Effects of education, literacy, and dementia on the Clock Drawing Test performance

Clock Drawing Test Performance of Young Adults Based on a One-Shot Case Study

OBJECTIVE

The clock drawing test (CDT) is being used regularly by medical professionals in a variety of settings to aid in assessing cognitive functioning in adults of all ages. As our technological environment has changed significantly, because of the inception of this measure, the use of and exposure to the analog clock have diminished. We investigated whether young adults, who have grown up in a mainly digital world, can draw and tell time on an analog clock.

METHOD

Participants aged 18-30 years (N = 80, Mage = 24.2, SD = 3.93), who self-identified as having normal cognition, completed the CDT, as well as setting hands on a pre-drawn clock and identifying analog clock times.

RESULTS

About 25% of participants received a CDT score below the expected range. There was a moderate, positive correlation between analog clock hand setting and time identification in the group who scored below the expected range on the CDT only (rs(16) = 0.472, p = .048). Most participants reported not wearing an analog watch.

CONCLUSIONS

Based on these findings, the CDT should be used with caution to screen cognitive functioning in young adults (i.e., aged 18-30 years). Consideration of an alternative approach to screening cognition and modifying cognitive assessments in which the CDT is embedded is recommended for this population. These findings warrant further investigation into CDT performance in the young adult population.

Normative Scores on the Clock Drawing Test Among Older Adults from a Large Population Survey in Norway: The HUNT Study

Background

The Clock Drawing Test (CDT) is used to screen for Alzheimer's disease and other dementia disorders. Normative scores on the version from the Montreal Cognitive Assessment (MoCA) do not exist in the Nordic countries.

Objective

To examine the normative scores of the CDT among adults aged 70 years and older.

Methods

We included 4,023 cognitively healthy persons aged 70-97 years from a population survey in Norway. They were examined with the CDT, which has a total score between zero and three. A multiple multinominal regression model was applied with a CDT score as the dependent categorical variable and estimated the probabilities of scoring a particular score, stratified by age, sex, and education. These probabilities correspond to an expected proportion of the normative population scoring at, or below a given percentile.

Results

None scored zero, 2.1% scored one, 14.9% scored two, and 83% scored three. Higher age, female sex and fewer years of schooling were associated with poorer performance. Scores of zero and one deviated from the normative score regardless of age, sex and education. A score of two was within the norm for a female older than 81 and a male older than 85.

Conclusions

The majority (83%) of people 70 years and older had a score of three on the CDT. Lower age, male sex, and higher education were associated with a better performance. Scores of zero and one were below the normative score. Except for the very old, a score of two was also well below the normative score.

[Discriminant validity and inter-rater concordance of two scoring systems for the clock test]

OBJECTIVE

To compare the discriminant validity and inter-rater reliability of the two scoring systems for the Clock test that are most used in Spain.

METHODOLOGY

Two collections of clock drawings obtained in a clinical context (116 cases; 56.8% women, mean age 73.1±7.7 years) and in a cohort of volunteers (2039 drawings of 579 subjects; 59.5% women, mean age 78.3±3.8 years) have been assessed. All subjects were classified as cognitively normal (CN) or cognitively impaired (CI) after extensive clinical and neuropsychological evaluation. Expert raters have evaluated these drawings independently and without knowledge of the diagnosis using the Sunderland and Solomon systems standardized in Spanish by Cacho (range 0 to 10) and del Ser (range 0 to 7) respectively. The discriminant validity of each method was calculated in the two samples using the area under the ROC curve (aROC), and the inter-rater reliability was calculated in the clinical sample, that was assessed by the two evaluators, using the intraclass correlation coefficient (ICC) and the kappa coefficient.

RESULTS

There are no significant differences in the discriminant validity of the Sunderland and Solomon systems in any of the samples (clinical: aROC 0.73 [CI95%: 0.64-0.81] and 0.77 [CI95%: 0.69-0.85] respectively, P=.19; volunteers: aROC 0.69 [CI95%: 0.67-0.71] and 0.72 [CI95%: 0.69-0.73] respectively, P=.08). The cut-off points ≤8 and ≤5 correctly classify 71% and 73% of the clinical sample and 82% and 84% of the volunteer sample, respectively. Both systems have good agreement in the clinical sample (Sunderland: ICC 0.90 [CI95%: 0.81-0.93], kappa 0.76 [CI95%: 0.70-0.83]; Solomon: 0.92 [CI95%: 0.88-0.95] and 0.77 [CI95%: 0.71-0.83] respectively), somewhat higher in the second, although the differences are not significant.

CONCLUSIONS

The discriminant validity and inter-observer reliability of these two Clock Test correction systems are similar. Solomon's method, shorter and simpler, may be more advisable in pragmatic terms.

Illiteracy, Neuropsychological Assessment, and Cognitive Rehabilitation: A Narrative Review

OBJECT

Νeuropsychological assessment is particularly important for the accurate discrimination of cognitive abilities and weaknesses of patients in order to determine the appropriate therapeutic intervention. However, the reliability and validity of neuropsychological assessment appears to be influenced by a wide range of factors, including literacy and educational level.

AIM

This systematic review evaluates neuropsychological tests appropriate for the valid assessment of illiterate individuals and the effectiveness of cognitive rehabilitation programs for illiterate and/or low-educated individuals according to the results of English language studies that have been published in the PubMed/Medline electronic database until August 2022 (no initiation date).

RESULTS

49 studies were included for neuropsychological assessment and 4 studies for cognitive rehabilitation. In terms of investigating the validity and reliability of neuropsychological tests for the assessment of healthy illiterate individuals, most studies concluded that for the majority of neuropsychological tests there is a significant difference in performance between healthy illiterate and literate individuals. However, there was consensus among studies that the performance of illiterate subjects was equivalent to the performance of literate subjects on tasks depicting colored and real objects. Regarding cognitive rehabilitation programs, all four studies concluded that they are effective in improving the cognitive functions of illiterate and/or low-literate patients with mild cognitive impairment and/or mild dementia.

CONCLUSIONS

For the assessment of illiterate individuals, it is imperative that neuropsychological tests with high ecological validity (i.e., tests related to activities of daily living) be administered so as not to underestimate their cognitive functioning. At the same time, cognitive enhancement/stimulation programs seem to be effective in this population group; however, this area needs further investigation.

Education bias in typical brief cognitive tests used for the detection of dementia in elderly population with low educational level: a critical review

Dementia is a significant decline in cognition that interfere with independent, daily functioning. Dementia is a syndrome caused by a myriad and include primary neurologic, neuropsychiatric, and medical conditions. It has been projected that the prevalence of dementia will triple in the elderly population by the year 2050. Despite the benefits of early diagnosis, there is an effective under-detection of around 62% of people with mild cognitive impairment (MCI) or dementia. One of the factors associated with this problem is that diagnostic techniques are affected by the educational level of those evaluated. This is an important aspect to consider in the use of brief cognitive tests for the detection of dementia. This review presents and critically analyzes the available evidence regarding the effect of educational level on the diagnostic utility of three of the most widely used tools in the clinical setting: the Mini-mental Test Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Addenbrooke's Cognitive Examination (ACE). Previous evidence shows that the tasks that require reading, writing, calculation, phonological fluency, and visuoconstruction are affected by educational level. These results lead to discourage the use of these tests in older people with less than 6 years of schooling. The development of brief cognitive tests appropriate for people with a low educational level is recommended. We posit that adequate cognitive tests should not consider tasks or items that resemble characteristics of academic contexts and should be more analogous to daily activities situations.

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.

Identifying Appropriate Neuropsychological Tests for Uneducated/Illiterate Older Individuals

OBJECTIVES

We investigated the utility of traditional neuropsychological tests in older uneducated/illiterate individuals without dementia to determine the possibility that they are likely not appropriate for this group.

METHODS

We assessed the neuropsychological performance of 1122 older adults [≥65 years old; mean age: 74.03 (SD = 5.46); mean education: 4.76 (SD = 2.5) years; women: n = 714], in the context of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD), a population-based study conducted in Greece.

RESULTS

We based our analyses on three groups: high-functioning/cognitively healthy (i.e., without dementia) uneducated/illiterate individuals (n = 80), high-functioning/cognitively healthy educated/literate individuals (n = 932), and low-functioning/cognitively impaired educated/literate individuals (presumably with dementia; n = 110). We used binary regression analyses with Bonferroni correction to investigate whether test performance differentiated uneducated/illiterate from educated/literate individuals. Models were adjusted for age and sex; raw test scores were the predictor variables. The uneducated/illiterate cohort was at a disadvantage relative to the healthy educated/literate group on all variables but verbal memory recognition and consolidation, congruent motor responses, and phonological fluency clustering (p > .002). Moreover, only word list learning immediate and delayed free recall and delayed cued recall differentiated the high-functioning/cognitively healthy uneducated/illiterate from the low-functioning/cognitively impaired educated/literate group, favoring the former (p's < .002).

CONCLUSIONS

Our findings suggest that only particular verbal memory test variables are fair in determining whether older uneducated/illiterate individuals have functional/cognitive impairment suggestive of a neurodegenerative process. On all other neuropsychological variables, this cohort was at a disadvantage. Therefore, we highlight the need for identifying appropriate methods of assessment for older uneducated/illiterate individuals.

Diagnostic Accuracy of the Overlapping Infinity Loops, Wire Cube, and Clock Drawing Tests in Subjective Cognitive Decline, Mild Cognitive Impairment and Dementia

Figure drawing tasks are commonly used standalone or as part of broader screening tests to detect cognitive impairment. Only one study has compared the classification accuracy of three common drawing tasks—overlapping infinity loops, wire cube, and the clock drawing task (CDT)—in mild cognitive impairment (MCI) and dementia, but age and education, which impact performance, were not accounted for. We replicated the research, adjusting for age and education and, for the first time, assessed subjective cognitive decline (SCD) too. Participants were recruited from the Tasmanian ISLAND Cognitive Clinic and healthy controls from a community sample. All participants completed the three figure drawing tasks. The clinic patients were categorised according to interdisciplinary consensus diagnosis. Binomial logistic regression and area under ROC curves (AUC) were calculated to determine the discriminatory ability of each drawing task. Overall, 112 adults were recruited; 51 had normal cognition (NC), 21 SCD, 24 MCI, and 16 had dementia. The infinity loops test did not discriminate any of the groups, casting some doubt on its usefulness. The wire cube discriminated NC from dementia (AUC 0.7; p < 0.05). The CDT discriminated NC from dementia (AUC 0.77; p < 0.01), NC from cognitive impairment (dementia + MCI; AUC 0.59; p < 0.05), and MCI from dementia (AUC 0.76; p < 0.01). None of the tests discriminated NC from MCI or NC from SCD. The CDT was the most discriminatory test, followed by the wire cube. This may help guide clinicians who often choose just one figure drawing task due to time constraints or patient fatigue.

Examination of the validity of the 'Papadum test': an alternative to the clock drawing test for people with low levels of education

Objectives: The clock drawing test (CDT) is a widely used cognitive screening test. However, CDT performance is affected by education. This study examined an alternative, the Papadum test, designed for people with low levels of education/literacy. The association between education and test performance, correlation between CDT and Papadum test, and diagnostic accuracy of both CDT and Papadum tests were examined. Method: 89 healthy literate adults and 59 literate adults (all Bengali speaking) with a diagnosis of mild-moderate dementia from hospitals in Kolkata, India undertook the CDT and the Papadum test. Results: Education had a significant association with the CDT but not with the Papadum test. Across the whole sample there was a significant correlation between CDT and Papadum, but not within separate groups of healthy controls and patients. Diagnostic accuracy for the Papadum test was similar to that for CDT. Conclusions: Results highlight the strong influence that education has on CDT performance indicating that it is not suitable for those with low levels of literacy. The Papadum test could provide a viable alternative as a screening tool to the CDT for use with people who are illiterate or have low levels of education. Further validation studies are required.

The effect of illiteracy on performance in screening tools for dementia: A meta-analysis

INTRODUCTION

Research indicates that many tools designed for screening dementia are affected by literacy level. The objective of this study was to estimate the overall effects of this confounding factor. A meta-analysis was conducted to evaluate differences in performance in dementia screening tools between literate and illiterate individuals.

METHOD

Electronic databases were searched from 1975 to June 2021 to identify empirical studies examining performance in dementia screening tools in literate and illiterate individuals over 50 years old. Data for effect sizes, participant demographic information, and study information were extracted.

RESULTS

We identified 27 studies methodologically suitable for meta-analysis. Multi-level random-effects modeling demonstrated a significant overall effect, with literate participants scoring significantly higher than illiterate participants (g = -1.2, 95% CI = -1.47, -0.95, p < .001). Moderator analyses indicated significant effects of test type and the presence of cognitive impairment on the extent of the difference in performance between literate and illiterate participants. The difference in performance between groups was smaller in screening tests modified for illiterate individuals (p < .01), and in individuals with cognitive impairment (p < .001).

CONCLUSIONS

Our findings substantiate the unsuitability of many dementia screening tools for individuals who are illiterate. The results of this systematic review and meta-analysis emphasize the need for the development and validation of tools that are suitable for individuals of all abilities.

Cognitive Screening Instruments for Older Adults with Low Educational and Literacy Levels: A Systematic Review

This study presents a systematic review on existing cognitive screening tools for mild cognitive impairment and dementia in populations with low education and literacy levels. Cochrane Library, PubMed and LILACS databases were examined for studies including adults aged 50 years old or older with low educational level. 61 articles were included. Despite its frequent use, studies on Mini-Mental State Examination (MMSE) revealed that educational level biased the score obtained, regardless of other factors. Separately, the Informant Questionnaire on Cognitive Decline in the Elderly, the Fototest, or the Eurotest, appear to minimize the effect of education and literacy. MMSE is unreliable for individuals with low literacy. Tasks involving reading, writing, arithmetics, drawing, praxis, visuospatial, and visuoconstructive skills have a greater educational bias than naming, orientation, or memory. An adequate determination of educational level and validation of instruments in populations with heterogeneous levels of literacy requires further research.

Clinical Impact of PET With 18F-FDG and 11C-PIB in Patients With Dementia in a Developing Country

Introduction: The objective of this study was to evaluate the clinical impact PET with ¹⁸F-FDG and ¹¹C-PIB in patients with dementia in a developing country.

Methodology: Retrospective study of the patients referred for the evaluation of dementia to the only PET center in Uruguay. A total of 248 patients were identified, from which 70 patients were included based on the availability of medical history and clinical follow-up. Main outcomes included change in diagnosis, diagnostic dilemma and AD treatment. We evaluated the association of clinical outcomes with PET concordance with baseline diagnosis, diagnostic dilemma, level of education, AD pathology/Non-AD pathology (AD/Non-AD), baseline diagnosis and ¹¹C-PIB PET result.

Results: Baseline clinical diagnosis was concordant with ¹⁸F-FDG and ¹¹C-PIB PET results in 64.7 and 77.1% of the patients, respectively. Change in diagnosis after PET was identified in 30.0% of the patients and was associated with discordant ¹⁸F-FDG (p = 0.002) and ¹¹C-PIB (p < 0.001) PET results, previous diagnostic dilemma (p = 0.005), low education (p = 0.027), Non-AD baseline diagnosis (p = 0.027), and negative ¹¹C-PIB PET result (p < 0.001). Only the last variable remained significant in the multivariate analysis (adjusted p = 0.038). Diagnostic dilemma decreased after PET from 15.7 to 7.1% (p = 0.11) and was associated with Non-AD diagnosis (p = 0.002) and negative ¹¹C-PIB PET result (p = 0.003). Change in AD treatment after PET occurred in 45.7% of the patients.

Conclusion:¹⁸F-FDG and ¹¹C-PIB PET had a significant clinical impact in terms of change in diagnosis and treatment in patients with dementia in a developing country, similar to that reported in high-income countries.

Association Among Preoperative Cognitive Performance, Regional Cerebral Oxygen Saturation, and Postoperative Delirium in Older Portuguese Patients

BACKGROUND

Postoperative delirium is common among older patients and preoperative identification of high-risk patients is widely recommended. The aim of this study was to assess whether preoperative cognitive performance using brief screening tools or regional cerebral oxygen saturation (Scto2) was associated with the development of postoperative delirium in older Portuguese patients undergoing elective surgery.

METHODS

Prospective observational cohort study where preoperative cognitive screening tools (Mini-Cog, Mini-Mental State Examination, verbal fluency) and Scto2 (INVOS 5100C; Medtronic, Ireland) were assessed in 238 patients ≥65 years old undergoing elective surgery between July 2017 and May 2019 at a tertiary academic center in Portugal. The primary outcome was postoperative delirium detected by the 3D-Confusion Assessment Method. Data were analyzed by univariate analysis and multivariable logistic regression.

RESULTS

Delirium was identified in 53 patients (22%); 162 patients (68%) had completed only 4 years of education. On multivariable analysis, probable cognitive impairment tested by the Mini-Cog (odds ratio [OR] = 1.57; 95% confidence interval [CI], 0.70-3.53; corrected P value >.999), by the Mini-Mental State Examination (OR = 2.75; 95% CI, 1.23-6.13; corrected P value = .052), and by the animal verbal fluency test (OR = 1.24; 95% CI, 0.49-3.16; corrected P value >.999) were not significantly associated with the development of postoperative delirium. In contrast, lower preoperative Scto2 (OR = 1.08; 95% CI, 1.02-1.14; corrected P value = .024 for each point decrease in Scto2) was associated with postoperative delirium.

CONCLUSIONS

We did not find enough evidence to suggest that poor preoperative cognitive performance was significantly associated with the development of postoperative delirium in an older Portuguese surgical population with an overall low level of formal education, but rather that preoperative Scto2 may be helpful in identifying patients at risk for delirium.

Early Detection of Alzheimer's Disease Based on the Patient's Creative Drawing Process: First Results with a Novel Neuropsychological Testing Method

Based on the knowledge of art therapy, we developed a new neuropsychological drawing test in order to identify individuals with mild cognitive impairment (MCI) as well as dementia patients and healthy controls (HC). By observing a variety of drawing characteristics of 92 participants with a mean age of 67.7, art therapy and dementia experts discriminate HC from MCI, early dementia of the Alzheimer-type (eDAT), and moderate dementia of the Alzheimer-type (mDAT) by the process analysis of tree drawings on a digitizing tablet. The art therapist's average categorical rating of healthy and MCI or demented individuals matched the clinical diagnosis by 88%. In a first small study, we analyzed interrater reliability, sensitivity, specificity, negative and positive predicted values of our tree drawing test (TDT) in comparison with the clock drawing test (CDT). Similar values of moderate interrater reliability were found for the TDT (0.56) as well as for the CDT (0.54). A significant high sensitivity of 0.9 within this binary impairment scale (HC versus impaired or demented) can be demonstrated. Substantial values for the specificity (0.67) could be obtained that however remain under a perfect value of the CDT (1.0). Considering 31 individuals that received the clinical diagnosis "impaired or demented" the TDT shows a higher recognition rate for the MCI group than the CDT. Furthermore in 8 of 12 borderline cases of clinical diagnosis, the outcome of the TDT diagnosis was consistent with the final clinical result.

Novel modification of the Reported Edmonton Frail Scale

OBJECTIVES

The Reported Edmonton Frail Scale (REFS) uses clock drawing as a measure of cognition. However, many patients in the acute hospital setting present with an inability to clock-draw. We considered an alternative method for assessing cognition based on a history of cognitive impairment.

METHODS

We created a modified version of the REFS (mod-REFS), utilising the same domains as the REFS, in which a screening question of cognition substitutes the clock-drawing task. Data were collected from a prospective cohort study.

RESULTS

Of 181 participants, frailty measured with either the REFS or the mod-REFS found equivalence. A comparison between clock drawing and cognitive question scores demonstrated a complete agreement for 152 patients (84%), a reduction in cognition score for 25 (14%) and an increase for 4 (2%).

CONCLUSION

We suggest the mod-REFS will improve the frailty assessment in the acute hospital setting, overcoming the limitations associated with clock drawing.

The illiterate brain and the neuropsychological assessment: From the past knowledge to the future new instruments

The lifetime learning of illiterate and low-educated individuals shapes their cognitive skills, which are challenging to grade by the current available neuropsychological tools. Eight hundred million of the global population are illiterate. It is very challenging to interpret the cognitive performance of this population by the available formal neuropsychological tests, mainly developed for higher educated people. From extensive literature investigation, we reviewed the cognitive process and performance of illiterate and low-educated population on various cognitive domains including language, executive function, memory, visual-related function, and motor skills. We also suggested the concept in the development of the appropriate tools for the cognitive assessment among this population. Finally, we provide the available cognitive screening tools validated in the illiterate and low-educated subjects within the last three decades.

Cognitive assessment tools in Asia: a systematic review

BACKGROUND

The prevalence of dementia is increasing in Asia than in any other continent. However, the applicability of the existing cognitive assessment tools is limited by differences in educational and cultural factors in this setting. We conducted a systematic review of published studies on cognitive assessments tools in Asia. We aimed to rationalize the results of available studies which evaluated the validity of cognitive tools for the detection of cognitive impairment and to identify the issues surrounding the available cognitive impairment screening tools in Asia.

METHODS

Five electronic databases (CINAHL, MEDLINE, Embase, Cochrane Library, and Science Direct) were searched using the keywords dementia Or Alzheimer Or cognitive impairment And screen Or measure Or test Or tool Or instrument Or assessment, and 2,381 articles were obtained.

RESULTS

Thirty-eight articles, evaluating 28 tools in seven Asian languages, were included. Twenty-nine (76%) of the studies had been conducted in East Asia with only four studies conducted in South Asia and no study from northern, western, or central Asia or Indochina. Local language translations of the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were assessed in 15 and six studies respectively. Only three tools (the Korean Dementia Screening Questionnaire, the Picture-based Memory Intelligence Scale, and the revised Hasegawa Dementia Screen) were derived de novo from Asian populations. These tools were assessed in five studies. Highly variable cut-offs were reported for the MMSE (17-29/30) and MoCA (21-26/30), with 13/19 (68%) of studies reporting educational bias.

CONCLUSIONS

Few cognitive assessment tools have been validated in Asia, with no published validation studies for many Asian nations and languages. In addition, many available tools display educational bias. Future research should include concerted efforts to develop culturally appropriate tools with minimal educational bias.

Performance of low-educated elders with depression on Addenbrooke's Cognitive Examination-Revised (ace-r) test

Along with cognitive disorders, depression has been a concern for mental health services due to its highly debilitating effect on the functioning and quality of life of the elderly. However, there is still little understanding of the cognitive alterations resulting from depression or of the difficult differential diagnosis with mild cognitive impairment (MCI). It is known that performance on cognitive tests is strongly influenced by education but few studies have been conducted involving low-educated populations.

Objective

To evaluate the performance of elders with low education and no dementia on Addenbrooke's Cognitive Examination-Revised (ACE-R) test and its cognitive domains, and compare patients with Current Major Depressive Episode (CMDE) against those without depressive symptoms.

Methods

A retrospective, cross-sectional analytical study was conducted based on medical files of patients treated at the Cerebral Aging Clinic of the Hospital São Lucas of the PUCRS. The study included 116 individuals with low education (< 8 years of education) aged between 60 and 84 (69.6 ± 6.4) years, with MCDE (N = 41) and controls (N = 75).

Results

No significant difference was observed between control and MCDE groups in median scores on the ACE-R, Mini-Mental State Examination, and the five cognitive domains. There was also no difference between the groups on separate analyses of results on the clock drawing test, the categorical verbal and phonological fluency test, and the naming test.

Conclusion

The results of this study showed that depressive symptoms did not influence scores on the ACE-R tests conducted in elders with low education.

The Times They Are a-Changin': Clock Drawing and Prediction of Dementia

Identification of individuals who will eventually develop dementia is critical for early intervention, treatment, and care planning. The clock drawing test (CDT) is a widely used cognitive screening tool that has been well accepted among clinicians and patients for its ease of use and short administration time. This review explores the value of the CDT for predicting the later development of dementia in cognitively intact older adults and patients with mild cognitive impairment (MCI). Additionally, we reviewed studies that examined the ability of the CDT to monitor declines in cognitive functioning over time. A PubMed literature search for articles that included a longitudinal analysis of the CDT was conducted. The search included articles published up to June 2013 and manual cross-referencing of bibliographies. Relevant studies were categorized, summarized, and critiqued. The consensus from the studies reviewed suggests that the CDT is a useful measure of cognitive decline over time. Conceptual clock drawing errors (eg, misrepresentation of time) detected this decline most effectively. In addition, the CDT appears to differentiate at baseline between cognitively intact older adults who will develop dementia up to 2 years postbaseline. Finally, the CDT has been found to differentiate between patients with MCI who will progress to dementia up to 6 years postbaseline. The CDT appears useful for the longitudinal assessment of cognitive impairment and together with other validated measures may be helpful for predicting conversion to dementia. Cost-effective and practical ways of predicting risk of dementia will become increasingly critical as we develop disease-modifying treatments.

A systematic review and meta-analysis of the diagnostic accuracy of the Phototest for cognitive impairment and dementia

The recently developed Phototest is a simple, easy and very brief test for detecting cognitive impairment or dementia.

OBJECTIVE

To evaluate the diagnostic accuracy of the Phototest for detecting cognitive impairment or dementia.

METHODS

We used a manually created database to search for studies evaluating the Phototest diagnostic yield and performed an initial meta-analysis to determine sensitivity (Sn) and specificity (Sp) of diagnostic parameters. We also performed a second meta-analysis of individual participant data.

RESULTS

In total, 6 studies were included in the meta-analysis. For dementia, Sn was 0.85 (95% CI, 0.82-0.88) and Sp 0.87 (95% CI, 0.85-0.99); for cognitive impairment, Sn was 0.80 (95% CI, 0.77-0.92) and Sp 0.88 (95% CI, 0.86-0.90). In the individual data meta-analysis, 1565 subjects were included, where best cut-off points for dementia and for cognitive impairment were 26/27 (Sn=0.89 (95% CI 0.85-0.91), Sp=0.84 (95% CI, 0.82-0.91)) and 28/29 (Sn=0.79 (95% CI, 0.76-0.81), Sp=0.88 (95% CI, 0.86-0.90)), respectively.

CONCLUSION

Phototest has good diagnostic accuracy for dementia and cognitive impairment. It is brief, simple and can be used in illiterate persons. This makes it suitable for use in primary care settings and/or in subjects with low educational level.

Multiple clock drawing scoring systems: simpler is better

OBJECTIVE

The clock drawing test (CDT) is a widely used cognitive screening tool that has been well accepted among clinicians and patients for its ease of use and short administration time. Although there is ample interest in the CDT as a screening instrument, there remains a range of CDT administration and scoring systems with no consensus on which system produces the most valid results while remaining user friendly. The aims of this review are to synthesize the available evidence on CDT scoring systems' effectiveness and to recommend which system is best suited for use at the clinical frontlines.

DESIGN

A Pubmed literature search was carried out from 2000 to 2013 including manual cross-referencing of bibliographies in order to capture studies published after Shulman's comprehensive review published in 2000. A brief summary of all original scoring systems is included, as well as a review of relevant comparative studies.

RESULTS

The consensus from multiple comparison studies suggests that increasing the complexity of CDT scoring systems does little to enhance the test's ability to identify significant cognitive impairment. Moreover, increased complexity in scoring adds to the administration time, thereby reducing the test's utility in clinical settings.

CONCLUSIONS

In comparing scoring systems, no system emerged as consistently superior in terms of predictive validity. The authors conclude that when scoring the CDT as a screening instrument in a primary/general medicine/community setting, simpler is better, and perhaps qualitative assessment of "normal" versus "abnormal" may be sufficient for screening purposes and the establishment of a baseline for follow-up.

Utility of the mini-cog for detection of cognitive impairment in primary care: data from two spanish studies

Objectives. To study the utility of the Mini-Cog test for detection of patients with cognitive impairment (CI) in primary care (PC). Methods. We pooled data from two phase III studies conducted in Spain. Patients with complaints or suspicion of CI were consecutively recruited by PC physicians. The cognitive diagnosis was performed by an expert neurologist, after formal neuropsychological evaluation. The Mini-Cog score was calculated post hoc, and its diagnostic utility was evaluated and compared with the utility of the Mini-Mental State (MMS), the Clock Drawing Test (CDT), and the sum of the MMS and the CDT (MMS + CDT) using the area under the receiver operating characteristic curve (AUC). The best cut points were obtained on the basis of diagnostic accuracy (DA) and kappa index. Results. A total sample of 307 subjects (176 CI) was analyzed. The Mini-Cog displayed an AUC (±SE) of 0.78 ± 0.02, which was significantly inferior to the AUC of the CDT (0.84 ± 0.02), the MMS (0.84 ± 0.02), and the MMS + CDT (0.86 ± 0.02). The best cut point of the Mini-Cog was 1/2 (sensitivity 0.60, specificity 0.90, DA 0.73, and kappa index 0.48 ± 0.05). Conclusions. The utility of the Mini-Cog for detection of CI in PC was very modest, clearly inferior to the MMS or the CDT. These results do not permit recommendation of the Mini-Cog in PC.

The Framingham Heart Study clock drawing performance: normative data from the offspring cohort

BACKGROUND/STUDY CONTEXT: Although the Clock Drawing Test (CDT) is a popular tool used to assess cognitive function, limited normative data on CDT performance exist. The objective of the current study was to provide normative data on an expanded version of previous CDT scoring protocols from a large community-based sample of middle to older adults (aged 43 to 91) from the Framingham Heart Study.

METHODS

The CDT was administered to 1476 Framingham Heart Study Offspring Cohort participants using a scoring protocol that assigned error scores to drawn features. Total error scores were computed, as well as for subscales pertaining to outline, numeral placement, time-setting, center, and "other."

RESULTS

Higher levels of education were significantly associated with fewer errors for time-setting (Command: p < .001; Copy: p = .003), numerals (Command: p < .001), and "other" (Command: p < .001) subscales. Older age was significantly associated with more errors for time-setting (Command: p < .001; Copy: p = .003), numerals (Command: p < .001), and "other" (Command: p < .001) subscales. Significant differences were also found between education groups on the Command condition for all but the oldest age group (75+).

CONCLUSION

Results provide normative data on CDT performance within a community-based cohort. Errors appear to be more prevalent in older compared with younger individuals, and may be less prevalent in individuals who completed at least some college compared with those who did not. Future studies are needed to determine whether this expanded scoring system allows detection of preclinical symptoms of future risk for dementia.

Recommended measures for the assessment of cognitive and physical performance in older patients with dementia: a systematic review

Aim/Goal

To recommend a set of neuropsychological and physical exercise tests for researchers to assess cognition and physical fitness in clinical trials with older patients with dementia; to create consensus, decrease heterogeneity, and improve research quality.

Methods

A literature search (2005–2011) yielded 89 randomized controlled trials. To provide information on test recommendations the frequency of test use, effect size of the test outcome, study quality, and psychometric properties of tests were analyzed.

Results

Fifty-nine neuropsychological tests (cognitive domains: global cognition, executive functioning, memory, and attention) and 10 exercise tests (physical domains: endurance capacity, muscle strength, balance, and mobility) were found.

Conclusion

The Severe Impairment Battery, Mini Mental State Examination, and Alzheimer Disease Assessment Scale – cognitive subscale were recommended to measure global cognition. The Verbal Fluency Test Category/Letters, Clock Drawing Test, and Trail Making Test-B were recommended to measure executive functioning. No specific memory test could be recommended. The Digit Span Forward, Digit Span Backward, and Trail Making Test-A were recommended to measure attention. As physical exercise tests, the Timed Up and Go and Six Meter Walk for mobility, the Six Minute Walk Distance for endurance capacity, and the Tinetti Balance Scale were recommended.