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

REM sleep without atonia and neurocognitive function in isolated REM sleep behaviour disorder: Cross-sectional and longitudinal study

This study investigated the relationship between rapid eye movement sleep without atonia and cognitive profiles in individuals diagnosed with isolated rapid eye movement sleep behaviour disorder, assesssing both cross-sectional associations and their link to phenoconversion in a longitudinal follow-up. Participants underwent video-polysomnography, neurological examination, neuropsychological tests and structured interviews to confirm isolated rapid eye movement sleep behaviour disorder. Rapid eye movement sleep without atonia was manually scored using the Montreal method, and participants were categorized into either high or low electromyography activity groups, based on their tonic and phasic electromyography activities. The cross-sectional study included 250 patients with isolated rapid eye movement sleep behaviour disorder, revealing that those with high tonic electromyography activity exhibited significantly lower scores in the constructional praxis recall than those with low tonic electromyography activity (p = 0.002). In the longitudinal study, 79 participants (63 isolated rapid eye movement sleep behaviour disorder and 16 phenoconversion), tracked for at least 5 years, demonstrated that high tonic electromyography activity (odds ratio: 6.14; 95% confidence interval: 1.23-30.60; p = 0.027) and lower performance on the Trail Making Test A (odds ratio: 0.23; 95% confidence interval: 0.11-0.70; p = 0.007) were associated with future phenoconversion. These results confirm the link between tonic electromyography activity and neurodegeneration in isolated rapid eye movement sleep behaviour disorder. Combining rapid eye movement sleep without atonia assessment with cognitive evaluation could serve as an early predictive marker for phenoconversion in clinical settings.

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.

Classifying Non-Dementia and Alzheimer's Disease/Vascular Dementia Patients Using Kinematic, Time-Based, and Visuospatial Parameters: The Digital Clock Drawing Test

BACKGROUND

Advantages of digital clock drawing metrics for dementia subtype classification needs examination.

OBJECTIVE

To assess how well kinematic, time-based, and visuospatial features extracted from the digital Clock Drawing Test (dCDT) can classify a combined group of Alzheimer's disease/Vascular Dementia patients versus healthy controls (HC), and classify dementia patients with Alzheimer's disease (AD) versus vascular dementia (VaD).

METHODS

Healthy, community-dwelling control participants (n = 175), patients diagnosed clinically with Alzheimer's disease (n = 29), and vascular dementia (n = 27) completed the dCDT to command and copy clock drawing conditions. Thirty-seven dCDT command and 37 copy dCDT features were extracted and used with Random Forest classification models.

RESULTS

When HC participants were compared to participants with dementia, optimal area under the curve was achieved using models that combined both command and copy dCDT features (AUC = 91.52%). Similarly, when AD versus VaD participants were compared, optimal area under the curve was, achieved with models that combined both command and copy features (AUC = 76.94%). Subsequent follow-up analyses of a corpus of 10 variables of interest determined using a Gini Index found that groups could be dissociated based on kinematic, time-based, and visuospatial features.

CONCLUSION

The dCDT is able to operationally define graphomotor output that cannot be measured using traditional paper and pencil test administration in older health controls and participants with dementia. These data suggest that kinematic, time-based, and visuospatial behavior obtained using the dCDT may provide additional neurocognitive biomarkers that may be able to identify and tract dementia syndromes.

Machine Learning Analysis of Digital Clock Drawing Test Performance for Differential Classification of Mild Cognitive Impairment Subtypes Versus Alzheimer's Disease

OBJECTIVE

To determine how well machine learning algorithms can classify mild cognitive impairment (MCI) subtypes and Alzheimer's disease (AD) using features obtained from the digital Clock Drawing Test (dCDT).

METHODS

dCDT protocols were administered to 163 patients diagnosed with AD(n = 59), amnestic MCI (aMCI; n = 26), combined mixed/dysexecutive MCI (mixed/dys MCI; n = 43), and patients without MCI (non-MCI; n = 35) using standard clock drawing command and copy procedures, that is, draw the face of the clock, put in all of the numbers, and set the hands for "10 after 11." A digital pen and custom software recorded patient's drawings. Three hundred and fifty features were evaluated for maximum information/minimum redundancy. The best subset of features was used to train classification models to determine diagnostic accuracy.

RESULTS

Neural network employing information theoretic feature selection approaches achieved the best 2-group classification results with 10-fold cross validation accuracies at or above 83%, that is, AD versus non-MCI = 91.42%; AD versus aMCI = 91.49%; AD versus mixed/dys MCI = 84.05%; aMCI versus mixed/dys MCI = 84.11%; aMCI versus non-MCI = 83.44%; and mixed/dys MCI versus non-MCI = 85.42%. A follow-up two-group non-MCI versus all MCI patients analysis yielded comparable results (83.69%). Two-group classification analyses were achieved with 25-125 dCDT features depending on group classification. Three- and four-group analyses yielded lower but still promising levels of classification accuracy.

CONCLUSION

Early identification of emergent neurodegenerative illness is criterial for better disease management. Applying machine learning to standard neuropsychological tests promises to be an effective first line screening method for classification of non-MCI and MCI subtypes.

An Arabic Version of the Mini-Mental State Examination for the Lebanese Population: Reliability, Validity, and Normative Data

BACKGROUND

The Mini-Mental State Examination (MMSE) has not been validated in the Lebanese population and no normative data exist at the national level.

OBJECTIVE

To evaluate the reliability and validity of an Arabic version of MMSE developed by the "Groupe de Travail sur les Démences de l'Université Saint Joseph" (A-MMSE(GTD-USJ)) and to provide normative data by gender, age, and education in adults over 55.

METHODS

Study design: national cross-sectional survey.

STUDY POPULATION

1,010 literate community-dwelling Lebanese residents aged 55 and above.

OUTCOMES

reproducibility, internal consistency, sensitivity, specificity, predictive values, and area under the curve of the A-MMSE(GTD-USJ) for the detection of cognitive impairment using the Clinical Dementia Rating (CDR) as the gold standard. Normative data were established from 720 healthy adults. A-MMSE(GTD-USJ) scores corresponding to the 5th, 10th, 15th, and 50th percentiles were identified according to gender, age, and education.

RESULTS

Intra-rater and inter-rater test-retest score correlations were 0.89 and 0.72, respectively. Cronbach alpha coefficient for internal consistency of the A-MMSE(GTD-USJ) was 0.71. A threshold value of 23 provided a sensitivity of 80% and a specificity of 89.4%. The area under the curve was 0.92. A-MMSE(GTD-USJ) scores increased with education and decreased with age. Women had significantly lower scores than men. Normative data for A-MMSE(GTD-USJ) stratified by gender, age, and education were generated.

CONCLUSION

In reference to the CDR, the A-MMSE(GTD-USJ) is a valid tool to assess cognitive status among Lebanese subjects aged 55 and above. Normative data will help clinicians in detecting cognitive impairment in this population.

Understated Cognitive Impairment Assessed with the Clock-Drawing Test in Community-Dwelling Individuals Aged ≥50 Years

OBJECTIVES

To estimate the prevalence of understated cognitive impairment by administering the Clock-Drawing Test (CDT) to community-dwelling individuals aged ≥50 years and to investigate the associated clinical phenotype.

DESIGN

A cross-sectional analysis of baseline data on community-dwelling individuals assessed at an outpatient clinic in the Paris region of France.

SETTING AND PARTICIPANTS

Participants aged ≥50 years (n = 488, median age: 62.1 years) prospectively included in the SUCCessful agEing outpatiEnt's Department survey between 2010 and 2014.

METHODS

A multidimensional geriatric assessment, including cognition [7-point CDT, Mini-Mental State Examination (MMSE), the 5-word screening test (5-WT), and the Frontal Assessment Battery (FAB)], gait speed in dual tasks, mood [the Geriatric Depression Scale (GDS)], balance, physical functions (gait speed and handgrip strength), nutrition, bone density, and comorbidities; major cardiovascular risk factors, and Scheltens and Fazekas scores on brain magnetic resonance imaging. Baseline characteristics were analyzed as a function of the CDT score (<7 vs 7), using age-adjusted logistic models.

RESULTS

The prevalence of impairment in the CDT was 23.6%; higher than the values for the MMSE (12.7%), 5-WT (2.3%), and FAB (16.6%). In age-adjusted analyses, a lower educational level (odds ratio [95% confidence interval] = 0.72 [0.58‒0.89]), diabetes (2.57 [1.14‒5.79]), metabolic syndrome (1.93 [1.05‒3.56]), lower gait speed in the cognitive dual task (1.27 [1.05‒1.53]), a poorer Geriatric Depression Scale score (1.86 [1.04‒3.32]), a poorer MMSE score (2.56 [1.35‒4.88]), a poorer FAB score (1.79 [1.01‒3.16]), impaired episodic memory in the 5-WT (4.11 [1.12‒15.02]), and a higher Scheltens score (P = .001) were significantly associated with CDT impairment.

CONCLUSIONS AND IMPLICATIONS

Understated cognitive impairment is common among young seniors and is associated with factors known to be linked to a higher risk of cognitive decline and dementia. These findings suggest that the CDT may be of value for identifying high-risk individuals who may then benefit from targeted multidomain prevention actions (diet, exercise, cognitive training, and vascular risk factor management).

The Neural Correlates of the Clock-Drawing Test in Healthy Aging

Importance: The clock-drawing test (CDT) is an important neurocognitive assessment tool, widely used as a screening test for dementia. Behavioral performance on the test has been studied extensively, but there is scant literature on the underlying neural correlates.

Purpose: To administer the CDT naturalistically to a healthy older aging population in an MRI environment, and characterize the brain activity associated with test completion.

Main Outcome and Measure: Blood-oxygen-level dependent (BOLD) functional MRI was conducted as participants completed the CDT using novel tablet technology. Brain activity during CDT performance was contrasted to rest periods of visual fixation. Performance on the CDT was evaluated using a standardized scoring system (Rouleau score) and time to test completion. To assess convergent validity, performance during fMRI was compared to performance on a standard paper version of the task, administered in a psychometric testing room.

Results: Study findings are reported for 33 cognitively healthy older participants aged 52–85. Activation was observed in the bilateral frontal, occipital and parietal lobes as well as the supplementary motor area and precentral gyri. Increased age was significantly correlated with Rouleau scores on the clock number drawing (R2) component (rho = -0.55, p < 0.001); the clock hand drawing (R3) component (rho = -0.50, p < 0.005); and the total clock (rho = -0.62, p < 0.001). Increased age was also associated with decreased activity in the bilateral parietal and occipital lobes as well as the right temporal lobe and right motor areas.

Conclusion and Relevance: This imaging study characterizes the brain activity underlying performance of the CDT in a healthy older aging population using the most naturalistic version of the task to date. The results suggest that the functions of the occipital and parietal lobe are significantly altered by the normal aging process, which may lead to performance decrements.

Qualitative analysis and identification of pattern of errors in Clock Drawing Tests of community-dwelling older adults

The Clock Drawing Test (CDT) is a frequently employed screening tool with different scoring systems. Quantitative and semi-quantitative scoring systems, such as Sunderland’s et al. (1989), do not discriminate different error patterns. Thus, the same score can represent a number of different neuropsychological profiles. Therefore, the use of a scoring method that emphasizes qualitative aspects to determine specific error patterns is fundamental.

Cognitive Estimation in Non-demented Parkinson's Disease

Objective

The Cognitive Estimation Test (CET) is widely used in clinical and research settings to assess the ability to produce reasonable estimates to items that individuals would not know that the exact answer (e.g., "How fast do race horses run?"). We examined the performance of non-demented Parkinson's disease (PD) patients on the CET, because previous studies reported heterogeneous results about possible cognitive estimation impairments in PD. We also examined whether PD patients improve their performance if given the chance to reconsider their initial CET responses.

Methods

Thirty non-demented idiopathic PD patients and 30 healthy controls matched in age, gender and years of education performed the two parallel forms of Italian CET. The estimation scores for initial and final responses as well as the number of times individuals changed their answers were examined. Additional neuropsychological tests, evaluating intellectual, frontal executive, speed of processing, naming and arithmetical abilities, were also administered.

Results

The PD group were not significantly poorer than healthy controls at estimating the answers to items on either CET versions. Moreover, PD patients did not significantly differ in their initial and final responses or number of response changes. Performance on the CET was significantly related to performance on a global measure of executive function, processing speed and arithmetic. However, PD patients were impaired compared to controls on the component involving mainly, but not exclusively, length-related estimations.

Conclusions

Non-demented PD patients have mild impairments in cognitive estimation ability, which may depend on the estimations they are required to provide.

The Clock Drawing Test versus Mini-mental Status Examination as a Screening Tool for Dementia: A Clinical Comparison

There is a growing incidence of dementia patients in the community, and with this growth, there is need for rapid, valid, and easily administrable tests for the screening of dementia and mild cognitive impairment in the community. This review looks at the two most commonly used tests in dementia screening, namely, the clock drawing test (CDT) and the mini-mental status examination (MMSE). Both these tests have been used in dementia screening over the past three decades and have been the subject of scrutiny of various studies, reviews, and meta-analysis. Both these tests are analyzed on their ability to assess dementia and screen for it in the community, general practice and general hospital settings. The methods of administration and scoring of each test are discussed, and their advantages and disadvantages are explained. There is also a direct comparison made between the MMSE and CDT in dementia screening. Future research needs with these tests are also elucidated.

Correlation of Visuospatial Ability and EEG Slowing in Patients with Parkinson's Disease

Background. Visuospatial dysfunction is among the first cognitive symptoms in Parkinson's disease (PD) and is often predictive for PD-dementia. Furthermore, cognitive status in PD-patients correlates with quantitative EEG. This cross-sectional study aimed to investigate the correlation between EEG slowing and visuospatial ability in nondemented PD-patients. Methods. Fifty-seven nondemented PD-patients (17 females/40 males) were evaluated with a comprehensive neuropsychological test battery and a high-resolution 256-channel EEG was recorded. A median split was performed for each cognitive test dividing the patients sample into either a normal or lower performance group. The electrodes were split into five areas: frontal, central, temporal, parietal, and occipital. A linear mixed effects model (LME) was used for correlational analyses and to control for confounding factors. Results. Subsequently, for the lower performance, LME analysis showed a significant positive correlation between ROCF score and parietal alpha/theta ratio (b = .59, p = .012) and occipital alpha/theta ratio (b = 0.50, p = .030). No correlations were found in the group of patients with normal visuospatial abilities. Conclusion. We conclude that a reduction of the parietal alpha/theta ratio is related to visuospatial impairments in PD-patients. These findings indicate that visuospatial impairment in PD-patients could be influenced by parietal dysfunction.

Patient and Clinician Assessments of Symptomatology Changes on Older Adults Following a Psycho-educational Program for Depression and Anxiety

Important attention has been given to the assessment of patients' perspectives on treatment, especially as outcomes have been typically evaluated by clinicians. This study examined the association between patient and clinician ratings on perceived improvement and symptomatology changes for an older adult population participating in an ongoing psycho-educational program. Pre-post measures including depression (GDS), anxiety (BAI) and general well-being (GWBS) were collected in a sample of 34 older adults (age = 71.32 ± 6.46 years). Post-testing data included perceived improvement rated by patients, and clinician assessment of depressive symptoms (CS-GDS). Results indicate significant correlations between pre-post changes of the GDS and patients' PIQ (r = -0.37, n = 31, p < 0.05), but not on symptomatic changes of the BAI (r = 0.012, n = 32, p > 0.05) or the GWBS (r = 0.12, n = 31, p > 0.05). Relationships between patients' PIQ and post-ratings on GDS (r = -0.74, n = 33, p < 0.05) and CS-GDS (r = -0.48, n = 32, p < 0.05) are also significant. Results imply that pre-post improvement in depressive symptoms is associated with a patient's perceived improvement and that clinician and patient ratings on depression symptoms post-treatment were both inversely correlated to patients' perceived improvement. Findings suggest that the PIQ is a good indicator to assess symptomatic change by patients and clinicians although they are possibly placing attention on different aspects of treatment outcome, as indicated by differences on sub-scales of the PIQ. Clinicians possibly place a strong focus on assessments of depression symptomatology. Future studies may integrate simultaneous assessments of instruments exploring aspects other than depression, especially those examining representations of illness in older adults.

The role of cognitive reserve on terminal decline: a cross-cohort analysis from two European studies: OCTO-Twin, Sweden, and Newcastle 85+, UK

OBJECTIVE

Cognitive performance shows a marked deterioration in close proximity to death, as postulated by the terminal decline hypothesis. The effect of education on the rate of terminal decline in the oldest people (i.e. persons 85+ years) has been controversial and not entirely understood. In the current study, we investigated the rate of decline prior to death with a special focus on the role of education and socioeconomic position, in two European longitudinal studies of ageing: the Origins of Variance in the Old-Old: Octogenarian Twins (OCTO-Twin) and the Newcastle 85+ study.

METHODS

A process-based approach was used in which individuals' cognitive scores were aligned according to distance to death. In a coordinated analysis, multilevel models were employed to examine associations between different markers of cognitive reserve (education and socioeconomic position) and terminal decline using the mini-mental state examination (MMSE), controlling for age at baseline, sex, dementia incidence and time to death from the study entry to the time of death within each cohort.

RESULTS

The current findings suggest that education was positively associated with higher MMSE scores prior to death in the OCTO-Twin, but not in the Newcastle 85+ study, independent of socioeconomic position and other factors such as baseline age, sex and time to death from the study entry. However, education was not associated with the rate of terminal decline in both of these studies.

CONCLUSIONS

Our results offer only partial support to the cognitive reserve hypothesis and cognitive performance prior to death.

Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations

BACKGROUND

The Mini Mental State Examination (MMSE) is a cognitive test that is commonly used as part of the evaluation for possible dementia.

OBJECTIVES

To determine the diagnostic accuracy of the Mini-Mental State Examination (MMSE) at various cut points for dementia in people aged 65 years and over in community and primary care settings who had not undergone prior testing for dementia.

SEARCH METHODS

We searched the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), LILACS (BIREME), ALOIS, BIOSIS previews (Thomson Reuters Web of Science), and Web of Science Core Collection, including the Science Citation Index and the Conference Proceedings Citation Index (Thomson Reuters Web of Science). We also searched specialised sources of diagnostic test accuracy studies and reviews: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). We attempted to locate possibly relevant but unpublished data by contacting researchers in this field. We first performed the searches in November 2012 and then fully updated them in May 2014. We did not apply any language or date restrictions to the electronic searches, and we did not use any methodological filters as a method to restrict the search overall.

SELECTION CRITERIA

We included studies that compared the 11-item (maximum score 30) MMSE test (at any cut point) in people who had not undergone prior testing versus a commonly accepted clinical reference standard for all-cause dementia and subtypes (Alzheimer disease dementia, Lewy body dementia, vascular dementia, frontotemporal dementia). Clinical diagnosis included all-cause (unspecified) dementia, as defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); International Classification of Diseases (ICD) and the Clinical Dementia Rating.

DATA COLLECTION AND ANALYSIS

At least three authors screened all citations.Two authors handled data extraction and quality assessment. We performed meta-analysis using the hierarchical summary receiver-operator curves (HSROC) method and the bivariate method.

MAIN RESULTS

We retrieved 24,310 citations after removal of duplicates. We reviewed the full text of 317 full-text articles and finally included 70 records, referring to 48 studies, in our synthesis. We were able to perform meta-analysis on 28 studies in the community setting (44 articles) and on 6 studies in primary care (8 articles), but we could not extract usable 2 x 2 data for the remaining 14 community studies, which we did not include in the meta-analysis. All of the studies in the community were in asymptomatic people, whereas two of the six studies in primary care were conducted in people who had symptoms of possible dementia. We judged two studies to be at high risk of bias in the patient selection domain, three studies to be at high risk of bias in the index test domain and nine studies to be at high risk of bias regarding flow and timing. We assessed most studies as being applicable to the review question though we had concerns about selection of participants in six studies and target condition in one study.The accuracy of the MMSE for diagnosing dementia was reported at 18 cut points in the community (MMSE score 10, 14-30 inclusive) and 10 cut points in primary care (MMSE score 17-26 inclusive). The total number of participants in studies included in the meta-analyses ranged from 37 to 2727, median 314 (interquartile range (IQR) 160 to 647). In the community, the pooled accuracy at a cut point of 24 (15 studies) was sensitivity 0.85 (95% confidence interval (CI) 0.74 to 0.92), specificity 0.90 (95% CI 0.82 to 0.95); at a cut point of 25 (10 studies), sensitivity 0.87 (95% CI 0.78 to 0.93), specificity 0.82 (95% CI 0.65 to 0.92); and in seven studies that adjusted accuracy estimates for level of education, sensitivity 0.97 (95% CI 0.83 to 1.00), specificity 0.70 (95% CI 0.50 to 0.85). There was insufficient data to evaluate the accuracy of the MMSE for diagnosing dementia subtypes.We could not estimate summary diagnostic accuracy in primary care due to insufficient data.

AUTHORS' CONCLUSIONS

The MMSE contributes to a diagnosis of dementia in low prevalence settings, but should not be used in isolation to confirm or exclude disease. We recommend that future work evaluates the diagnostic accuracy of tests in the context of the diagnostic pathway experienced by the patient and that investigators report how undergoing the MMSE changes patient-relevant outcomes.

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

The Clock Drawing Test (CDT) is an inexpensive, fast and easily 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 can be applied in different ways 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 adapted 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 State Examination (MMSE) were administered to all participants. Six independent examiners scored the CDT of 30 participants to evaluate inter-rater reliability.

Results and Conclusion

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

Geriatric multidimensional assessment for elderly patients with acute respiratory diseases

The case of an 87-year-old woman who falls at home and is admitted to the Emergency Department of an acute hospital with delirium exemplify a common situation that physicians face in their everyday clinical practice. We describe the typical context of frailty in which acute illnesses frequently present in frail elderly patients and, in particular, the relationship between comorbidity, disability and frailty. We also report the current knowledge about frailty theories and we focus on the "atypical" presentation of many acute illnesses. Major attention is devoted on delirium and on mobility impairment, two of the most common atypical symptoms of elderly frail subjects. Finally we describe the evidence on the comprehensive geriatric assessment, i.e., the method that is required to identify and understand the ultimate needs of elderly complex subjects.

Cognitive function is a risk for health literacy in older adults with diabetes

AIMS

Cognitive impairment is common in older adults with diabetes, yet it is unclear to what extent cognitive function is associated with health literacy. We hypothesized that cognitive function, independent of education, is associated with health literacy.

METHODS

The sample included 537 African American, American Indian, and White men and women 60 years or older. Measures of cognitive function included the Mini-Mental State Examination (MMSE), Verbal Fluency, Brief Attention, and Digit Span Backward tests. Health literacy was assessed using the S-TOFHLA.

RESULTS

Cognitive function was associated with health literacy, independent of education and other important confounders. Every unit increase in the MMSE, Digit Span Backward, Verbal Fluency or Brief Attention was associated with a 20% (p<.001), 34% (p<.001), 5% (p<.01), and 16% (p<.01) increase in the odds of having adequate health literacy, respectively.

CONCLUSIONS

These results suggest that cognitive function is associated with health literacy in older adults with diabetes. Because poor cognitive function may undermine health literacy, efforts to target older adults on improving health literacy should consider cognitive function as a risk factor.

Detection of memory impairment in a community-based system: a collaborative study

The ability to distinguish between older people with cognitive impairment and those who age in a healthy manner is crucial because cognitive impairment may be a precursor to full-blown dementia. Therefore, an early diagnosis of cognitive impairment is important. However, patients are often admitted to a hospital only when they already have a serious cognitive impairment. Consequently, cooperative studies between clinics and community-based organizations may assist hospitals in detecting early cognitive impairment. This article examines how community-based organizations can contribute to the early diagnosis of dementia. A cooperation model between the Neurology Department of Mersin University Hospital and the Mersin branch of the Alzheimer's Association was developed. Trained professionals used a neuropsychological battery to evaluate 50 individuals at the Mersin branch of the Alzheimer's Association in Turkey. Individuals whose performance fell below the average (1 standard deviation or less) were subsequently referred to the hospital. On the basis of the neurological and neuropsychological assessments, 11 participants were placed in the mild cognitive impairment group and 39 were placed in the healthy group. The results suggest that the Standardized Mini-Mental State Examination and the Three Words-Three Shapes Test are useful tools for detecting early memory impairments in a community-based setting.

A quick test of cognitive speed (AQT): usefulness in dementia evaluations in primary care

OBJECTIVE

To validate A Quick Test of Cognitive Speed (AQT) as an instrument in diagnostic dementia evaluations against final clinical diagnosis and compare AQT with the Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) in primary care.

DESIGN

Primary health care cohort survey.

SETTING

Four primary health care centres and a geriatric memory clinic in Sweden.

PATIENTS

81 patients (age 65 and above) were included: 52 with cognitive symptoms and 29 presumed cognitively healthy. None of the patients had a previous documented dementia diagnosis. All patients performed MMSE, CDT, and AQT at the primary health care clinic and were referred for extensive neuropsychological testing at a memory clinic. AQT was validated against final clinical diagnosis determined by a geriatric specialist and a neuropsychologist.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratios, correlation data, and receiver operating characteristic (ROC).

RESULTS

For MMSE, sensitivity and specificity was 0.587 and 0.909; CDT 0.261 and 0.879; and AQT 0.783 and 0.667, respectively. For the combination of MMSE and CDT, sensitivity and specificity was 0.696 and 0.788, for MMSE and AQT 0.913 and 0.636. The ROC curve for AQT showed an area under curve (AUC) of 0.773.

CONCLUSION

Our results suggest AQT is a usable test for dementia assessments in primary care. Sensitivity for AQT is superior to CDT, equivalent to MMSE, and comparable to the combination MMSE and CDT. MMSE in combination with AQT improves sensitivity. Because AQT is user-friendly and quickly administered, it could be applicable for primary care settings.

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.

The relationship between cognitive function and non-prescribed therapy use in older adults

OBJECTIVES

To examine the association of cognitive function with use of non-prescribed therapies for managing acute and chronic conditions, and to determine whether use of non-prescribed therapies changes over time in relation to baseline cognitive function.

METHODS

200 community-dwelling adults aged 65 and older were recruited from three counties in south central North Carolina. Repeated measures of daily symptoms and treatment were collected on three consecutive days at intervals of at least one month. The Mini-Mental State Examination, the primary cognitive measure, was collected as part of the baseline survey. Data were collected on the daily use of common non-prescribed therapies (use of prayer, ignore symptoms, over-the-counter remedies, food and beverage therapies, home remedies, and vitamin, herb, or supplements) on each of the three days of the follow-up interviews for up to six consecutive months.

RESULTS

Older adults with poorer cognitive function were more likely to pray and ignore symptoms on days that they experienced acute symptoms. Poorer cognitive function was associated with increased use of home remedies for treating symptoms related to existing chronic conditions.

CONCLUSIONS

Cognitive function may play a role in why older patients use some non-prescribed therapies in response to acute and chronic conditions.

[Establishment of a short-form screening test for cognitive decline as part of a newly developed comprehensive geriatric assessment initiative named 'Dr. Superman']

AIM

The assessment of cognitive function is important in comprehensive geriatric assessment (CGA), and several standardized screening tests for dementia such as the Mini-Mental State Examination (MMSE) are available. However, it takes 5 to 20 minutes to perform the MMSE. We have developed a CGA initiative named 'Dr. Superman' which is designed to accomplish CGA within 10 minutes. In this study, we evaluated a short-form screening test for cognitive decline preceding the MMSE.

METHODS

The MMSE and a question on episodic memory, ("What kind of food did you have last night?") were administered to 90 elderly outpatients with various diseases. They were divided into 2 groups according to their MMSE scores: a normal group (MMSE score≥24) and an abnormal group (MMSE score≤23). Within these groups, each domain (D) (D1: time orientation, D2: place orientation, D3: immediate memory, D4: calculation, D5: recall, D6: language, and D7: spatial cognition) and episodic memory was separately scored and the sensitivity, specificity, and positive predicative value of each were calculated. Based on these data, the best combination of the domains was evaluated for practical use as an assessment tool.

RESULTS

The MMSE scores ranged from 10 to 30, and 42 cases were classified into the normal group. High sensitivity, specificity, or positive predicative value was observed in D1, D2, D4, D5 and episodic memory categories. On the basis of the characteristics of each item in these domains in order to make a short-form assessment, a combination of "What is this year" in D1, "Serial 7's twice" in D4, and a question on episodic memory was found to be superior to other combinations (sensitivity: 93.8%; specificity: 71.4%; positive predicative value: 78.9%). Using this combination for 50 outpatients with 2 raters, it took 32 to 55 seconds to accomplish the assessment with good inter-rater reliability (κ=0.861).

CONCLUSIONS

The combination of "What is this year?", "Serial 7's twice", and "What kind of food did you have last night?" was the best and most valuable short-form screening test for cognitive decline.

Screening and case-finding tools for the detection of dementia. Part II: evidence-based meta-analysis of single-domain tests

AIM

To evaluate the diagnostic validity of single-domain cognitive tests for detecting dementia. These methods were defined as those that focus mainly on one domain of cognitive function such as orientation, memory, or executive function.

METHODS

A meta-analysis of robust studies was conducted. There were 15 categories of single-domain methods assessed in 45 analyses, including 27 performed head-to-head against the Mini-Mental State Examination (MMSE). Thirteen studies took place in community settings, 9 in primary care, and 23 in specialist settings.

RESULTS

In community settings, single-domain cognitive tests helped detect 64.2% of all dementias. In this setting, specificity (Sp) was 84.9%, positive predictive value (PPV) was 57.1%, and negative predictive value (NPV) was 88.3%. This was significantly less accurate than the MMSE itself. The optimal individual method was the memory impairment screen (MIS). In primary care, the sensitivity (Se) and specificity of single-domain tests were 69.5% and 82.5%, respectively. The PPV and NPV were 36.5% and 95.8%. Considered together, these methods were less specific but equally sensitive as the MMSE when applied in primary care. Here, the most successful methods were the selective reminding test (SRT) and clock drawing test, the latter having data from independent samples. In specialist settings, single-domain methods had a Se of 76.6%, a Sp of 81.9%, a PPV 80.8%, and a NPV 74.9%. This represented almost equivalent accuracy to the MMSE. The optimal method for specialist settings (based on accuracy alone) was the memory alteration test.

CONCLUSION

Brief single-domain methods offer diagnostic performance for detection of dementia that is surprisingly close to that offered by cognitive batteries such as the MMSE. As a method of screening or as part of a diagnostic algorithm, brief single-domain tests may be an efficient first step in identifying cognitive impairment.

Computerized kinematic analysis of the clock drawing task in elderly people with mild major depressive disorder: an exploratory study

BACKGROUND

Developments in data collection technology enable evaluation of kinematic characteristics of the drawing process. We examined the clock drawing task in elderly patients with mild Major Depressive Disorder (MDD), assessed the relative importance of kinematic measures that differentiate the groups and analyzed associations between computerized measures, and the cognitive and depression status of the study groups.

METHODS

The participants comprised 20 elderly people with mild MDD and 20 matched controls. Both groups performed a clock drawing task using a computerized system. Kinematic measures included: number of segments drawn, performance time, pressure implemented towards the drawing surface, and pen azimuth. Three representative spatial characteristics were analyzed per segments drawn on the paper: height, width and length. The clock drawing tasks were blindly scored with Freedman's method. Cognitive state was quantified using the Mini-mental State Examination (MMSE) and depression with the Geriatric Depression Scale (GDS).

RESULTS

Freedman's method found no between-group differences. Pressure and azimuth measures and spatial measures of segments height, width and length were significantly lower in the mild MDD group, while the number of paper segments and performance time did not differ. The azimuth measure correlated with the GDS score, and pressure with the MMSE and the GDS scores. Spatial measures did not correlate with either the MMSE or GDS. Pressure, segment width and length, azimuth and segment height allowed correct classification of 81.1% of the participants.

CONCLUSIONS

A computerized system focusing on the clock drawing task might be sensitive to altered performance among elderly people with mild MDD.

The Mini-mental State Examination revisited: ceiling and floor effects after score adjustment for educational level in an aging Mexican population

BACKGROUND

The Mini-mental State Examination (MMSE) is the most widely used cognitive test, both in clinical settings and in epidemiological studies. However, correcting its score for education may create ceiling effects when used for poorly educated people and floor effects for those with higher education.

METHODS

MMSE and a recent cognitive test, the seven minute screen (7MS), were serially administered to a community sample of Mexican elderly. 7MS test scores were equated to MMSE scores. MMSE-equated 7MS differences indicated ceiling or floor effects. An ordinal logistic regression model was fitted to identify predictors of such effects.

RESULTS

Poorly educated persons were more prevalent on the side of MMSE ceiling effects. Concentration (serial-sevens), orientation and memory were the three MMSE subscales showing the strongest relationship to MMSE ceiling effects in the multivariate model.

CONCLUSION

Even when MMSE scores are corrected for educational level they still have ceiling and floor effects. These effects should be considered when interpreting data from longitudinal studies of cognitive decline. When an education-adjusted MMSE test is used to screen for cognitive impairment, additional testing may be required to rule out the possibility of mild cognitive impairment.

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

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.

A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment

The MMSE is the most widely used cognitive test but its accuracy and clinical utility in diagnosing cognitive disorders is not fully known. A meta-analysis of 34 dementia studies and five mild cognitive impairment (MCI) studies was conducted, separated into high and low prevalence settings. In memory clinic settings the MMSE had a pooled sensitivity (Se) of 79.8%, a specificity (Sp) of 81.3%, a positive predictive value (PPV) of 86.3% and a negative predictive value (NPV) of 73.0%. In mixed specialist hospital settings the Se, Sp, PPV and NPV were 71.1%, 95.6%, 94.2% and 76.4%, respectively. In non-clinical community settings the MMSE had a pooled Se of 85.1%, a Sp of 85.5%, a PPV of 34.5% and an NPV of 98.5%. In those studies conducted purely in primary care the Se, Sp, PPV and NPV were 78.4%, 87.8%. 53.6% and 95.7%, respectively. Thus the case-finding ability of the MMSE was best when confirming a suspected diagnosis in specialist settings with correct identification made in 27/30 positive results. It was modestly effective at ruling-out dementia in specialist settings. Conversely, in non-specialist settings, the MMSE was best at ruling out dementia, achieving about 29/30 correct reassurances with less than three false negatives out of every 100 screens. Regarding use of the MMSE in identifying MCI, limited evidence was found with only five robust studies comparing MCI with healthy subjects and three comparing Alzheimer's disease with MCI. Provisionally, the MMSE had very limited value in making a diagnosis of MCI against healthy controls and modest rule-out accuracy. It had similarly limited ability to help identify cases of Alzheimer's disease against MCI. In conclusion the MMSE offers modest accuracy with best value for ruling-out a diagnosis of dementia in community and primary care. For all other used it should be combined with or replaced by other methods.

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.

Screening for dementia in primary care: a review of the use, efficacy and quality of measures

BACKGROUND

Despite evidence that early identification of dementia is of growing policy and practice significance in the U.K., limited work has been done on evaluating screening measures for use in primary care. The aim of this paper is to offer a clinically informed synthesis of research and practice-based evidence on the utility, efficacy and quality of dementia screening measures.

METHOD

The study has three elements: a review of research literature, a small-scale survey of measures employed in three primary care trusts, and a systematic clinical evaluation of the most commonly used screening instruments. The study integrates data from research and clinical sources.

RESULTS

The General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS), and the Mini-Cognitive Assessment Instrument (Mini-Cog) were found to be brief, easy to administer, clinically acceptable, effective, and minimally affected by education, gender, and ethnicity. All three have psychometric properties similar to the Mini-mental State Examination (MMSE).

CONCLUSIONS

Although the MMSE is widely used in the U.K., this project identifies the GPCOG, MIS and Mini-Cog as clinically and psychometrically robust and more appropriate for routine use in primary care. A coherent review of evidence coupled with an indepth evaluation of screening instruments has the potential to enhance ability and commitment to early intervention in primary care and, as part of a wider educational strategy, improve the quality and consistency of dementia screening.

Clocking Delirium: The Value of the Clock Drawing Test with Case Illustrations

Screening for impaired cognition is very important in geriatric and palliative medicine. There are several validated screening tools for delirium; the Confusion Assessment Method, The Memorial Delirium Assessment Scale, and the Bedside Confusion Scale. The Clock Drawing Test, which was initially described in 1963, has also been used to assess cognition and is validated in Alzheimer's disease and in elderly hospice patients with a negative predictive value greater than 0.95. The Clock Drawing Test is quickly and easily performed by patients and can be kept in the patient's medical record for future reference. However, very few studies have used the Clock Drawing Test to assess delirium in cancer and even fewer have used the Clock Drawing Test to determine response to interventions for delirium.

Clock drawing performance and brain morphology in mild cognitive impairment and Alzheimer's disease

The Clock Drawing Test (CDT) is a widely used instrument in the neuropsychological assessment of Alzheimer's disease (AD). As CDT performance necessitates several cognitive functions (e.g., visuospatial and constructional abilities, executive functioning), an interaction of multiple brain regions is likely. Fifty-one subjects with mild cognitive impairment, 23 with AD and 15 healthy controls underwent high-resolution magnetic resonance imaging. Optimized voxel-based morphometry (VBM) was performed to investigate the putative association between CDT performance and gray matter (GM) density throughout the entire brain. In the first step of analysis (p<.001, uncorrected), VBM revealed a reduced GM density in numerous cortical (temporal lobe, frontal lobe, parietal lobe, cerebellum) and subcortical (thalamus, basal ganglia) brain regions to be associated with poorer CDT performance. When corrected for multiple comparisons (p<.01), the associations remained significant predominantly in the left temporal and--less pronounced--the right temporal lobe. VBM demonstrated CDT performance to depend on the integrity of widely distributed cortical and subcortical areas in both brain hemispheres with accentuation in the left-sided temporal lobe region.

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.

Use of the clock-drawing test in a hospice population

BACKGROUND

Cognitive impairment is common in patients with advanced disease and has significant implications for the patient, their carers and hospice staff. The effectiveness of screening tools is limited by a number of factors. The clock-drawing test (CDT) has performed well in other settings but has rarely been studied in the hospice setting.

AIM

To assess the performance of the CDT in a hospice population.

METHODS

Consecutive admissions to a large hospice over three months were assessed using the CDT, the abbreviated mental test score and brief tests of attention and memory function.

RESULTS

One-hundred and nine eligible patients were admitted and 77% took part. Thirty per cent were cognitively impaired. The CDT had a sensitivity of 0.92, a specificity of 0.73 and a negative predictive value of 0.95. No patient refused to complete it.

CONCLUSIONS

The CDT performs well as a screening tool for cognitive impairment in a hospice population.

What is the best dementia screening instrument for general practitioners to use?

OBJECTIVE

The objective of this study was to review existing dementia screening tools with a view to informing and recommending suitable instruments to general practitioners (GPs) based on their performance and practicability for general practice.

METHOD

A systematic search of pre-MEDLINE, MEDLINE, PsycINFO, and the Cochrane Library Database was undertaken. Only available full-text articles about dementia screening instruments written in English or with an English version were included. Articles using a translation of an English language instrument were excluded unless validated in a general practice, community, or population sample.

RESULTS

The General Practitioner Assessment of Cognition (GPCOG), Mini-Cog, and Memory Impairment Screen (MIS) were chosen as most suitable for routine dementia screening in general practice. The GPCOG, Mini-Cog, and MIS were all validated in community, population, or general practice samples, are easy to administer, and have administration times of 5 minutes or less. They also have negative predictive validity and misclassification rates, which do not differ significantly from those of the Mini-Mental Status Examination.

CONCLUSIONS

It is recommended that GPs consider using the GPCOG, Mini-Cog, or MIS when screening for cognitive impairment or for case detection.

Performance of three clock scoring systems across different ranges of dementia severity

The ability of three different Clock Drawing Test (CDT) scoring systems to detect Dementia of the Alzheimer Type (DAT) was investigated. As part of a neuropsychological battery, fifty DAT Type patients and fifty matched controls drew a clock. Each drawing was scored by three independent raters according to three different scoring systems: the 3-Factor system, the Template system, and the Abbreviated system. The CDT scoring systems were able to detect Dementia of the Alzheimer Type when the disease was moderate to severe, but lacked sensitivity in milder dementia. Animal Fluency was a better single predictor of dementia. Clinicians are advised to interpret the results of the Clock Drawing Test cautiously in an outpatient setting, where milder forms of dementia and low base rates are likely.

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.

Correlation between the CAMCOG, the MMSE, and three clock drawing tests in a specialized outpatient psychogeriatric service

Our objective was to assess the correlation between (1) the Cambridge Cognitive Examination (CAMCOG) (including the Mini-Mental State Examination [MMSE]) score and three clock drawing tests (CDT) and (2) the three CDTs independently, in a specialized outpatient psychogeriatric service. One hundred and fourteen subjects completed a comprehensive evaluation and were allocated to one of the following groups: dementia of the Alzheimer's type (DAT) in 52; vascular dementia (VD) in 36; non-dementia (ND; Mood or Anxiety Disorders) in 26. When the entire sample of patients is considered, all three CDTs used were highly and significantly correlated to the MMSE score, the CAMCOG score, and to each other. In this patient population, these cognitive tests may be interchangeable for providing an initial objective measure of cognitive function. However, when the same correlations were studied in the separate diagnostic groups, in the dementia group (DAT and VD) even though the high correlations between the various CDTs themselves did not change, the correlations between the MMSE score, the CAMCOG score and the CDTs decreased, more evidently in the VD group. This trend became even more conspicuous in the ND group, where some of the above mentioned correlations became non-significant. We hypothesize that in a real clinical situation the clinician initially assumes the role of cognitive "evaluator" (in terms of the total sample) followed by the role of cognitive "monitor" (in relation to specific diagnostic groups). In the first instance, CDTs, the MMSE, and the CAMCOG might be considered interchangeable as an initial objective measure of cognitive dysfunction, while in the second role, different CDTs might be diversely used, presumably supplemented by other cognitive tests and clinical methods.

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.

The clock-drawing test in elderly Italian community dwellers: associations with sociodemographic status and risk factors for vascular cognitive impairment

To evaluate whether performance in the clock-drawing test (CDT) is associated with sociodemographic status and risk factors for cognitive impairment, we examined 744 Italian community dwellers aged > or =65 (73 +/- 6) years scoring > or =24 on the MMSE. CDT was scored by two different methods, the Sunderland and the Wolf-Klein methods. Sociodemographic, lifestyle, clinical and biochemical variables were also recorded. For both scoring methods, lower CDT scores were associated with age, poor education, increased serum C-reactive protein and history of cancer. Associations of lower CDT scores with increased serum glucose and history of cerebrovascular disease were also found for the method with the highest sensitivity to cognitive impairment. This study shows that in elderly community dwellers, CDT may be not totally free from sociodemographic biases, and that it is associated with risk factors for cognitive impairment and frailty.

Are the clock-drawing test and the MMSE combined interchangeable with CAMCOG as a dementia evaluation instrument in a specialized outpatient setting?

This study examines whether the Clock-Drawing Test (CDT) combined with the Mini-Mental State Examination (MMSE) is interchangeable with the more detailed and lengthy Cambridge Cognitive Examination (CAMCOG) as a dementia evaluation instrument in a specialized psychogeriatric outpatient setting: 114 outpatients (88 with dementia, 26 with depressive and anxiety disorders) were included. Each subject underwent a comprehensive evaluation in which the CAMCOG (MMSE included) was administered. DSM-IV diagnoses were independently established. CAMCOG-derived clock drawings were blindly scored according to Freedman's method. The authors found that a combination of CDT and MMSE enhanced the psychometric properties of the above scales approximating them to CAMCOG's. They conclude that CDT in combination with the MMSE is valid for differentiation of dementia sufferers from nondemented psychiatric controls in a specialistic setting and might replace CAMCOG. However, the generalizability of these findings (a wider range of diagnoses, primary care settings) still needs to be verified.

The clock drawing test and questionable dementia: reliability and validity

OBJECTIVES

In order to evaluate the suitability of the clock drawing test (CDT) for the detection of questionable dementia (QD), we assessed the inter-rater reliabilities and intercorrelations of four common scoring methods of the CDT in a sample of non-demented subjects and determined the concurrent validity.

METHODS

The study sample consisted of 253 discharged general hospital patients, aged between 65 and 85 years. Subjects were screened for cognitive impairment during their hospital stay. Four to six weeks after discharge each non-demented patient was visited at home and interviewed by a trained psychologist. The interview procedure included a cognitive test battery incorporating the CDT, the Mini-Mental State Examination (MMSE), the Syndrome Short Test (SKT), and a verbal fluency test (VF). The criteria of the Clinical Dementia Rating (CDR) were used to differentiate between cognitively normal subjects and those with QD. Clock drawings were scored independently and blindly by two raters according to four different methods. The agreement between raters was assessed, as well as the agreement between the different scoring methods. The association of gender, education, age, test performance and CDR-rating with CDT scores was examined. Accuracy of the CDT for the detection of QD was calculated.

RESULTS

Inter-rater reliabilities were high for all four scoring methods. However, substantial differences among the scoring methods were observed, the proportion of abnormal test results varying between 9% and 50%. The CDT correlated significantly with MMSE, SKT and VF, but correlation coefficients were low (r = 0.13 to r = 0.32). Furthermore, CDT scores were influenced by age, gender, and education. Sensitivity of the CDT for QD was 66%, specificity was 65%; the negative predictive value was 73%, the positive predictive value 58%.

CONCLUSION

In a sample of non-demented elderly, the reliability of the CDT was sufficiently high, but the different scoring methods were not equivalent. When established cut-off scores were used, the proportion of abnormal CDTs were significantly different. Concurrent validity with other common cognitive tests was unsatisfactory. The CDT lacks sufficient sensitivity and specificity for the identification of QD and should not be used alone to screen for possible prodromal stages of dementing illnesses. The association of age, gender and level of education with CDT scores should be taken into account by clinicians using the CDT.