clock Drawing Exam (CDT) is an cheap, fast and hands 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 tin can be applied in different means 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 adjusted 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 Country Examination (MMSE) were administered to all participants. 6 independent examiners scored the CDT of xxx participants to evaluate inter-rater reliability.

Results and Decision

A score of 5 on the proposed algorithm ("Numbers in reverse lodge or concentrated"), equivalent to 5 points on the original Sunderland scale, was the most frequent (53.5%). The CDT specific algorithm method used had loftier 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 than nuanced evaluation criteria, which are sensitive to differences in levels of impairment in visuoconstructive and executive abilities during crumbling.

Keywords: Clock Drawing Exam, inter-rater reliability, elderly, neuropsychology

Abstract

O Teste do Desenho do Relógio (TDR) é uma barata e rápida medida de função cognitiva, de fácil aplicação, especialmente em idosos. Este instrumento é uma ferramenta clínica muito conhecida, amplamente utilizada no rastreamento de transtornos cognitivos eastward demência. O TDR pode ser aplicado de diferentes formas e a sua pontuação também varia.

Objetivo

Os objetivos deste estudo foram analisar o desempenho dos idosos no TDR e avaliar a confiabilidade inter-examinadores practice TDR pontuado por um método com algoritmo específico, adaptado a partir dos critérios estabelecidos por Sunderland et al. (1989).

Métodos

Analisamos o TDR de 100 idosos cognitivamente saudáveis com 60 anos de idade ou mais. O TDR ("desenho livre") e o Mini-Exame do Estado Mental (MEEM) foram administrados em todos os participantes. Seis avaliadores independentes pontuaram 30 TDR para avaliar a confiabilidade inter-examinadores.

Resultados due east Conclusão

A pontuação 5 do algoritmo proposto ("Os números em ordem inversa ou concentrados") equivalente a 5 pontos na escala original de Sunderland foi a mais frequente (53,5%). O método com algoritmo específico do TDR utilizado teve alta confiabilidade entre avaliadores (p<0,01), e a média da pontuação variou entre 5,06 e 5,96. A alta frequência de v pontos na pontuação geral pode sugerir a necessidade da elaboração de critérios de avaliação mais sutis, que sejam sensíveis às diferenças entre indícios de comprometimento nas habilidades visuoconstrutivas e executivas durante o envelhecimento.

INTRODUCTION

The Clock Drawing Test (CDT) is a simple and ecological neuropsychological instrument that covers a wide range of cognitive functions, including selective and sustained attention, auditory comprehension, verbal working retention, numerical cognition, visual memory and reconstruction, visuospatial abilities, on-need motor execution (praxis) and executive role.^ane Some studies have demonstrated the robust psychometric properties of the CDT.^ii-4

The CDT has been used as a cognitive screening tool, specially in the elderly population, to differentiate cognitively normal individuals from individuals with cerebral impairment and dementia.^5-7 This test has the capacity to evaluate multi-domain impairments that may go undetected by other cognitive screening instruments, such as the Mini-Mental State Examination (MMSE).^2,eight The relative independence of verbal abilities^9,10 makes it peculiarly useful in patients presenting marked verbal harm or aphasia. In addition, the CDT has also shown strong associations with other cognitive measures, such as the Cambridge Cognitive Examination (CAMCOG),^vi,11,12 justifying the inclusion of the CDT in several neuropsychological cognitive screening batteries.^1,10,12

Although there is peachy involvement in CDT equally a screening instrument, a broad variety of CDTs take been developed, each relying on different systems of assistants and quantitative or qualitative error scoring, with no consensus on which system produces the about valid results.^{iii,five,xiii} The currently used methods are Shulman et al.,¹⁴ Sunderland et al.¹⁰ and Mendez et al.^1-three,15 These different applications and systems of scoring are somewhat similar and highly correlated in some aspects, but their diagnostic accuracy, and the cognitive processes involved in their functioning are different.^sixteen

CDT functioning is associated with several brain regions, including the bilateral parietal lobes, right and left posterior and middle temporal lobes, right heart frontal gyrus, and the right occipital lobe.^16,17 These areas can too exist associated with a broad spectrum of pathologies. A number of studies have shown the potential of the CDT for investigating cerebral performance in patients with schizophrenia, Alzheimer'south disease, Parkinson's disease, depression and other disorders.^9,xviii,19

Previous studies take investigated the test-retest reliability,^1,9 and determined inter-rater reliability, of the CDT.^{half dozen,10,20-24} These studies compared the different application systems and showed that the systems were well correlated, took little time and had high inter-rater reliability. On the other hand, CDT reliability has rarely been assessed in population-based studies, particularly in developing countries. Three studies determining inter-rater reliabilities of the CDT in elderly in Brazil were found: 1 scored the tests with Shulman's method,^twenty while the others compared the accuracy of scales (Mendez, Shulman and Sunderland;⁶ Sunderland, Shulman, Manos & Wu and Wolf-Klein²⁴) and adamant the inter-rater reliability of CDT functioning. These investigations showed good inter-rater reliabilities.

One of the well-nigh used methods of CDT scoring is Sunderland et al.¹⁰ This method of scoring is well established in the literature^10,25-27 and widely used in Brazil, being part of cognitive screening batteries for the elderly.^28,29

With the aim of providing a more detailed, specific and quantitative analysis of the different aspects of CDT assessment, the nowadays study proposed an algorithm method for scoring the CDT adapted from Sunderland et al.¹⁰ To this end, the operation of 100 elderly was analyzed using the new algorithm, and its inter-rater reliability was evaluated.

METHODS

Participants. The sample was role of a larger written report involving 350 elderly from community centers, known as "Casas de Convivência", belonging to the Rio de Janeiro municipal administration. One hundred elderly took function in this study (93 females and 7 males). The inclusion criteria were:

• [i] to be literate (a person who tin can read and write; hateful=9.8 years of education, SD=4.2),

• [2] to be aged sixty years or older (mean age=72.6 years old, SD=five.9), and

• [3] to be cognitively healthy (MMSE mean score=25.three, SD=3.iv).

Cut-off scores for the MMSE were defined according to educational level. MMSE scores range from 0 to thirty, with higher scores indicating better cognitive function; the cut-off for cognitive damage was 18 in individuals with fewer than four years of formal education and 24 for participants with more than four years of educational activity.^8,thirty Exclusion criteria were: to be visually and/or hearing dumb or have uncorrected deficits, presence of endocrine and metabolic abnormalities, neurological and psychiatric disorders, or difficulty executing manus movements due to rheumatic diseases.

Before entry to the study all participants received an explanation on the objectives of the enquiry, and signed an informed consent form. The Research Ethics Committee of the State University of Rio de Janeiro approved this study.

Materials and procedures. Subjects were first submitted to a standardized questionnaire, which collected information on sociodemographic variables (i.e., gender, age and educational activity), on subjective memory impairment (i.east., "Practise y'all experience like your memory has gotten worse?"), and on comorbidities. All participants so completed the aforementioned protocol of cognitive screening tests. The tests were practical in the following sequence (based on Nitrini et al.³¹):

• [1] MMSE;^8,30

• [ii] Memory Test Figures;³¹

• [3] Verbal Fluency – Animals;^nine,32

• [four] CDT (described beneath);

• [five] The Lawton Instrumental Activities of Daily Living^33,34 (for further details come across Charchat-Fichman et al.³⁵). As well the cognitive and functional evaluations, participants completed the Geriatric Low Scale (GDS).³⁶

The CDT was applied to all participants in the spontaneous modality that uses a pencil and blank sheet of newspaper. The patients were asked to draw a clock without a model. Trained examiners issued a standardized instruction: "Depict a clock, put in all the numbers, and set up the hands to two hours and 45 minutes." In that location was no time limit.

Table i shows the original CDT scoring scale by Sunderland et al.,^ten which forms the footing of the new algorithm (Table ii). Both Tables ane and ​ 2 nowadays the correspondence of higher scores indicating better performance. Examples of the CDT scoring scale by Sunderland et al.^x are given in Effigy 1. According to the new algorithm (Table two), the examiner must first mark with an "10" all the items present in the clock drawing. The list of items has increasing complexity.

Table one

The original Sunderland method for scoring the CDT.¹⁰

10-6	Drawing of clock face with circle and numbers is generally intact.
x	Easily are in correct position.
9	Slight errors in placement of hands.
viii	More noticeable errors in placement of 60 minutes and minute hands.
vii	Placement of hands is significantly off grade.
half-dozen	Inappropriate utilise of clock hands (i.e., utilise of digital display or circumvoluted of numbers despite repeated instructions).
5-one	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 notwithstanding exist present in some way.
four	Further baloney 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 up).
3	Numbers and clock face up no longer obviously connected in cartoon. Hands are not present.
ii	Drawing reveals some evidence of instructions being received just only a vague representation of a clock.
ane	Either no attempt or an uninterpretable attempt is made.

Table 2

New algorithm method for CDT scoring based on the original criteria of Sunderland et al.¹⁰

Yous should mark with an "10" all the items nowadays in the clock drawn
(a)	Presence of circumvolve.		(j)	Presence of hour manus.
(b)	Presence of 12 numbers.		(k)	Presence of minute hand.
(c)	Numbers entered in the internal limit of the clock.		(l)	Minute mitt proportionally larger than the 60 minutes hand.
(d)	Number in the correct ascending society.		(m)	One of the hands between ii and iii.
(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 utilize of hands (digital or circling the numbers).
(k)	Can yous describe a straight horizontal line between iii and ix.		(p)	Some prove of having understood that it is a clock.
(h)	Numbers non concentrated in ane function 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 ii points.
iii. If the item "q" is checked, the score is 1 point.
The score will be 10-six if the clock and the numbers are drawn correctly
10	Correct time (no "10" in the items: "o", "p", "q").
ix	Very mild disorder of hands (absence of "X" in at least one particular: "50", "g" or "north").
8	Mild disorder of hands (absence of "X" in at least two items: "l", "chiliad", "n").
vii	Severe disorder of hands (absence of "X" in the items: "fifty", "m", "n").
six	Wrong use of easily (presence of "X" in item "o").
The score will be v-1 if the drawing of the clock and the numbers are wrong
v	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	Absenteeism of hands (no "Ten" in the items: "i", "j", "thou").
two	Only some prove of having understood that information technology is a clock (presence of "X" in detail p).
i	Not tried or did not correspond a clock (presence of "X" item in q).

Examples of CDT score in accordance with the specific algorithm method based on Sunderland et al.¹⁰: 9, 5 and two (right to left), respectively.

Inter-rater reliability was assessed by comparing CDT scores from six independent examiners, who each scored the same 30 clocks from subjects sampled randomly.

RESULTS

A summary of the participants' sociodemographic characteristics, functioning on cerebral screening tests, equally well as cognitive function and depression scales is given in Table three. Table iv shows performance on the CDT.

Table three

Participants' sociodemographic characteristics, and performance on cognitive screening tests, besides every bit cognitive office and depression scales.

Sociodemographic characteristics		Mean	SD*	Minimum value	Maximum value
Age		72.6	five.ix	lx	84
Years of didactics		9.8	4.2	3	24
Instruments and scales	MMSE (Retentiveness Figures Test)	25.2	iii.3	eighteen	30
	• Incidental Memory	25.four	1.1	two	8
	• Firsthand Retentiveness ane	seven.ix	one.3	four	ten
	• Immediate Memory two	eight.6	1.ane	5	10
	• 5 Minutes - Delayed Memory	7.vii	1.5	4	x
	• Recognition	9.9	0.3	8	10
Verbal Fluency		15	four.8	v	27
Lawton'south Calibration		xx.ane	1.4	eighteen	21
GDS		i.nine	2.i	0	eight

Table 4

Participants' performance on CDT: mean, median, standard deviation, minimum and maximum score.

Northward	Mean	Median	Standard difference	Minimum score	Maximum score
100	5.22	five	2.02	2	10

Co-ordinate to the histogram shown in Figure 2, regarding the performance of the elderly on the CDT, the frequency of score "5" was 53.5%, and scores "1" and "7" were not nowadays in the current sample.

Histogram showing the frequency of CDT scores co-ordinate to the scoring organisation developed by Sunderland et al.¹⁰.

Pearson'south correlation was used to evaluate the relationship between schooling, age and MMSE with CDT scores. No meaning correlation was found between schooling and CDT (r=0.014, p>0.05) or historic period and CDT (r=0.04, p>0.05), but a pregnant positive correlation was found between MMSE and CDT (r=0.22, p<0.05).

On the other hand, the investigation of inter-rater reliability of the CDT, scored by criteria based on Sunderland et al.,¹⁰ showed that the mean ranged from 5.06 to five.96 (Table 5).

Table 5

Mean and SD of CDT scores rated past the half dozen examiners.

Examiners	Mean	SD
1	five.06	2.24
two	5.66	ii.57
3	5.96	2.74
4	5.73	2.55
5	five.23	1.95
6	v.6	ii.71

Pearson'due south correlation analysis was performed between the scores found by the half-dozen independent raters for 30 tests. A significant positive correlation was found between the examiners (p<0.01): 1 and ii (r=0.79), 1 and 3 (r=0.seven); 1 and 4 (r=0.75); i and 5 (r=0.84), 1 and 6 (r=0.71), 2 and iii (r=0.87), 2 and 4 (r=0.79), ii and five (r= 0.79), 2 and half-dozen (r=0.79), 3 and 4 (r=0.79), 3 and 5 (r=0.69), three and half-dozen (r=0.8), iv and v (r=0.79), 4 and 6 (r=0.88) and 5 and 6 (r=0.74).

The understanding between raters was high, consistently remaining statistically significantly to a higher place expected chance understanding (in all cases, p<0.001). The combined kappa for all six examiners was 0.60, with pairwise analyses between evaluators indicating an average level of agreement of 90.2% and an average weighted kappa of 0.69.

DISCUSSION

The electric current study analysed the performance of a cognitively normal elderly community sample on the CDT using a specific algorithm score method based on the Sunderland et al.¹⁰ organization. The mean score of participants was five.22, and the standard deviation two.02. The score 5 ("Numbers in reverse society or concentrated") was observed in 53.five% of clock drawings.

In general, studies with the CDT compare the performance of patients and controls in dissimilar applications and scoring systems^2,25,37 or verify the clinical validity of the examination,^21,23,38 or investigate the translation and accommodation of the CDT model for a particular population.^39,40 There are few studies in community-dwelling samples or cognitively normal elderly.^22,41-43

Five Brazilian studies using Sunderland'southward scoring method found college scores than the present report (5.22, and standard deviation 2.02). Ii of these studies did not mention CDT scores,^6,24 while the other results were: 9.seven (±ane.07),⁴¹ 7.8 (±2.2),²⁸ and 9.1 (±1.8).^xi Still, comparison of the current findings with results of these studies is hampered because of a number of differences in study design. The most important difference was related to the intrinsic characteristics of the sample. The cited studies used small clinical samples recruited in hospital settings, in dissimilarity to the nowadays study which used a large sample of normal elderly from community centers with heterogeneous age and educational levels.^{6,eleven,24,28,31,41} The objectives of the studies too varied. Some compared different methods of CDT scoring,^24,41 others compared the musical instrument with other tests and finally there was a study that evaluated the profile of the elderly subjects on the CDT²⁸ based on a selected grouping of normal elderly as a control group compared to Alzheimer's disease patients.

Studies in the international literature that used the same method as Sunderland to score the CDT found the following results: 7.5 (±i.nine),²⁵ 8.iv (±ane.6),²⁷ 8.7 (±i.1),^x and eight.9 (±1.4).²⁶ Similar to the Brazilian studies, all of these found higher scores for normal elderly individuals^10,26,27 than in the present study, except Kirby et al.²⁵ who found lower scores compared to the other international studies. Some studies failed to mention all of import information, for example, the educational level^10,26 or did not use formal cognitive testing for normal controls¹⁰ (including the MMSE^ten,27) while some other did not carve up the clinical grouping when describing the sample characteristics,²⁷ hindering comparisons amongst the studies. The aim of the present study differs from the primary objective of the previous studies in that its aim was to evaluate the performance of the elderly with and without cognitive impairment.^ten,25-27

An important event regarding the performance of the elderly is the high percentage (53.v%) of the sample with scores of "v". The criterion for a score of "five" in Sunderland's original method is "Crowding of numbers at one cease of the clock or reversal of numbers. Clock Hands may still exist present in some fashion" and in the new algorithm denoted: "Numbers in reverse order or concentrated". The lower mean scores on the CDT compared to other studies, and the high frequency of elderly that scored at this level could be explained past the fact that strict correction was used to score the CDT in this study. Sunderland's method in its original version had a more subjective approach, for case, very high CDT scores, even with numbers slightly full-bodied, could be found in Sunderland et al.^ten (Effigy 1, p. 727). According to Sunderland's method, particular 5 should be scored but when there is a drastic concentration, and in the present research this item included people with slight and astringent difficulty in planning. Thus, when strict criteria are used, different results are obtained compared to the literature.

In this sense, it would exist necessary to develop more than specific scoring criteria that may be sensitive to planning strategy and visual-constructive execution of the CDT, and which could better differentiate specifically those elderly with possible executive dysfunction. Other methods of scoring the CDT, including semi-quantitative and qualitative scoring systems, endeavour to discriminate the level of executive planning in clock drawings,^42,44,45 and emphasize the evaluation of executive components in CDT.^42-44 For example, Royall et al.⁴⁵ developed the Executive Clock Drawing Task (CLOX) in gild to discriminate these components and allow a more than specific analysis of how the executive functions can be tested in the CDT.

No significant correlation was found between education or aging and CDT scores. The relationship between education, crumbling and CDT performance is controversial in the literature.^{22,24,38,41,43} This finding may besides be related to the existence of various awarding methods and different scoring scales. For example, Brodaty and Moore institute a correlation of CDT score with years of didactics for the Shulman and Sunderland, but not for the Wolf-Klein scoring arrangement.^two Sunderland et al.¹⁰ did not report the educational level of command subjects in the original report.

On the other paw, a pregnant positive correlation was institute between the CDT and MMSE, confirming previous findings.^{half-dozen,7,15} A high correlation has been found for the scales of Shulman,¹⁴ Mendez¹ and the CLOX scale.⁴⁵ The association betwixt MMSE score and several CDTs was also high in the report by Schramm et al.⁷

These various systems of awarding and scoring are an obstruction to establishing direct comparisons and drawing conclusions. The different forms of application include differences in the clock time requested (ii:45, 11:10, 8:05) and presence of cartoon assistance (eastward.g. some have a pre-drawn circle). In add-on, the diverse scoring systems include: 10 hierarchical patterns (0-10), scale based on errors each scored 0/1 (0-20), clock divided into eighths, points given for numbers and easily in right identify (0-x) and others.^{three,14,37,43}

In this study, an algorithm with more specific scores based on Sunderland et al.¹⁰ criteria was devised to increase inter-rater reliability. The examination of the inter-rater reliability showed that the criteria adult for the present written report were reliable and a meaning positive correlation was institute between the 6 independent examiners. These results are similar to those found in previous studies, besides indicating high inter-rater reliability of CDT scores.^10,21-23 Once again, the various ways of presenting the test and the different principles involved in scoring, make comparisons hard. Another aspect that hampers comparisons is the use of several different report designs. Some studies examined inter-rater reliabilities of the CDT scored by one scoring system in cognitively normal elderly^twenty or in differentiating between cognitively normal and individuals with dissimilar types of pathologies,² while others examined inter-rater reliability using dissimilar scoring systems amongst cognitively normal elderly^22,37 or cognitively normal and individuals with different types of diseases.²¹ Two other studies that evaluated the inter-rater reliability using diverse score systems, including the method of Sunderland et al.,¹⁰ compared subjects with and without pathologies (fibromyalgia and mild cognitive impairment, MCI)^37,46 and showed good inter-rater reliability.

The idea of systematic scoring of the CDT has focused on the development and standardization of elementary and easy-to-interpret scoring methods.^21,22 At that place are two general CDT scoring approaches, including qualitative and quantitative approaches. The Sunderland et al.^x is a semi-quantitative scoring organisation that focuses on scoring the whole clock.³⁷ Other quantitative scoring systems focus on dissimilar aspects of the clocks (such as clock face, numbers or hands) and score them separately (i.e., the Clock Drawing Interpretation Scale past Mendez et al.^one and Rouleau et al.¹²). Furthermore, the scoring systems differ regarding scoring procedures.

One limitation of this study is the non-stratification of participants by age for comparison. Perhaps the advanced age of some participants may have influenced the low average scores. Another question to be considered centers on the intrinsic characteristics of the sample and on the volunteers that participated in the activities of the Casas de Convivência. For case, the sample comprises mostly women (93%), with few health weather. However, because this is a convenience sample, it was not possible to limit recruitment on the footing of personal characteristics In improver, other Brazilian studies besides feature a college pct of women,^11,20,24,41 making it unlikely that this represents a major bias in results. These subjects were normal elderly (criterion for inclusion in the sample was to score to a higher place the cut-off bespeak on the MMSE), but some older adults with MCI might take been included in the sample; a number of weather associated with aging could be present, and some comorbidities not directly related with cognition may have influenced the results. Another limitation to be considered is associated with the method of sample selection. To adequately address selection bias, a randomized sample would have been ameliorate than the convenience sample used in the present study. Moreover, other limitations were the absence of other measures of executive functions to compare with the CDT and no functional literacy examination.

The nowadays findings correspond an of import contribution to the discussion on which CDT assistants and scoring system produces the most valid results. The results confirmed the consistency of the scoring criteria of Sunderland et al.^ten. Furthermore, the findings contribute to the discussion about the lack of consensus on the different scoring criteria developed for the CDT and on which would produce more valid results. On the other mitt, they may further suggest the need for creating more subtle evaluation criteria, which are sensitive to the differences between impairment in visuoconstructive and executive abilities during aging.

Future research should replicate these findings in elderly with higher and lower formal instruction to compare the bear on of educational level on the CDT. Additional studies could explore more than qualitative aspects of the CDT, including strategies implemented, also as comparing it to other scoring criteria, and clinical validation in the case of Alzheimer's disease, MCI and depression.

Acknowledgement

Christina Martins Borges Lima, Ana Lara Soares Blum Malak, Amanda Buhler Riccieri, Marina Zaitune Baumgratz Lopes Bueno, Maria Fernanda Fernandes de Castro Barbosa, Eduarda Naidel Barboza e Barbosa.

Footnotes

This written report was conducted at the Section of Psychology, Pontifical Cosmic Academy of Rio de Janeiro, Brazil.

Disclosure: The authors report no conflicts of interest.

Contributed by

Writer contributions. Liana Chaves Mendes-Santos wrote the paper and participated in statistical assay. Daniel Mograbi participated in statistical analysis and revised the paper. Bárbara Spenciere wrote the newspaper. Helenice Charchat-Fichman designed the study, wrote the newspaper, participated in statistical analysis and revised the paper.

Grant Support. CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), FAPERJ (Fundação Carlos Chagas Filho de Amparo à Pesquisa do Rio de Janeiro).

REFERENCES

i. Mendez MF, Ala T, Underwood KL. Evolution of scoring criteria for the clock drawing task in Alzheimer's disease. J Am Geriatr Soc. 1992;40:1095–1099. [PubMed] [Google Scholar]

two. Brodaty H, Moore CM. The clock drawing test for dementia of the Alzheimer's blazon: a comparison of 3 scoring methods in a memory disorders dispensary. Int J Geriatr Psychiatry. 1997;12:619–627. [PubMed] [Google Scholar]

three. Shulman KI. Clock-drawing: is information technology the ideal cerebral screening examination? Int J Geriatr Psychiatry. 2000;fifteen:548–561. [PubMed] [Google Scholar]

4. Todd ME, Dammers PM, Adams SG Jr, Todd HM, Morrison M. An examination of a proposed scoring process for the clock drawing exam reliability and predictive validity of the clock scoring system. Am J Alzheimer's Dis. 1995;4:22–26. [Google Scholar]

five. Aprahamian I, Martinelli JE, Neri AL, Yassuda MS. The Clock Drawing Examination: a review of its accuracy in screening for dementia. Dement Neuropsychol. 2009;3:74–80. [PMC free commodity] [PubMed] [Google Scholar]

six. Aprahamian I, Martinelli JE, Neri AL, Yassuda MS. The accurateness of the Clock Cartoon Examination compared to that of standard screening tests for Alzheimer's disease: results from a written report of Brazilian elderly with heterogeneous educational backgrounds. Int Psychogeriatr. 2010;22:64–71. [PubMed] [Google Scholar]

vii. Schramm U, Berger Thousand, Muller R, Kratzsch T, Peters J, Frolich L. Psychometric backdrop of Clock Drawing Test and MMSE or Short Performance Test (SKT) in dementia screening in a retention dispensary population. Int J Geriatr Psychiatry. 2002;17:254–260. [PubMed] [Google Scholar]

viii. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the mental state of patients for clinicia. J Psychiat Res. 1975;12:189–198. [PubMed] [Google Scholar]

9. Strauss Eastward, Sherman EMS, Spreen O. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary. 3rd ed. New York: Oxford Academy Press; 2006. [Google Scholar]

x. Sunderland T, Hill JL, Mellow AM, et al. Clock cartoon in Alzheimer's disease: a novel measure of dementia severity. J Am Geriatr Soc. 1989;37:725–729. [PubMed] [Google Scholar]

xi. Nunes PV, Diniz BS, Radanovic One thousand, et al. CAMCOG equally a screening tool for diagnosis of mild cognitive harm and dementia in a Brazilian clinical sample of moderate to high instruction. Int J Geriatr Psychiatry. 2008;23:1127–1133. [PubMed] [Google Scholar]

12. Rouleau I, Salmon DP, Butters North, Kennedy KC, McGuire K. Quantitative and qualitative analyses of clock drawings in Alzheimer'southward and Huntington's disease. Brain Cogn. 1992;18:70–87. [PubMed] [Google Scholar]

13. Mainland BJ, Amodeo S, Shulman KI. Multiple clock drawing scoring systems: simpler is meliorate. Int J Geriatr Psychiatry. 2014;29:127–136. [PubMed] [Google Scholar]

14. Shulman KI, Aureate DP, Cohen CA, Zucchero CA. Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry. 1993;viii:487–496. [Google Scholar]

15. Richardson HE, Glass JN. A comparing of scoring protocols on the clock cartoon examination in relation to ease of use, diagnostic group, and correlations with Mini-Mental State Examination. J Am Geriatr Soc. 2002;l:169–173. [PubMed] [Google Scholar]

16. Matsuoka T, Narumoto J, Okamura A, et al. Neural correlates of the components of the clock cartoon examination. Int Psychogeriatr. 2013;16:1–seven. [PubMed] [Google Scholar]

17. Ino T, Asada T, Ito J, Kimura T, Fukuyama H. Parieto-frontal networks for clock cartoon revealed with fMRI. Neurosci Res. 2003;45:71–77. [PubMed] [Google Scholar]

18. Royall DR, Palmer RF, Chiodo LK, Polk MJ, Markides KS, Hazuda H. Clock-drawing potentially mediates the effect of depression on mortality: replication in three cohorts. Int J Geriatr Psychiatry. 2008;23:821–829. [PMC costless commodity] [PubMed] [Google Scholar]

xix. Saur R, Maier C, Milian M, et al. Clock test deficits related to the global cognitive country in Alzheimer's and Parkinson's illness. Dement Geriatr Cogn Disord. 2012;33:59–72. [PubMed] [Google Scholar]

twenty. Fuzikawa C, Lima-Costa MF, Uchoa Eastward, Barreto SM, Shulman KI. A population based written report on the intra and inter-rater reliability of the clock drawing examination in Brazil: the Bambuí Health and Ageing Study. Int J Geriatr Psychiatry. 2003;eighteen:450–456. [PubMed] [Google Scholar]

21. García-Caballero A, Recimil MJ, García-Lado I, et al. ACE clock scoring: A comparing with eight standard correction methods in a population of depression educational level. J Geriatr Psychiatry Neurol. 2006;19:216–219. [PubMed] [Google Scholar]

22. Hubbard EJ, Santini V, Blankevoort CG, et al. Clock drawing performance in cognitively normal elderly. Arch Clin Neuropsychol. 2008;23:295–327. [PMC free commodity] [PubMed] [Google Scholar]

23. Nair AK, Gavett BE, Damman M, et al. Clock Drawing Test Ratings by Dementia Specialists: Interrater Reliability and Diagnostic Accuracy. J Neuropsychiatry Clin Neurosci. 2010;22:85–92. [PMC complimentary article] [PubMed] [Google Scholar]

24. Lourenço RA, Ribeiro-Filho ST, Moreira IFH, Paradela EMP, Miranda AS. The Clock Drawing Test: performance amidst elderly with low educational level. Rev Bras Psiquiatr. 2008;thirty:309–315. [PubMed] [Google Scholar]

25. Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The Clock Drawing Test in chief care: sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry. 2001;16:935–940. [PubMed] [Google Scholar]

26. Lee H, Swanwick GRJ, Coen RF, Lawlor BA. Employ of the clock drawing chore in the diagnosis of mild and very mild Alzheimer's disease. Int Psychogeriatr. 1996;eight:469–476. [PubMed] [Google Scholar]

27. 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. [PubMed] [Google Scholar]

28. Hamdan Air-conditioning, Hamdan EMLR. Teste exercise desenho do relógio: desempenho de idosos com doença de Alzheimer. RBCEH. 2009;six:98–105. [Google Scholar]

29. Hollveg P, Hamdan AC. Avaliação neuropsicológica em idosos. RBCEH. 2008;5:110–123. [Google Scholar]

30. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Suggestions for utilization of the Mini-Mental State Test in Brazil. Arq Neuropsiquiatr. 2003;61:777–781. [PubMed] [Google Scholar]

31. Nitrini R, Lefevre BH, Mathias SC, et al. Neuropsychological tests of unproblematic application for diagnosing dementia. Arq Neuropsiquiatr. 1994;52:457–465. [PubMed] [Google Scholar]

32. Mitrushina MN, Boone KB, D'Elia LF. Handbook of Normative Data for Neuropsychological Assessment. New York: Oxford Academy Press; 1999. [Google Scholar]

33. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969;nine:179–186. [PubMed] [Google Scholar]

34. Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira da Escala de Atividades Instrumentais da Vida Diária. RBPS. 2008;21:290–296. [Google Scholar]

35. Charchat-Fichman H, Fernandes C, Oliveira R, Caramelli P, Aguiar D, Novaes R. Predomínio de Comprometimento Cognitivo Leve Disexecutivo em idosos atendidos no ambulatório de geriatria de um hospital terciário na cidade do Rio de Janeiro. Rev Neuropsi Latinoam. 2013;5:31–xl. [Google Scholar]

36. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent show and evolution of a shorter version. Clin Gerontol. 1986;5:165–173. [Google Scholar]

37. Ehreke 50, Luck T, Luppa One thousand, König H, Villringer A, Riedel-Heller SG. Clock Drawing Test - screening utility for mild cerebral impairment according to unlike scoring systems: results of the Leipzig Longitudinal Written report of the Anile (LEILA 75+) Int Psychogeriatr. 2011;23:1592–1601. [PubMed] [Google Scholar]

38. Bozikas VP, Giazkoulidou A, Hatzigeorgiadou M, Karavatos A, Kosmidis MH. Do age and education contribute to performance on the clock cartoon test? Normative data for the Greek population. J Clin Exp Neuropsychol. 2008;thirty:199–203. [PubMed] [Google Scholar]

39. Atalaia-Silva KC, Lourenço RA. Tradução, adaptação due east validação de construto do Teste do Relógio aplicado entre idosos no Brasil. Rev Saúde Pública. 2008;42:930–937. [PubMed] [Google Scholar]

40. Royall D. The "Alzheimerization" of dementia enquiry. J Am Geriatr Soc. 2003;51:277–278. [PubMed] [Google Scholar]

41. Cecato JF, Fiorese B, Montiel JM, Bartholomeu D, Martinelli JE. Clock Drawing Exam in Elderly Individuals With Different Pedagogy Levels Correlation With Clinical Dementia Rating. Am J Alzheimers Dis Other Demen. 2012;27:620–624. [PubMed] [Google Scholar]

42. Crowe M, Allman RM, Triebel K, Sawyer P, Martin RC. Normative Performance on an Executive Clock Drawing Job (CLOX) in a Community-Dwelling Sample of Older Adults. Arch Clin Neuropsychol. 2010;25:610–617. [PMC free article] [PubMed] [Google Scholar]

43. Menon C, Hall J, Hobson V, Johnson L, O'Bryant SE. Normative functioning on the executive clock cartoon task in a multi-ethnic bilingual cohort: A project FRONTIER written report. Int J Geriatr Psychiatry. 2012;27:959–966. [PMC gratis article] [PubMed] [Google Scholar]

44. Juby A, Tench S, Baker Five. The value of clock cartoon in identifying executive cognitive dysfunction in people with normal Mini-Mental State Examination Score. CMAJ. 2002;167:859–864. [PMC gratis article] [PubMed] [Google Scholar]

45. Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry. 1998;64:588–594. [PMC gratuitous article] [PubMed] [Google Scholar]

46. Can SS, Gencay-Tin can A, Gunendi Z. Validity and reliability of the clock drawing examination as a screening tool for cerebral impairment in patients with fibromyalgia. Compr Psychiatry. 2012;53:81–86. [PubMed] [Google Scholar]

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5619351/

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