A comparison of the clock drawing test and the Pfeiffer Short Portable Mental Status Questionnaire in a geropsychiatry clinic

Clock Drawing Test: Types of Errors and Accuracy in Early Cognitive Screening

BACKGROUND

Clock Drawing Test (CDT) is a commonly used screening tool for cognitive disorders, known for its ease of administration and scoring. Despite frequent use by clinicians, CDT is criticized for its poor predictive value in mild cases of impairment.

OBJECTIVE

To evaluate CDT as a screening tool for early stage of cognitive impairment in biomarker-verified Alzheimer's disease (AD) and depressive disorder (DD).

METHODS

We analyzed CDT of 172 patients with verified AD, 70 patients with DD, in whom neurodegenerative disorder was excluded using cerebrospinal fluid biomarkers, and 58 healthy older adults. CDT was scored using the semi-quantitative (Shulman) and itemized criteria (adapted from Mendez).

RESULTS

Logistic regression showed that for both DD and AD patients with high Mini-Mental State Examination (MMSE) scores (27 and above) the significant predicting variable is uneven number spacing. As MMSE deteriorates (24-26 points), an additional error of setting clock hands is predictive of the disease. In the low MMSE condition, CDT showed an acceptable discrimination for AD (AUC itemized 0.740, Shulman 0.741) and DD (AUC itemized 0.827, Shulman 0.739) using both scoring methods. In the high MMSE condition, discrimination rates were acceptable using itemized scoring but poor using Shulman scoring for both AD (AUC itemized 0.707, Shulman 0.677) and DD (AUC itemized 0.755, Shulman 0.667) groups.

CONCLUSION

Ideally, modern diagnostic process should take place before the cognitive performance drops beneath the healthy range. This makes CDT of little use when screening patients with very mild cognitive deficits.

Cultural influence on clock drawing test: A systematic review

OBJECTIVE

Dementia among migrants is an emerging phenomenon worldwide and the development of neuropsychological tests sensitive to cultural differences is increasingly regarded as a priority. The Clock Drawing Test (CDT) is one of the most used screening tools for the detection of cognitive decline. Nevertheless, there is still a debate about its adoption as a cross-cultural assessment.

METHODS

To identify cultural variables influencing performance at CDT, we performed a systematic review of literature on three databases of all studies considering the role of at least one of the following: (1) language; (2) education; (3) literacy; (4) acculturation; and (5) ethnicity.

RESULTS

We extrapolated 160 analyses from 105 studies. Overall, an influence of cultural determinants on performance at CDT was found in 127 analyses (79.4%). Regarding specific cultural factors, 22 analyses investigated the effect of ethnicity on CDT scores, reporting conflicting results. Only two scoring systems turned out to be sufficiently accurate in a multicultural population. Language influenced performance in only 1 out of 8 analyses. A higher level of education positively influenced test performance in 118 out of 154 analyses (76.6%), and a better quality of education in 1 analysis out of 2. A negative influence of illiteracy on CDT performance emerged in 9 out of 10 analyses. Acculturation affected performances at CDT in 1 out of 2 studies.

CONCLUSIONS

Based on the present findings, caution is needed when using CDT in a multicultural context, even if it requires limited linguistic competence.

Teste do Desenho do Relógio: Dados Normativos Para Idosos

Resumo Trata-se de um estudo quantitativo, retrospectivo, correlacional e de corte transversal, com objetivo de fornecer dados normativos do TDR para idosos, levando em consideração diferentes faixas etárias e níveis de escolaridade. Duzentos e trinta e cinco foram entrevistados individualmente, distribuídos em cinco grupos etários e quatro níveis de escolaridade. Os instrumentos foram Ficha de Dados Sociodemográficos, Miniexame do Estado Mental (MEEM), Escala de Depressão Geriátrica, versão reduzida (GDS-15), Tarefa de Fluência Verbal Semântica (TFVS) e o TDR. Utilizou-se estatísticas descritivas, correlação de Pearson e análise univariada (one-way ANOVA) com post hoc Scheffe. Os escores do TDR apresentaram associações significativas com os anos de idade, anos de escolaridade, MEEM, TFVS e GDS-15. Houve diferença de desempenho no TDR ao considerarem os grupos por idade. O estudo fornece valores normativos para o TDR em uma amostra de idosos do sul do Brasil que foram influenciados pela idade, escolaridade, sintomatologia depressiva e fluência verbal.

Evaluation of Cognitive Functions in Traumatic Brain Injury Patients Using Mini Mental State Examination and Clock Drawing Test

Background:

Traumatic brain injuries (TBIs) are the leading cause of morbidity, mortality, disability, and socioeconomic losses globally, but of more concern, in India and other developing countries. The Mini mental state examination (MMSE) and clock drawing test (CDT) are the two mostly adapted methods for cognitive impairment screening. Therefore, it is necessary to establish a robust evaluation system exclusively for post-TBI cognitive impairment.

Materials and Methods:

One hundred and thirty-four cases treated previously at the health facility for TBIs were evaluated for cognitive functions during the follow-up period ranging from 3 weeks to 6 months in the out-patient department. All cases underwent mini-mental score examination (MMSE) and CDT to assess their cognitive performances. The data were analyzed statistically using Chi-square and ANOVA tests of significance.

Results:

Statistically significant association (P < 0.001) between the cognitive status of patients on the basis of overall MMSE score and the site of brain injury was observed. It was noted that 76 (56.7%) of the cases had cognitive impairment (MMSE score <24) with majority 44 (32.8%) patients having frontal lobe injuries, followed by 14 (10.1%) having brain injuries in the temporal lobe. On the other hand, using CDT score, it was observed that 102 (76.1%) of the cases had cognitive impairment (CDT score <5) with the majority 49 (36.6%) cases having frontal lobe injury followed by 19 (14.2%) having brain injury in the parietal lobe.

Conclusion:

The CDT was able to access cognitive function disruption in those patients, in whom the mini-mental score examination was not able to assess the same, and this difference in detection capabilities of both the tests was statistically found significant.

Scoring systems for the Clock Drawing Test: A historical review

The Clock Drawing Test (CDT) is a simple neuropsychological screening instrument that is well accepted by patients and has solid psychometric properties. Several different CDT scoring methods have been developed, but no consensus has been reached regarding which scoring method is the most accurate. This article reviews the literature on these scoring systems and the changes they have undergone over the years. Historically, different types of scoring systems emerged. Initially, the focus was on screening for dementia, and the methods were both quantitative and semi-quantitative. Later, the need for an early diagnosis called for a scoring system that can detect subtle errors, especially those related to executive function. Therefore, qualitative analyses began to be used for both differential and early diagnoses of dementia. A widely used qualitative method was proposed by Rouleau et al. (1992). Tracing the historical path of these scoring methods is important for developing additional scoring systems and furthering dementia prevention research.

The Mini-Cog, Clock Drawing Test, and the Mini-Mental State Examination in a German memory clinic: specificity of separation dementia from depression

BACKGROUND

The aim of this study was to assess the specificities of the Mini-Cog, the Clock Drawing Test (CDT), and the Mini-Mental State Examination (MMSE) against depression and healthy controls in a German Memory Clinic. Furthermore, we analyzed the specificities of all three screening instruments in dependence of actual depression severity.

METHODS

Data from 142 depressed elderly, 438 dementia patients, and 64 healthy controls were retrospectively analyzed. The CDT and an extraction of the three-item recall of the MMSE were used to constitute the Mini-Cog algorithm. Depression severity was rated by either the Beck Depression Inventory (BDI) or the Geriatric Depression Scale (GDS) depending on the age of the patients.

RESULTS

The Mini-Cog achieved a specificity of 79.6% against depressed elderly and 100.0% against healthy subjects (p < 0.001). Similarly, the specificities of the CDT (83.8%) and MMSE (92.3% at a cut-off ≤24 and 90.8% at ≤25, respectively) against healthy subjects were significantly higher than the specificities against depressed patients (each p < 0.05). Concerning the depressed patients, the MMSE demonstrated significant higher specificity than the Mini-Cog and the CDT, but also showed the lowest sensitivity for the detection of dementia. Surprisingly, the depression severity had no effect on the specificity of the Mini-Cog and the CDT, only the MMSE was susceptible for the depression severity.

CONCLUSION

Although the MMSE showed higher specificities, the weighting between the sensitivities and specificities in all tests prove again the Mini-Cog as a short, valid, and sensitive screening tool.

Comparing the influences of age and disease on distortion in the clock drawing test in Japanese patients with schizophrenia

OBJECTIVE

The Clock Drawing Test (CDT) is commonly used for cognitive screening, but there are few studies that compare performance on the CDT among schizophrenic patients of different ages. The objective of this study was to investigate the influence of schizophrenia and aging on performance in the CDT.

METHOD

Schizophrenic patients (N = 244) and a comparison group (N = 875) were recruited as subjects. Freedman's CDT was completed by all subjects, and the influences of disease and aging on performance in the CDT were examined. Multiple comparisons of the CDT scores between patients and the comparison group and within three age subgroups (young: less than 40 years, middle aged: 40-59 years, elderly: more than 60 years) were performed.

RESULTS

There was a significant interaction of diagnosis and age, and the education significantly influenced the total score for all CDT conditions. For almost all age subgroups of patients, individuals with schizophrenia had significantly lower scores on all the CDT conditions than did the comparison group subjects. For patients and the comparison group, the elderly subgroup performed significantly worse than the young and middle-aged subgroups on almost all conditions of the CDT. Qualitative analysis of the clocks drawn revealed that the number of CDT categories in which schizophrenic patients scored significantly lower than the comparison group tended to increase with aging across both groups.

CONCLUSIONS

This study suggests that performance on the CDT was impaired not only by disease but also by aging. The study confirms that the CDT is sensitive enough to screen for cognitive impairments in schizophrenia.

Can an 18-point clock-drawing scoring system predict dementia in elderly individuals with mild cognitive impairment?

The purpose of this study was to develop a clock-drawing scoring system better suited to detecting possible early markers of dementia in individuals with mild cognitive impairment (MCI). We modified the scoring system of Freedman et al. (1994), in which the major components are integrity of the circle, placement and size of the hands, and placement and sequence of the numbers. We rescored the clock-drawing test using a novel 18-point scoring system, which emphasizes hand elements-number of hands, direction indicated, and size differences. We retrospectively assessed 123 individuals (ages 58-88 years) selected from the Memory Clinic at the Jewish General Hospital in Montreal. These consisted of 21 normal elderly individuals (NORM group), 41 participants with mild cognitive impairment who did not develop dementia on follow-up visits (MCI-NP), 41 participants with mild cognitive impairment who became demented after a 48-month follow-up (MCI-D), and 20 participants diagnosed with Alzheimer's disease (AD). On the 18-point system, the MCI-NP and the MCI-D did not show any difference on overall total score (p = .166), However, using Pearson chi-squares to examine the within-categories effects comparing the mildly cognitively impaired groups (MCI-NP and MCI-D), there were three significant hand items that appear to be possible early markers of progression to dementia. The clock has two hands (p = .043), hour hand is towards correct number (p = .023), and size difference of the hands is respected (p = .004), all showed significant differences between progressors and nonprogressors. The 18-point clock-drawing scoring system may have advantages in better indicating MCI individuals more likely to progress to dementia.

Diagnostic accuracy of the clock drawing test: the relevance of "time setting'' in screening for dementia

OBJECTIVE

We aimed to evaluate the overall diagnostic accuracy of clock drawing test methods which require a defined time setting. In addition, diagnostic relevance of time setting was analyzed qualitatively.

METHODS

Clock drawing test performance of 462 consecutive memory clinic patients were analysed by 5 different clock drawing test methods. The sensitivity, specificity, positive and negative predictive value as well as the overall misclassification rate was calculated against a clinical diagnosis of dementia. Further, qualitative analysis of error types was done when subjects failed in the time setting task.

RESULTS

All clock drawing test methods that require time setting revealed higher sensitivities and superior negative predictive values as well as overall misclassification rates compared to methods which do not. Failure in the time setting task did not exclusively occur in dementia patients. However, error types which reflect a severely reduced capacity in abstract and conceptual thinking occurred exclusively in dementia patients.

DISCUSSION

Clock drawing test methods that require time setting should be favoured above methods which do not. An additional analysis of time setting errors may yield valuable diagnostic information.

Sensitivity and specificity of the clock drawing test, incorporating Rouleau scoring system, as a screening instrument for questionable and mild dementia: Scale development

OBJECTIVE

The objective of this study was to validate the Rouleau scoring system for the Clock Drawing Test (CDT) in northern Taiwan, a non-English speaking area, to increase its generalization by detecting subjects with questionable dementia (QD) from normal controls (NC) and subjects with mild dementia (AD). The system consists of two parts: a 10-point scoring and error types. A cross-sectional design was used. One hundred and sixteen subjects were recruited from a memory disorder clinic (n=40 NC; n=34 QD; n=42 AD). Reliability and validity were estimated, the predictive accuracy was calculated using the receiver operating characteristic (ROC) curve analysis, and the error types were counted.

RESULTS

The results indicated that most of the error types committed were conceptual deficiencies and graphic difficulties; more errors were found in the command condition (CDT-command) than in the copy condition (CDT-copy); 15% of the subjects drew smaller clock circles in CDT-command, which did not relate to any other errors. No small clock was found in CDT-copy because a pre-dawn circle was provided. The inter-rater reliability of the Rouleau scoring system was .87 and .83 for the CDT-command and -copy, respectively, while the discriminate accuracy of the scoring system was relatively low in detecting QD vs. NC, QD vs. AD, but somewhat better in distinguishing AD vs. NC groups for the areas under the ROC curves was equal to .72 for the CDT-command, and .73 for the CDT-copy. Visuospatial construction and executive functioning explained the largest score variance of the CDT in both conditions, while depressive symptoms were not significantly associated with the CDT performance.

CONCLUSION

The CDT using the Rouleau scoring system has been validated in mild AD subjects in Taiwan; however, to screen for QD sufferers, alternative scoring systems emphasizing hands or combining CDT with different neuropsychological tests such as the Clinical Abilities Screening Instrument are recommended.

Interrater reliability of scores derived from two methods for scoring the clock drawing test

Scores on the Clock Drawing Test have long been considered a useful screening tool for neuropsychological dysfunction, and a number of scoring methods have been developed to evaluate various aspects of performance. This study compared quantitative and qualitative scoring by briefly trained students on 145 clock drawings produced by patients in a geriatric psychiatry outpatient clinic to estimate the interrater reliability of the methods, user's acceptance of the methods, and whether the methods provide differential diagnosis. Both systems showed acceptable interrater reliability. Using the quantitative method, raters scored drawings by patients with organic mental disease as more impaired than those patients diagnosed as depressed or schizophrenic. Results suggest that the Clock Drawing Test is a reliable screening tool for cognitive impairment in a geropsychiatric population, but the scoring methods examined do not yet appear psychometrically sound enough to provide a differential diagnosis.

The clock drawing test as a measure of executive dysfunction in elderly depressed patients

The aims of this research were to determine whether performance on the Clock Drawing Test (CDT) could accurately distinguish between older patients with depression and older patients with depression and previously undocumented executive dysfunction and to determine if there was a correlation between CDT and depression severity. The authors studied 52 patients consecutively admitted to a geriatric psychiatry inpatient unit of a university hospital who met DSM-IV criteria for major depression or depression not otherwise specified but had no concurrent diagnosis of dementia. All the subjects completed the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale (DRS), and the CDT, as well as the Geriatric Depression Scale (GDS). The patients were divided into 2 subgroups based on the DRS score: <129 (cognitive impairment) versus = 129. Results indicated that the depressed patients with a score of DRS <129 had significantly lower CDT scores than did patients with DRS = 129 and normal comparison subjects (P< .01). The results support the hypothesis that CDT score is lower in elderly depressed patients with executive dysfunction versus nondepressed seniors as well as depressed patients without executive dysfunction.

Clock Drawing Test-Modified and Integrated Approach (CDT-MIA): description and preliminary examination of its validity and reliability in dementia patients referred to a specialized psychogeriatric setting

The authors developed a scoring system for clock drawing, based on modification and integration of 3 established scoring methods. The Clock Drawing Test-Modified and Integrated Approach (CDT-MIA) is a 4-step, 20-item instrument, with a maximum score of 33, which emphasizes differential scoring of contour, numbers, hands, and center. It was administered to 139 patients (93 with and 46 without dementia). Dementia patients revealed significantly more impairment on the CDT-MIA total score and hours and hands subscores. Correlations between CDT-MIA and 2 CDTs were high. With receiver operating characteristics (ROC) curves, the area constructed under CDT-MIA curve was large. The best trade-off between sensitivity and specificity for CDT-MIA was the cut-point 23 (91% and 80%, respectively). The internal consistency of CDT-MIA was high, and there was a high degree of interrater reliability. Thus, CDT-MIA was found to be a valid and reliable evaluation instrument for dementia patients in a specialized setting.

Clock Drawing Test in patients with schizophrenia

Investigations of the usefulness of the Clock Drawing Test (CDT) in schizophrenia have focused primarily on institutionalized or elderly patients. The purpose of the present study was to compare CDT performance of patients with schizophrenia living in the community with that of normal controls. Fifty-three patients with schizophrenia were compared with 66 age- and gender-matched normal controls. The CDT ('free-drawn', 'pre-drawn' and three 'examiner' conditions) and the Mini-Mental State Examination (MMSE) were administered to all participants. In patients with schizophrenia, symptom severity was assessed with the Positive and Negative Syndrome Scale (PANSS). Patients with schizophrenia had significantly lower scores on the MMSE and the five CDT conditions than the control group. When MMSE scores and level of education were included in the comparisons as covariates, the differences between the two groups remained significant. MMSE scores of the patients with schizophrenia correlated significantly with four clock conditions: 'free-drawn' 'pre-drawn' and two of the 'examiner' conditions (11:10 and 8:20). Poorer performance on the CDT correlated with higher scores on the PANSS positive symptoms subscale. Qualitative analysis of the clocks that were drawn revealed specific errors in the schizophrenia group relating to frontal processes: difficulty placing numbers in the correct position, failure to indicate the minute targets, displacement of the minute hand from the minute number, and failure to draw a longer minute hand. The fact that the CDT is sensitive enough to detect the cognitive impairment inherent in schizophrenia, as well as being correlated with symptom severity, makes this test useful in roughly assessing cognitive state in schizophrenia.

A population based study on the intra and inter-rater reliability of the clock drawing test in Brazil: the Bambuí Health and Ageing Study

BACKGROUND

Reliability should be considered when selecting a scoring system since it influences validity. CDT reliability has rarely been assessed in population based studies and in developing countries. The aim of the present study was to determine intra and inter-rater reliabilities of the CDT scored by the Shulman (2000) method, in elderly with very low formal educational level from Brazil.

METHODS

CDTs performed by a random sample of 202 subjects of a population-based cohort of elderly were scored on two occasions by the same rater and by two independent raters. Reliability was measured using the kappa statistic, weighted kappa and the intraclass correlation coefficient. Data were stratified according to gender, age and schooling level.

RESULTS

Intra and inter-rater reliabilities were excellent when CDTs were classified as 'normal' (scores 4 or 5) or 'abnormal' (scores 0 to 3) (kappa = 0.99 and 0.94, respectively) and were in the good to excellent range when scored from 0 to 5 (kappa = 0.88 and 0.74, respectively). Difficulties in distinguishing between scores 4 and 5, and a low proportion of score 1 tests were found.

CONCLUSIONS

The CDT scored by the Shulman (2000) method appears to have good to excellent reliability in an elderly population with very low formal educational level. However, difficulties in distinguishing between scores 4 and 5, and a low proportion of score 1 tests suggest these scores may not be totally adequate for this population. Further studies are necessary to determine the consistency of our results in similar populations.

The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly

OBJECTIVES

The aim of this study was to examine the sensitivities and specificities of the clock drawing test (CDT) in the detection of dementia among older people in primary care, with particular emphasis on the effect of depression on CDT specificity. Most previous studies have been sited in specialist settings and few have addressed the issue of specificity against depression.

METHODS

Comparison of cohorts identified from community-based screening with GMS-AGECAT. The CDT and the Mini-Mental State Examination (MMSE) were administered to 41 elderly subjects with organic disorder (dementia), 84 elderly subjects with case level depression and 523 normal elderly subjects. Sensitivities and specificities of the CDT were calculated.

RESULTS

The sensitivity of the CDT in the detection of dementia in the general community was 76%. The specificities of the CDT against normal elderly and depressed elderly was 81% and 77% respectively. Higher sensitivity and specificity were achieved by the MMSE.

CONCLUSIONS

The use of the CDT in the detection of dementia syndromes is likely to be more relevant in the primary care context than in specialist settings. The CDT provides good sensitivity and specificity but may not be as sensitive or specific in the general community as previous studies have suggested, particularly in mild dementia. Community-based late life depression does not appear to alter the specificity of the CDT.

Clock drawing, clock copying, and physical abilities in geriatric rehabilitation

OBJECTIVES

To determine whether clock drawing and clock copying assess domains that are critical for successful rehabilitation and to evaluate the use of these tasks in predicting physical abilities during rehabilitation.

DESIGN

Observational survey study of geriatric cohorts.

SETTING

Inpatient university hospital rehabilitation unit.

PATIENTS

A total of 172 urban geriatric rehabilitation patients with orthopedic, neurologic, or medical diagnoses.

MAIN OUTCOME MEASURES

Clock drawing and copying, FIM instrument, Mattis Dementia Rating Scale, and Neurobehavioral Cognitive Status Examination.

RESULTS

Clock drawing and copying correlated highly with other measures of general cognitive ability. Classifying patients according to established cutoffs on clock drawing and copying revealed that patients with cognitive impairment had poorer physical abilities at discharge.

CONCLUSION

Clock drawing can be used as a brief screening measure to determine cognitive integrity. Clock copying can yield valuable information about geriatric patients' potential acute rehabilitation course and discharge status.

Comparison of a clock drawing test in elderly schizophrenia and Alzheimer's disease patients: a preliminary study

The objective of this study was to compare between the quantitative and qualitative aspects of a clock drawing test in elderly schizophrenic and Alzheimer's disease (AD) patients. Three independent raters performed a retrospective analysis of the clock drawing item from the Cambridge Cognitive Examination (CAMCOG), in long-term open wards of a public psychiatric hospital and an outpatient psychogeriatric clinic. The study group comprised 21 elderly schizophrenic patients ('graduates') and 21 AD patients matched for gender and education, and cognitive impairment confirmed by a Folstein mini-mental state examination (MMSE) score of 18-23. The Clock Drawing Interpretation Scale (CDIS) was the measure used. Schizophrenic patients were significantly younger than AD patients (63.5 versus 81.3 years, p<0.0001), however, similar concerning gender, education, MMSE and CAMCOG scores. CDIS scores were not correlated with age in eight group. Inter-rater reliability was high (range 0.84-0.97). No significant differences between patient groups were found in mean CDIS total scores. A CDIS specific item analysis revealed that schizophrenic patients were significantly less impaired than AD patients on three out of 20 items: Number 7 (most symbols are aligned in a clockwise or a rightward direction). Number 8 (all symbols are totally within a closure figure), and Number 13 (numbers do not go beyond 12). Although schizophrenic patients and AD patients had similar total scores on the clock drawing test, they differed on specific test items related to spatial/planning deficit and preservation.

Clock-drawing: is it the ideal cognitive screening test?

OBJECTIVE

The clock-drawing test has achieved widespread clinical use in recent years as a cognitive screening instrument and a significant amount of literature relates to its psychometric properties and clinical utility. This review aims to synthesize the available evidence and assess the value of this screening test according to well-defined criteria.

DESIGN

A Medline and Psycho-info literature search of all languages was done from 1983 to 1998 including manual cross-referencing of bibliographies. A brief summary of all original scoring systems is provided as well as a review of replication studies. Psychometric data including correlations with other cognitive tests were recorded. Qualitative aspects of the test are also described.

RESULTS

Among published studies, the mean sensitivity (85%) and specificity (85%) of the clock-drawing test are impressive. Correlations with the Mini-Mental State Examination and other cognitive tests was high, generally greater than r = 0.5. High levels of inter-rater and test-re-test reliability and positive predictive value are recorded and despite significant variability in the scoring systems, all report similar psychometric properties. The clock test also shows a sensitivity to cognitive change with good predictive validity.

CONCLUSIONS

The clock-drawing test meets defined criteria for a cognitive screening instrument. It taps into a wide range of cognitive abilities including executive functions, is quick and easy to administer and score with excellent acceptability by subjects. Together with informant reports, the clock-drawing test is complementary to the widely used and validated Mini-Mental State Examination and should provide a significant advance in the early detection of dementia and in monitoring cognitive change. A simple scoring system with emphasis on the qualitative aspects of clock-drawing should maximize its utility.

Correlation between the Folstein Mini-Mental State Examination and three methods of clock drawing scoring

The objective of this study was to assess the correlation between (1) the Folstein Mini-Mental State Examination (MMSE) score and three methods of clock drawing scoring and (2) three methods of clock drawing scoring themselves. A convenience sample of consecutive community-dwelling seniors and attendees at a referral seniors clinic in a tertiary care hospital was used. One hundred fifty participants (72 women, 78 men) were seen with an average age of 76 years. There was a significant correlation (P = .01) between MMSE scores and all three methods of clock drawing (R = .67, .618, -.498, respectively), as well as among the three methods of clock drawing scoring. The clock drawing scores showed good correlation with the MMSE score. The clock drawing is well accepted (by the patient) and easily administered (by the health care provider). Clock drawings are recommended as the minimum requirement for cognitive assessment of elderly patients in busy primary care practices and can be used to highlight those patients requiring additional cognitive testing.